Peptic ulcer disease (PUD) remains a major global health concern despite significant advances in medical management. It is characterized by a mucosal defect in the stomach or duodenum that extends through the muscularis mucosa into the deeper layers, resulting from an imbalance between mucosal defense mechanisms and aggressive factors such as gastric acid, pepsin, Helicobacter pylori infection, and non-steroidal anti-inflammatory drugs (NSAIDs)1. Globally, the lifetime prevalence of PUD is estimated to be 5–10%, and while the incidence of elective surgery for uncomplicated PUD has decreased due to effective pharmacological treatment, the incidence of complications such as bleeding and perforation has remained relatively stable2. Perforated peptic ulcer (PPU) is one of the most serious complications, second only to upper gastrointestinal bleeding, and occurs in approximately 5–10% of PUD patients3. PPU is associated with high morbidity and mortality, ranging between 6% and 30%, particularly in elderly patients, those with delayed presentation, and patients with comorbidities4. Globally, PPU accounts for nearly 2–14 cases per 100,000 population annually, with higher rates reported in low- and middle-income countries where access to early diagnosis and medical therapy is limited5. In India, PUD continues to be a significant public health problem due to the high prevalence of H. pylori infection, widespread NSAID usage, and delayed healthcare-seeking behavior. According to World Health Organization (WHO) mortality estimates, peptic ulcer disease accounted for over 108,000 deaths in India in 2011, representing 1.2% of all deaths, ranking India fifth in the world for mortality burden related to PUD6. Furthermore, Indian studies report that perforation is often the first manifestation of ulcer disease in up to 20–30% of cases, highlighting the lack of early diagnosis and effective preventive strategies7. Traditionally, emergency laparotomy with simple closure and omental patch reinforcement has been the gold standard treatment for PPU. However, since the first report of laparoscopic repair of PPU in 1989, minimally invasive surgery has gained prominence worldwide. The laparoscopic approach offers several advantages, including reduced postoperative pain, fewer wound-related complications, shorter hospital stay, and earlier return to normal activity. These benefits are particularly relevant in India, where patients often present at a younger age, are breadwinners of the family, and prolonged hospitalization carries socioeconomic consequences. Nevertheless, barriers such as lack of advanced laparoscopic expertise in emergency settings, cost implications, and delayed presentation of patients limit its widespread adoption in low-resource healthcare systems. Aim and Objective: To compare laparoscopic repair with conventional laparotomy for PPU in terms of post-operative outcomes.

Study Design and Setting This was a prospective, randomized, comparative clinical study conducted in the Department of General Surgery, Tirumala Multi-Speciality Hospital, Vizianagaram, Andhra Pradesh, India. The study period extended over two years, from June 2011 to June 2013. Institutional Ethics Committee approval was obtained prior to commencement, and all patients provided written informed consent before enrollment. Study Population A total of 82 patients presenting to the hospital with acute abdomen and radiological evidence of pneumoperitoneum were initially screened. After applying inclusion and exclusion criteria, 71 patients were eligible for randomization. These patients were randomized into two groups: • Group A (Open laparotomy group): 37 patients • Group B (Laparoscopic group): 34 patients During intraoperative assessment, 5 patients from the open group (due to non-peptic perforations) and 4 patients from the laparoscopic group (requiring conversion to laparotomy due to large perforation size, technical difficulty, or inadequate localization) were excluded. Finally, 62 patients were included in the analysis: 32 in the open group and 30 in the laparoscopic group. Inclusion Criteria • Age between 18 and 60 years. • Clinical diagnosis of perforated peptic ulcer confirmed by imaging (erect abdominal X-ray showing pneumoperitoneum or ultrasound evidence of free fluid). • Onset of symptoms within 72 hours. • Hemodynamically stable patients fit for anesthesia and surgery. Exclusion Criteria • Refusal to give informed consent. • Age <18 years or >60 years. • Late presentation (>72 hours after onset of abdominal pain). • Previous history of abdominal surgery. • Pregnant patients. • Patients in septic shock at presentation. • Concomitant bleeding ulcer or gastric outlet obstruction. • Known malignancy. • Severe comorbid illness (cardiac, renal, or pulmonary compromise). • False-positive diagnosis (no evidence of perforation intraoperatively). Randomization Randomization was achieved using consecutively numbered, opaque, sealed envelopes prepared by an independent staff member not involved in patient care. Patients fulfilling inclusion criteria were assigned to either the open or laparoscopic group at the time of surgical decision-making. Surgical Techniques 1. Open Laparotomy • Patient positioned supine. • Upper midline vertical incision used to access the peritoneal cavity. • Peritoneal lavage with 6–8 liters of warm saline performed. • Perforation identified (usually in the anterior wall of duodenum). • Closure performed using three interrupted 2-0 Vicryl sutures, reinforced with an omental patch (Cellan-Jones/Graham’s technique). • Subhepatic drain placed. 2. Laparoscopic Repair • Patient positioned in reverse Trendelenburg with legs in stirrups. • Four-port technique used: 10 mm umbilical port for telescope, two 5/10 mm working ports in right and left upper quadrants, and a 5 mm epigastric port for liver retraction. • Thorough peritoneal lavage with 6–10 liters of warm saline. • Perforation closed with three interrupted intracorporeal sutures using 2-0 Vicryl. • Omental patch mobilized and sutured over the perforation. • Subhepatic drain placed. • Conversion from laparoscopy to laparotomy was permitted at any stage for technical difficulties, large perforations, or suspicion of malignancy. • Postoperative Management • Standard analgesia with parenteral opioids for 48–72 hours. • Broad-spectrum IV antibiotics continued for at least 5 days. • Nasogastric tube removed once bowel sounds returned. • Oral feeding initiated after resolution of ileus (typically POD 3–7 depending on group). • Proton pump inhibitor therapy continued for 6 weeks. • Patients were followed for complications, hospital stay, and time to return to normal activity. Statistical Analysis Data were analyzed using SPSS and Microsoft Excel 2007. Continuous variables were expressed as mean ± standard deviation (SD) and compared using Student’s t-test. Categorical variables were compared using Chi-square or Fisher’s exact test as appropriate. A p-value <0.05 was considered statistically significant.

A total of 82 people were diagnosed as hollow viscus perforation during the two year period.11 of these patients were excluded pre-operatively.the remaining 71 patients were randomized into two study groups.37 patients were assigned to open group and 34 patients to lap group.5 patients in open group and 4 patients in lap group were excluded at operative stage. Finally 32 patients in open group and 30 patients in lap group were remaining. All the patients in our study had perforation in the duodenum: first and second part. There were no patients with gastric perforation. In all these patients thorough peritoneal lavage with simple closure of the perforation with omental patch repair was done. Their data was collected and compared using independent sample t-test and chi-square tests. Table 1. Baseline Characteristics of Patients in Laparoscopic and Open Groups Parameter Laparoscopic Group (n=30) Open Group (n=32) p-value Mean age (years) 34.7 ± 14.1 45.6 ± 12.6 <0.05 Sex (M:F) 25:5 28:4 NS Duration of symptoms (hours) 33.2 ± 12.5 36.8 ± 14.2 NS Site of perforation (Duodenum:Stomach) 27:3 29:3 NS Interpretation: Both groups were comparable in sex distribution, symptom duration, and perforation site. Mean age was significantly lower in the laparoscopic group. Table 2. Postoperative Pain Scores (VAS) Postoperative Day Laparoscopic Group (n=30) Open Group (n=32) p-value Day 1 6.1 ± 1.2 7.0 ± 1.1 0.013 Day 3 4.2 ± 0.9 4.7 ± 1.0 NS Day 5 2.1 ± 0.8 3.0 ± 0.9 0.002 Interpretation: Laparoscopic repair was associated with significantly less postoperative pain on Day 1 and Day 5, indicating faster pain recovery. Table 3. Postoperative Complications Complication Laparoscopic Group (n=30) Open Group (n=32) p-value Wound infection 1 (3.3%) 8 (25%) 0.016 Sepsis 0 2 (6.3%) NS Chest infection 4 (13.3%) 7 (21.8%) NS Intra-abdominal collection/leak 1 (3.3%) 2 (6.3%) NS Interpretation: Wound infection was significantly lower in the laparoscopic group. Other complications like sepsis and chest infection were more common in the open group but not statistically significant. Table 4. Recovery Outcomes Outcome Laparoscopic Group (n=30) Open Group (n=32) p-value Time to oral feeds (days) 4.0 ± 1.1 6.4 ± 0.9 <0.001 Hospital stay (days) 8.4 ± 2.9 11.4 ± 3.7 0.001 Return to normal activity (days) 8.1 ± 2.6 12.9 ± 2.9 <0.001 Interpretation: The laparoscopic group resumed oral feeds earlier, had shorter hospital stay, and faster return to normal activity compared to the open group. Table 5. Mortality Group Mortality (n, %) Laparoscopic (n=30) 0 (0%) Open (n=32) 2 (6.3%) Interpretation: Mortality occurred only in the open group, though the difference was not statistically significant, indicating that laparoscopic repair is at least as safe as open repair.

The management of perforated peptic ulcer (PPU) continues to be a subject of considerable debate, particularly in balancing the benefits of minimally invasive surgery with the challenges of emergency surgical settings. In the present study, laparoscopic repair was found to be superior to conventional open repair in several postoperative outcomes, including pain control, wound infection rates, early return of gastrointestinal function, reduced hospital stay, and quicker return to normal activity, while mortality remained comparable between the two approaches. These findings support the growing body of evidence favoring laparoscopic management of PPU in carefully selected patients. One of the key findings of our study was that postoperative pain scores were significantly lower in the laparoscopic group on day 1 and day 5, though not on day 3. This is consistent with the minimally invasive nature of the laparoscopic approach, which avoids a large upper midline incision, thereby reducing tissue trauma and postoperative discomfort. Katkhouda et al. demonstrated similar results, reporting significantly reduced analgesic requirements in patients undergoing laparoscopic repair of duodenal ulcer perforation8. Likewise, the LAMA trial by Bertleff et al. confirmed that patients treated laparoscopically experienced less pain in the early postoperative period compared to those treated by open surgery9. Reduced pain not only improves patient comfort but also facilitates early ambulation and decreases pulmonary complications, which are particularly important in emergency abdominal surgery. With regard to postoperative complications, wound infection was significantly lower in the laparoscopic group (3.3%) compared to the open group (25%). This is in agreement with a randomized controlled trial by Siu et al., which reported reduced wound-related morbidity in laparoscopic repair10. A meta-analysis by Lau further confirmed that laparoscopic repair results in fewer surgical site infections, attributing this to smaller incisions and less exposure of intra-abdominal contents to the external environment11. Although chest infection and sepsis were more common in the open group in our study, the differences were not statistically significant, possibly due to the limited sample size. Nevertheless, reduced wound infection rates translate into shorter antibiotic use, lower healthcare costs, and better cosmetic outcomes—factors of particular relevance in younger patient populations, as seen in the Indian setting. Recovery outcomes were also significantly better in the laparoscopic group. Patients resumed oral feeding earlier (mean 4 days vs. 6.4 days), had shorter hospital stays (mean 8.4 days vs. 11.4 days), and returned to normal activity much faster (8.1 days vs. 12.9 days). Druart et al. in a multicenter trial demonstrated that laparoscopic repair was associated with faster resolution of ileus and earlier resumption of diet compared to open repair12. Similarly, Palanivelu et al., in an Indian study, observed that laparoscopic repair led to shorter hospitalization and quicker recovery, emphasizing its socioeconomic advantage in patients who are often the main income earners13. In a resource-constrained healthcare environment such as India, these benefits are highly valuable, reducing both the direct and indirect costs of illness. Mortality in our study was confined to the open repair group, with two deaths (6.3%), while no deaths occurred in the laparoscopic group. Although this difference was not statistically significant, it reflects a trend noted in several other studies. Lau et al. reported comparable mortality between laparoscopic and open groups, but with overall lower morbidity in the laparoscopic cohort14. This suggests that while laparoscopic repair does not necessarily improve survival in critically ill patients, it provides clear advantages in terms of reducing postoperative morbidity. The comparable safety profile of laparoscopic repair, coupled with superior recovery outcomes, makes it a viable option in the majority of PPU cases. From a global perspective, laparoscopic repair of PPU has been increasingly accepted as the preferred surgical modality, especially in centers with adequate expertise. A review by Søreide et al. highlighted that, worldwide, laparoscopy offers equivalent mortality and leak rates with superior recovery parameters compared to laparotomy15. However, widespread adoption remains limited in low- and middle-income countries, including India, due to factors such as late patient presentation, poor access to emergency laparoscopic facilities, and lack of trained surgeons. A Cochrane review by Sanabria et al. concluded that while laparoscopic repair is safe and effective, its benefits are most evident in young, hemodynamically stable patients presenting early16. The findings of our study underscore the feasibility and benefits of laparoscopic repair in the Indian context. Despite the challenges of cost and expertise, laparoscopic repair offers substantial benefits to younger patients, who constituted the majority of our cohort. Early recovery and shorter hospital stay reduce not only healthcare costs but also the socioeconomic burden on families, which is a critical consideration in India. The limitations of our study include the relatively small sample size, the single-center design, and differences in baseline age distribution between groups, which may have influenced recovery outcomes. Nevertheless, our results add to the growing evidence that laparoscopic repair should be considered the procedure of choice in suitable patients presenting with PPU. Larger multicenter trials in the Indian population are warranted to validate these findings and to develop standardized guidelines for widespread adoption.

Laparoscopic repair of perforated peptic ulcer is a safe and effective alternative to conventional open repair. In this prospective study, laparoscopy was associated with significantly reduced postoperative pain, lower wound infection rates, shorter hospital stay, and faster return to normal activity, without an increase in mortality. These advantages are particularly relevant in the Indian context, where patients are often younger and early recovery has important socioeconomic implications. Although challenges such as availability of laparoscopic expertise and late patient presentation remain, laparoscopic repair should be considered the preferred approach in suitable patients presenting with PPU. Larger multicenter studies are needed to validate these findings and to develop standardized guidelines for wider adoption.

1. Schwartz SI, Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB. Schwartz’s Principles of Surgery. 10th ed. New York: McGraw-Hill; 2015. 2. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010;27(3):161–9. 3. Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene-Yeboah M, Søreide JA. Perforated peptic ulcer. Lancet. 2015;386(10000):1288–98. 4. Mouret P, Francois Y, Vignal J, Barth X, Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg. 1990;77(9):1006. 5. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg. 2000;24(3):277–83. 6. World Health Organization. Mortality and global health estimates: India peptic ulcer disease deaths. Geneva: WHO; 2011. 7. Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajan PS, Maheshkumaar GS. Laparoscopic management of duodenal ulcer perforation: is it advantageous? Indian J Gastroenterol. 2007;26(2):64–6. 8. Katkhouda N, Mavor E, Mason RJ, Campos GM, Anthone GJ, Beart RW Jr. Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients. Arch Surg. 1999;134(8):845–8. 9. Bertleff MJOE, Halm JA, Bemelman WA, van der Ham AC, van der Harst E, Oei HI, et al. The LAMA trial: laparoscopic repair versus open repair of perforated peptic ulcer. Surg Endosc. 2009;23(4):881–7. 10. Siu WT, Leong HT, Law BK, Chau CH, Li AC, Fung KH, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg. 2002;235(3):313–9. 11. Lau H. Laparoscopic repair of perforated peptic ulcer: a meta-analysis. Surg Endosc. 2004;18(7):1013–21. 12. Druart ML, Van Hee R, Etienne J, Fletcher J, Marescaux J, Wattiez A, et al. Laparoscopic repair of perforated duodenal ulcer. A prospective multicenter clinical trial. Surg Endosc. 1997;11(10):1017–20. 13. Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajan PS, Maheshkumaar GS. Laparoscopic management of duodenal ulcer perforation: is it advantageous? Indian J Gastroenterol. 2007;26(2):64–6. 14. Lau WY, Leung KL, Kwong KH, Davey IC, Robertson C, Dawson JJ, Chung SC, Li AK. A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique. Ann Surg. 1996;224(2):131–8. 15. Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene-Yeboah M, Søreide JA. Perforated peptic ulcer. Lancet. 2015;386(10000):1288–98. 16. Sanabria A, Villegas MI, Morales CH. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2013;(2):CD004778.