The open procedure for a perforated duodenal ulcer involves oversewing the gap; due to the tendency for dyspeptic symptoms to recur in these patients, oversewing may be combined with a vagotomy.
A midline incision above the umbilicus is the route of entry. The peritoneum is breached and the stomach and pylorus are drawn out. The perforation is usually small and conspicuous. Thick sutures of chromic catgut, e.g. 0/0 are passed through all layers of the duodenal wall. Only 2 or 3 are needed for the majority of perforations. They are left untied while an inferior frond of omentum is grasped with forceps by an assistant. The omentum should be large enough to plug the gap. It is drawn up and the sutures are tied over it without undue tension.
After oversewing the lesion and before wound closure, it is prudent to irrigate the abdominal cavity with several litres of saline.
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