Surgery Today

https://doi.org/10.1007/s00595-018-1681-4

HOW TO DO IT

Laparoscopic omental filling with intraoperative endoscopy

for a perforated duodenal ulcer
Yuki Sakamoto1,2 · Masaaki Iwatsuki2 · Kazuya Sakata1 · Eiichiro Toyama1 · Noboru Takata1 · Ichiro Yoshinaka1 ·
Kazunori Harada1 · Hideo Baba2

Received: 16 April 2018 / Accepted: 27 May 2018

© Springer Nature Singapore Pte Ltd. 2018

Abstract
As a surgical treatment for a perforated duodenal ulcer, duodenal omental filling is effective. However, filling the perfora-
tion site with a sufficient amount of omentum is difficult in some situations. We herein report that we successfully filled a
perforated duodenal ulcer with a sufficient amount of omentum using intraoperative endoscopy. The operation was performed
with three ports, the operation time was 110 min, and the estimated blood loss was small. The postoperative course was
good. No stenosis of deformity of the duodenum was observed on follow-up endoscopy. Laparoscopic surgery has a shorter
operation time, shorter postoperative hospital stay, and less postoperative pain than open surgery. The combined use of
intraoperative endoscopy with laparoscopic surgery is effective for a large perforation, and it can be expected to reduce the
rate of conversion to open surgery. This combined procedure is considered useful as a laparoscopic omental filling operation.

Keywords Perforated duodenal ulcer · Omental filling · Laparoscopic surgery

Introduction part have been reported [2–4]. However, the amount of

Duodenal ulcer perforation accounts for approximately 50%
of upper gastrointestinal ulcer perforations and is a common
disease [1]. Surgical treatment is the first choice for general
peritonitis due to perforation of the gastrointestinal tract.
Surgical treatment for duodenal ulcers can be divided into
suturing of the perforated portion or omental filling opera-
tions. Omental filling operations are less likely to cause ste-
nosis or deformation of the duodenum after surgery than
single closure of the perforated part of the ulcer, but reliably
filling a sufficient amount of omentum is difficult in some
situations. The single closure of the perforated part of the
ulcer and the attachment of the omentum to the perforated
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00595-018-1681-4) contains
supplementary material, which is available to authorized users.
* Hideo Baba
hdobaba@kumamoto-u.ac.jp
1
Department of Surgery, Amakusa Medical Center,
Kumamoto, Japan
2
Department of Gastroenterological Surgery, Graduate School
of Medical Sciences, Kumamoto University, 1-1-1 Honjo,
Chuo-Ku, Kumamoto 860-8556, Japan
omentum that can be filled in each of these procedures is
small.
We herein report a surgical procedure that reliably fills a
perforated duodenal ulcer with omentum using intraopera-
tive endoscopy in combination with laparoscopic surgery.
Materials and surgical technique (Online
Resource 1)
We performed our procedure with a total of three ports.
First, we placed a 5-mm camera port in the umbilicus. Sec-
ond, two other 5-mm trocars were placed, with one each in
the epigastric region and the right upper part of the abdomen
(Fig. 1). After intraperitoneal observation, we performed
intraperitoneal washing with a large amount of warm physi-
ological saline and adhesiolysis, followed by detection of the
perforated part of the duodenum. Because the perforated part
of the duodenum was large, single closure was difficult, and
we considered that a sufficient amount of omental filling was
necessary. We determined that there was a sufficient amount
of omentum to be filled and placed as a support suture on
the tip of the omentum using the Endloop PDS II (Johnson
& Johnson Co., Ltd., Tokyo, Japan). The endoscope was

13
Vol.:(0123456789)

Fig. 1 Port placements at (1) 5 mm, (2) 5 mm, and (3) 5 mm
Fig. 2 Intraoperative endoscopic findings
guided to the punctured section, and a support thread that
was applied to the omentum was caught using snare forceps.
The omentum was towed and filled into the stomach with
confirmation by an endoscope (Fig. 2). The omentum was
sutured and fixed to the stomach wall and the duodenal wall
using absorbable thread. We placed a drain under the right
diaphragm and completed the operation. The operation time
was 110 min, and the amount of bleeding was small.
Drinking water was resumed from the sixth postopera-
tive day just after the naso-gastric tube was removed. Oral
ingestion was resumed from the tenth postoperative day. The
postoperative course was good with no complications, and
the patient was discharged on the 17th postoperative day.
13
Surgery Today
The omentum that was filled up to the stomach during sur-
gery showed shrinkage on endoscopy on the 16th day after
surgery (Fig. 3A). The omentum had completely disappeared
as shown by endoscopy on the 54th postoperative day, and
the perforated part of the duodenum was covered with regen-
erating epithelium (Fig. 3B). Proton pump inhibitor adminis-
tration was started after the surgery, and Helicobacter pylori
eradication was performed after discharge.
Discussion
Although the prevalence of peptic ulcers varies depend-
ing on an individual’s race and geographical location, the
incidence of such ulcers tends to range from approximately
10–20% [5–7]. A total of 1–2% of peptic ulcers is accom-
panied by complications such as perforation, bleeding, and
stenosis [8]. Conservative treatment is becoming common
for managing perforated duodenal ulcer, but approximately
30% of cases require surgery [9], and surgical treatment still
plays an important therapeutic role [4]. In the present case,
we successfully filled a sufficient amount of omentum into
a large perforated part of the duodenum using intraopera-
tive endoscopy in combination with surgery. An endoscopic
examination performed for postoperative follow-up observa-
tion showed no obstruction due to duodenal deformation or
stenosis.
Since the introduction of laparoscopic surgery, the useful-
ness of this surgery for managing perforated peptic ulcers
has been reported [10–12]. Laparoscopic surgery has a
shorter operation time and postoperative hospital stay and
less postoperative pain, allowing for a quicker return to pre-
operative life than open surgery [10]. However, while sev-
eral reports have shown that the probability of postoperative
complications is not significantly different in laparoscopic
surgery compared with open surgery [4, 12–15], the rate
of suture line leakage is high in laparoscopic surgery [13].
Among the reports that showed no significant difference in
the probability of postoperative complications, laparoscopic
surgery had a higher rate of suture failure than open surgery
[12–15].
The combination of intraoperative endoscopy and lapa-
roscopic surgery enables filling the perforated part of the
duodenal ulcer with a sufficient amount of omentum in
high-risk cases, such as patients with large or difficultly
located ulcers, and has a lower conversion rate to open
surgery for laparoscopic surgery. Laparoscopic surgery
for perforated peptic ulcers requires conversion to open
surgery at a rate of approximately 8–19%, and conversion
is usually performed because of large perforation, fragility
of the organ tissue, difficult location of the ulcer (posterior
duodenum), intraoperative bleeding, and poor tolerance of
surgical pneumoperitoneum [4, 15–17]. Some studies have
Surgery Today
Fig. 3 Postoperative endoscopic findings. a 16th day after surgery; b 54th day after surgery
described the risk factors for requiring conversion surgery
in laparoscopic surgery for perforated duodenal ulcer [18,
19]. Kim et al. reported that a large perforation (> 9 mm)
and a duration of perforation exceeding 12.5 h were reli-
able risk factors for conversion and suture leakage [18].
Therefore, we performed omental filling to the perforated
part of the duodenum with intraoperative endoscopy to
fill a sufficient amount of omentum and confirm a lack of
duodenal deformation or stenosis.
However, several limitations associated with laparoscopic
omental filling with intraoperative endoscopy for a perfo-
rated duodenal ulcer should be mentioned. First, in addi-
tion to the surgeon, an endoscopist for performing intraop-
erative endoscopy must be present. Therefore, more human
resources are necessary in this procedure than with open
surgery. Consequently, performing this procedure may be
difficult for small hospitals and after hours. In the present
case, the operation was performed on a holiday morning,
and another surgeon performed intraoperative endoscopy.
Second, the operation duration is likely to be longer than that
for open surgery. Therefore, physicians should not hesitate to
convert high-risk patients to open surgery. However, intra-
operative endoscopy is also useful in open surgery because
we can confirm leakage and passage during the operation.
We believe that the combined use of intraoperative endos-
copy with laparoscopic surgery is effective for managing
large perforations and can be expected to reduce the rate of
conversion to open surgery.
Acknowledgements The authors have no financial conflicts of interest
to disclose. We thank Ellen Knapp, PhD, from Edanz Group (http://
www.edanz editi ng.com/ac) for editing a draft of this manuscript.
Approval from an Ethics Committee was deemed to be unnecessary
for this report.
References
1. Itamoto T, Kajitani T, Okamoto Y, Katayama K, Urushibara T,
Kawaishi H. A clinical study of perforation of gastroduodenal
ulcer (in Japanese with English abstract). Nihon Rinshogeka Gak-
kaizasshi (J Jpn Surg Assoc). 1988;49(12):2275–81.
2. Cellan-Jones CJ. A rapid method of treatment in perforated duo-
denal ulcer. BMJ. 1929;1(3571):1076–7.
3. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review
of history and treatment. Dig Surg. 2010;27(3):161–9.
4. Mouly C, Chati R, Scotté M, Regimbeau JM. Therapeutic man-
agement of perforated gastro-duodenal ulcer: literature review. J
Viscer Surg. 2013;150(5):333–40.
5. Lam SK. Differences in peptic ulcer between east and west. Clin
Gastroenterol. 2000;14(1):41–52.
6. Lau JY, Barkun A, Fan DM, Kuipers EJ, Yang YS, Chan FK.
Challenges in the management of acute peptic ulcer bleeding.
Lancet. 2013;381(9882):2033–43.
7. Ji XQ, Du JF, Chen G, Chen G, Yu B. Efficacy of ilaprazole in the
treatment of duodenal ulcers: a meta-analysis. World J Gastroen-
terol. 2014;20(17):5119–23.
8. Milosavljevic T, Kostić-Milosavljević M, Jovanović I, Krstić M.
Complications of peptic ulcer disease. Dig Dis. 2011;29(5):491–3.
9. Niwa K, Mikami S, Enomoto T, Otsubo T. Investigation of the
indications for conservative therapy to treat perforated gastroduo-
denal ulcers. J St Marian Univ. 2016;7:85–93.
10. Siu WT, Leong HT, Law BK, Chau CH, Li AC, Fung KH, et al.
Laparoscopic repair for perforated peptic ulcer a randomized con-
trolled trial. Ann Surg. 2002;235(3):313–9.
11. Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T. Laparo-
scopic omental patch repair for perforated peptic ulcer. Ann Surg.
1995;221(3):236–40.
12. Tan S, Wu G, Zhuang Q, Xi Q, Meng Q, Jiang Y, et al. Laparo-
scopic versus open repair for perforated pepic ulcer: a meta analy-
sis of randomized controlled trials. Int J Surg. 2016;33:124–32.
13. Lunevicius R, Morkevicius M. Systematic review comparing lapa-
roscopic and open repair for perforated peptic ulcer. Br J Surg.
2005;92(10):1195–207.
14. Byrge N, Barton RG, Enniss TM, Nirula R. Laparoscopic ver-
sus open repair of perforated gastroduodenal ulcer: a national
13
 Surgery Today

surgical quality improvement program analysis. Am J Surg. 18. Kim JH, Chin HM, Bae YJ, Jun KH. Risk factors associated with
2013;206(6):957–62. conversion of laparoscopic simple closure in perforated duodenal
15. Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair ulcer. Int J Surg. 2015;15:40–4.
for perforated peptic ulcer disease (review). Cochrane Database 19. Lunevicius R, Morkevicius M. Risk factors influencing the early
Syst Rev. 2013;28(2):CD004778. outcome results after laparoscopic repair of perforated duode-
16. Rosin D, Zmora O, Hoffman A, Khaikin M, Bar Zakai B, Munz Y, nal ulcer and their predictive value. Langenbecks Arch Surg.
et al. Low incidence of adhesion-related bowel obstruction after 2005;390(5):413–20.
laparoscopic colorectal surgery. J Laparoendosc Adv Surg Tech
A. 2007;17(5):604–7.
17. Mouret P, Francois Y, Vignal J, Barth X, Lombard-Platet R.
Laparoscopic treatment of perforated peptic ulcer. Br J Surg.
1990;77(9):1006.

13