Professional Documents
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MR
05
28
16
SURGERY REPORT
Name : Mrs. Sari Gumilang
Operator
Prof. dr. H. I. O. Marsis, SpOG
Asistant 1
dr. Reza Marsis
Asistant 2
Ramot Arif Banamtuan
Sex : Female
Anesthetic
Instrumentator
Observer
Age : 27 Years
Dr. Widodo, SpAn
Zr. Ida Tupa
Anggun Valensia Manja
4. Curettage
5. Hysteroscopy Diagnostic
Operation Procedures:
I.
II.
Aseptic and antiseptic were done on abdominal region, external genital region, internal genital, and
around.
III.
Applied sims speculum at posterior vagina continue with sims speculum at anterior vagina
IV.
Anterior portio clamped with kohel tang at 12 hour direction. Put off anterior sims speculum.
V.
Doing sonde uterus to determine the length to the uterus, uterine length 8 cm anteflexion.
VI.
Doing the curettage of the uterine cavity, clockwise direction starting at 12.00 with curette tang 0 to 3
VII.
2.
Insertion of hysteroscopy to see the endometrial wall and ostium tubae internum dextra et
sinistra. Do exploration :
a. The mucosa of cavum uteri is looked pink and normal
b. The ostium tubea internum dextra : bubble (+), sinistra : bubble : (-)
3.
Conclusion :
a. Left fallopian tube is occluted
VIII.
Planning : LD/LO
IX.
Patient made in tredelenburg position or the head lower than pelvic area
2.
Skin on the left and right of umbilicus were clamped using two doek tissue clamped made
incision 1 cm below the umbilicus using scalpel
3.
Abdominal wall was lifted and the Verees needle inserted into umbilical area to intraperitoneal
space.
4.
Pneumoperitoneum procedure or the abdominal cavity is filled with CO2 gas help move
abdominal wall and any organs way out, creating a larger space to work.
5.
Incision 0,5 cm was made on the right and left ilioinguinal region using scalpel, and then the
trocar was inserted into the incision.
6.
Laparoscope was inserted into the main trochar and the gasper was inserted into the small
trochar.
7.
Uterus, pelvic cavity, ovaries, fallopian tubes and the abdominal cavity were inspected
(explored) :
a. Corpus uteri is looked pink, slippery surface, as big as pears.
b. The left ovarian adhesion with the left fallopian tube
c. The right ovarian looks white with slippery surface, as big as egg.
d. The left fallopian tube looks a mass, as big as egg.
e. The right fallopian tube normal.
8.
9.
X.
Conclusion
a. The left ovarian is adhesion to the left fallopian tube.
b. Ectopic Pregnancy.
Planning :
a. Adhesiolysis
b. Salphingectomy Sinistra
c. Micro curettage
XVII.
Consciouness
: Compos Mentis
Blood pressure
110/70
mmHg
Pulse rate
98 x/minute
Respiration
22 x/minute
Temperature
36,7 oC
Operator,