A duodenal perforation is a surgical emergency because leakage of gastric and duodenal contents into the peritoneal cavity leads to chemical peritonitis, followed by bacterial contamination. Delaying treatment increases the risk of sepsis, multiple organ failure, and death.

While open surgery has been the standard for decades, laparoscopic repair is increasingly adopted because it minimizes surgical trauma while offering the same effectiveness in repair.

Laparoscopic Repair: Step-by-Step Technique
Patient Preparation and Anesthesia

The procedure is performed under general anesthesia. Patients are stabilized with intravenous fluids, nasogastric tube decompression, and antibiotics before surgery.

Port Placement

A 10 mm camera port is inserted at or near the umbilicus.

Two or three additional 5 mm working ports are placed in the upper quadrants for instrument access.
This setup provides triangulation for working around the duodenum.

Exploration of the Abdominal Cavity

On entering the peritoneal cavity, purulent or bilious fluid is usually encountered. Thorough suctioning and irrigation are performed to clear contamination. The site of perforation is then identified, typically located on the anterior wall of the first part of the duodenum.

Closure of the Perforation

The defect is closed using laparoscopic suturing techniques:

Interrupted sutures with absorbable material are placed across the perforation.

A Graham’s omental patch repair is often performed, where a piece of omentum is sutured over the perforation to reinforce the closure.

Peritoneal Toilet (Irrigation)

The entire abdominal cavity is irrigated with warm saline to dilute contamination and reduce the risk of infection or abscess formation.

Drain Placement

One or more drains may be placed near the repair site to monitor for leakage and facilitate postoperative drainage.

Closure

The ports are removed, and incisions are closed with sutures.

Advantages of Laparoscopic Repair

Minimally invasive: Small incisions with less pain and scarring

Better visualization: Magnified laparoscopic view aids precise closure

Reduced morbidity: Lower risk of wound infection compared to open surgery

Shorter hospital stay: Early mobilization and faster recovery

Cosmetic benefit: Tiny scars instead of large midline incisions

Limitations and Challenges

While laparoscopic repair offers many advantages, it is not always feasible. Limitations include:

Hemodynamically unstable patients who cannot tolerate pneumoperitoneum

Large perforations (>2 cm), which may require open repair or resection

Gross contamination with widespread peritonitis in some cases

Lack of laparoscopic expertise in emergency settings

Postoperative Care

Nasogastric decompression is continued for 24–48 hours

Intravenous antibiotics are administered to control infection

Proton pump inhibitors are given to reduce gastric acid secretion

Gradual return to oral feeding is initiated once bowel sounds return and leakage is ruled out

H. pylori eradication therapy is prescribed to prevent recurrence of ulceration

Outcomes and Success Rates

Studies have shown that laparoscopic repair of duodenal perforation has outcomes comparable to open surgery in terms of mortality and recurrence, but with distinct advantages of reduced postoperative pain, shorter hospital stays, and faster return to normal activity. In experienced hands, success rates exceed 90–95% for small to moderate-sized perforations.

Conclusion

Laparoscopic repair of duodenal perforation is a safe and effective surgical option that combines the principles of minimally invasive surgery with time-tested repair techniques like omental patching. It reduces surgical trauma, enhances recovery, and provides excellent outcomes in appropriately selected patients.

Although not suitable for every case, especially in unstable patients or those with massive perforations, laparoscopic repair is increasingly becoming the gold standard in specialized centers. Prompt diagnosis, timely surgical intervention, and careful postoperative care remain the keys to saving lives in this critical condition.