A novel combined laparoscopic-endoscopic overstitch technique for pediatric gastric ulcer perforation: an innovative approach to repair of hollow viscus perforations

Abstract

We report the first pediatric use of a laparoscopic-assisted endoscopic overstitch technique for managing an acutely perforated gastric ulcer in a 16-year-old female. The patient presented with symptoms consistent with gastrointestinal perforation, confirmed by radiologic pneumoperitoneum. Diagnostic laparoscopy identified inflammatory adhesions and a gastric ulcer perforation. Concurrent endoscopy precisely located the defect, which was effectively closed using an endoscopic overstitch device mounted on a therapeutic double-channel gastroscope. Closure involved three full-thickness inverted figure-of-eight sutures, verified by an intraoperative leak test and reinforced with an omental patch. Postoperative recovery was rapid and uncomplicated, progressing to a regular diet within 3 days. This innovative hybrid laparoscopic-endoscopic technique demonstrates efficacy, safety, and the benefits of minimally invasive surgery for pediatric gastrointestinal perforations, emphasizing its potential superiority over traditional methods.

Keywords: advanced endoscopy; hybrid procedure; laparoscopy; minimally invasive surgery; overstitch; pediatric endoscopy; perforated ulcer.

Figure 1

CT with intravenous contrast demonstrating large pneumoperitoneum.

Figure 2

Intraoperative pictures demonstrating the sequelae of the hollow viscus perforation. The pictures in (a) and (b) demonstrate contamination and associated inflammatory adhesions in the left and right upper quadrant, respectively. The pictures in (c) and (d) demonstrate the antral perforation. The tip of the Maryland dissector was able to insert into the perforation (d) to assist with identification of the perforation endoscopically for closure.

Figure 3

Endoscopic view of the perforation. The picture in (a) demonstrates the site of the perforation. The picture in (b) shows the use of the overstitch technique to perform the closure endoscopically. Pictures (c) and (d) demonstrate the area of perforation once the first and second layers of endoscopic closure are completed, respectively.

Figure 4

Following endoscopic closure, a leak test performed under water (a) did not demonstrate any bubbling after gastric insufflation with air. Photos (b–d) demonstrate performance of a graham patch with a redundant lip of omentum over the endoscopically closed perforation.

Figure 5

Follow-up endoscopy 3 months postoperatively demonstrating a well-healed suture line.