laporan kasus magelang

7/22/2019 LAPORAN KASUS magelang

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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





- 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





- Balance cairan

- Diit cair I- Aff NGT

- Pertahankan DC


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Manajemen H 4 :





- 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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