Bayi ny H/M/3 day

69.31.80
Keluhan Utama : Tidak dijumpai lubang anus
Hal ini terjadi saat setelah pasien dilahirkan 3 hari
yang lalu sebelum masuk rumah sakit Pirngadi
Medan. Riwayat dilahirkan dengan sectio caesaria,
waktu kehamilan 37 minggu, dengan berat 4000 gr,
panjang badan 50 cm, riwayat sianosis (-), riwayat
demam (-). Muntah (+) setelah diberikan susu.
Riwayat konsumsi obat herbal dan tradisional di
sangkal. Riwayat kelainan bawaan di keluarga
disangkal.
Status present :
Sensorium : Compos mentis
HR : 160 x/i
RR : 34 x/i
T : 37.0 °C
BW : 4000 gr
Status Generalisata
Kepala : dalam batas nornal
Leher : dalam batas nornal
Dada : dalam batas nornal
Abdomen : status lokalisata
Extremitas : dalam batas nornal
Genitalia : laki-laki, dalam batas nornal
Anal : status lokalisata
Localized state
Abdomen:
I: Simetris , distention (+),
bowel movement (-),
P: Soeple (+),palpable mass(-),
P: Tympani, undulation (-)
A: Peristaltic (+) melemah.
Stasus lokalisata
Perianal :
Lubang anus (-) , fistula (-),
flat bottom (-), bucket
handle (+)
Knee chest position
Babygram
 Laboratorium findings:
•Hb / Ht / Wbc / Plt : 14.1/39.1/5.44/305
•Ur / Cr : 44/0.97
•Neu : 47.7
Working Diagnosis:
Anorectal malformation lower type without
fistula
• Terapi di IGD:
- IVFD D5%: ND 0,225% 20 gtt/i
- OGT
- Inj.Antibiotic  inj cefotaxime 100mg (skin
test)
- Inj ranitidin 10 mg
- Kateter urin
In Operating theater
• Patient in supine position with ETT general anasthesia, aseptic
antiseptic procedure was performed
•Transverse incision on contra Mc burney skin, subcutaneous ,
fascia, muscle was cut and peritoneum was opened, came out 5cc
serous fluid
•Identification of sigmoid and then performed temporary fixation
with nelathon catheter
•Spoor the sigmoid with 2 sututes on each sides, sigmoid is fixated in
8 directions
•Stoma was then separated into proximal and distal stomas, with
proximal stoma on lateral side and distal stoma on medial side, and
meconium came out
•Control bleeding
•Stoma was closed with stoma bag
•Operation was finished
Durante op
Post OP