UNEXPECTED INTRAOPERATIVE DISCOVERY OF A RARE CHRONIC SEALED DUODENAL PERFORATION DURING CHOLECYSTECTOMY: A CASE

Abstract

Background: Perforated peptic ulcer remains one of the commonest surgical emergencies worldwide. However, chronic sealed perforation of the duodenum is an uncommon clinical entity because spontaneous sealing by the greater omentum prevents generalized peritonitis and often masks the diagnosis. Incidental identification of a chronic sealed duodenal perforation during elective cholecystectomy is exceedingly rare and scarcely described in the literature. Case Presentation:  A [43]-year-old [female] presented with recurrent right upper quadrant pain suggestive of symptomatic cholelithiasis. Ultrasonography confirmed gallstones without evidence of perforation or pericholecystic collection. Elective cholecystectomy was planned. During surgery, dense inflammatory adhesions were encountered between the gallbladder, liver, greater omentum, and first part of the duodenum. Careful adhesiolysis unexpectedly revealed a chronic sealed perforation on the anterior wall of the first part of the duodenum, completely covered by adherent omentum. Cholecystectomy was completed safely, and the duodenal perforation was repaired by primary closure reinforced with a Graham's omental patch. Copious peritoneal lavage and drain placement were performed. The postoperative period was uneventful, and the patient was discharged in stable condition. Clinical Discussion: Dense inflammatory adhesions extending beyond the gallbladder fossa should alert surgeons to the possibility of occult pathology involving adjacent organs. Chronic sealed duodenal perforation may mimic severe chronic cholecystitis, making intraoperative diagnosis challenging. Careful adhesiolysis and systematic exploration are essential to avoid iatrogenic injury. Conclusion: This case illustrates an extremely rare intraoperative diagnosis of chronic sealed duodenal perforation during cholecystectomy. Prompt recognition and repair using Graham's omental patch resulted in an excellent outcome.