PRESENTASI KASUS

Pria umur 36 tahun dengan benjolan di perut dan inguinal

Disusun Oleh
Galih Arya Wijaya
20090310130


Diajukan Kepada :
Dr. Sutikno Sp. B




ILMU BEDAH
RSUD MUNTHILAN
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH YOGHYAKRTA
2013




REFLEKSI KASUS

I. IDENTITAS
Nama : Ambar Ariyanto
Umur : 36 tahun
Jenis Kelamin : Laki-laki
Status : Kawin
Alamat : Gergunung, Mungkid
Tanggal Masuk : 05 Januari 2014

II. ANAMNESIS
A. Keluhan utama : Benjolan pada perut
B. Riwayat penyakit sekarang
Pasien pria berumur 36 tahun datang dengan keluhan benjolan di bagian perut
yang semakin membesar dengan cepat mulai dari awal Juli lalu. Ukuran benjolan
sebesar bolas epk takraw. Belakangan ini berat badan turun banyak. Dari anamnesis
didapatkan bahwa pasien pernah menjalani operasi di bagian inguinal di rumah sakit
cirebon. Benjolan yang pertama kali terasa keluar adalah benjolan yang di inguinal
lalu disusul benjolan yang ada di perut. Pasien pernah beroat ke herbal membaik
sebentar lalu memburuk kembali. Pasien mengaku testis tidak turun ke scrotum dari
kecil.

III. PEMERIKSAAN FISIK
Keadaan Umum: Lemah Kesadaran : Compos Mentis
Vital Sign
- Td :120/80
- t : 37,6 C
- RR : 22x/m
- Nadi : 80x/m
Kepala dan leher
Kepala : simetris, tidak ada hematoma
Mata : conjunctiva anemis (-/-). Sklera ikterik (-/-)
Mulit : lidah tidka kotor, faring hiperemis (-)
Leher: tidak ada benjolan dan pembesaran kalenjer limfe
Thorax
Jantung : s1, s2 reguler, gallop(-), murumur(-)
Paru : vesikuler(+/+), bronki (-/-), wheezing (-/-)
Abdomen
Inspeksi : Massa pada regio abdomen dengan ukuran 20x20x10, benjolan pada regio
inguinal 3x10cm
Auskultasi : bising usus (+), .metalic sound (-)
Palpasi : massa keras, immobile, nyeri (-)
Perkusi : pekak (+)
Ekstremitas
DBN

IV. PEMERIKSAAN LABORATORIUM
AL : 13,51 ribu/ul
Hb : 10,5g /dl
Eritrosit : 4,1juta/ul
MCV : 75,1 fl
MCH : 25,6 pg
MCHC : 34,1 g/dL
Trombosit : 408 ribu /ul
Ureum : 44
Creatinine : 1,08
EKG : normal ECG
USG Abd : Sugestif Tumor Omentum
V. DIAGNOSIS
Pre-Op:
Tumor Omentum
Post-Op:
Tumor retroperitonial post laparotomy
Biopsi eksisi


VI. PENATALAKSANAAN
Laparatomi
IVFD RL 20 tpm
Ceftriaxone 2x1 gr
Kalnex 3x1 500mg
Ketorolac 3x30mg
Ranitidine 2x1 amp



VII. PEMBAHASAN
Retroperitonial tumors are malignant and arise from a mesenquimatous origin.
Usually involving important anatomical structures such as main abdominal vessels
and organs, their radical approach often necessitates major resections of these
viscera.
Surgery of the inferior vena cava
I nferior vena cava involvement by primary and secondary tumors has been
traditionally considered an unresectability criterion. Currently, thanks to the
technical development of surgery (mainly after liver transplantation
development) and the creation of new prosthetic materials for vascular repair,
inferior vena cava resections are feasible and safe in a selected group of
patients.

The retroperitoneum is the anatomical space limited by the peritoneum at the
front, the abdominal wall at the back, the twelfth rib at the top, and the sacrum and
crest of the ileum at the lower side. Some organs, such as the kidneys, ureters, and
adrenal glands are located in this space.

The primary retroperitoneal tumors develop a great variety of neoplasia due to
their histogeny. Most primary retroperitoneal tumors are malignant and have a
mesenchymal origin. They represent the 0.3% to 0.8% of all types of neoplasia.

Their clinic occurrences are seldom and not precise, but when present, the
retroperitoneal tumors normally appear in later stages and are caused by
compression or movement of organs or near-by structures.

The liposarcoma is the most frequent malignant retroperitoneal tumor and is one
of the most common sarcomas among all possible locations (25-35%).

The pleomorphic and lipomatous are the most usual types. The malignant
fibrous histiocytoma is a common neoplasy in the elderly and in extremities of
soft tissue. In the retroperitoneum, the most frequent histological variety is the
pleomorphic one. The leiomyosarcoma can be present at different locations and
the evaluation of the number of atypical mitosis prior to evaluating the
retroperitoneal tumors malignancy is necessary.

Those retroperitoneal tumors located in the retroperitoneum have a bigger size,
indicating malignancy itself. They frequently present Schimmelbusch's disease
and necrosis.

The schwannomas or nerve sheath tumors can appear at any age, and those located
in the retroperitoneal area usually present a big size. Morphologically speaking,
they can be identified by the presence of fusiform, wavy cells that tend to form
palisades. Chromaffinomas are tumors formed in chromaffin-cell groups and they
synthesize catecholamines and other amines. They are connected to the
sympathetic and parasympathetic nervous systems. The tumors originated in these
structures are called chromaffinomas. Extra-adrenal chromaffinomas are present
in the midline, especially in the upper or lower para-aortic region. One of the most
frequent origins is the Zuckerkandl organ. Extraadrenal chromaffinomas are
usually functional: they produce high levels of catecholamine and are responsible
for clinic manifestations such as arterial hypertension.

I n most cases, the presence of germinal retroperitoneal tumors represents
metastasis of primary gonad tumors. In adults, the most frequent types are the
seminoma, followed by the embryonic carcinoma and teratoma. In children,
mature and immature, teratomata are more frequent, whereas the embryonic
carcinoma and the endodermic sinus tumor are less common. Signs and symptoms
are generally quite unspecific and they appear due to the compression of the
structure of nearby organs.

Radiologic explorations, helical computed tomographies and resonance
angiographies facilitate the diagnosis of the injury as well as its vascular
connections.

The involvement of the inferior vena cava in tumoral processes has been
considered for a very long time an unquestionable reason for surgical inoperability
or unresectability.

The great difficulty of this technique and the unclear risk/benefit relation are
important reasons which determine this attitude.

The important progress made in the last two decades for the inferior vena cava
surgery (most of them thanks to liver transplant) and the use of new prosthetic
materials have permitted vena cava resections, with or without substitute
prosthesis, as a therapeutic alternative for patients with locally-advanced tumoral
diseases. Thus, a therapeutic approach may be offered to a particular number of
patients with a curative intention.

Our experience in resection of the inferior vena cava following different process
goes up to 20 different cases. The indications for their performance were:

- Liver metastasis from colorectal carcinoma
- Intrahepatic cholangiocarcinoma
- Renal carcinoma
- Inferior vena cava tumoral thrombosis from renal carcinoma
- Inferior vena cava primary tumors
- Retroperitoneal tumors with involvement of the inferior vena cava
- Liver hydatid disease with involvement of the inferior vena cava and consequent
thrombosis
In 40% of the cases described, a resection of the inferior vena cava and a
restitution of the systemic vascular flow were performed thanks to a ring
prosthesis 20 mm diameter. In most cases, a saphenous-femoral arterio-venous
fistula was added in order to increase venous flow in the prosthesis.

The results obtained, in terms of surgical morbimortality, permeability of the
substitute prosthesis, and long, medium and short term survival rates justify this
kind of surgical procedures in a particular number of patients in which a
venous excision might be required for the complete resection of the tumor. As
long as the characteristics of the tumor require it, following chemoradiotherapy
completes the therapeutic treatment.
The retroperitoneum represents a complex potential space with
multiple vital structures bounded anteriorly by the peritoneum, ipsilateral colon
and mesocolon, pancreas, liver or stomach. The posterior margins are by large
composed of the psoas, quadratus lumborum, transverse abdominal and iliacus
muscles but, depending on the tumour location and size, may be formed by the
diaphragm, ipsilateral kidney, ureter and gonadal vessels. Similarly, the medial
boundaries may include the spine, paraspinous muscles, the inferior vena cava
(for right-sided tumours) and the aorta (for left-sided tumours). The lateral margin
is formed by the lateral abdominal musculature and, depending on tumour
location, may include the kidney and colon. Superiorly, retroperitoneal tumours
may be in contact with the diaphragm, the right lobe of the liver, the duodenum,
the pancreas or the spleen. The inferior margin may relate to the iliopsoas muscle,
the femoral nerve, the iliac vessels or pelvic sidewall.
5

Due to the inaccessibility of the region and since these tumours often give
no or non-specific symptoms until they have reached a substantial size, they are
usually large at presentation.
4
Sarcomas comprise a third of retroperitoneal
tumours, with two histological subtypes predominating, namely liposarcoma
(70%) and leiomyosarcoma (15%).
6
Other retroperitoneal neoplasms include
primary lymphoproliferative tumours (Hodgkin's and non-Hodgkin lymphoma)
and epithelial tumours (renal, adrenal, pancreas) or might represent metastatic
disease from known or unknown primary sites (germ cell tumours, carcinomas,
melanomas) (Fig 2).
6
Benign tumours can cause concern and are often an
incidental finding during an investigation for unrelated symptoms. They may be
referred on suspicion of being a sarcoma. The most common benign pathologies
encountered in the retroperitoneum include benign neurogenic tumours
(schwannomas, neurofibromas), paragangliomas (functional or non-functional),
fibromatosis, renal angiomyolipomas and benign retroperitoneal lipomas tracts
are often displaced, they are rarely invaded and gastrointestinal or urinary
symptoms are unusual.