A 50-year-old woman with known duodenal ulcer presents with sudden onset severe epigastric pain that became generalized. Erect chest X-ray shows free air under the diaphragm. After initial resuscitation, surgery reveals a 1 cm perforation on the anterior wall of the first part of the duodenum with peritoneal soiling. What is the most appropriate surgical management?

• A Highly selective vagotomy (HSV) with repair of the perforation
• B Truncal vagotomy with pyloroplasty incorporating the perforation
• C Billroth II partial gastrectomy as definitive acid-reduction surgery
• D Graham patch (omental patch repair) with peritoneal lavage and H. pylori eradication postoperatively ✓

Explanation

Graham patch repair (approximating omentum over the perforation with interrupted sutures) is the operation of choice for perforated duodenal ulcer in the modern era. It is quick, reliable, and avoids complex reconstruction. With effective H. pylori eradication and PPI therapy postoperatively (success in >90%), recurrence rates are very low, making definitive acid-reducing procedures (vagotomy, Billroth operations) unnecessary and associated with higher morbidity. Laparoscopic Graham patch repair has equivalent outcomes to open repair in experienced hands.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.