No.

MR
00

02

20

OBSTETRIC AND GINECOLOGY DEPARTEMENT

BUDHI JAYA MOTHER AND CHILD HOSPITAL
JL. Dr. Sahardjo No. 120 Jakarta Selatan 12960
Telp. (021) 8292672, 8311722, 8312378
Fax. 8301901

SURGERY REPORT
Nama : Mrs. Rina Kusumawati
Operator
Prof. Dr. H.I.O Marsis, SpOG
Asisten 1 dr. Benhur
Asisten 2

Sex : Female
Anesthetic
Instrumentato
r
Observer

Age : 35 Years
dr. Widodo, SpAn
Zr. Maratus

Ni Luh Made Murniasih

Jayanthi
Pre-surgical Diagnose : history of section caesarean with 37
weeks of gestation, G2P1A0

Putu Eka Pujanta Putra

Post-surgical Diagnose : history of section caesarean with 37

weeks of gestation, G2P1A0

Date of operation : November 12th

2012
Duration of operation : 1 hours 30
minutes
Type of surgery
Emergency
Minor
Polyclinic
Medium
Elective
Major

Tehnique of operation :
1. Sectio caesarea trans peritoneal profunda
2. Myomectomy
3. Operation Prosedures :
I.

Patient slept in supine position with spinal anastesia

II.

Aplied inside the dower catheter

III.

Aseptic and antiseptic on abdomen adjacent regio until 1/3 proximal upper leg and the
operation field was limited with steril doek

IV.

Pfanenstiel incision was made around fibritio tissue, 15 cm length and the skin fold in
down abdomen regio was thrown, the incision was made deeper sliece by sliece from
cutis, subcutis, fascia musculus rectus abdominis, and then it separated to lateral section
with dull technique, bleeding was taken care off.

V.

Peritoneum parietal was opened upside and downside so we can see uterine gravidarum,
and the 2 curavor were put inside the right and left abdomen cavity for sperating the
uterine and the other organ.

VI.

Transversal incision was made on lower segment of uterus, extend to right and left until
we can saw liquor amnii membran and then the operator brook the liquor amnii
membran, liquor amnii was clear and we could saw babys head.

VII.

Babys head was pulled out using forceps and with mild pressure on the fundus uterine
by assistant. Then delivered step by

step head, fronts shoulder, back shoulder,

backward trochanter anterior, trochanter posterior, breech and extremitas inferior was
delivered with a sort umbilical cord coil attached to the baby.
VIII.

The baby was crying, umbilical cord was clomped on 2 place 5 cm and 7 cm from the
umbilical cord, then it was cut between 2 clamp and the baby was delivered to
perinatologi

IX.

The new born baby was delivered at 06.21 WIB, with male gender, body weight birth
3300 gr, leght birth 49 cm, Apgar Score 9/10, anal (+) and didt saw major congenital
disorder

X.

Plasenta was completely born in manual, cavum uterine was cleaned from the residual
plasenta tissue with sharp curretase post partum until surely clean. Bleeding was
controlled. After that the uterine tissue was sewed and over hecting with chromic cat
gut no. 2

XI.

Suture was done on lower segmen of uterine at two pole with chromic cat gut no. 2
and then the miometrium tissue was suture by continue
a. First slice of miometrium tissue with Chromic cat gut no. 2 by continue
b. Second slice of miometrium tissue and serosum was suture by continue with
Chromic cat gut no. 2

XII.

On exploration founded mioma uteri with size 1,5 x 1 x 0,5 cm. The operator do
myomectomy and then hecting with chromic cat gut no. 2.

XIII.

The abdomen cavity was cleaned and 2 curavor was pulled out from the abdomen
cavity

XIV.

Before the abdomen cavity was sewed, it was giving cortisone asetat 2,5 mg 10 cc into
peritoneal cavity.

XV.

After sure its no bleeding, abdomen cavity was objed slice by slice
a. Peritoneum parietal was sutured with Plain cat gut no. 2.0 by continue
b. M. Rectus abdominis was sutured with chromic cat gut no. 2.0 by simple
c. Fascia was sutured with plain cat gut no. 1 by simple suture
d. Subcutis was sutured with chromic cat gut no. 2.0 by simple suture
e. Cutis was sutured with Chromic cat gut no. 2.0 by subkuticuler

XVI. Bleeding approximately 500 cc.

XVII. Cavum uterine was cleaned pervaginam with cassa and bethadine.

XVIII. The operation wound was cleaned by cleaning stole cell from the vagina, the operation
wound was cleaned with Nacl 0,9 % and then it was given antibiotic zalf and then was
closed by sufratulle, sterill cassa and tegaderm.
XIX. The operation finished.

The condition of patient post operation:

General condition

: Look mild sick

Blood pressure

: 130/70

Pulse rate

: 96 x/minute

Respiration

: 22 x/minute

Temperature

: 37 oC

Tissue to Pathology of Anatomy :

Yes : Type of tissue: uterus
No

Operator,

(Prof. dr. H.I.O Marsis, SpOG)

mmHg