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LAPORAN KASUS0leh :
Hermawan A
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Case Report :
Wanita, 85 tahun datang dengan keluhan perut kembung
RPS
3 hari sebelum masuk rumah sakit penderita tiba-tibamengeluh perut kembung ,BAB(-),Flatus (-),mual(+),muntah (-) oleh keluarga di bawa ke RS Tidarmagelang
RPD :
Riwayat BAB lendir (-),darah (-),sulit (-)
.
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Pemeriksaan fisik:KU= sadar,TV : T : 120/80 mmHg RR : 22 x/mnt
BB : 50 kgN : 86 x/mnt S : 36,8 C(aksiler)
Kepala : Turgor menurun (-), mata cowong -Konjungtiva palp anemis (-),sklera tidak ikterik
Thoraks :Jantung : I : ic tak tampak
Pa : ic teraba di SIC V 2 cm medial lmc sinPe : konfigurasi jantung dbnA : suara jantung murni
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Paru : I : simetris statis dinamis
Pa: SF kanan=kiri
Pe: sonor slp
A: SD vesikuler, ST
Abdomen :
I : cembung, gambar/gerak usus +,
venektasi
Pa: tegang, NT -, DM
Pe: hipertimpani, PS +, PA -, PH +
A: BU +, metallic sound (+)
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Genitalia eksterna : wanita dbn
Ekstremitas : akral dingin -, sensorik +/+,
motorik +/+
Colok dubur : TSA cukup, mukosa licin,
ampula rekti kolaps, nyeri tekanmassa/tumor
Sarung tangan : F -, D -, L
Rontgen : FPA 2 posisi
Lab :Hb : 14,9 gr% Na : 138 mmol/l Ureum : 57
L : 14.300 /mm K : 4,1 mmol/l Creat : 0,72
T : 228.000 /mm Cl : 107 mmol/l
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Diagnosis : Ileus obstruksi ecc/ - Hernia Obturator
- Volvulus.
- Malignancy- Intussuseption
Manajemen :- Informed consent
- Inf RL
- Pasang kateter uretra
urine kuning- Pasang NGT 50cc kehijauan
- Inj Ceftriaxzone 1 gram iv
- Persiapan laparotomi eksplorasi
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LAPORAN OPERASI
- Penderita tidur telentang dalam GA
- Desinfeksi daerah op, persempit dgn doeksteril
- Insisi median, setelah peritoneum dibukakeluar cairan jernih, didapatkan dilatasi usus
halus.
- Lakukan eksplorasi tampak ileum terjepitdiforamen obturatorium 30 cm dari ileocecal
junction.- Bebaskan ileum evaluasi non vital
- Lakukan reseksi anastomose end to end
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- Repair hernia ring dengan silk 2.0
- Eksplorasi lebih lanjut, didapati: gaster,duodenum, colon dbn. Hepar, lien dbn.
- Cuci cavum abdomen dengan NaCl fisiologishangat hingga bersih
- Pasang 1 buah drain
- Tutup luka operasi lapis demi lapis- Operasi selesai
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Manajemen H 1 :
- Total Parenteral nutrisi
- Inj Ceftriaxzone 2 X 1 gram iv
- Inj metronidazole 3 X 500 mg iv
- Inj ketorolac 3 X 30 mg
- Inj Ranitidine 2 X 50 mg
- Balance cairan
- Pertahankan DC,NGT,drain
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Evaluasi :
NGT produksi 5 cc
Drain 50 cc
Urine 1 cc/Kg BB
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Abdomen :
I : datar, gambar/gerak usus -,
venektasi
Pa : supel, NT -, DM
Pe : timpani, PS +, PA -, PH +
A : BU (+) min
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Manajemen H 2 :
- Parsial Parenteral nutrisi
- Inj Ceftriaxzone 2 X 1 gram iv
- Inj metronidazole 3 X 500 mg iv
- Inj ketorolac 3 X 30 mg
- Inj Ranitidine 2 X 50 mg
- Balance cairan
- Diit air gula- Pertahankan DC
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Evaluasi :
NGT produksi (-)
Drain 10 ccaff
Urine 1 cc/Kg BB
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Manajemen H 3 :
- Parsial Parenteral nutrisi
- Inj Ceftriaxzone 2 X 1 gram iv
- Inj metronidazole 3 X 500 mg iv
- Inj ketorolac 3 X 30 mg
- Inj Ranitidine 2 X 50 mg
- Balance cairan
- Diit cair I- Aff NGT
- Pertahankan DC
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Manajemen H 4 :
- Inj Ceftriaxzone 2 X 1 gram iv
- Inj metronidazole 3 X 500 mg iv
- Inj ketorolac 3 X 30 mg
- Inj Ranitidine 2 X 50 mg
- Diit cair II
- Pertahankan DC
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Manajemen H5 :
- Inj Antibiotik,analgetik stop
- Obat oral ciprofloxacin 2 X 500 mg
- Diit Lunak
- Aff DC
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Manajemen H5 :
Pulang
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disscusion
Hernia
Protrusion of the peritoneum or
preperitoneal fat through an abnormal
opening in the abdominal wall
Presents as a bulge
Peritoneal contents may be trapped in
sac
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Contents of hernia sac
Bowel (small and large, appendix)
Omentum, bladder, ovary, fallopian tubes
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Causes
Any condition that increases the pressure in the
intra-abdominal cavity may contribute to theformation of a hernia, including the following:
Marked obesity
Heavy lifting
Coughing Straining with defecation or urination
Ascites
Peritoneal dialysis
Ventriculoperitoneal shunt
Chronic obstructive pulmonary disease (COPD)
Family history of hernias[
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Types of Hernia
Indirect hernia
An indirect inguinal hernia follows the tractthrough the inguinal canal
Direct hernia
A direct inguinal hernia usually occurs due to a
defect or weakness in the transversalis fascia
area of the Hesselbach triangle
Femoral hernia
The femoral hernia follows the tract below the
inguinal ligament through the femoral canal
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Umbilical hernia
The umbilical hernia occurs through the
umbilical fibromuscular ring, which usuallyobliterates by 2 years of age
Richter hernia
The Richter hernia occurs when only theantimesenteric border of the bowel herniates
through the fascial defect
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Spigelian hernia
This rare form of abdominal wall hernia occurs
through a defect in the spigelian fascia, whichis defined by the lateral edge of the rectus
muscle at the semilunar line (costal arch to
the pubic tubercle)
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Incisional hernia
This iatrogenic hernia occurs in 2-10% of all
abdominal operations secondary to
breakdown of the fascial closure of prior
surgery
Obturator hernia
This hernia passes through the obturator
foramen, following the path of the obturator
nerves and muscles
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Obturator hernia was first described by Ronsil
in 1724
Incidence of obturator hernia nearly 1% of allhernias
Much more common in females, with a
female:male ratio of 6:1
The gender discrepancy is often explained by
differences in female pelvic anatomy,
including a broader pelvis, a wide obturatorcanal
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Most cases of obturator hernia present in the
seventh and eighth decades
The most common clinical manifestation isintestinal obstruction over 80% of patients
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Anatomy
The obturator foramen is located within the
anterolateral aspect of the pelvis
largest foramen in the body
closed off by the obturator membrane
obturator nerve, artery, and vein enter the
canal
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Clinical Manifestations
An obturator hernia is called the skinny old
lady hernia because thin, elderly, multiparousand debilitated women are at greatest risk for
the development of an obturator hernia
difficult diagnosis common clinical manifestation is intestinal
obstruction
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Obturator neuralgia is manifested as cramping
or as hypoesthesia or hyperesthesia extending
from the inguinal crease to the anteromedialaspect of the thigh
Howship-Romberg sign pain radiating down
the medial aspect of the thigh to the knee
The obturator hernia mass may also be
palpated laterally on a vaginal exam
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Treatment
Methods of repair
simple suture closure
closure of the obturator with adjacent
tissue, and mesh replacement
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