𝙇𝙖𝙥𝙖𝙧𝙤𝙨𝙘𝙤𝙥𝙞𝙘 𝙍𝙚𝙥𝙖𝙞𝙧 𝙤𝙛 𝙋𝙚𝙧𝙛𝙤𝙧𝙖𝙩𝙚𝙙 𝘿𝙪𝙤𝙙𝙚𝙣𝙖𝙡 𝙐𝙡𝙘𝙚𝙧 𝙬𝙞𝙩𝙝 𝙋𝙧𝙞𝙢𝙖𝙧𝙮 𝘾𝙡𝙤𝙨𝙪𝙧𝙚 & 𝙊𝙢𝙚𝙣𝙩𝙖𝙡 𝙋𝙖𝙩𝙘𝙝 Presentation: 🔵1 day history of sever upper abdominal pain 🔵Smoker and excess ETOH 🔵CXR ➡️Pneumoperitoneum 🔵CT ➡️Perforated duodenal ulcer 🔵Time from ED➡️theatre 3 hours Operative Approach: 🔴Thorough peritoneal lavage ➡️Lap washout allows for thorough removal of intra-abdominal... contamination ➡️Modern OR table tilting can provide better view then open in select cases 🔴If fragile tissue then omental patch only ➡️This approach is a modified version of Grahams patch repair ➡️When suitable, we prefer primary closure with patch after 🔴For large perforations kocherisation of duodenum may be indicated 🔴Convert to open if: ➡️Large ulcer ➡️Associated ulcer bleed 🔴H. Pylori eradication therapy on discharge 🔴OGD in 6-8 weeks to confirm healing Key Points: 🟢Timely intervention critical 🟢Lap approach in EGS should be encouraged 🟢Compared to open, advantages of lap are: ➡️Reduced pain ➡️Reduced LOS ➡️Reduced incisional hernia rate 🟢Trainees should be exposed to lap EGS early to develop skills and confidence #FOAMed #GITwitter #MedEd #SurgEd #EGS #SoMe4Surgeryshow more

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @altaf_awan12 @ib9994 @javlatif There is remarkably little contamination... by chance was it sealed already and it took some dissection to reveal the perforation? 😉 (legitimate question though… when we see this, should we dissect in there or leave it alone and just leave a drain?)

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Great video! How was the evolution of the patient? Did it leak?

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Great video! What was your port placement? Thanks .

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Thanks for your comment. We used: ➡️10mm suprapumbilical camera port ➡️10mm and 5mm LUQ ports ➡️5mm RUQ port The two 5mm ports were used for placement of drains.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Great video. Which suture do you use? When do you use slip knot here? I notice you used it only few times. Thanks.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Suture is 2/0 vicryl. Our preference is to use slip knot for all stitches in cases of perf peptic ulcers for both primary closure and omental patch.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Nice. For a hole this size, I suspect standard graham patch is sufficient but it I guess it depends on the quality of the tissue.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif ✅ Pneumoperitoneum auf CXR, Perforation CT-klar. 🔴 Duodenalulkus-Perforation (Klinik + Bildgebung). 🧠 Säureexzess + Mukosaläsion → freie Perforation. ⚠️ Bei großer Läsion ggf. Kocherisation der Duodenalschlinge.

@BehindTheKnife @Innov_Medicine @SAGES_Updates @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif The omental patch technique, described by Professor Graham in the 1950s, is designed to achieve a tension-free repair by covering the perforation with omentum and securing it with sutures.

@BehindTheKnife @Innov_Medicine @SAGES_Updates @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif A clean and clear video !! We prefer a True Graham Patch or a Cellan Jone’s repair (whichever term u prefer using).. what’s your reason for doing a Modified Graham patch repair ? We are worried about cheese wiring of sutures through the inflammed indurated ulcer edge..

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif There is no need for omental patch if you trust your suturing 😉

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Great They could just get rid of the extra fat while they're at it too👌🏼

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Buen parche.. Así se hace.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Eu costumo debridar a borda antes de suturar. Deixar cruento.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif I’d be curious how you’re selecting primary closure alone versus adding an omental patch in these laparoscopic cases—and whether you track leak rates by ulcer size. Sci-Quest can help map the literature:

@solar2029 @Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif Good I loved this surgery. So satisfying.

@Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @rbarbosa91 @altaf_awan12 @ib9994 @javlatif 私は穿孔部閉鎖にPROLENEを使用しています。VICRYLでも問題ないのですか？

@rbarbosa91 @Innov_Medicine @SAGES_Updates @BehindTheKnife @BrownJHM @imedverse @roux_group @altaf_awan12 @ib9994 @javlatif I use v-lok