Laporan Operasi

RSUDZA-Banda Aceh Class

Nama : Alamat : No CM :
Mrs. Husna, 39 tahun Darussalam 1-18-04-59
Dokter Bedah : Assistants : Dokter Anaesthesi :
dr. Tgk Puspa Dewi, Sp. OG dr. Riza / dr. Maqbul dr. Yusmalinda, Sp.AN
Pre-operative diagnosis : Tanggal Operasi :
G5P3A1 hamil 41-42 Minggu Janin Presentasi Kepala Tunggal Hidup, air ketuban 5/11/2018
berkurang (ICA 4), Servik Belum Matang (PS 4), belum inpartu
Pre-op diagnosis: Durasi operasi:
P4A1 post sc ai gagal Induksi 20.00-21.30
NOSOCOMIAL DATA :
Jenis Operasi :  Bersih  Bersih Terkontaminasi  Terkontaminasi  Kotor
Operasi ke :  1 2 3
Antibiotic Profilaxis :  Ya  Tidak
Jenis Antibiotic : Cefazoline 2 gr
Waktu Pemberian : 30 menit sebelum tindakan
Prosedur Operasi:
Seksio Caesaria,Tubektomi Elective Cito

 Pasien dalam posisi supine dalam anestesi spinal

 Asepsis dan antisepsis daerah operasi dan sekitarnya dengan povidon iodine
 Insisi pfannenstiel 12 cm
 Setelah peritoneum dibuka tampak uterus gravidus
 Segmen bawah rahim disayat tajam, ditembus tumpul dan dilebarkan secara tumpul kelateral
 Dengan meluksir kepala, Lahir bayi Laki-laki 3800 gram, 50 cm, AS 8/9
 Air ketuban minimal
 Implantasi plasenta dinilai, didapatkan plasenta berimplantasi di corpus anterior, dengan tarikan ringan pada tali pus
dilahirkan plasenta kesan lengkap.
 Segmen Bawah Uterus dijahit 1 lapis dengan polisorb no. 1
 Pada eksplorasi, kedua tuba dan ovarium kiri dan kanan dalam batas normal, Dilakukan Tubektomi Bilateral
 Setelah diyakini tidak ada perdarahan, alat dan kasa lengkap
 Dinding abdomen ditutup lapis demi lapis
 Peritoneum dijahit jelujur dengan chromic cat gut no. 2.0.
 Otot dijahit interuptus dengan benang chromic Cat Gut no. 2.0. Fascia dengan jahitan jelujur dengan polisorb no.1
 subcutis di jahit interuptus dengan chromic cut gut no. 2.0. Kulit dengan jahitan subkutikuler dengan prolene 3.0
 Operasi selesai, perdarahan selama operasi 300 cc, urin jernih 150 cc


Specimen dikirim ke Laboratorium Pathology: Penguji DOPS :

TidakPatient on supine position, with spinal anaesthesi

1. Asepsis and antisepsis on surgery part with

povidon iodine dr.Sarah Ika, Sp. OG (K)
2. Incision pfanenstiel 15 cm,following previous
scar
3. Abdominal wall was opened layer by layer
4. After the peritoneum was opened, we could
 seen the uterus gravidus
5. Lower segment of uterus identified,
plikavesikouterina identified, then it sliced and
lowered down
6. Lower segment of uterus is sharply sliced,
bluntly penetrated, and sharply dilated to
lateral side
7. Diminished amniotic fluid
8. By luxated the head Born female baby, 2900
grams, BL 48 cm, AS 8/9,
9. With gently traction of the umbilical cord,
placenta was delivered with complete cotyledon
10. Inserted IUD trans Caesarian
11. Hemostatic suturing in both side lateral scare of
lower uterine segment
12. Uterine lower segment was sutured 1 layer
with no. 1 Polysorb. Reperitonealisasi plica
vesikouterina, no bleeding, adequate
contraction of uterine
13. In exploration, left and right tuba and ovarium
was normal
14. Instrument and gauze was complete
15. The abdominal was closed layer by layer.
Peritoneum sutured continuous with no.2/0
chromic cat gut. Muscle sutured interuptus with
no. 2/o chromic cat gut. Fascia sutured
continuous with No. 1 polysorb. Subcuntaneous
layer sutured with no. 2/0 chromic cat gut. Skin
was sutured subcuticular with no. 3.0 Prolene
16. Operation was done. Bleeding during operation
100 cc. urine 100 cc.
17.