UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma

Period January 19th – 23th 2022

Patient
No Date Name Detail of Patient Treatment Recommendation
1. 21/01/2022 Ms.D  Consulted by orthopedic surgeon with - Treatment By  Vaginal
22 years old Closed Fracture Transabdominal Left Sacral Orthopedic Surgeon : hygiene
MR : I-V Denis Classification Zone 2 + Closed - Open Reduction  Educate to
962829 Fracture Transbadominal Right Sacral V of Fracture with increase fiber
Denis Classification Zone 2 + Closed internal fixation, intake, drinking
Wahidin Fracture Coccygeal + Closed Fracture dorsal and plenty of water
Sudirohsodo Bilateral Superior et Inferior Ramus Pubis + dorsolumbar and using stool
Hospital Lacerated Wound Right Perianal Grade I fusion, posterior softener for 2
 History of being hit by Motorcycle and Truck technique weeks
2 hours before admission  Perform pelvic
floor and anal
Pelvic X-Ray Result : - Treatment by Obgyn : sphincter
 Bilateral ramus superior and inferior - Repair 3A degree exercise
fractures of perineal  Evaluation of
 Intermediate left crista sacralis fracture laceration with end sphincter healing
with displaced cranioposterior to end in 3-6- 9-12
 Intermedia crista sacralis fracture at the sphincteroplasty : weeks after
level of the right 5th sacral vertebra - EAS repaired with operation
PGA 2.0 end to  Inform the
Abdominal CT-Scan Result : end technique patient about risk
 Bilateral fracture of superior and inferior - Vaginal muscle of developing
ramus repaired with PGA anal
 Left Intermediate sacral crista fracture of 2.0 continuous incontinence
I– IV sacral vertebrae with fracture suture
fragment shifting cranioposteriorly - Vagina mucosa
 Right Intermediate crista sacralis fracture repaired with PGA
at the level of the 5th sacral vertebra 2.0 continuous
suture
 Other intrabadominal organs within
- Lactulose syrup 30
normal limits
mg/ 8 hours/orally
Pre-Operative Diagnosis
3A degree of perineal laceration + Closed
Fracture Transabdominal Left Sacral I-V
 UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma
Period January 19th – 23th 2022
Denis Classification Zone 2 + Closed
Fracture Transbadominal Right Sacral V
Denis Classification Zone 2 + Closed
Fracture Coccygeal + Closed Fracture
Bilateral Superior et Inferior Ramus Pubis

Post-Operative Diagnosis
3A degree of perineal laceration + Closed
Fracture Transabdominal Left Sacral I-V
Denis Classification Zone 2 + Closed
Fracture Transbadominal Right Sacral V
Denis Classification Zone 2 + Closed
Fracture Coccygeal + Closed Fracture
Bilateral Superior et Inferior Ramus Pubis

Pelvic X-Ray : Abdominal CT-Scan :

UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma
Period January 19th – 23th 2022
 UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma
Period January 19th – 23th 2022

2. 21/01/2022 Ms.GE  History of being hit by Motorcycle 1 hour  Repair 3B degree of  Vaginal
24 years old before admission perineal laceration hygiene
MR :  Chief Complaint : Bleeding from the anus with end to end  Educate to
963718 sphincteroplasty : increase fiber
- EAS repaired with intake, drinking
Wahidin Pre-Operative Diagnosis PGA 2.0 end to plenty of water
Sudirohsodo 3B degree of perineal laceration end technique and using stool
Hospital - Lactulose syrup 30 softener for 2
Post-Operative Diagnosis mg/ 8 hours/orally weeks
3B degree of perineal laceration  Perform pelvic
floor and anal
sphincter
exercise
 Evaluation of
sphincter healing
in 3-6- 9-12
weeks after
operation
 Inform the
patient about risk
of developing
anal
incontinence
UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma
Period January 19th – 23th 2022

Pre-Operative : Post-Operative :

EAS
 UROGYNECOLOGY AND RECONSTRUCTIVE DIVISION / Edward Chandra Koesuma
Period January 19th – 23th 2022

Total Cases :
• End to End sphincteroplasty :2

Makassar, January 24th 2022

Resident :

dr. Edward Chandra Koesuma

Known By
Supervisor :

dr. David Lotisna, Sp.OG(K)

UROGY
NECOL
OGYDIV
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