Keywords
intraoperative endoscopy
pyloric exclusion
damage control surgery
How to Cite
Abstract
Introduction: Posterior perforated duodenal ulcer penetrating the hepatoduodenal ligament is an exceedingly rare and technically demanding surgical emergency. The intimate proximity of the portal vein, proper hepatic artery, and common bile duct often renders standard perforation closure impossible, necessitating alternative strategies.
Case Presentation: We report an 86-year-old man who presented with diffuse bile peritonitis secondary to posterior duodenal perforation penetrating the hepatoduodenal ligament. Conventional intraoperative exposure failed to identify the perforation site. On-table gastroscopy was performed and successfully localized the defect, guiding primary suture closure. Pyloric exclusion with gastrojejunostomy and feeding jejunostomy was performed for diversion and decompression. The postoperative course was complicated by gastrointestinal bleeding requiring angioembolization, wound evisceration, and hemorrhagic stroke. In the best of our knowledge, it is the first described case in the English medical literature.
Conclusion: Intraoperative endoscopy represents a valuable localization tool in posterior duodenal perforation when conventional surgical exposure is inadequate. Primary closure guided by endoscopic tools, may be safely considered in highly selected patients.
Keywords: perforated duodenal ulcer, intraoperative endoscopy, pyloric exclusion, damage control surgery
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