P/M/77yo

81.22.14
Chief complaint : Unable to defecate
It has been suffered in 2 days before admission. History of having
lump was found at his right inguinal for 3 years, the lump
occured oftenly when patient doing an excessive job or straining,
and the lump dissapeared when the patient resting. The lump
has persisted for 7 days. Pain (+) inttermitenly. Nausea and
vomitus (-), flatus (-). Micturation (+). History of chronic cough
(-). Patient work as a porter in factory for 30 years.
History of smoking (-)
History of past illness : DM (-), HT (-)
History of previous surgery (-)
Present State :
• Awareness : Alert
• BP : 130/70 mmHg
• HR : 88 beats/minute
• RR : 18 times/minute
• Temp : 36,8 0 C
• VAS Score : 3
Generalized State
• Head : No abnormalities was found
• Neck : No abnormalities was found
• Chest : No abnormalities was found
• Abdomen : In localized state
• Genital : Male, In localized state
• Extremity : No abnormalities was found
Localized state:
• Abdomen:
I : symmetrical, distention (-), visible bowel movement (-)
A: peristatic (+) increase, metallic sound (-)
P: liver dullness (+), tympani
P: smooth, muscular rigidity (-)

• DRE :
Perineum was normal, Anal Sphincter Tone was tight,
smooth mucosal layer, ampula recti was collapsed,
mass(-), pain (-)
Gloves : blood (-), feces (+),mucous (-).
• Genitalia:
Male, mass (+) on (R) scrotum, soft consistency,
smooth surface, well circumscribed, color similar
to the surrounding skin, transillumination (-),
pain (-), peristaltic (+), size 7x4x2 cm.
Clinical
Chest x-ray
Laboratory Finding
• Hb/Ht/Wbc/Plt : 12.5/35/16830/287
• Na/K/Cl : 135/2.5/103
• Rapid Test anti Covid-19 : Non reaktif
Working Diagnosis : (R) Incarcerated Lateral
Inguinal Hernia + Hipocalcemia
Management at Emergency Department :
• Fasting
• IVFD Crystalloid
• Inj.Antibiotic
• Inj.Analgetic
• Installation of NGT, came out clear liquid about 100 cc
• Installation of Catheter, came out initial urine output
about 100 cc with clear yellow colour
• Calium substitution : 15 meq KCl on D 5%
• Plan for (R) Hernioraphy emergency
 Operation Theatre
• Patient in supine position under Spinal
Anesthesia, aseptic and antiseptic
procedure was done.
• Incision (R) inguinal oblique: cutis,
subcutis, external oblique aponeurosis
were divided
• Both flaps were mobilized
• Lifting sprematic cord from inguinal
canal at pubic tubercle and then
dissecting bluntly until the cord
completely free
• Sac was seen and opened.
Sac content was small bowel
and caecum approximately
20 cm illeocaecal junction to
caecum.
• Internal ring was release,
then identification of wedge
area. Compressed with
warm saline, and tactile
stimulated, color
reddish,peristaltic (+), seems
viable.
• Sac content returned
to abdominal cavity.
• Proximal and distal
sac were separated
and the proximal one
was ligated at the
preperitoneal fat.
• A 15x7 cm prolene mesh
was applied and fixated
to tuberculum pubicum,
conjoint tendon,
inguinal ligament.
• Bleeding was controlled,
surgical wound was
closed layer by layer.
• Operation was done.