Decubitus X-Ray - Figure 1 A 5-year old boy with an 8-day history of vomiting & intermittent fever.  He responded to supportive care at home & tolerated liquids fairly well.   On the day prior to going to the ER, the boy began to complain of abdominal pain.  A CT scan was completed but no sign of any problems found.  After being transferred to the children’s hospital, the child appeared to have an acute surgical abdomen.  Plan decubitus x-rays showed free air in the abdominal cavity (fig. 1).

Clinical Photograph of the Ulcer at Presentation - Figure 2 The boy was taken to the operating room & laparoscopic evaluation demonstrated a perforated post pyloric channel ulcer (fig. 2).  Repair & Graham patch (omental patch).  The repair was completed laparoscopically with three 5mm working ports.