OPERATION REPORT

RSUDZA-Banda Aceh Class

Name : Address : Hosp.Reg :
Ny. Yusniar, 30 th 1-17-28-77
Surgeon : Assistants : Anaesthesiologist :
dr. Sarah Ika Nainggolan Sp. OG (K) dr. Maqbul / dr. Iqbal dr. Eka, Sp.AN
Pre-operative diagnosis : Date of operation :
Mola Persisten post Kuretase Hisap, dd Penyakit Trofoblastik Ganas, Polip vagina 15/08/2018
Pre-op diagnosis: Duration of operation:
Mola Persisten post Kuretase Hisap, dd Penyakit Trofoblastik Ganas, Polip vagina 11.00-13.00
NOSOCOMIAL DATA :
Type of Surgery ( 1.Clean 2. Clean contaminated 3. Contaminated 4. Dirty ): 2
Type of wound ( 1. Superficial, 2. Deep, 3. Organic Wound ) : 2
Number of operation ( 1. 1st operation, 2. 2nd operation, 3. 3rd operation ) : 1
Antibiotic Profilaxis ( 1. Yes, 2. No ) : 1
Type of Antibiotic : Cefazoline 2 gr
Time of injection : 30 menit before procedure
Operation Procedure :
Laparotomi Total Histerektomi, Eksisi Polip Vagina Elective Mayor

 Pasien dalam posisi telentang di atas meja operasi dalam anastesi spinal
 A dan anti septik daerah operasi dan sekitarnya
 Insisi mediana sampai 1 jari dibawah umbilikus
 Dinding abdomen dibuka lapis demi lapis
 Setelah peritoneum dibuka tampak uterus ukuran 16 x 16 x 10 cm
 Uterus diputuskan untuk dilakukaan histerektomi total
 Kedua Ligamentum rotundum dijepit dijepit, dipotong dan diikat,
 Dilakukan windowing pada ligamentum latum
 Tuba dan ligamentum ovarium propii dijepit, dipotong dan diikat
 Dilakukan blader flap, kemudian kedua vasa uterina dijepit, dipotong dan diikat
 Kedua Ligamentum sacro uterina di jepit, dipotong dan diikat
 Kedua Ligamentum kardinale dijepit, dipotong dan diikat
 Uterus dipotong setinggi portio
 Kemudian tunggul vagina dijahit denga PGA no 1 menggunakan teknik continous interlocking
 Kontrol perdarahan
 Kavum abdomen dicuci dengan NaCl 0,9%,dipasang drain intra abdomen
 Alat dan kassa lengkap
 Abdomen ditutup dilapis demi lapis
 Pada eksplorasi lanjutan, didapatkan benjolan pada vagina posterior, bertangaki, uk 3x2 cm, kesan polip vagina.
Diputuskan untuk dilakukan eksisi polip vagina  kirim ke PA
 Perdarahan 250 cc urine 300 cc

Specimen sent to Pathology Lab: yaPatient on supine Team of surgeon :

position, with spinal anaesthesi

dr. Sarah Ika Nainggolan, Sp. OG (K)

1. Asepsis and antisepsis on surgery part with
povidon iodine
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.