I did a lap cholecystectomy on a 70 year old woman with symptomatic gall stones. She had one huge stone, about the size of a small egg, and several smaller ones. On exploration, the duodenum pulled up with the gall bladder, but stripped down easily, and the rest of the operation was uneventful. She went home after the operation, but continued to complain of severe pain, no fever or elevated WBC.
Subsequent workup included and US which was normal, and a gastrograffin swallow which showed a questionable leak from the dudenum. Probably from the point where I stripped it down.
Relaparoscoped 24h after copletion of previous operation via the same ports. There was some bile stained fluid under the liver and along the right gutter, but could not identify source. Filled the stomach with methylene blue, and was able to see a small, 3mm perforation in the anterior wall of the duodenum at the junction of the 1st and 2nd parts. There was very little inflammation or fibrinous exudates, and the perforation was clean, without bulging mucosa.
What now? We considered the following:
1. open via a kocher incision and
a: close with omentopexy
b: close with serosal patch
c: put a T-tube through the hole as a duodensotomy.
2. Do a laparoscopic omentopexy and
Which would you have done, or do you have any other suggestions?