Advances in the medical treatment of peptic ulcer disease and Helicobacter pylori (H.P.) eradication have led to a significant decline in peptic ulcer prevalence and a dramatic decrease in the number of elective ulcer surgeries performed. Nonetheless, the number of patients requiring surgical intervention for complications such as perforations remains relatively unchanged [1, 3, 13–16].
Minimally invasive surgery has gained a highly expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. In the last few years, the role of laparoscopic surgery in management of perforated peptic ulcer has gained more popularity among laparoscopic gastrointestinal procedures [17–21]. Literature review showed some randomized trials highlighting the feasibility of laparoscopic repair of PPU [11, 22–24]. Only a few literatures had reported patients’ series of more than 100 patients while some did emphasize results from subgroups of patients [25, 26].
In our study of the 47 PPU patients it was evident during the operation that none of the patient had a diagnosis different from PPU. This discovery revealed the benefit of laparoscopy as a diagnostic procedure. These results can be compared to previously published data .
Conversion rate from laparoscopy to laparotomy was 4.3% (2/47) this may be compared to previously published data of a conversion rate of 8% (4/52) . Moreover, it is also much lower compared to that reported in literature, where conversion rates as high as 60% were found [11, 12, 23]. This may be partially attributed to the experience and training of the laparoscopic surgeon who participated in this work, confirming the belief that this procedure should only be done by experienced surgeons [22, 23, 29]. In the current study, the mean Operating time was 42 ± 16.7. This can be considered as significantly shorter compared to previously published data in the literature for laparoscopy group of (75 min) , and also shorter than other reports in the literature [22, 24].
A possible explanation for the shorter operative time is that laparoscopic suturing is easier especially if the edges of the perforation are not infiltrated and non friable [30, 31]. Sutures easily tear out and it is more difficult to take large bites and to tie knots properly. In our series, the use of a single-stitch method described in the literature , fibrin glue, or a patch might have aided in shorting the mean operative time of the laparoscopic procedure [26–32]. Another reason for the decrease in operating time is that we did not perform the irrigation procedure in most of the cases. It was recorded that irrigation through a 5-mm or even a 10-mm trocar is time consuming, and suction of fluid decreases the volume of gas and reduces the pneumoperitoneum. There is no evidence that irrigation lowers the risk of sepsis . We therefore have performed irrigation in limited cases when necessary in instants where there were food remnants in the abdomen.
Our patients required significantly less parenteral analgesics that more than half of them did not ask for any pethidine injection. They had a lower visual analog pain score on postoperative days 1 and 3. This can be explained by the already existing evidence that laparoscopic correction of PPU causes less postoperative pain [11, 21, 26, 30]. The meta-analysis published by Lau  reported that eight out of ten studies showed a significant reduction in dosage of analgesics required in the laparoscopic group. Also, the three studies that had included VAS pain scores showed consistently lower pain scores, as was observed in our study as well. Whether this will lead to a better quality of life for patients, especially during the first weeks after surgery still needs to be analyzed. Patients in our series who underwent laparoscopy had less postoperative pain and also a less length of hospital stay 75 ± 12.6 h. It appears that the age of PPU patients may have influenced this relatively shorter hospital stay; it was 39.5 ± 8.6 years. In most of the published series the age is increasing. This not only increases the mean hospital stay time but it may eventually represent a significant problem in the future [22, 32]. One benefit of the laparoscopic procedure not often mentioned in literature pain  is cosmetic outcome. Nowadays patients are aware of this benefit, and sometimes this is the reason why they demand laparoscopic surgery .
In conclusion, the results of the current trial confirm the results of other trials that laparoscopic correction of PPU is safe, feasible for the experienced laparoscopic surgeon, and causes less postoperative pain. Operating time was less than previously reported and complications are less.
These results however, need further evaluation on bigger patients sample with more advanced age on the future studies.