Page 14 - Jourmal of World Association of Laparoscopic Surgeon

PN Sreeramulu et al

SURGICAL PROCEDURE for open surgery was 8 days as compared with 6 days in lap
group (p = 0.001). There was wound infection in three
A pneumoperitoneum was created using Hasson open 25-27
technique, insufflation pressure was maintained at (9%) patients in open group as compared with one (3%)
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11 mm Hg. Four ports were inserted, the upper port in in lap group, one patient had wound dehiscence in open
subxiphoid area used for irrigation and suction, retraction group (3%). Two patients had died in open group (6%), no
mortality in lap group. No leakage in either of the groups.
of liver. An umbilical port was used for camera and two Three (9.6%) of lap group were needed to be converted
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remaining ports were placed on each side of camera port in to open surgery due to large perforation and extensive
triangular position. Surgeon stands on left of patient, with adhesions (Figs 1 to 4 and Tables 1 to 3).
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assistant on each side. The gallbladder was retracted
upward and held by assistant. Inflammatory adhesions were DISCUSSION
released and suctioned. The perforation area isolated and There was no difference in age, weight, duration of
tip of the suction tube is used as to measure the size of symptoms and the time to surgery in both groups. Often it
perforation. The next step was irrigation and thorough is mentioned that the age of presenting with peptic ulcer in
suction of intra-abdominal fluid using normal saline. All more so in older age group due to excessive use of NSAIDs
the quadrants were cleaned in clockwise fashion. The and aspirin usage. The results in Table 1 show that 57% of
perforation was closed using the classical omental patch the population was among the 40 to 60 age groups, with
with 2 to 3 stitches of absorbable sutures before tying the mean age of 52 years which correlates with literature. 20,22,23
knot intracorporealy. Pelvic and subhepatic drains were The mean operating time of the laparoscopic patch repair
placed at the end of procedure. The open surgery was was significantly longer than the open procedure (52.4:62.1
conducted by midline incision and followed the same minutes; p = 0.001) which correspond to other studies.
technical guidelines. All the data expressed as median and A disadvantage of the laparoscopic approach is longer
in quartile range unless stated. Comparison between operating time, but this had no impact on the outcome. Three
two groups was made using nonparametrical methods. (9.6%) patients were needed conversion to open surgery
Comparison was done using independent samples t-test, due large perforation (>1 cm) and other 2 patients had dense
p < 0.05 taken as statistically significant. adhesions. In analyzing our results with other studies, we
observed that clinical parameters that are excluded for safe
RESULTS
laparoscopic procedure are shock and symptom duration
There was male preponderance with 80% of patients, and >24 hours. Patients who presented with shock and delayed
57% of the cases in 4, 5 and 6th decade of life the mean age presentation have higher conversion rate and worse post-
is 50 years. The mean duration of surgery in open group is operative course.
56 minutes compared with 62 minutes in lap group which The best parameters to compare the two different
was statistically significant (p = 0.003). The mean number surgical techniques are morbidity and mortality. Peptic ulcer
of antibiotic used in open group was 5 days compared with perforation has high morbidity with problems of wound
4 days in lap group (p = 0.001). The mean usage of infection, sepsis, leakage at repair and pulmonary infections.
analgesics in open group was 7 days as compared with In our study, high morbidity three (9%) and mortality two
5 days 5,17,22 (p = 0.001). The mean duration of hospital stay (6%) was noticed in open group which is consistent with

Fig. 1: Laparoscopic position of trocars Fig. 2: Duodenal ulcer perforation (D1)
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