On the surface, perforation repair is the most usual procedure, as if flushing the abdominal cavity is the biggest job. At the same time, it is also one of the strangest surgical procedures, and most of the time, most surgeons resort to the simplest in situ suture to close the perforation, and despite the later popularity of vagotomy and despite the partial replacement of the open abdomen by laparoscopy, the most primitive surgical approach has survived across history and is still widely used. Is there no need for improvement? Or is there no room for improvement? Or is no one willing to try? 1, pyloric exploration in the open to determine the perforation, should first abdominal cavity flushing, and then the first job is to explore the pyloric ring, the purpose of four: (1), there is no pyloric obstruction. If there is, simple suturing is wrong! (2) The size, location, and shape of the ulcer. After many (probably very many) doctors do the repair, the surgical record only has the location and size of the perforation and does not describe the ulcer. Has he forgotten that the perforation is only a complication of the ulcer and the real disease is the ulcer! (3), determine the exact location of the pylorus, for deformed pylorus, it is difficult to judge by eye. (4), determine the direction of the transverse and longitudinal axes of the gastric sinus, pylorus and duodenum, especially the intraluminal direction, not just the external morphology. Probing methods, as you may know, but note one: the probing point should not be too close to the pylorus! Incisional probing can be considered at your discretion and avoided if possible! 2, gastric ulcer or duodenal ulcer perforation For the surgeon, the main difference between the two is that a gastric ulcer may be malignant, while a duodenal ulcer may cause pyloric obstruction. This would have been a simple matter of determining the location of the pylorus. But as it happens, most ulcers are immediately adjacent to the pylorus, or cross it, or even right on the pyloric ring. Here we do not make further analysis, but only a simple judgment, based on the location of the perforation, only the perforation below the pyloric ring is a duodenal ulcer perforation. Above the pyloric ring, including across the pyloric ring, regardless of the upper and lower, are considered gastric ulcer perforation. 3.Whether to take biopsy pathology, how to take My suggestion is to take biopsy, and rapid frozen pathology examination. How to take which? You can remove a corner of the perforation at 6 o’clock, be careful not to make it too small. Then just close the perforation with normal sutures. 4.Suture the perforation (1), how wide is the appropriate suture? Is it a uniform 8~10mm, or does it depend on the size of the ulcer? If the width is set, what if the ulcer is huge, and will suturing within the ulcer surface affect healing? If it depends on the ulcer, should it go beyond the edge of the ulcer? What if the ulcer is huge? Will an overly wide suture cause pyloric stenosis? These are questions you may or may not have thought about. All of them are followed, but the results are basically the same, most of them can heal. What does this mean? Perhaps the large number of successful conservative treatment cases can explain everything! (2), suture cut tears I think many people have encountered a similar situation, or at least the vast majority of people are paying attention to this problem. Preventive measures are: full layer, vertical access, across the base of the ulcer, and gentle. Don’t stress if there is a tear, just widen the suture and span the ulcer. As mentioned earlier, this surgical approach does not require a very high state of perforation suturing, and the basic requirements can be met as long as the perforation can be closed. Giant perforations It should be noted that there are no ulcer perforations that are just a big hole once broken. A giant perforation is at least an indication of a large ulcer base and a long perforation time. In case of gastric ulcer perforation, there is a high possibility of gastric cancer perforation. However, at this time, the abdominal cavity condition can no longer complete larger surgical operations, and perforation repair becomes almost the only option. Before repair, the ulcer should be explored more carefully. The bottom of the ulcer should be excised and sent for pathological examination to remove necrotic tissue from the ulcer surface, determine the proportion of the ulcer surface to the circumference of the pyloric ring (pyloric stenosis is bound to occur in those with more than half), and probe the ulcer surface for bleeding (if there is bleeding, the corresponding gastric supply vessels should be ligated according to the location of the vessels). When suturing a giant perforation, there will be some tension (unlike a small perforation) and the sutures must span the ulcer margin. Large omental caulking reduces tension and increases the chance of healing, but increases the incidence of pyloric obstruction. The pylorus needs to be re-explored after completion of suturing, and both upper and lower ends need to be explored, with additional surgery if there is pyloric obstruction or significant stenosis. Gastric body and fundic ulcers If possible, a major one-stage gastrectomy is preferable. If the contamination is heavy, local excision of the ulcer can be tried and does not increase the time or risk of surgery. Additional surgery For cases with heavy abdominal contamination, even if the intraoperative pathology diagnoses gastric cancer, the perforation can be temporarily closed and left for second-stage radical treatment. Phase I surgery is risky, long and difficult to achieve the standard of radical treatment. So, which should be considered as the radical treatment of gastric cancer, or a major gastrectomy? Is it necessary to have stage II simple lymph node dissection? What really must be additional surgery is pyloric obstruction!!! Gastrojejunostomy alone has a high success rate, but one has to face the problems of pyloric recanalization, anastomotic ulceration and stage II major gastrectomy, each of which is tricky. To solve these problems requires selective vagotomy, permanent closure of the pylorus, and high posterior wall gastrointestinal anastomosis. As you can see, it is now more problematic than a major gastrectomy. Therefore, a simple gastrojejunostomy is a helpless and consequential emergency procedure, and a definitive procedure must be performed in the near future. Since it is only a temporary emergency surgery, is there any need to go through the trouble of looking for trouble? Is there a simpler, safer, and less risky solution? Gastrostomy and supra-jejunal tube placement basically meet the above requirements.