D/M/43 yo

80.49.57
• Chief complaint: site of operation was open
It has been suffered by the patient since 7 days before
admitted to Adam Malik Hospital. It started when he
was operation 3 weeks ago because he can’t to stool. It
followed by vomitting (-), Fever (-), Defecation (+)
Present State
•Awareness : Alert
•BP : 98/60 mmHg
•HR : 120 bpm
•RR : 20 x/i
•T : 360 C
•VAS :4
Generalized State
•Head : no abnormality was found
•Neck : no abnormality was found
•Chest : no abnormality was found
•Abdomen : In localized state
•Genitalia : no abnormality was found
•Extremities : no abnormality was found
 Localized State

Abdomen :
I : wound post operation o/t mid line,
symmetric, stoma bag (+), distention
(-), visible bowel movement (-), visible
bowel contour (-)
A : peristaltic (+) decrease
P : tympani, liver dullness (-), shifting
dullness (-)
P : pain (+) o/t wound, muscular rigidity
(-), rebound tenderness (-)
Laboratory findings
•Hb/Ht/WBC/Plt : 9,3/27/11.890/485
•Na / K / Cl : 133/4,5/101
•Ur / Cr : 28 / 0,82
•Random Blood Glucose : 128
X-RAY
Working Diagnose :
Burst Abdomen post Hartman Procedure d/t
Adenoma Ca Recti
Treatment in Emergency Dept.
• Nil per mouth
• IVFD Crystalloid 30 gtt/i
• NGT insertion  came out greenish dark fluid 40
cc
• Urine catheter insertion, came out initial urine
100cc  UOP 50cc/hour
• Inj Ceftriaxone 1gr/12 hours
• Paracetamol drips 1gr/8 hours
• Prepare for Exploratory Laparotomy
At the operating theatre :
•In supine position, under GA-ETT
anasthesia, aseptic and antiseptic
procedure
•The midline incision was made, skin,
subcutaneous, linea alba, peritoneum
was opened then came out air and
gastric juice with pus ± 1000 cc  pus
was taken for microbiology examination
•Abdominal cavity was washed with
normal saline.
•Identification of gastric, gastric was
preserved, found perforation on antrum
with size 1,5 x 1 cm; regular edge, active
bleeding (-), mass (-).
At the operating theatre :

•Gastrocolic ligament was opened,

identification posterior gastric wall
 intact
•Excision edge of wound was
performed and take for
histopatology examination.
•Primary Suture was performed
using multifilament absorbable
material 3/0 round body
interuptedly and continued with
omental patch with same material.
•Explore from lig. treitz until rectum
there was fibrin contamination on
the wall of bowel.
At the operating theatre :

•Identification of solid organ  liver and spleen were intact, fibrin (+)
•Fibrin was freed up and abdominal cavity was rinsed until clean using normal
saline.
At the operating theatre :

•Surgical wound closed

layer by layer with leaving
two drainage at
subhepatic and cavum
douglas pouch.
•Operation done.
Follow Up 25 December
S:decrease of conciousness
O: Awareness : be affected by drugs
BP: 130/80 mmHg RR: 22x/I (intubated)
HR: 98 bpm T : 37.60 C

•Abdomen:
I: Symmetric, distension (-), dry surgical wound
P: Soepel,
P: Tympani
A: Peristaltic (+) Normal

•Subhepatic Drain/12hr 200cc seroushemorrage

•Douglas pouch Drain/12hr 20cc seroushemorage
NGT/12hr  Dark fluid
A: Post Exploratory Laparotomy + primary suture + omental patch d/t Gaster perforasi
POD1
P: -Inj Ceftriaxone 1gr/12 hours
-Paracetamol drips 1gr/8 hours
-Inj Ranitidine 25mg/12 hours
Follow Up 26 December
S: decrease of conciousness
O: Awareness : be affected by drugs
BP: 110/80 mmHg RR: 20x/I (intubated)
HR: 90 bpm T : 37.40 C

•Abdomen:
I: Symmetric, distention (-), dry surgical wound
P: Soepel,
P: Tympani
A: Peristaltic (+) Normal

•Subhepatic Drain/12hr 100cc seroushemorrage

Douglas pouch Drain/12hr 10cc seroushemorage
NGT/12hr  Dark fluid

A: Post Exploratory Laparotomy + primary suture + omental patch d/t Gaster perforasi
POD2
P: -Inj Ceftriaxone 1gr/12 hours
-Paracetamol drips 1gr/8 hours
-Inj Ranitidine 25mg/12 hours
Follow Up 27 December
S: decrease of conciousness
O: Awareness : be affected by drugs
BP: 90/60 mmHg RR: 20x/I (intubated)
HR: 98 bpm T : 37.40 C

•Abdomen:
I: Symmetric, distension (-), dry surgical wound
P: Soepel
P: Tympani
A: Peristaltic (+) Normal

•Subhepatic Drain/12hr 100cc seroushemorrage

Douglas pouch Drain/12hr 50cc seroushemorrage
NGT/12hr  Dark fluid

A: Post Exploratory Laparotomy + primary suture + omental patch d/t Gaster perforasi
POD2
P: -Inj Ceftriaxone 1gr/12 hours
-Paracetamol drips 1gr/8 hours
-Inj Ranitidine 25mg/12 hours
• Janitan bekas luka operasi laparotomy
dibuka, tampak bowel conteint
menggenangi small bowel dan dilatasi
small bowel, dilakukan identifikasi
ligamentum treitz, sampai rectum,
tampak adhesi pada small bowell dan
large bowell, fibrin dijumpai dilakukan
adhesiolisi. Identifikasi sekum, tampak
perforasi disekum ukuran 1,5 cm x 1,5 cm.
tampak small bowell odema dan dijumpai
fibrin dan diputuskan untuk melakukan
tindakan hemicolectomy dan dilanjutkan
dengan ileostomy. Kontrol perdarahan,
cuci kavum abdomen dengan NaCl sampai
bersih, jahit luka operasi lapis demi lapis
dan meninggalkan di rectovesika.operasi
selesai.