Preoperative preparation and surgical approach
Surgical intervention is performed in the operating room. The patient is placed in the supine position. Modern endotracheal anesthesia is used as the method of anesthesia. The primary surgical approach for abdominal cavity exploration and perforation repair is upper midline laparotomy.
Anatomical localization of pathology
In the vast majority of clinical cases, the perforation site is localized in a strictly defined zone. Most often, the defect is found in the pyloric region on the anterior wall of the stomach. This exact area is examined first after opening the abdominal cavity.
Defect closure technique
The main stage of the operation consists in reliable closure of the perforation:
- The defect is closed using interrupted seromuscular sutures.
- Critically important: The orientation of the threads must be strictly transverse relative to the longitudinal axis of the stomach. This is necessary to prevent narrowing of its lumen.
- A second row of seromuscular sutures is placed over the first row in a similar transverse direction.
- Additionally, peritonealization with the greater omentum may be performed to reinforce the surgical site.
Lavage and completion of the procedure
After sealing the gastric wall, mandatory treatment of the operative field is performed. The abdominal cavity is thoroughly cleansed of pathological effusion and gastric contents using a suction device and dry sponges. The operation is completed by standard layered tight closure of the abdominal wall wound.
Briefly: answers to topical questions
Which layers of the anterior abdominal wall are sequentially dissected during an upper midline laparotomy?
In the sources, upper midline laparotomy is indicated as the approach. The incision and closure of the anterior abdominal wall are performed in layers. Before opening, the peritoneum is bluntly separated from the transversalis fascia and preperitoneal tissue, then opened under visual control. The complete layered tissue composition in upper midline laparotomy is not specified in the sources.
What eponymic methods of omental peritonealization of the suture line in perforated ulcers exist?
The following methods of covering the suture line with the omentum are described: closure with interrupted single-row sutures with additional suturing of a greater omentum flap to the suture line ("in the form of a cape"); Oppel–Polikarpov operation — closure with interrupted single-row sutures with tamponade of the perforation site using a pedunculated omental flap.
What are the surgical indications for simple closure of a perforated gastric ulcer instead of resection?
Simple closure is the method of choice for a perforated ulcer less than 2 cm in size.
In which cases is it necessary to excise the edges of a perforated ulcer before its closure?
Excision is performed for a perforated callosal gastric ulcer larger than 2 cm — the ulcer is excised along with the infiltration zone, after which the defect is closed with interrupted sutures without narrowing the gastric lumen.
What antiseptic solutions are used for adequate peritoneal lavage in peritonitis?
Solutions approved for intravenous administration are used for peritoneal lavage: hydroxymethylquinoxalinedioxide, sodium hypochlorite, and furazidin. An aqueous chlorhexidine solution 1:1000 is also used for purulent peritonitis.
Place sutures TRANSVERSELY — protect the gastric lumen!
Class and exam questions
What surgical approach is used for a perforated ulcer?
Upper midline laparotomy with the patient in the supine position is used to access the affected area.
Why are sutures placed on the stomach in a transverse direction?
The transverse orientation of sutures relative to the gastric axis is necessary to prevent narrowing of its lumen.
How is the suture line on the stomach reinforced?
In addition to placing two rows of seromuscular sutures, peritonealization with the greater omentum may be performed.
What else to study on this topic
- Detailed preoperative patient preparation
- Anatomical boundaries of the pyloric region of the stomach
- Step-by-step technique of greater omentum peritonealization
- Rules for abdominal cavity exploration in peritonitis
- Features of layered tight closure of the abdominal wall
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