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SURGERY CASE REPORT

Created by Satya Wardhana, MD, General Surgeon


in Kanujoso Djatiwibowo Hospital Balikpapan East Borneo Indonesia

Case I :
Man, 19 years old, came to hospital on July 11th,
2008 with chief complain: pain at the lower abdomen
History : Had been suffered since about 2 hours
before admitted to the hospital cause of traffic
accident.
Mechanism of Injury : Patient was riding motorcycle,
abruptly another motorcycle struck him from left
direction, then the patient fell to right direction and a
right wrist was pinned beneath handlebar of him
motorcycle.
Furthermore, the patien complained about pain at a
right wrist too. No pain at right flank.
Micturation not yet since the accident.
Primary Survey:
A : patent
B : RR = 24 x/mnt, symetric, thoracoabdominal
type
C : PR = 88 beat/mnt, regular and adequat
BP = 120/80 mmHg
D : GCS 15 (E4M6V5)
E : normothermy, (axillary temperaturer = 37.1 oC)
Secondary Survey
Abdomen
I : Convex, excoriated lesion and bulging at the left
lower abdomen, synchronize with breath motion
(see picture below)
P : Tenderness and crepitation at left lower abdominal

wall, bulging can pull in and turn up again,


no defans muscular
P : There were liver dullness and tympanic
A : There was bowel sound at bulging area, peristaltis
was normal
Digital Rectal Examination :
Sphincter tone was still tight, mucous layer was
smooth, ampula empty, no collapse and no
dilatation,
Gloves : no blood, no slime, no feces
Abdomen X-Ray
Laboratory Findings

WBC : 22.3x103/µl
RBC : 4.84X106µL
HGB : 14.4 gr/dl
HCT : 42,7 %
PLT : 334.000/µL
CT : 7’00”
BT : 2’00”
Preoperation Diagnosis

Rupture of Small Intestine Cause of


Abdominal Blunt Trauma
Management :

Stop oral intake


IV-line
Apply NGT
Prophylactic antibiotic
Analgetic
Laparotomy exploration
OPERATION PROCEDURE
Patient lied supine under general anesthesia
Sterilization procedure and drapping
Incision midline 3 finger above umbilicus until 3 finger above
symphysis pubis
Deepen until peritoneum, open peritoneum
Flew out blood about 300 cc derive from laceration of rectus
abdominis muscle and aa. jejunalis
Explorate solid organs did not find any laceration, continued
explorate hollow viscus, found total jejunum laceration about
55 cm from treitz’s ligament, laceration of jejunomesenterium
about 80 cm from treitz’s ligament
Perform excision both of jejunum stump, then perform end to
end jejuno-jejunal anastomosis and stitches the mesenterium
on both side.
Wash the abdomen cavity until clearly.
Close the wound layer by layer without drain
Operation finished.
Incision midline 3 finger above umbilicus until 3 finger above symphysis pubis
Deepen until peritoneum, open peritoneum
Flew out blood about 200 cc derive from laceration of rectus abdominis muscle and aa. jejunalis
Explorate solid organs did not find any laceration
Explorate hollow viscus
Laceration of jejunomesenterium about 80 cm from treitz’s ligament
Laceration of jejunomesenterium about 80 cm from treitz’s ligament
Perform excision both of jejunum stump
Perform tegel stich at both side
Continued end to end jejunojejunal anastomosis serosubmuscular continuous suture
End to end jejunojejunal anastomosis finished, continued Lambert’s suture
Stitches the mesenterium on both side with interuptus suture
Stitches the mesenterium on both side with interuptus suture finished
caudal cranial
Postoperation Diagnosis

Total Rupture of Jejunum


Laseration of Jejunomesenterial