الفهرس 
ANATOMY AND LAPAROSCOPIC ANATOMY OF DUODENUMOnly 14 pages are availabe for public view
 |  | from | 114 |  |  |
| | | from | 114 | | |
Abstract
Perforated peptic ulcer (PPU) is the most common indication for emergency gastric operation. Perforation occurs in about 2–10% of peptic ulcers and of these about 60% are duodenal. The origins of PPU seem to be multifactorial, but most are associated with nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (HP) infection. The vast majority of PPU patients require emergency operation.
Prompt diagnosis of gastroduodenal perforation requires a high index of suspicion based on history and clinical examination. Patients with gastroduodenal perforation usually present with abdominal pain and peritoneal irritation from leakage of acidic gastric contents. At physical examination pulse might be quickened, but seldom goes beyond 90 beats per minute. About 5-10% of patients experience shock with a mean arterial pressure of less than 80 mmHg . Hypotension is a late finding as is a high fever.
Imaging choices for diagnosing bowel perforations include plain films and computed tomography. An upright chest x-ray is an excellent first choice. A positive upright chest x-ray (free air beneath the diaphragm) can acutely make the diagnosis. Laboratory studies are not useful in the acute setting as they tend to be nonspecific, but leukocytosis, metabolic acidosis, and elevated serum amylase may be associated with perforation.
Perforated peptic ulcer can be treated by using a wide range of options, which varies from conservative non-operative treatment to immediate definitive ulcer surgery. Some patients with perforated ulcer can be managed successfully by non-operative means . However, in many cases the uncertainty of the exact underlying pathology and diagnosis can deter from this line of management.
Acid reduction surgery, is now being replaced by simpler procedures, such as primary closure of the perforation, owing to better understanding of the pathophysiology of peptic ulcer diseases and the improvement in anti-ulcer medications Simple closure remains an attractive option for perforated duodenal ulcer in most centres and hence the laparoscope is gradually gaining popularity to treat perforated duodenal ulcer .
Nathanson et al. and Mouret et al. reported laparoscopic treatments of perforated peptic ulcer in 1990 for the first time. Following these reports, perforated peptic ulcer treatment by laparoscopy has gained popularity. There have been several reports of successful laparoscopic repairs of perforated peptic ulcers, because laparoscopy provides a better vision of the peritoneal cavity and avoids an unnecessary laparotomy, allowing for the repair of the perforation and adequate peritoneal lavage without a large upper-abdominal incision. Furthermore, the procedure has been reported to have less postoperative pain, the opportunity for early mobilization, and a reduction of postoperative complications.
Despite the rapid increase in laparoscopic experience, controversies of the laparoscopic treatment of perforated peptic ulcer continue because of some concerns about a longer operation time, equivocal postoperative effectiveness, leakage, and high rate of reoperation. These disadvantages of laparoscopic treatment can likely be attributed to the facts that the surgeons have less experience, laparoscopic repair with an omental patch and irrigation of the peritoneal cavity are difficult, and take a long time .
But with efforts to develop new instruments and new trends to avoid drawbacks of laparoscope in management of perforated duodenal ulcer laparoscope is now being more safe and more reliable.