Name : Errawan R. Wiradisuria, MD

Birth Place & Date : Bandung (Indonesia), April 2nd, 1957

Present Position : General Surgeon, Consultant in Digestive and Laparoscopic Surgery

FORMAL EDUCATION

1. General Practitioner : Faculty of Medicine, University of Padjadjaran, Bandung -Indonesia (March, 23rd, 1983)

2. General Surgeon : Dept. of Surgery, Faculty of Medicine University ofIndonesia/Cipto Mangunkusumo Hospital, Jakarta - Indonesia (Oct., 08th ,1991)

3. Digestive Surgeon : Div. of Digestive Surgery, Dept of Surgery - Faculty ofMedicine, University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta –Indonesia (May, 20th, 1997)

4. Magister of Hospital Management : Faculty of Public Health, University ofGadjah Mada, Yogyakarta – Indonesia (April, 24th, 2008)

Curriculum Vitae

ACTIVITY (ENDO-LAPAROSCOPIC SURGERY FIELD)

2002 – now : Board of Governor Member of Endoscopic Laparoscopic Surgeons of

Asia ( ELSA )

Aug. 2006 – now : Board Member of Asia Endosurgery Task Force ( AETF )

May 2008 – now : President of Indonesian Society of Endo-laparoscopic Surgeons

( ISES / PBEI )

• May 2008 – now : Secretary General of Indonesian Hernia Society

Dec. 2008 – now : Editorial Board Member of Asian Journal of Endoscopic Surgery

Oct. 2009 – now : International Member of Society of American Gastrointestinal and

Endoscopic Surgeons ( SAGES )

Nov. 2013 – 2015 : Vice President of Endoscopic Laparoscopic Surgeons of Asia

( ELSA )

Feb 2016 – now : Vice President of Indonesian Digestive Surgeons Association

( IDSA / IKABDI )

April 2016 – now : President of ASEAN Society of Colo-Rectal Surgeons ( ASCS )

Dec. 2016 – now : Board Member of Asia Pacific Endo-Lap Surgery Group ( APELS )

Jan. 2017 – now : International Honorary Member of Japan Society for Endoscopic

Surgery ( JSES )

Laparoscopic Repair for Peptic Ulcer Perforation

dr. Errawan Wiradisuria, SpB-(K)BD, M.Kes

Introduction

• Peptic ulcer disease ( PUD ) is a results from animbalance between stomach acid-pepsin & mucosaldefense barriers

• Incidence: 7 – 10 cases / 100.000 adults per year

• Perforation happens in 2 – 10 % of the cases ( PUD )

• The perforation site: Anterior wall of the duodenum (60%) Antrum (20%) Lesser-curvature (20%)

* Abhishek A, et al. Validation of Boey’s score in predicting morbidity and mortality in peptic perforation peritonitis in Northwestern India. Tropical Gastroenterology 2015;36(4):256–260

Risk Factors

1. NSAIDs• About a quarter of chronic NSAID users will develop PUD

& 2 - 4% will bleed or perforate

2. H. pylori• H. pylori prevalence in patients with perforated duodenal

ulcers ranges from 50%-80%

3. Smoking• About 23% of PUD could be associated with smoking

• Tobacco is thought to inhibit pancreatic bicarbonatesecretion, leading to increased acidity in duodenum

• It also inhibits the healing of duodenal ulcers.

Risk Factors

4. Others Genetic

Steroid

Alcohol

Gastrinomas

Zollinger-Ellison Syndrome

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

General Clinical Symptoms

1. Initial phase (< 2 hours of onset)• Epigastric pain, tachycardia & cool extremities

2. Second phase (2 – 12 hours)• Generalized pain worsen on movement, abdominal

rigidity & upper abdominal discomfort followed by rightlower quadrant tenderness

3. Third phase (> 12 hours)• Abdominal distension, pyrexia & hypotension with acute

circulatory collapse

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Diagnostic

1. X-Ray• Erect chest X-ray: free air• Abdominal X-ray:

• Rigler’s sign: gas on both sides of the bowel wall• Football sign: a large volume of free gas resulting in a large round

black area• Gas outlining soft tissue structures such as liver edge or falciform

ligamentIt is authors’ practice not to perform an abdominal X-ray in patients withsuspected PPU when chest X-ray does not show free air under thediaphragm

2. CT Scan Abdomen• Diagnostic accuracy as high as 98%• CT scan can exclude acute pancreatitis.• Free air is usually seen below the anterior abdominal wall

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Diagnostic

3. Laboratory result• Serum amylase less than four times its normal level may

be associated with perforation

• Leukocytosis & C-reactive protein

• Creatinine , urea & metabolic acidosis reflects systemicinflammatory response syndrome (SIRS) & prerenal injury

• Serum gastrin levels are indicated in patients with historyof recurrent ulcers or recalcitrant PUD and can helpestablish diagnosis of Zollinger Ellison syndrome.

• In patients with suspected parathyroid disorders, serumcalcium levels are indicated

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Laparoscopic Repair

• First laparoscopic repair for perforated peptic ulcer:Phillipe Mouret (1990)

• Laparoscopic approaches are now being applied widely& become the gold standard in patients with < 10 - 15mm perforation size presenting within the first 24 hoursof onset

• Laparoscopy is a useful diagnostic tool whenpreoperative findings are not conclusive, especially if alaparoscopic treatment is likely

• Laparoscopy is a possible alternative to open surgery inthe treatment of perforated peptic ulcer

Laparoscopic Repair

Laparoscopy tends to be more difficult to perform &were considered the main risk factors for conversionin:

• Older patients (> 70 y.o)

• Perforations > 15 mm

• Posterior duodenal ulcers

* Guadagni S, et al. Laparoscopic repair of perforated peptic ulcer. Surg Endosc. 2014;28:2302-8.

Laparoscopic Repair

Several advantages of laparoscopic

• Less tissue dissection and disruption of tissue planes

• Less pain postoperatively

• Low intraoperatively & postoperative complications

• Early return to work

• Cosmetically better outcome

Patient Selection

Duodenal perforation is a laparoscopic emergency.

Patient with stable condition & peritonitis is diagnosed within 12 hours of onset laparoscopic method

• Laparoscopic repair is not advisable after 12 hoursbecause chemical peritonitis will give way tobacterial peritonitis with possibility of severe sepsis

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Scale surgical risk: Score

• State of shock on admission (SBP < 90 mmHg) 1

• ASA III-IV (presence of severe comorbidities) 1

• Duration of symptoms (> 24 hours) 1

* Score 0-1 preferred laparoscopic approach

* Cocorullo G. Emergency Laparoscopy. Springer. 2016

Boey Score

Surgical Technique

Patient position

• The patient was placed inLloyd - Davis’ (French)position with reverseTrendelenberg tilt

* Lionel R., et al. Laparoscopic Surgical Technique for perforated duodenal ulcer. 10.1016/j.jviscsurg.2016.02.004

Surgical Technique

Trocar position

1. A 10 mm trocar just above theumbilicus by the close / open(Hassan) technique.

2. A 5 mm trocar through theright rectus muscle.

3. A 10 mm trocar through theleft rectus muscle.

4. An additional 5 mm trocarmay be placed in the leftsubcostal region based onintra-operative findings (i.e.,large left hepatic lobe fallingdown over the duodenum &obscuring exposure of theoperative field).

Surgical Technique

• Exploration of the peritonealcavity.

• Copiously lavage, remove anyfalse membranes, particularlyfrom the anterior surface of theduodenum in order tovisualize the perforation.

Dilution is the best solution for pollution

* ERW

* Lionel R., et al. Laparoscopic Surgical Technique for perforated duodenal ulcer. 10.1016/j.jviscsurg.2016.02.004

Surgical Technique

Blue dye test

• If the site of perforation is notimmediately evident, occlude the2nd portion of the duodenum withan atraumatic laparoscopic bowelclamp while methylene blueinstilled through the NGT.

• If instillation of blue dye fails toidentify the site of perforation,instillation of intragastric air mayidentify the perforation.

* Lionel R., et al. Laparoscopic Surgical Technique for perforated duodenal ulcer. 10.1016/j.jviscsurg.2016.02.004

Surgical Technique

The choice of the method of closure depends fundamentally onthe characteristics of the lesion:

If the margins are infiltrated, friable & less mobile applyomental patch

If the margins can be easily brought together, withouttension direct suturing with or without omentoplasty

* Mandala V. The Role of Laparoscopy In Emergency Abdominal Surgery. Springer. 2014

Graham omentoplastyA free graft of epiploon is used to repair the perforation

* Cocorullo G. Emergency Laparoscopy. Springer. 2016

Surgical Technique

Cellan-Jones repairA strand of omentum is drawn over the perforation & held inplace by full thickness sutures placed on either side of theperforation

* Cocorullo G. Emergency Laparoscopy. Springer. 2016

Surgical Technique

Primary suture of the perforation overlapped by a pedicleomentum flap

* Cocorullo G. Emergency Laparoscopy. Springer. 2016

Surgical Technique

A viable mobile piece of omentumpulled intraluminally through the site ofperforation

The omentum is fixed to the mucosa ofthe luminal wall with severalendoscopic clips

Sutureless Technique

Laparoscopic-assisted NOTES (Natural Orifice TransluminalEndoscopic Surgery)

* Cocorullo G. Emergency Laparoscopy. Springer. 2016

Surgical Technique

Sutureless Technique

Gelatin sponge plug with fibrin glue sealant• Easily performed• Have a higher leak rate has not been widely accepted

Surgical Technique

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Surgical Technique

Drain placement

There is no indication to biopsy the margins of the perforation, since the incidence of duodenal malignancy is essentially zero in

patients with perforated duodenal ulcer.

* Lionel R., et al. Laparoscopic Surgical Technique for perforated duodenal ulcer. 10.1016/j.jviscsurg.2016.02.004

Open Conversion

Open conversion may be required especially in the presence ofcertain high-risk factors as:

• Inadequate ulcer localization

• Posterior location of gastric ulcer

• Pancreatic infiltration (penetrating ulcer)

• Localized abscess formation

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Complication

• Suture leak

• Pneumonia (~ pneumoperitoneum)

• Prolonged dynamic ileus

• Intraabdominal abscess formation

• External fistula

• Hemorrhage

* Cung KT, et al. Perforated peptic ulcer - an update. World J Gastrointest Surg 207 January 27; 9(1): 1-12

Post Operative Management

• Removal of the NGT on the day following surgery (?)

• Maintaining total parenteral nutrition status for the first 48hours after surgery

• Medication with proton pump inhibitors (PPI) (40 mg/day byintravenous route) for 48 hours; antibiotic for 48 hours, whileawaiting results of intra-operative cultures

• PPI therapy is continued orally for a month & antibiotictherapy to eradicate H. pylori is started at the time of hospitaldischarge

Post Operative Management

• An upper abdominal CT scan with GI contrast is not routinelyperformed. CT scan is reserved for patients with clinical signssuggesting a postoperative duodenal fistula.

• Follow-up one month after surgery with a scheduled upperendoscopy to confirm good healing of the duodenal ulcer &resolution of H. pylori gastritis & to verify the absence ofother associated lesions.