a) Indications for suturing a perforated ulcer : – Absolute indications : confirmed perforated ulcer. – Alternative operations : radical treatment of peptic ulcer disease by resection of the stomach, especially with stomach ulcers. Laparoscopic surgery. 
 
 

b) Preoperative preparation : – Preoperative examinations: plain radiography of the abdominal organs, endoscopy is possible. – Patient preparation: nasogastric tube, fluid and electrolyte transfusion for peritonitis, antibiotic therapy. 

c) Specific risks, informed consent of the patient : – The need for concomitant treatment of peptic ulcer disease (otherwise the risk of recurrence may increase up to 60%) – Malignant process, combined with a stomach ulcer in 8% of cases – Inconsistency of sutures – Damage to the bile duct – Intra-abdominal abscess – Violation of evacuation from the stomach 

d) Pain relief . General anesthesia (intubation). 

e) Position of the patient . Lying on your back. 

f) Access when suturing a perforated ulcer . Upper median laparotomy. 

g) Stages of suturing a perforated ulcer : – Excision of an ulcer – Suturing of an ulcer – Peritonization with an omentum – Mobilization of the duodenum (Kocher’s maneuver) 

h) Anatomical features, serious risks, surgical techniques : – The location of the gatekeeper corresponds to the border between the stomach and the duodenum, is defined as a palpable muscular ridge, the transverse vein is also visible here. – Most often, perforation occurs in the anterior wall of the postpyloric part of the duodenum. – With insufficient access to the duodenum, the Kocher maneuver can be used. – Warning: remember that in 8% of cases, perforated gastric ulcer is caused by a malignant tumor: take a biopsy and, if possible, send the material for histological examination. – If during laparotomy it is not possible to identify an ulcerative defect, examine the posterior wall of the stomach. 




 

i) Measures for specific complications . For extensive (amputated) ulcers, distal gastrectomy with Billroth I reconstruction is usually required. 

j ) Postoperative care after suturing of a perforated ulcer : – Medical care: remove the nasogastric tube after 2-3 days if there is no significant reflux of stomach contents. Give antibiotics for 5 days, if possible, according to culture results. Prescribe an H2 receptor antagonist. Perform endoscopic control after 4-6 weeks. – Resumption of feeding: small sips of liquid after removal of the nasogastric tube, then feeding with liquid food; solid food is allowed after the first stool. – Bowel function: enemas from the 3rd day if there is no independent stool. – Activation: Immediately. – Physiotherapy: breathing exercises. – Period of incapacity for work: 2-4 weeks. 

k) Operative technique of suturing a perforated ulcer : – Excision of an ulcer – Suturing of an ulcer – Peritonization with an omentum – Mobilization of the duodenum (Kocher’s maneuver) 

1. Excision of the ulcer . Perforated duodenal ulcers and small prepyloric ulcers without signs of malignancy can be sutured without excision. Stomach ulcers or ulcers suspected of malignancy must be completely excised. If in doubt, a wedge excision may be performed. 

Excision is necessary to establish a pathological diagnosis, as well as to prepare for pyloroplasty with intrapyloric localization. Excision with a scalpel or diathermy is performed, and the possibility of suturing should be taken into account. For intrapyloric ulcers, partial pyloroplasty, including longitudinal excision and transverse suturing, should be performed.

2. Closure of the ulcer . The suture of the ulcer is performed with deep separate sutures (2-0 PGA) between the two holding sutures. The distance between the seams and the indentation from the edges of the defect should be 0.6-0.8 cm. Usually three or four separate seams are sufficient. 

3. Peritonization with an omentum . If the tissue trapped in the sutures does not provide them with sufficient support, and if the sutures are under tension in fragile tissue, it is recommended to cover the suture line with a strand of omentum, which is fixed to the anterior wall of the stomach with separate sutures (2-0 PGA). 

4. Mobilization of the duodenum ( Kocher’s maneuver ). To relieve tension in cases of large defects of the anterior wall and with significant tension in the sutures, it is recommended to mobilize the duodenum according to Kocher. If the perforated ulcer extends over more than half of the intestinal circumference (that is, in the case of an “amputating ulcer”), then Billroth I gastroduodenostomy is recommended after resection of the antrum and the pylorus.