P/M/58yo

20.97.98
Chief complaint : Pain on the Left inguinal
It has been suffered by the patient since 1 day before admitted
to Pirngadi hospital, pain was felt intermittently. Previously there
was a lump on the left scrotum since 10 years ago, initially the
lump can reduce spontaneously when patient rested. The lump
was getting bigger since 2 days ago and can’t reduced and
remain in the scrotum. History of nausea was found and
vomiting was not found. Patient was unable to pass stool since 2
days ago but flatus was found. Micturition was found normal.
History of traditional massage and trauma were not found.
History of chronic cough wasn’t found. Patient was a farmer and
used to lift heavy weight.
History of Past Illness : (-)
History of Past Medication : (-)
 Generalized State
• Awareness: Alert
• BP : 115/79 mmHg
• HR : 104 bpm
• RR : 22 tpm
• T : 36,7°C
• VAS :5
• BW : 70 kg
 Localized State
• Head : no abnormality was found
• Neck : no abnormality was found
• Chest : no abnormality was found
• Abdomen : in Localized state
• Genitalia : Male, in Localized state
• Extremities : No abnormality was found
Localized State :

Abdomen
I : Symmetrical, distension (-),
visible bowel contour (-), visible
bowel movement (-)
A : Peristaltic (+) increased ,
Metallic sound (-)
P : Soepel, tenderness (+),
Muscular rigidity (-)
P : Tympany, liver dullness (+)

DRE :
Perineum was normal, tight anal
sphincter tone, smooth mucosal layer,
ampula recti was not colapse, mass (-)
Gloves: feces (+), blood (-), mucous (-)
Genitalia:
I : Lump on the left inguinal,
color similar to the surrounding
skin, Hyperemic (-)
P : Lump with soft consistency,
smooth surface, well
circumscribed, immobile,
unclear border, sized7x5x5 cm,
transilumination test (-), testis
was palpable, tenderness (+)
 Laboratory Findings

• Hb/Hct/WBC/PLT : 13.2 / 41,5 / 12,000 / 217.000

• Na/K/Cl : 139 / 3,13 / 107,20
• Ur/Cr : 28 / 0,78
• Blood Glucose : 140
Chest Xray Erect
 Working Diagnosis:
(R) Incarcerated Lateral Inguinal Hernia

Plan:
Herniorraphy Emergency
 Treatment at The Emergency Room
TIME TREATMENT
11.00 • Fasting
• Insertion of NGT  came out yellowish fluid about 50cc
• Insertion of Urinary catheter, came out 150 cc clear yellow urine, UOP
60cc/hr
• IVFD Crystalloid  Ringer Lactate 20 dpm
• Inj. Antibiotic  Ceftriaxone 1 gram IV
• Inj. Analgetic  Ketorolac 30 mg IV
12.15 • Laboratory test
• Chest X-Ray
13.00 • Plan : Herniorraphy Emergency
• Consult to Anesthesiologist
15.00 • Patient undergone surgery
 In Operation Theatre
• Patient in supine position under
Spinal Anesthesia, aseptic and
antiseptic procedure was done.
• Incision (L) inguinal oblique, 2 cm
medial from the anterios
superios iliac spine to pubic
tubercle about 1 cm above,
cutis, subcutis, external oblique
aponeurosis was opened sharply
until internal ring.
• Incarcerated part was released.
• Sac was dissected free from
ilioinguinal nerve and sprematic
cord. Hernia sac was opened.
• Sac content was omentum
approximately as long as 20 cm
and came out ascites fluid about
200cc, omentum seen pale (-),
viable (-), perforation (-), oedem
(+), contamination (+) from
ascites fluid.
• Decided to perform
omentectomy, omentum was
sutured using multifilament
material 2.0 RB.
• Sac content returned to
abdominal cavity.
• Proximal and distal sac were
separated and the proximal part was
ligated.
• The polypropylene mesh was cut into
keyhole shaped and sutured medially
to pubic tubercle. Inferiorly to the
inguinal ligament and laterally to
conjoint tendon.
• Wound was cleaned with normal
saline. Bleeding was controlled,
surgical wound was closed layer by
layer leaving 1 drain subcutis.
• Operation was done.