Perforated peptic ulcer (PPU) disease represents about 5% of abdominal surgical emergencies. The sooner the patient is operated, the better the outcome is going to be. Surgery can be performed by either an open or a laparoscopic approach. In general, in the hemodynamically stable patient and in the absence of absolute contraindications (i.e., cardiac/pulmonary contraindication to pneumoperitoneum, simultaneous bleeding in unstable patients, expected hostile abdomen), a minimally invasive approach is a safe and feasible option allowing for decreased postoperative pain and length of hospital stay without significant increased rates in suture line leakage, intra-abdominal collection and postoperative ileus. No consensus exists as to how to perform the repair of the perforation site. According to the latest World Society of Emergency Surgery (WSES) and European Association of Endoscopic Surgery (EAES) guidelines, the choice of the closure technique should depend on the lesion characteristics. When the margins can be easily brought together without tension, primary repair by direct suturing is indicated. So far, no recommendations are made on the use of an omental patch, as literature evidence is sparse. Damage control surgery should be considered in case of big holes (diameter >2.0–2.5 cm), poor local conditions (i.e., ischemic, necrotic, or severely inflamed margins, difficult to mobilize), and patient’s instability. The present article is accompanied by a video describing a standard laparoscopic direct closure technique in a step-by-step and self-explanatory manner, which will help the reader to visualize the key steps of the procedure.
