Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Duodenal ulcers are in large part attributed to 
the presence of Helicobacter pylori infection 
(>90%). Additional contributors to the development 
of duodenal ulcer disease include Non-Steroidal 
Anti-Inflammatory Drugs, gastrinoma, and smoking. 
Due in large part to the medical advancements in 
treating H. pylori, the number of patients presenting 
with ulcer perforations has greatly declined. 
However, when a patient presents with a perforated 
ulcer, prompt surgical consultation and operative 
intervention is indicated. Due to the morbidity and 
mortality that can result from this condition if not 
treated expeditiously, the general surgeon must be 
comfortable and confident managing peptic and 
duodenal ulcer disease. One indication for operative 
repair is a perforated duodenal ulcer in a patient that 
may have a classic history of sudden onset of 
epigastric abdominal pain radiating to the back 
associated 
with 
signs 
and 
symptoms 
of 
pneumoperitoneum 
and 
peritonitis. 
Duodenal 
perforations are usually small (less than 1 cm in 
diameter) and can be treated by primary repair with 
omental reinforcement or omental or Graham’s patch 
if tissue quality will not allow primary repair. Large 
perforation may require pyloroplasty closure, 
resection, duodenostomy or pyloric exclusion in 
some cases.  
A brief overview of the essential steps of 
repair is listed below: 
● Upper midline incision and culture any 
peritoneal fluid 
● Explore the abdomen and identify the duodenal 
perforation  
● Mobilization of the duodenum (Kocherization) 
and evaluation of the lesser sac for any posterior 
perforation 
● Place interrupted sutures across the margins of 
the perforation  
● Place a pedicle of healthy omentum over the 
defect 
● Tie previously placed sutures 
● Intra-operative leak test 
● Placement of drain and abdominal closure 
 
Steps: 
1. Workup 
for 
the 
patient 
includes 
CBC, 
comprehensive metabolic panel, Coagulation 
studies, Type and Screen, and upright chest x ray 
or abdominal CT scan. The patient will likely 
have CXR showing pneumoperitoneum or 
abdominal CT scan showing pneumoperitoneum, 
intra-abdominal 
fluid, 
and 
thickened 
gastric/duodenal wall. Be cautious administering 
IV contrast to patients in septic shock.  
 
Subdiaphragmatic free air, seen on both the left and the right 
sides. On the patient’s left, the air can be seen outlining the 
adjacent small bowel, which helps distinguish it from the 
gastric bubble in this location. Case courtesy of Kewal 
Arunkumar Mistry, from the case 
 https://radiopaedia.org/cases/35318?lang=us  
 
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
CT scan with oral contrast only shows extravasation of contrast 
from a hole in the duodenum (Red circle). For most 
presentations of duodenal ulcer, a careful history and an 
upright chest x-ray showing free air are enough to make the 
diagnosis.  
 
2.  Fluid resuscitation and correction of electrolyte 
abnormality should be performed as soon as 
possible.  Also, start the patient on broad 
spectrum antibiotics and administer an IV proton 
pump inhibitor. There is no current evidence 
showing that antifungal therapy improves 
outcome on patients with perforated peptic ulcer 
disease.  
3. The operative procedure should be conducted 
under general anesthesia. 
4. The patient should be placed in supine position 
on the operating table and consider tucking the 
right arm. Nasogastric tube and foley catheter 
should be placed before the initiation of the 
procedure.   
5. An upper midline incision is made using a 
scalpel. Mobilization and adequate exposure are 
paramount as well as determining whether the 
perforation can be primarily repaired or will 
require resection and reconstruction.  
6. Use a culture swab to take a sample of any 
intraperitoneal fluid that is present upon 
abdominal entry and send for gram stain and 
culture if possible. Next, use a Poole suction to 
evacuate the intraperitoneal fluid to allow for 
adequate visualization.  
 
Typical appearance after entry into the abdomen with 
perforated duodenal ulcer. Cloudy fluid and exudate cover most 
surfaces, and some of the fluid collections are already “walled 
off” from the rest of the abdomen, typically in the subphrenic 
spaces, the paracolic gutters, and the pelvis. The fluid or a piece 
of the inflammatory exudate can be sent for culture.  
 
7. Inspect the stomach and duodenum to identify 
the perforation. Debride to healthy tissue. Unlike 
gastric ulcers, duodenal ulcers do not 
traditionally have to be biopsied unless 
suspicious findings are present.  
 
Typical location of a perforated duodenal ulcer, in the first 
portion of the duodenum just distal to the pylorus (which can 
often be palpated.)  
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Careful exploration reveals the perforated ulcer (Black arrow) 
 
8. Once the perforation has been identified, use 
interrupted 3-0 suture (generally silk, Vicryl or 
PDS) across the margins of the perforation 
beginning about 5 mm superior to the perforation 
but do not tie the sutures, instead place a 
hemostat or other clamp on each end of each 
sutures.  
 
The sutures are each placed separately, oriented longitudinally 
as shown, rather than transversely to avoid narrowing the 
duodenum. 
 
When placing the sutures, it is important not to pass the needle 
through the posterior wall of the duodenum. Here, the surgeon 
has inserted the forceps into the ulcer to hold the anterior wall 
of the duodenum up away from the posterior wall.  
 
 
After you pass each suture, leave it long enough to tie and hold 
it with a hemostat. Continue until you have enough sutures 
placed to hold a tongue of omentum over the entire hole, each 
one held by its own hemostat: usually 3 to 5 sutures are enough. 
 
9. Position 
and 
confirm 
placement 
of 
the 
nasogastric tube.  
10. Mobilize a healthy tongue of omentum using 
either a combination of clamps and ties or by 
using a bipolar or ultrasonic ligation device. 
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Bear in mind that the blood supply to the omentum comes from 
the gastroepiploic arcade, along the greater curvature of the 
stomach. Divide a pedicle of omentum to create a flap that is 
proximally based, arising from the stomach.  
 
 
As shown here, the plane between the omentum and the 
transverse colon is avascular: gain extra length to your omental 
flap by dissecting it off this structure. 
 
11. Place the omentum over the ulcer defect, 
ensuring that it is placed overlying the previously 
placed sutures.  
 
In this illustration, the sutures have simply been left free after 
being placed and the flap of omentum is laid between them.  
 
 
Here, the sutures are held by hemostats which are held up by 
the hand at the top of the photo. The Babcock clamp is shown 
passing underneath the clamps, in between the sutures, and 
used to grasp the omental flap. 
 
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Then pull the omental flap into place under the sutures, as 
shown here. The Babcock’s tip has passed from caudal to 
cranial (from the bottom towards the top of the photo,) taking 
the omentum with it and pulling it under the sutures to cover the 
ulcer. 
 
12. Tie the sutures down over the omentum. Do not 
over-tighten these and strangulate the omental 
patch.  
 
By tying the sutures, secure the omental flap in place and cover 
the ulcer.  
 
The omental patch is secured in place with sutures. The 
omentum distal to the tied sutures (Black arrow) is clearly 
viable and not dusky.  
 
13. Irrigate the abdomen with warm saline until all 
signs of contamination are gone (return of clear 
irrigation). Pay close attention to the right and 
left subphrenic spaces, the right and left paracolic 
gutters, and the pelvis.  
14. Perform Leak Test: Fill the abdomen with warm 
saline until the repair is submerged. Request the 
anesthetist to gently insufflate air via the NG tube 
and look for air bubbles. If present, further repair 
or revision is indicated, if absent, repair is 
deemed adequate. Evacuate the irrigation. 
 
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Gently hold the stomach and duodenum away from the inferior 
edge of the liver and fill this space with water. Ask the 
anesthetist to inflate the stomach with air through the 
nasogastric tube. No bubbles should appear.  
 
15. Place a closed suction drain next to the repair, 
and secure the drain to the skin using 2-0 nylon 
suture.  
16. Close the abdomen  
17. Leave the skin open if patient has advanced 
peritonitis with severe contamination, otherwise 
close the skin in routine fashion.  
18. Postoperatively keep the patient strict NPO with 
intravenous fluids and nasogastric drainage for 4 
days. 
19. On postoperative day 4, perform a contrast study. 
This can be conducted by administration of 
water-soluble contrast through the nasogastric 
tube and obtaining a plain abdominal x-ray.  
Another option is to administer colored liquid 
orally or by nasogastric tube and monitor to see 
any color change in the drain (example: have 
patient drink blue juice or dye and monitor drain 
for blue output). If leak test negative, the patient 
can be started on oral diet.  
Editor’s note: some surgeons do not consider this 
step mandatory, instead advancing the diet 
cautiously and watching for signs of toxicity that 
might indicate a postoperative leak.  
20. Monitor drain output throughout post-operative 
course; if character changes to bilious or enteric 
contents, this represents a leak. Additionally, 
monitor for signs of abscess via purulent drain 
output. The drain can be removed when serous in 
character, minimal output, and patient is 
tolerating oral diet.  
21. Treat the patient for Helicobacter pylori 
infection after they have recovered (amoxicillin, 
clarithromycin, and a proton pump inhibitor with 
or without Metronidazole depending on local 
resistance patterns.) 
 
 
Pitfalls: 
● Inadequate resuscitation prior to anesthesia 
induction 
● Inadequate mobilization and exposure 
● Failure of adequate debridement: Incorporating 
dead tissue in the repair and closure increases the 
chance of leakage.  
● Closure of perforation under tension: complete 
mobilization of the duodenum helps prevent this 
problem.  
● Inadequate patch coverage resulting in leak. The 
omental patch should not be under tension and 
should lie easily in place even before it is 
secured.  
● Ensure the vascular supply to the omental patch 
is intact to prevent patch failure. The sutures that 
hold the patch in place should be snug, but not 
over-tight. 
● When conducting a primary repair, prior to 
placing the patch ensure that the bowel lumen is 
adequately patent, to help prevent duodenal 
stenosis. Longitudinal (parallel to the duodenum) 
rather than transverse orientation of the sutures 
helps prevent this.  
● Ensure adequate hemostasis of the bowel edges 
to prevent bleeding requiring reoperation.  
● Post-operative 
intra-abdominal 
abscess 
development: watch the patient’s vital signs 
closely during the postoperative period. (The 
differential diagnosis of postoperative sepsis 
always includes leakage of the repair.) See 
Recognizing Post-Operative Intra-Abdominal 
Sepsis. 
 
 
Graham Patch Closure of Duodenal Ulcer 
Erin Burton and Ariel Santos 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Variations: 
● The Graham patch as originally described is 
shown in this chapter. The modified Graham 
patch involves closure of the ulcer first, then 
tying the patch into the tails of the suture from 
the ulcer closure. No difference between the two 
techniques has ever been shown.  
 
In the modified Graham patch (Left) the ulcer is closed first and 
then the tails of the sutures are used to secure the omental 
patch. The classic Graham Patch (Right) incorporates the 
omentum in the same suture that closes the ulcer. 
 
● Use upper intraoperative endoscopy to inspect 
the repair site, confirm the duodenum is not 
narrowed by the repair, and insufflate during the 
leak test 
● Perform the repair laparoscopically: This is an 
advanced 
skill 
and 
requires 
specialized 
equipment, including a suction/irrigation device 
that will allow you to thoroughly irrigate and 
aspirate all four quadrants of the abdomen. The 
modified Graham patch technique may be more 
easily adapted to a laparoscopic approach.  
Editor’s note: we have not seen a laparoscopic 
Graham Patch repair performed in resource-limited 
settings, but it is certainly possible. Proper 
mobilization of an omental patch that would lie over 
the ulcer without tension is probably the most 
difficult part.  
 
Erin Burton MD 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA 
 
Ariel Santos MD MPH, FRCSC, FACS, FCCM 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA 
 
October 2023 
