Graham Patch Repair (Perforated Ulcer)
What the Examiner Expects
Emergency repair of a perforated peptic ulcer using a pedicled omental (Graham) patch sutured over the perforation with interrupted silk sutures. The examiner expects you to diagnose perforation clinically (acute epigastric pain, peritonitis, free air on upright chest X-ray or CT), resuscitate the patient (fluids, IV PPI, NG tube, antibiotics), and proceed to operation without delay. The patch is created by placing three sutures across the perforation, laying a tongue of omentum over the defect, and tying the sutures to secure it. The abdomen is copiously irrigated. Gastric ulcer perforations MUST be biopsied to rule out gastric cancer.
Key Examiner Focus Points
- Omental (Graham) patch over a perforated duodenal ulcer
- Perform thorough peritoneal lavage (all four quadrants)
- Biopsy the ulcer edges for gastric perforations to rule out malignancy
- Postop: PPI therapy, H. pylori testing and eradication
- Definitive acid-reducing surgery rarely needed in the PPI era
Common Curveballs
The perforation is a gastric ulcer, not duodenal
You MUST biopsy the ulcer edges. Gastric ulcers can harbor malignancy (unlike duodenal ulcers). If biopsy returns cancer, the patient will need definitive oncologic resection (gastrectomy) after recovery.
The perforation is very large (> 2 cm) and the omental patch does not provide adequate coverage
Options include a pedicled omental plug (Cellan-Jones), resection of the ulcer with primary closure if the tissue is healthy, or distal gastrectomy if the ulcer is gastric. For a giant duodenal ulcer, consider controlled tube duodenostomy for damage control.
Patient is found to be H. pylori positive postoperatively
Triple therapy eradication (PPI + amoxicillin + clarithromycin for 14 days). Confirm eradication with urea breath test or stool antigen 4 weeks after completing therapy. This dramatically reduces ulcer recurrence.
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