Set up the room as you would for laparoscopic cholecystectomy (see Fig. 64.1A). Enter the abdomen through an infraumbilical puncture site and explore. Aspirate and irrigate all four quadrants of the abdomen. Frequently, the perforation is sealed by overlying liver. Leave this seal intact until you are finished irrigating and inspecting the rest of the abdomen. Be alert to the possibility of another etiology for the problem (e.g., appendicitis, diverticulitis). If the appearance is consistent with a perforated duodenal ulcer, place secondary trocars as shown (Fig. 52.1A).

Gently elevate the liver to expose the perforation. An easy way to obtain initial exposure is to pass a grasper (closed) under the liver from the right lateral port and carefully lift up on liver and falciform ligament. Elevating the falciform ligament will lift the liver. Inspect the subhepatic space. Place a liver retractor to obtain a stable working field.