S/F/40Yo

90.11.75
 Chief Complaint : Unable to defecate
It has been suffered by the patient since 4 days before admitted to
Adam Malik Hospital. The symptom was followed by abdominal
enlargement. Patient also felt pain on his abdomen intermittently,
fever was not found, nausea and greenish vomiting was found.
Micturition was normal. History of bowel habit changing was found,
history of diarrhea was found since 1 month ago, history of goat like
stool was not found, bloody stool was not found. History of fever was
not found. History of body weight loss was found. History of trauma
or traditional massage and traditional medicine consumption was
denied. History of previous abdominal surgery was found (Section
Caesarean).
History of past illness : -
History of past medicine : -
 Present State :
Awareness : Alert
Blood pressure : 100/70 mmHg
HR : 98 bpm
RR : 22 tpm
Temp : 37.3 C
VAS :4
BW : 50 kg
 Generalized State :
Head : No abnormality was found
Neck : No abnormality was found
Chest : No abnormality was found
Abdomen : Localized state
Genitalia : female, no abnormality was found
Extremities : No abnormality was found
Localized state :
Abdomen :
• I : Symmetrical, distension (+), visible
bowel contour (+), visible bowel
movement(-).
• A : Peristaltic (+) increased ,metallic
sound (+)
• P : Tenderness (+), muscular rigidity (-)
• P : Tympani (+), liver dullness (+)

DRE :
• Perineum was normal, tight anal sphincter
tone, smooth mucosal surface, pain (-),
mass (-), Ampulla recti was collapse.
• Gloves : feces (+), blood (-), mucus (-).
 Laboratory findings:
Hb / Hct / WBC / PLT : 15.1 /48/ 11.730/282.000
Na / K / Cl : 152 / 3.4 / 112
Ur / Cr : 0,64 / 37
Random Blood Glucose : 76
Chest X-Ray
Abdominal X-Ray
 Working diagnosis
Total Mechanical Bowel Obstruction d/t Susp. Sigmoid colon
tumor sugg malignant cT3N0M0

Plan
Exploratory Laparotomy
 Management at Emergency Room
Time Treatment
01.00 • Nil per mouth
• IVFD Crystalloid 30 dpm
• Insertion of NGT → came out greenish fluid 200 cc.
• Insertion of urinary catheter → came out clear yellow urine, initial
100 cc, UOP 30cc/hour dark yellow
• Inj. Antibiotic → Ampicillin sulbactam 1gr iv
• Inj. Analgesic → Ketorolac 30 mg iv

02.00 • Laboratory Test

• Radiology Test
03.00 • Plan : Exploratory Laparotomy
• Consult to internal medicine department
• Consult to Anesthesiologist
05.00 • Patient undergone Surgery
 In operating theatre
 Patient in supine position under general
anasthesia, aseptic and antiseptic
procedure was performed.
 Midline incision, cutis, subcutaneous,
linea alba and peritoneum was opened,
seen dilated small bowel, small bowel
was brought aside, covered with moist
gauze
 Identification of small bowel, from
Ligamentum Treitz to Ileocecal Junction,
dilatation (+), adhesion (-), perforation
(-)
 In operating theatre
 Identification of large bowel from
caecum until rectum, seen dilated
large bowel from Caecum to
descending colon and found mass
on sigmoid colon, adhere to the
mesosigmoid, solid consistency,
irregular border, immobile,
intraluminal, size 6x4x2cm, at the CRANIAL
7 cm orally from peritoneal
reflection.
• Identification of solid organ, liver
was smooth. No palpable nodes.
• Decided to performed
sigmoidectomy
• By performed an incision in left white
line close to the lateral wall of the
descending colon from the sigmoid proximal
upward to lienalis flexure.
• Descending colon was mobilized with
care preserving of (L) ureter.
distal
• All of sigmoidalis artery and vein
branches were identified, ligated and
cut.
• Sigmoid colon is then resected until 10 CRANIAL
cm from peritoneal reflection. The
resected colon was sent to pathology
anatomy for histopathology
examination.
• Distal stump was closed with
distal
nonabsorbable material 2.0 tapered
body
• Proximal stump was made single
barrel stoma on the contra
Mcburney position by fixated it on
aponeurosis at 8 direction with
nonabsorbable material 2.0
tappered body.
• The abdominal cavity was washed
with warm normal saline until
clean.
• Bleeding was controlled.
• The surgical wound was closed
layer by layer with leaving 1
drainage at cavum Douglass
pouch.
• Operation was done.