Laligen Awale, Saroj Rajbanshi, Rohit Prasad Yadav, Bal Krishna Bhattarai, Shailesh Adhikary and Chandra Shekhar Agrawal
Background: Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated duodenal ulcer in many institutions. The literature established that laparoscopic repair of perforation when compared to open repair, is associated to lower wound dehiscence, less analgesic use, less pain and hospital stays. The drawbacks are length of operative time and the laparoscopic surgeon's experience in intra corporeal suturing and knotting. Methods: Over a one year period 83 patients presenting with perforated duodenal ulcer were randomly assigned to undergo either an open or a laparoscopic omental patch repair. They were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Those with clinically sealedoff perforations without signs of peritonitis or sepsis were treated without surgery. The endpoint was operative time, postoperative pain score, post-operative analgesic requirement, and length of postoperative hospital stay, morbidity, mortality and the date of return to normal daily activities. Results: Out of a total of 95 cases with diagnosis of duodenal perforations, 12 were excluded and 83 patients were analyzed. Both the groups were comparable in terms of age, gender, duration of symptoms, history of acid peptic disease, NSAIDs use, presence of comorbid conditions and size of perforation. Most of them presented after 24 hrs of onset of pain with the mean duration of 54.58 ± 32.4 hrs. There was one conversion in laparoscopic group due to intolerance to pneumoperitoneum. The duration of surgery was not significantly different but was high in the first five laparoscopic repairs (mean 91 mins as compared with 65 mins for the last 5 laparoscopic repairs). Those in laparoscopic group had significantly (p<0.001) less postoperative pain, analgesic requirement, time to return to normal diet, full ambulation and hospital stay. Morbidity was significantly high in open group (36.29 % vs 13.88 % in laparoscopic group; p 0.01). Open group had significantly high surgical site infection (19.14 vs 0%; p 0.005) and chest infection (29.78 vs 11.11%; p 0.04). One case in each group had mortality. Conclusion: Laparoscopic repair is safe and is a reliable procedure even in delayed presentation. It has significantly less postoperative pain, less need for analgesics, shorter hospital stay, early return to normal diet and work, and less complications without any difference in mortality.