Case Report
Single Incision Laparoscopic Peptic Ulcer Repair with the Use Extracorporeal Mishra Knot: A Case Report
Ross O. Downes*
Department of General Surgery, Doctors Hospital Nassau, USA
*Corresponding author: Ross O. Downes, Department of General Surgery, Doctors Hospital Nassau, Bahamas, USA
Published: 06 Mar, 2017
Cite this article as: Downes RO. Single Incision
Laparoscopic Peptic Ulcer Repair with
the Use Extracorporeal Mishra Knot: A
Case Report. Clin Surg. 2017; 2: 1330.
Abstract
Background: Single-port laparoscopic surgery is increasingly been used in cases of complex and
complicated laparoscopic surgical intervention. We present a case of the cost effective Mishra’s
extracorporeal knotting approach for treatment of a perforated duodenal ulcer (PUD).
Methods: We present a case report of a patient with perforated duodenal ulcer who underwent
single-port laparoscopic repair. She had peritoneal lavage and suture of the perforation using the
Mishra’s knot. This was reinforced with an omental patch repair. After surgery, the patient was
placed on an indefinite course of proton pump inhibitors.
Results: We successfully completed the procedure via SILS (single incision laparoscopic surgery).
We subsequently placed a drain in the right lower quadrant. The operative time was 57 min, and
hospital stay was 5 days. She had minimal analgesic requirements. There was no operation-related
morbidity. Follow-up to 6 months was done.
Conclusion: Single-port laparoscopic repair using the Mishra knot technique is a feasible and
safe Procedure. It is a cost technique for Single incision laparoscopic surgery (SILS) treatment of
perforated duodenal ulcers.
Keywords: Laparoscopy; Single incision; Single port; Peptic ulcer; Patch repair
Introduction
Peptic ulcer disease has a perforated rate of 2-10% with more than 70% of PUD-related deaths
being attributed to perforation [1]. Complex surgical intervention for perforated duodenal ulcers
has seen a revolution and replaced by more minimalist techniques [1]. The efficacy of gastric
antisecretory medication and eradication of Helicobacter pylori have improved [1-3], thus primary
repair of the perforation has become the standard of care. Laparoscopy offers the possibility of
diagnosis as well as treatment with laparoscopic primary repair now becoming the gold standard
due to less postoperative pain, faster recovery times, and shorter hospital stays [4-11].
With advances in laparoscopic instruments and skills, SILS has been developed and adaptable
to many kinds of abdominal surgical procedures [6,8].This approach offers better cosmetic results
and considered scarless, less incisional pain, and the capability to convert to multiport surgery if
required [6-9]. The decreased risk of incisional hernias with SILS remains unsubstantiated. Making
a ‘‘knot’’ when using the SILS technique was more time-consuming and challenging than when
using the conventional multiport laparoscopy. There was limited movement with SILS, which
lengthened the procedure. We report a case SILS peptic ulcer repair.
Case Presentation
A 68-year-old woman with a body mass index of 30.3 kg/m2 was admitted to the emergency room for pain in the upper abdomen since few hours. She presented to the emergency department with a history of abdominal pain of 12 hr duration that was gradual in onset, beginning epigastric then becoming generalized. The pain was associated with nausea and vomiting. She is known to have Addison’s disease and was recently placed on high dose steroids without gastric protection. Initial examination revealed a dehydrated patient with blood pressure of 130/84 and pulse rate of 54-110/min. Her abdomen exhibited generalized peritonitis with increased intensity in epigastrium with guarding and rebound tenderness. Her laboratory results were all normal expect for an elevated White cell count of 17.1. Abdominal X-ray showed presence of sub-phrenic free air in the left upper quadrant and abdominal computed tomography scan confirmed pneumoperitoneum with free liquid in the hepato-renal (Morison’s) pouch and in the pelvic (Douglas’) pouch as well. A clinical diagnosis of perforated peptic ulcer disease was made and an emergency single port laparoscopic repair was advised. After a short period of resuscitation the patient was taken to the operating room. The patient was placed in a supine position with arms placed to the sides. A nasogastric tube was inserted, and prophylactic antibiotics were administered intravenously at the time of the incision. The surgeon was on the patient’s right and the assistant to the left of the patient. After the abdomen was entered, they both stood on the patient’s right with the assistant to the surgeon’s left. A television monitor and the insufflators system Karl Storz HD were placed to the left side of the patient. A 2.0 cm vertical trans-umbilical skin incision was made and directed down into the peritoneum. An S-retractor was introduced into the incision to facilitate the ease of port insertion. A special single incision port (GelPOINT™ port) was placed through the incision. After pneumoperitoneum was established using 15 mmHg of carbon dioxide, a 10/12 mm trocar and 2 x 5-mm trocars were then inserted through the GelPOINT™ in a triangular fashion. The platform was positioned to place the 10/12 mm port at the 7 o’clock with other ports at 12 and 5 o’clock respectively. After port access had been achieved, the operating table was tilted to the right and was placed in the reverse Trendelenberg position at angles of 15 degrees and 25 degrees respectively. We used a standard length 10-mm 30° laparoscope placed in the 7 o’clock position. Exploration of the abdominal cavity showed the presence of free purulent liquid in the hepato-renal (Morison’s) pouch and in the pelvic (Douglas) pouch as well. A perforated 1 cm duodenal ulcer on the anterior surface of the first part of the duodenum, covered in part by fibrin was evidenced. We used standard disposable instruments for the procedure. There was bacteriological sampling of the free liquid and irrigation of the cavity with 4 L of warm saline solution. The duodenum ulcer was closed by 2/0 silk x 2 using Mishra’s knot technique. Omentoplasty was performed as well using 2/0 silk sutures. Mishra knot allowed us to quickly tie the sutures in the absence of the classic laparoscopic working triangulation established inside as in multi-trocar laparoscopy. Due to this patient’s ASA score of 4 we thought it imperative to place a drain. A 5 mm trocar was inserted in the right lower quadrant and a 10F Jackson Pratt drain inserted and snaked along the right paracolic gutter to the Morison’s pouch. The instruments and trocar were removed under vision, and a meticulous closure of the umbilical fascia and loose approximation of the skin performed. Proton pump inhibitors were intravenously injected during the fasting periods and then orally administered after starting a meal. If a patient complained of pain at the operation site, 50 mg of pethidine was injected intravenously. The patients resumed oral intake after passing the first flatus and was discharged when they were able to tolerate an oral diet. A Proton pump inhibitors was prescribed as long as she remained on steroids. The patient was prophylactically treated with triple therapy, including a proton pump inhibitor, amoxicillin, and clarithromycin.
Figure 1
Figure 2
Figure 3
Figure 3
Steps in tying Mishra’s knot: (A) place the short limb of the suture
over the long limb, (B) take the first hinge, (C) take a wind,(D) make a half
knot, (E) make the 2nd wind, (F) again make the 2nd half knot, (G) then
make 3rd wind, (H) and make the 3rd and final half knot and (I) the final
configuration of Mishra’s knot Adapted from Rasaq Akindele.
Discussion
Laparoscopic surgery has become the standard of care for
treatment in a variety of gastrointestinal pathologies. Laparoscopic
surgery illustrated superior outcomes with respect to less
postoperative pain, shorter hospital stays, better comes is, and early
recovery [4-12]. Nathanson et al. [13] in 1990 reported the first
laparoscopic management of a perforated duodenal ulcer. Since then
perforated duodenal ulcers have been managed laparoscopically with
ulcer over-sewing and Graham’s patch. One caveat is ulcers with
diameter greater than 3 cm usually required formal resection [14],
which could also be accomplished laparoscopically in skilled hands.
Single incision laparoscopic surgery or deduced port laparoscopic
surgery offers the benefit of less parietal trauma. This can augment
reduction in the acute stress response, which already is heightened
in the patient with peritonitis. With advances in instrumentation
and surgical experience, SILS has become more commonplace for
complicated abdominal pathology. The list of surgical procedures
been preformed with SILS has steadily grown and has the added
advantages of being virtually scarless, have less incisional pain, with less parietal trauma [15-18]. Another trocar can be easily inserted to
perform multiport surgery [6-9]. Conversion should never be seen
as failure and should be prompt when required. Advances such as
energy devices (LigaSureTM, Harmonic); and dedicated single access
platforms (e.g. GelPoint, Triport, SILS, etc) have eliminated many
of the hidden pitfalls earlier seen with limited resources. Inline
viewing is a concept, which evolved following the development
of natural orifice transluminal endoscopic surgery (NOTES). All
instruments occupied one line of sight. Conventional laparoscopy
advocates triangulation around a central optical instrument and thus
SILS is thought to be contrary to this. Newer port systems (SILSTM,
GelPOINTTM, TriPORTTM) allow a combination of inline viewing and
triangulation to accomplish the surgery. Thus clashing of instruments
was minimized. These factors decreased the complexity and technical
challenges of the operation.
We developed our SILS skills and techniques using as many
standard instruments as possible. From our earlier accounts we were
able to demonstrate that SILS was not more time-consuming than
multiport surgery (19). Traditional laparoscopic skills were easily
adaptable to this application. Thus, it shouldn’t take much time for
surgeons to acclimate themselves to this new technique. Even in the
face of these advances, we found that the degree of triangulation was
still not sufficient enough to comfortably suture. The Mishra’s knot
was chosen as a simple and less time-consuming technique. There
are many variants of the extracorporeal slipknot. These knotting
techniques are variations of turns around the axis or the number
of reversed half hitches. The Mishra’s knot uses 3 half hitches in
the completed knot. Extracorporeal Mishra's Knots can tolerate
better distraction forces than other slipknot variants [20]. The
major advantage in this technique is that any number of additional
knots may be tied extra corporeally and pushed into the abdomen
in a single maneuver. These knots slide down with equal ease, thus
minimizing the risk of traction-induced trauma and of risk of stitches
cutting through [20]. We used #0 silk for our repair. Even if the
surgeon was somewhat lacking in experience with SILS, moderate
laparoscopic experience allows this technique to be performed
without any challenges. Exposure of perforation site may occasional
be inhibited by the liver bed or gallbladder, making the repair process
more difficult. The Mishra’s knot allowed us to use one hand to
elevate the liver/gallbladder to expose the operative field, while we
drove the suture through the tissues and delivered externally. This
technique allowed us to confidently suture inflamed, friableness tissue
in a satisfactory closure. To strengthen the weak point, we extended
the omentum over the perforated site. As a result, this would reduce
leakage at the perforation site or need for conversion to multiport
surgery. We believed this patient required a drain because of her comorbidities.
We placed a 5mm port in the right lower quadrant and
introduced a Jackson Pratt drain, which was then snaked along the
right paracolic gutter. This port was placed in the lower abdominal
crease for optimal cosmesis. We believe placing the drain through the
umbilicus has the risk for incisional hernia formation and increase
wound infection rates, thus it is avoided. Although more costly, we
prefer to use a special single access platform. This avoids the direct
puncture technique used by some authors that we believe directly
increases port site hernia rates [21].
Conclusion
SILS for the treatment of a perforated duodenal ulcer using the Mishra’s knot technique can be performed successfully without technical challenges and does not require any specialized instruments.
References
- Bertleff ME, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010; 27: 161-169.
- Chung SC, Li AK. Helicobacter pylori and peptic ulcer surgery. Br J Surg. 1997; 84: 1489–1490.
- Hopkins RJ, Girardi LS, Turney EA. Relationship between Helicobacter pylori eradication and reduced duodenal and gastriculcer recurrence: a review. Gastroenterology. 1996; 110: 1244-1252.
- Kathouda N, Mouiel J. Laparoscopic treatment of peptic ulcer disease. In: Hunter JG, Sackie JM, eds. Minimally invasive surgery. McGraw-Hill. 1998; 123-130.
- Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcers. Br J Surg. 2005; 92: 1195-1207.
- Bertleff ME, Halm JA, Bemelman WA, van der Ham AC, van der Harst E, Oei HI, et al. Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA Trial. World J Surg. 2009; 33: 1368-1373.
- Siu WT, Leong HT, Law BB, Chau CH, Li AN, Fung KH. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg. 2002; 235; 313-319.
- Lau WY, Leung KL, Kwong KH, Davey IC, Robertson C, Dawson JJ, et al. A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique. Ann Surg. 1996; 224: 131-138.
- Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg. 2005; 92: 1195-1207.
- Lau H. Laparoscopic repair of perforated peptic ulcer: a meta-analysis. Surg Endosc. 2004; 18: 1013-1021.
- Bhogal RH, Athwal R, Durkin D, Deakin M, Cheruvu CV. Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg. 2008; 32: 2371-2374.
- Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, Stryker SJ, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004; 350: 2050-2059.
- Nathanson LK, Easter DW, Cushieri A. Laparoscopic repair peritoneal toilet of perforated duodenal ulcer. Surg Endosc. 1990; 4: 232-233.
- Montalvo-Javé EE, Corres-Sillas O, Athié-Gutiérrez C. Factors associated with postoperative complications and mortality in perforated peptic ulcer. Cir Cir. 2011; 79: 141-148.
- Merchant AM, Cook MW, White BC, Davis SS, Sweeney JF, Lin E. Transumbilical gelport access technique for performing single incision laparoscopic surgery (SILS). J Gastrointest Surg. 2009; 13:159-162.
- Hong TH, You YK, Lee KH. Transumbilical single-port laparoscopic cholecystectomy: scarless cholecystectomy. Surg Endosc. 2009; 23: 1393-1397.
- Pappalepore N, Tursini S, Marino N, Lisi G, Lelli Chiesa P. Transumbilical laparoscopy-assisted appendectomy (TULAA): a safe and useful alternative for uncomplicated appendicitis. Eur J Pediatr Surg. 2002; 12: 383-386.
- Castellucci SA, Curcillo PG, Ginsberg PC, Saba SC, Jaffe JS, Harmon JD. Single port access adrenalectomy. J Endourol. 2008; 22: 1573–1576.
- Downes RO, McFarlane M, Diggiss C, Iferenta J. Single incision cholecystectomy using a clipless technique with LigaSure in a resource limited environment: The Bahamas experience. Int J Surg Case Rep. 2015; 11: 104-109.
- Akindele RA, Fasanu AO, Mondal SC, Komolafe JO, Mishra RK. Comparing Extracorporeal Knots in Laparoscopy using Knot and Loop Securities. World J Lap Surg. 2014; 7: 28-32.
- Dapri G, El Mourad H, Himpens J, Evola G, Marsili L, Cadière G. Transumbilical single-access laparoscopic perforated gastric ulcer repair. Surg Innov. 2012; 19: 130-133.