The management of perforated peptic ulcers emphasizes timely surgical intervention, with laparoscopic approaches recommended for stable patients and specific criteria for surgical repair based on size. Evidence from five university hospitals in South Korea suggests that laparoscopic methods lead to fewer complications and quicker recovery, particularly in uncomplicated cases. Overall, a focus on skilled surgical techniques and enhanced recovery protocols is vital for improving patient outcomes.

1. z
Perforated Peptic Ulcer
 each hour of surgical delay beyond hospital admission
was associated with an adjusted 2.4% decreased
probability of survival compared with the previous
hour
 Stable patients + equipment + human resources 
laparoscopic approach, otherwise  open approach is
recommended
 Boey score 0-1
 Perforated peptic ulcer < 2 cm primary repair, no
difference of leak rate with shorter operative time

2. z
 Even in unstable case : experienced center
 Five university hospitals in South Korea, 2009 – 2019
• Favor laparoscopic approach
• Single tertiary university hospital 2001-2017

3. z
Complications

4. z
Open conversion
 Intraoperative difficulties:
 Unclear perforation site
 Fragile tissue
 Large defect
 Etc.

5. z
ERAS ?
• Non opioid multimodal analgesia,
oral conversion on POD 2
• NG removed when < 300 ml/24
jam
• DC removed when UO adequate
• Drain removed when < 100 ml/24
jam
• POD 1 liquid diet
• POD 2 semisolid food
• IV PPI during hospitalization

6. z
Laparoscopy
Appendectomy
• Uncomplicated appendicitis  laparoscopic
appendectomy within 24 h does not increase the
risk of complication
• Delay beyond 48 h: increase 30 day mortality and
major complication
• laparoscopic appendectomy  preferred
approach, where laparoscopic equipment and
expertise are available
Case Laparoscopy Open approach
Uncomplicated Less POD1 pain
Shorter PO-LOS
Reduce SSI
Faster return to
activity
Less IAA ??
Complicated Less SSI
Reduced time oral
intake
Shorter PO-LOS
Shorter Operative
time ?

7. z
Conclusion
Intraoperative:
 Good surgeons know how to…., (lap experience, lap suturing, lap adhesiolysis)
 Better ones when to ….., and (patient selection)
 The best when not to ….. (conversion, open approach)
Pre and post-operative:
- medication (antibiotic), Enhanced recovery

8. z
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