Page 10 - Laparoscopic Surgery Online Journal

T Anil Kumar et al

the case, and several studies have documented that
laparoscopic surgery is to be safe even in the presence of
peritonitis. 44,45
The most common reason for conversion was the size
of perforation, but by using an omental patch this might not
necessarily have to be a reason anymore to convert. From
literature it was already known that other common reasons
for conversion include failure to locate the perforation. 46
Shock at admission was associated with a significant higher
24
conversion rate (50 vs 8%). In our study reason for
conversion were dense adhesions which increased with
increase in time for presentation, and unable to locate site
of perforation which occurred mostly in patients presented
after 5 days.
Fig. 4: Sutures are tied over omental flap
Overall there seems to be significant proof of the benefits
this procedure laparoscopically or open?’ Is there really a of laparoscopic repair, but it is technical demanding surgery
sixth decision to be made, or are there enough proven which needs a surgeon experienced with laparoscopy. 24,46
benefits of laparoscopic correction that this should not be a CO insufflation of the peritoneal cavity in the presence of
2
question anymore? Management of peptic ulcer perforation peritonitis has been shown in rat models to cause an increase
24
is controversial. 29,30 Laparoscopic surgical treatment is in bacterial translocation. This led to the assumption that
attractive due to a lower morbidity rate associated with it laparoscopic surgery might be dangerous in patients with
31
than with conventional surgery. A recent review 32 prolonged peritonitis. Vaidya et al performed laparoscopic
compared laparoscopic vs open peptic perforation surgery; repair in patients with symptoms of PPU for more than
24 hours and concluded that it was safe even in patients
laparoscopic repair was associated with lesser postoperative
analgesic use, decreased hospital stay, lower wound with prolonged peritonitis, which has been confirmed by
24,44,47,48
infection rate, and lower mortality rate; open repair was others. In our study laparoscopic repair could be
associated with reduced operating time and suture-site done with ease in patients presenting less than 3 days, also
leakage. A variety of laparoscopic techniques, 33-40 including it could be done in patients presenting after 3 days with
41
a combined laparoscopic-endoscopic method, have been increasing difficulty, morbidity complications like localized
described. We prefer intracorporeal suturing against peritoneal abscess, port site infection and with increase
extracorporeal knotting because the latter is likely to cut conversion rates.
through the friable edge of the perforation. Laparoscopic
CONCLUSION
perforation closure can be performed effectively with viable
Graham’s patch omentoplasty as in conventional surgery. Laparoscopic treatment of PPU is safe, feasible, done with
CO insufflation of the peritoneal cavity in the presence ease in patients presenting less than 3 days and also in some
2
of peritonitis has been shown in rat models to cause an cases of late presentation, with anesthetic complication,
increase in bacterial translocation 42,43 from the peritoneal postoperative complications, conversion rate, duration of
cavity to the bloodstream. Although, laparoscopic inter- hospital stay with increasing morbidity increasing with
vention would have been thought to be unsafe, such is not delayed presentation.

Table 1: Comparison of results between early and delayed presentation. Thorough abdominal toileting could not be done because of
intestinal matting. Port site infection was managed conservatively with dressing. Intraperitoneal localized abscess was aspirated under
ultrasound guidance
Variables Early presentation Delayed presentation
Mean operating time 60 minutes 90 minutes
Conversion rate 0 out of 37 cases (0%) 10 out of 21 (47.6%)
Thorough abdominal toileting 0 out of 37 cases (0%) 6 out of 11 (54.5%)
Delayed recovery from anesthesia 0 out of 37 cases (0%) 3 out of 11 case (27.3%)
Postoperative opioid analgesia Mean 3 days Mean 4 days
Nasogastric tube removal 3rd day 4th day
Port site infection 5 out of 37 cases (13.5%) 2 out of 11 cases (18.2%)
Intraperitoneal localized abscess 0 out of 37 cases (0%) 2 out of 11 cases (18.2%)
Duration of hospital stay Mean 5 days Mean 7 days

118