LAPORAN KASUS0leh :

Hermawan A

Case Report :Wanita, 85 tahun datang dengan keluhan perut kembung RPS± 3 hari sebelum masuk rumah sakit penderita tiba-tiba

mengeluh perut kembung ,BAB(-),Flatus (-),mual (+),muntah (-) oleh keluarga di bawa ke RS Tidar magelang

RPD :Riwayat BAB lendir (-),darah (-),sulit (-)

.

Pemeriksaan fisik:KU= sadar, TV : T : 120/80 mmHg RR : 22 x/mnt BB : 50 kg

N : 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 sin Pe : konfigurasi jantung dbn

A : suara jantung murni

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 (+)

Genitalia eksterna : wanita dbnEkstremitas : akral dingin -, sensorik +/+, motorik +/+Colok dubur : TSA cukup, mukosa licin, ampula rekti kolaps, nyeri tekan

massa/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

Diagnosis : Ileus obstruksi ec c/ - 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

LAPORAN OPERASI- Penderita tidur telentang dalam GA- Desinfeksi daerah op, persempit dgn doek

steril- Insisi median, setelah peritoneum dibuka

keluar cairan jernih, didapatkan dilatasi usus halus.

- Lakukan eksplorasi tampak ileum terjepit diforamen obturatorium 30 cm dari ileocecal junction.

- Bebaskan ileum evaluasi non vital

- Lakukan reseksi anastomose end to end

- Repair hernia ring dengan silk 2.0- Eksplorasi lebih lanjut, didapati: gaster,

duodenum, colon dbn. Hepar, lien dbn.- Cuci cavum abdomen dengan NaCl fisiologis

hangat hingga bersih - Pasang 1 buah drain- Tutup luka operasi lapis demi lapis- Operasi selesai

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

Evaluasi :

NGT produksi 5 cc

Drain 50 cc

Urine 1 cc/Kg BB

Abdomen :

I : datar, gambar/gerak usus -, venektasi –

Pa : supel, NT -, DM –

Pe : timpani, PS +, PA -, PH +

A : BU (+) min

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

Evaluasi :NGT produksi (-) Drain 10 cc affUrine 1 cc/Kg BB

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

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

Manajemen H5 :

- Inj Antibiotik,analgetik stop

- Obat oral ciprofloxacin 2 X 500 mg

- Diit Lunak

- Aff DC

Manajemen H5 :

Pulang

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”

• Contents of hernia sac

– Bowel (small and large, appendix)– Omentum, bladder, ovary, fallopian tubes

Causes Any condition that increases the pressure in the

intra-abdominal cavity may contribute to the formation 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[

• Types of Hernia• Indirect hernia An indirect inguinal hernia follows the tract

through 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

• Umbilical hernia The umbilical hernia occurs through the

umbilical fibromuscular ring, which usually obliterates by 2 years of age

• Richter hernia• The Richter hernia occurs when only the

antimesenteric border of the bowel herniates through the fascial defect

• Spigelian hernia This rare form of abdominal wall hernia occurs

through a defect in the spigelian fascia, which is defined by the lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic tubercle)

• 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

• Obturator hernia was first described by Ronsil in 1724

• Incidence of obturator hernia nearly 1% of all hernias

• 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 obturator canal

• Most cases of obturator hernia present in the seventh and eighth decades

• The most common clinical manifestation is intestinal obstruction over 80% of patients

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

Clinical Manifestations• An obturator hernia is called “the skinny old

lady hernia” because thin, elderly, multiparous and debilitated women are at greatest risk for the development of an obturator hernia

• difficult diagnosis• common clinical manifestation is intestinal

obstruction

• Obturator neuralgia is manifested as cramping or as hypoesthesia or hyperesthesia extending from the inguinal crease to the anteromedial aspect 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

Treatment Methods of repair simple suture closure closure of the obturator with adjacent

tissue, and mesh replacement