Graham Patch Technique for Perforated Peptic Ulcers

Introduction to Graham Patch

The Graham patch is a surgical technique where an omental patch is sutured over a perforated peptic ulcer to seal the defect and prevent peritoneal contamination, as recommended by the World Journal of Emergency Surgery 1, 2

The technique is particularly valuable for perforations smaller than 2 cm in diameter, where primary closure with omental reinforcement is the standard approach, according to the World Journal of Emergency Surgery and Praxis Medical Insights 1, 3
For perforated peptic ulcers in the emergency setting, laparoscopic suture repair reinforced with an omental patch is the recommended approach, as stated by the World Journal of Emergency Surgery 1, 2

Specific indications for Graham patch include perforated marginal ulcers or gastric/duodenal perforations less than 1 cm in hemodynamically stable patients, as suggested by Praxis Medical Insights 3
Ulcers with friable edges can benefit from the omental patch, which reduces the risk of sutures cutting through the tissue, according to Praxis Medical Insights 3
Perforations up to 2 cm in diameter have shown low postoperative leak rates with this technique, as reported by Praxis Medical Insights 3

Monofilament absorbable sutures are recommended for omental patch repair, as they cause less bacterial seeding and lower infection risk compared to multifilament options, according to Praxis Medical Insights 3
Monofilament synthetic sutures such as poliglecaprone and polyglyconate are preferred, as stated by Praxis Medical Insights 3
Continuous non-locking suturing techniques distribute tension more evenly across the suture line, according to Praxis Medical Insights 3

The Graham patch has been used in 37% of patients with complicated ulcers in excluded gastric segments after bariatric surgery, alongside other techniques like oversewing, as reported by the World Journal of Emergency Surgery 1, 2
Multiple retrospective studies show low postoperative leak rates even for perforations up to 2 cm, according to Praxis Medical Insights 3

Avoid overly tight sutures that can strangulate tissue and impair healing, particularly important in vascular areas like the omental patch, as advised by Praxis Medical Insights 3
Ensure adequate assessment of the jejuno-jejunostomy in bariatric patients, as gastric remnant perforation could be secondary to bowel obstruction, as recommended by the World Journal of Emergency Surgery 1, 2
While omental patch may not be necessary for all repairs, it remains valuable for cases with friable tissue edges or larger perforations, according to Praxis Medical Insights 3

The World Journal of Emergency Surgery guidelines recommend laparoscopic primary suture repair reinforced with an omental patch (the modified Graham patch) as the preferred emergency treatment for perforated peptic ulcers in hemodynamically stable patients. 4

In patients undergoing bariatric surgery who develop a perforated peptic ulcer, the same laparoscopic primary repair with omental‑patch reinforcement is advised. 4

For hemodynamically unstable patients with a perforated peptic ulcer, the modified Graham‑patch technique should be avoided; immediate damage‑control surgery is recommended instead. [4][5]
When the perforation exceeds 2 cm in diameter, neither the classic nor the modified Graham patch is considered optimal; surgeons should consider gastric resection or other alternative approaches based on perforation location and patient stability. 5

Mandatory smoking cessation is required after repair because smoking is a major predisposing factor for peptic‑ulcer perforation. 4