In selected nonseptic, nonperitoneal patients, nonoperative management is appropriate if perforation is contained without free extravasation of contrast on enhanced imaging. Rapid exploration and repair in the operating room is the cornerstone of treatment for patients who present critically ill with pneumoperitoneum. Even with prompt care, mortality reaches 15%. While the open approach remains the gold standard, laparoscopy has been described for omental patching and vagotomy procedure with good outcomes. Limited studies are available as this continues to be an evolving technique. In patients with profound shock or hemodynamic instability, open repair is required. For most small (<1 cm) duodenal ulcers patching, the defect with omentum without primary closure is satisfactory. Although some surgeons prefer primary closure and omentoplasty, the editors do not favor primary closure given the edema and friability of the ulcer’s edges. The same technique may be used in small gastric ulcers if the suspicion for malignancy is low or if the patient is too unstable to tolerate a more complex repair. Gastric ulcers should always be biopsied intraoperatively. For larger or more suspicious lesions, a distal gastrectomy including the ulcer bed should be performed. Ideally, a Billroth I (antrectomy with gastroduodenostomy) reconstruction is preferred but a Billroth II (antrectomy with gastrojejunostomy) may be required depending on condition of the duodenal stump and the extent of the gastrectomy.