Enter the abdomen through an upper midline or right paramedian incision (Fig. 51.1A) and thoroughly explore the abdomen. Often the site of perforation will have been sealed off by the overhanging liver and the omentum. Leave this seal undisturbed as you explore the left subphrenic space (over the stomach and spleen), the right subphrenic space (over the dome of the liver), and the rest of the abdomen. Culture the peritoneal fluid and remove as much contamination as possible by irrigation and suction. Then gently elevate the liver to expose the duodenum.

Place a Harrington retractor on the liver, lift it up, and expose the subhepatic space by applying gentle downward traction on the stomach and duodenum (Fig. 51.1B). Frequently, the left lobe of the liver will have “sealed” the perforation, which is typically located at the pylorus or first portion of the duodenum. This seal must be gently broken to expose the perforation. A flow of clear bile into the field usually results.