Set up the room as you would for laparoscopic cholecystectomy (see Figure 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. 60.1A).

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.

The initial laparoscopic view of the left upper quadrant demonstrates the liver, falciform ligament, omentum, colon, and gallbladder (Fig. 60.1B). As the liver is elevated, stomach and duodenum come into view (Fig. 60.1C). The prepyloric vein of Mayo provides a convenient visual dividing point between the stomach and the duodenum. Branches of the supraduodenal

artery are sometimes found in this region. As the laparoscope is brought closer, the manner in which gallbladder and segment IV of the liver overly the first and second portions of the duodenum becomes apparent (Fig. 60.1D).