Graham Patch Repair (Perforated Ulcer)

The Graham patch repair — also called an omental patch or Graham-Steele patch — is the workhorse operation for perforated peptic ulcer disease, most commonly a perforated duodenal ulcer on the anterior wall of the first portion of the duodenum. The procedure is appropriate for any patient with a free perforation who is hemodynamically reasonable and whose ulcer is small (typically <2 cm), with healthy surrounding tissue.

Indications include free intraperitoneal air on imaging with peritonitis, an intraoperative finding of a perforated anterior duodenal or pyloric ulcer, and selected gastric ulcer perforations where definitive resection is not safe. In the era of effective acid suppression with proton pump inhibitors and Helicobacter pylori eradication, the operation has shifted from a definitive acid-reducing procedure (vagotomy, antrectomy) to a damage-control closure with the ulcer disease then managed medically.

Contraindications and cautions include very large perforations (>2–3 cm), shock requiring damage control, malignant ulcers (especially gastric — biopsy at operation), and chronic ulcers with severe fibrosis or stricture where pyloric exclusion or resection may be required instead.

Workup begins with the history (sudden epigastric pain, often a known history of ulcer or NSAID use), examination (peritonitis, often with rigid abdomen), and an upright chest X-ray or CT showing free air. CT with IV contrast is now standard and reveals not only pneumoperitoneum but the site of perforation and degree of contamination. Laboratory studies including type and screen, CBC, BMP, and lactate are standard.

Resuscitation begins immediately: large-bore IV access, crystalloid, broad-spectrum antibiotics (cover gram-negative and anaerobic organisms — typically piperacillin-tazobactam or ceftriaxone with metronidazole), nasogastric decompression, IV proton pump inhibitor, and a urinary catheter. Patients should not be allowed to deteriorate awaiting imaging if peritonitis is clear on examination — proceed to operation.

Upper midline laparotomy is standard for an unstable patient or one with extensive contamination. The peritoneum is entered with caution given the typical presence of bilious fluid. The four quadrants are evacuated of fluid and the upper abdomen examined. The perforation is most commonly on the anterior wall of the first part of the duodenum at the pylorus.

Kocher maneuver is performed if needed to expose a posterior perforation or to obtain better exposure. The perforation is identified and any fibrinous debris is gently cleared. Three to four interrupted 3-0 absorbable sutures (typically Vicryl) are placed across the perforation in a longitudinal axis without tying. A well-vascularized pedicle of omentum is brought up to lie over the perforation, and the previously placed sutures are then tied gently over the omentum — gently is the operative word, because tying them tightly will strangulate the omentum and the repair will fail.

After the patch is secured, the abdomen is irrigated thoroughly with warm saline until the effluent is clear. A drain near the repair is optional and surgeon-dependent; for clean repairs with limited contamination it is often omitted, while for delayed presentations or significant peritonitis a closed-suction drain near the duodenum is reasonable. The fascia is closed in standard fashion.

Laparoscopic Graham patch is increasingly the default for stable patients with limited contamination. Standard four-port placement (camera at umbilicus, working ports in upper abdomen) is used. The principles are identical to the open operation: identify the perforation, place absorbable interrupted sutures longitudinally, mobilize a tongue of omentum, and tie the sutures gently over the omental pedicle.

Conversion to open is appropriate for hemodynamic instability, inability to identify the perforation, perforations >2 cm, or any concern for malignancy that requires more definitive resection or biopsy.

The nasogastric tube is typically left in place for 24–48 hours. IV proton pump inhibitor is continued, and the patient is started on H. pylori eradication therapy empirically — outcomes are markedly worse without it given that >70% of these ulcers are H. pylori related. Diet is advanced as the patient tolerates oral intake and bowel function returns. Most patients are eating within 3–5 days and discharged within a week.

Outpatient endoscopy is recommended at 6–8 weeks for any patient with a gastric ulcer to rule out malignancy (mandatory) and to confirm healing. Duodenal ulcers do not require routine biopsy unless atypical features were present.

The feared complication is leak from the repair, presenting with persistent or worsening peritonitis, fever, leukocytosis, and persistent ileus. Reoperation with reinforcement of the patch — or, for very large defects, pyloric exclusion with gastrojejunostomy and tube drainage — is required. Mortality is non-trivial in elderly or septic patients.

Other complications include intra-abdominal abscess (drainable percutaneously in most cases), gastric outlet obstruction from edema or stricture (usually self-limiting; persistent obstruction may require pyloroplasty or resection), recurrent ulcer (almost always due to inadequate H. pylori treatment or ongoing NSAID use), and standard postoperative risks of bleeding, wound infection, and venous thromboembolism.

On the oral boards, examiners frequently probe how you would handle a perforation that is too large to be closed primarily, a posterior ulcer with active bleeding requiring suture ligation of the gastroduodenal artery, and the patient who deteriorates 72 hours postoperatively — all of which test whether you can pivot to pyloric exclusion or resection rather than dogmatically performing a Graham patch on a defect that cannot hold one.