Operative tactics at a perforated ulcer. Operational tactics for ulcerative perforation
Surgery for a perforated ulcer can be performed both under local anesthesia and under general anesthesia. We use anesthesia, because we believe that only when the patient is in deep sleep can the necessary examination be carried out and the spilled contents removed from the abdominal cavity. In the successful outcome of the operation, the treatment of the abdominal cavity, i.e., the removal of the contents that have poured out of the stomach, is of great importance. When opening the abdominal cavity, some of the contents are poured out, but most of it remains, and it must be removed with a suction device or tampons. In this case, special attention should be paid to the subhepatic and right iliac regions, where it accumulates most of all. The contents of the stomach should also be removed by suction through the perforation or insertion of a gastric tube through the mouth. Any washing of the abdominal cavity, and even more so, bowel eventration is contraindicated. After removing the contents, antibiotics can be introduced into the abdominal cavity, and in addition they are administered before sewing it up. After finishing the treatment of the abdominal cavity, the presence of a perforated ulcer, its localization, and nature are specified. Be sure to check for other perforated or non- perforated ulcers. To do this, you need to examine the back wall of the stomach. Combined statistics show that in 65% of cases there are perforated stomach ulcers and in 36% of duodenal ulcers. It should be remembered that perforation of the ulcer may be in the presence of other acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, acute pancreatitis, etc.). In our clinic, a patient was operated on, who had a volvulus of the small intestine and the simultaneous perforation of two stomach ulcers. The surgeon made a U-turn and sutured the perforated hole of the anterior wall of the stomach, and the perforated ulcer of the posterior wall was examined, which caused the death. It remains a debatable question which operation to apply for a perforated ulcer. At present, both supporters of gastrectomy and suturing have been identified among Soviet surgeons. The majority believes that both resection and suturing can and should be used. Which of them to apply in this or that case is the main task of the surgeon. When choosing a method of operation, one should take into account: the age of the patient, his general condition, the duration of perforation of the ulcer, its localization and nature, changes that have occurred in the abdominal cavity, as well as the conditions in which the operation is performed. The choice of the method of operation is of great importance, because the outcome of treatment also depends on it. Indications for resection of the stomach may be: the presence of two or more perforated ulcers, a pronounced inflammatory process around the perforated ulcer, or proliferation of connective tissue (calle ulcer). Resection is also indicated in cases where suturing will narrow the pyloric or duodenal lumen. Of course, resection is indicated in patients with a good general condition, in the absence of severe peritonitis. In other cases, suturing of the perforated hole using plasty with an omentum is indicated. When suturing, the edges of the ulcer should not be screwed into the lumen of the stomach or duodenum, they should be brought together with catgut sutures, after which peritonization is performed with interrupted silk sutures, and a strip of omentum on the leg is sewn over them.