Laparoscopy or Open Surgery: Which Method Is Better for Perforated Ulcer?

Introduction: Choosing a Surgical Approach

In modern surgery, there is a constant search for the most effective and safe treatment methods. One of the key questions is the choice between traditional open (laparotomy) surgery and minimally invasive laparoscopy. This choice is particularly relevant in emergency conditions, such as perforated peptic ulcer (PPU) — a serious complication requiring immediate surgical intervention [2, 3]. Traditionally, open surgery was used for PPU, but with the development of technology, the laparoscopic approach is becoming increasingly popular [3]. However, despite numerous studies, the question of the superiority of one method over the other remains a subject of debate [3].

What Are Laparoscopy and Open Surgery?

• Open (Laparotomy) Surgery: This is a traditional surgical method in which the surgeon makes one large incision in the skin and tissues to gain direct access to the organ being operated on. This approach provides a wide view of the surgical field and tactile control, which can be critical in complex cases.

• Laparoscopy: This is a minimally invasive surgical technique in which the operation is performed through several small incisions (usually 0.5–1.5 cm). Special instruments and a laparoscope — a thin tube with a camera that transmits an image to a monitor — are inserted through these incisions. The surgeon monitors the progress of the operation on the screen while controlling the instruments.

Perforated Peptic Ulcer: Emergency Surgery

Perforated peptic ulcer (PPU) is a perforation of the stomach or duodenal wall, which leads to the leakage of contents into the abdominal cavity and the development of peritonitis. This condition is an urgent surgical pathology, accounting for up to 37% of all deaths associated with peptic ulcer disease [2]. Surgical intervention remains the standard of care for PPU [2].

For many years, open surgery was the only available treatment method. However, with the advent of laparoscopic technologies, surgeons began to apply them to PPU as well, aiming to reduce the invasiveness of the intervention and improve postoperative outcomes [3].

Advantages of Laparoscopy for Perforated Ulcer

Numerous studies and meta-analyses show that the laparoscopic approach has a number of significant advantages over open surgery in the treatment of perforated ulcers:

• Reduced Complication Rate: A systematic review and meta-analysis showed that laparoscopic surgery is associated with a reduction in overall postoperative morbidity (8.9% versus 17.0% for open surgery) [8]. In particular, there are fewer wound infections [4], pneumonias [4], and other respiratory complications [4]. Unplanned reoperations were also less frequently required after laparoscopy (4.7% versus 14%) [1].

• Reduced Hospital Stay: Patients who undergo laparoscopic surgery generally stay in the hospital for a shorter time. Studies show a reduction in hospital stay from 8 to 6 days [1] and from 9.8 to 7.1 days [6]. The total postoperative hospital stay is significantly shorter with laparoscopy [4].

• Less Blood Loss: The laparoscopic approach is associated with less intraoperative blood loss [4].

• Faster Recovery and Less Pain: Due to smaller incisions, patients usually experience less pain after surgery and recover faster, returning to daily activities.

• Effectiveness Even in Elderly Patients: The benefits of the laparoscopic approach are well established even for elderly patients, which is especially important given their increased vulnerability to complications [2].

When Might Open Surgery Be Preferable?

Despite the obvious advantages of laparoscopy, there are situations where open surgery may be more appropriate or even necessary:

• Increased Operation Time: In some cases, laparoscopic surgery may take longer. For example, one study showed that laparoscopy lasted an average of 14 minutes longer than open surgery [1].

• Increased Time to Surgery: The time from patient admission to the start of laparoscopic surgery may be longer (on average by 4 hours) [1]. This can be critical in rapidly progressing peritonitis.

• Risk of Paralytic Ileus: Paralytic ileus (impaired bowel motility) is more common after laparoscopic interventions (42% versus 18% for open surgery) [1].

• Conversion to Open Surgery: In some cases, especially with complicated perforations, extensive peritonitis, poor visualization, or technical difficulties, laparoscopic surgery may be converted to open surgery. According to one study, conversion occurred in 5% of cases [1].

• Patient Condition and Surgeon Experience: In cases of extremely severe patient condition, severe peritonitis, or a lack of sufficient surgeon experience in emergency laparoscopic interventions, open surgery may be a safer choice [2, 6].

• No Differences in Mortality and Readmission: Some studies have not found significant differences in mortality rates or readmission rates between the two approaches [1, 3].

Robotic Surgery: The Next Step in Minimally Invasive Interventions

In addition to laparoscopy, robotic surgery is actively developing. This is an even more advanced technology that in some cases demonstrates advantages over traditional laparoscopy, especially in elective surgery. However, its role in emergency general surgery, including perforated ulcer, is still being actively studied and is not yet the standard [5].

Choosing the Method: An Individual Approach

The choice between laparoscopic and open surgery for perforated peptic ulcer is a complex decision that must be made individually for each patient. The surgeon considers many factors, including the patient's general condition, the severity of peritonitis, the size and location of the perforation, the presence of comorbidities, as well as their own experience and the clinic's equipment [2].

In general, in the absence of contraindications, the laparoscopic approach is preferred due to its advantages regarding postoperative complications and recovery times. However, open surgery remains an important and often life-saving method, especially in complex and emergency situations.

The information provided in the article is for reference purposes only and cannot replace consultation with a qualified medical professional. Always consult a doctor for diagnosis and treatment.

Sources

1. Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study.
2. Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach.
3. Comparison of Mortality and Postoperative Complications Between Open and Laparoscopic Repair of Perforated Peptic Ulcer: An Umbrella Review.
4. A comparative study on laparoscopic and open surgical approaches for perforated peptic ulcer repair: efficacy and outcomes analysis.
5. Robotic versus laparoscopic general surgery in the emergency setting: a systematic review.
6. [Comparison of laparoscopic and open suturing of perforated peptic ulcer complicated by advanced peritonitis].
7. Comparative study of postoperative complications after open and laparoscopic surgery of the perforated peptic ulcer: Advantages of the laparoscopic approach.
8. Laparoscopic Repair for Perforated Peptic Ulcer Disease Has Better Outcomes Than Open Repair.