Figure 1

Schematic drawing and intraoperative images during laparoscopic repair of PPU. (A) Schematic drawing showing the establishment of ports. The three-port method was used, with a periumbilical camera port (12 mm), one working port (12 mm) in the left midclavicular line, and the third port (5 mm) in the right abdominal region. After the initial exploration of the peritoneal cavity, purulent collections over (B) the Morrison’s pouch and (C) the left subphrenic area were evacuated with a laparoscopic suction instrument. (D) Purulent fluid at the Cul-de-sac was evacuated, and a surgical gauze was then placed for further fluid absorption before the patients were placed into the reverse Trendelenburg position. (E) The transabdominal suture traction of the round ligament with a 2-O straight PROLENE was applied to elevate the liver to improve the exposure of the pyloroduodenal region. (F) A two-layer, simple interrupted suture with 3-O Vicryl plus was used to repair the perforated site. (G) One surgical gauze was placed in the splenophrenic space and the Morison’s pouch to soak up any remaining purulent fluid. Next, the patient was turned into the Trendelenburg position to assess the lower abdominal cavity. (H) Any interloop adhesions were cautiously divided, and the gauze wiping maneuver was used to soak up the residual peritoneal fluid. All bowel loops were investigated to the root of the mesentery. Drainage tubes were placed at the dependent area of the abdomen cavity such as the Morrison pouch (I) and the left subphrenic area or Cul-de-sac (J). (K) Before pulling out any dirty and soaked gauze (white arrow), we siphoned off as much excess fluid as possible using the suction device. Then, a clean gauze (black arrowhead) was carpeted underneath the trocar to take up surplus fluid as the moist gauze passed and squeezed through the laparoscopic trocar. Ome omentum, Mes mesentery, Pu pubic bone.