P/F/37yo

77.45.02
Chief Complain : Unable to defecate
It has been suffered by the patient since 2 days
before admitted to Adam Malik Hospital. Previously,
patient had diarhea 2 weeks ago. History of nausea
and vomiting were found. Patient has undergone
right hemicolectomy 2 years ago due to colon tumor,
then followed by chemotherapy 6 times. History
changing of bowel habit was found in this 3 months.
History of losing body weight was found ± 8 kg in 3
months. History of anorexia was found. Micturition
was normal.
 Present state :
Awareness: Alert
BP : 100/70 mmHg
HR : 96 x/minutes
RR : 20 x/minutes
T : 36,80 C
VAS :5
 Generalized State
Head : no abnormality was found
Neck : no abnormality was found
Chest : no abnormality was found
Abdomen : in localized state
Genitalia : female, no abnormality was found
Extremity : no abnormality was found
Localized state
Abdomen:
I : Symmetric, distention (+), midline incision
scar (+), visible bowel contour (+), visible
bowel movement (+)
A : peristaltic (+) increased, metallic sound (-)
P : Palpable mass in right lower abdomen
sized 5x4x2 cm, with solid consistency,
immobile, clear margin, tenderness (+),
muscular rigidity (-)
P : hypertymphani

Digital rectal Examination:

Perineum normal, tight anal sphincter tone,
slippery mucosa, ampulla recti was collapse,
mass (-)
Gloves : stool (+), blood (-), mucous (-)
 Laboratory findings

•Hb / Ht / L / Plt : 10.8 / 32 / 9.030 / 357.000

•Ur / Cr : 32 / 0,65
•Na / K / Cl : 137 / 3,8 / 98
•Glucose ad random : 119
Chest X-ray
Abdomen X-ray in Supine & Erect Position

Supine Erect
 Working Diagnosis
Total Mechanical Bowel Obstruction d/t Suspect
 Management in the ER:
– Nil per mouth
– IVFD crystalloid
– Insertion of NGT  came out yellowish liquid for
about 100 cc
– Insertion of urine catheter  came out initial clear
yellowish urine for about 200cc, UOP 40 cc/hour
– Inj. Antibiotic
– Inj. Analgetic

– Plan: Laparatomy Exploration Emergency

 At Operating Theatre
• Patient in supine position, with GA-ETT anesthesia. Aseptic and antiseptic
procedure were perfomed
• The midline incision was made, skin, subcutaneous, linea alba and peritoneum was
opened
• Identification of abdominal cavity, small bowel was dilated, tumor was found 217
cm from treitz ligament, intralument, size 5x4x2 cm, immobile. Limph node was
found 315 cm from treitz ligament.
• Identification of bowel proximally from the blockage, the bowel was colapsed until
large bowel, tumor was found on the ovarium, extralument, size 10x5x4 cm,
moblle.
• Tumor was resection with margin 5 cm from tumor and perform ileo colon
anastomosis with silk material 2.0.
• Ovarium mass was resection and histopatological examination .
• Decompression was performed from small bowel to distal, passage was clear
• Bleeding was controlled, abdominal cavity was rinsed with normal saline
• Surgical wound was closed layer by layer by leaving 1 drain to rectovesical pouch
• Operation was finished
During Operation
Post Operation