COMBINED LAPAROSCOPIC AND ENDOSCOPIC TREATMENT OF PERFORATED GASTRODUODENAL ULCER USING THE LIGAMENTUM-TERES-HEPATIS (LTH)

We propose a novel technique for laparoscopic treatment of perforated gastroduodenal ulcers. The principle of this procedure involves the cl osure of the perforated ulcer using the ligamentum teres hepatis (LTH) . The LTH is cut near its hepatic insertion. The umbilical extremity o f LTH is grasped with a Dormia noose passed through the ulcerated perf oration via a gastroscope. Using the noose, the LTH is pulled through the ulcerated perforation until its volume fits and completely closes the perforation. This laparoscopic technique was performed in 15 patie nts (12 M, 3 F) with anterior perforated duodenal ulcer revealed withi n the previous 6 h. The procedure could not be performed in three case s: diameter of the perforation exceeding 1.5 cm (n = 1), general purul ent peritonitis (n = 2). In the other 12 cases, closure of the ulcerat ed perforation with the LTH was realized without technical difficulty. The postoperative course was uncomplicated. The posttreatment comfort was excellent; the mean period of hospitalization was 10 days (range, 8-14 days). An endoscopic examination carried out following 5 weeks o f anti-H-2 treatment showed that cicatrization of the ulcer was good a nd that no pyloric stenosis remained. These initial results suggest th at laparoscopic treatment of perforated gastroduodenal ulcer using the LTH is a simple procedure which can be performed with general assuran ce of success in patients whose perforated ulcers have occurred quite recently. As the laparoscopic procedure is less aggressive than a lapa rotomy, it enhances the postoperative comfort of patients and prevents the risk of parietal complications. Compared to laparoscopic endosutu re this procedure is simple, effective, easier, and particularly adapt ed to large ulcerated perforation or when an ulcer's edges are tough o r friable, tending to tear when knots are tied.