1.

BPH
 Adalah : pembesaran prostat

 Urinary frequency
 Urinary urgency
 Nocturia- Needing to get up frequently at night to urinate
 Hesitancy - Difficulty initiating the urinary stream; interrupted, weak
stream
 Incomplete bladder emptying - The feeling of persistent residual urine,
regardless of the frequency of urination
 Straining - The need strain or push (Valsalva maneuver) to initiate and
maintain urination in order to more fully empty the bladder
 Decreased force of stream - The subjective loss of force of the urinary
stream over time
 Dribbling - The loss of small amounts of urine due to a poor urinary
stream as well as weak urinary stream

Fisiologi miksi

Bladder penuh  stretch reseptor  med spinalis segmen  Kembali ke bladder

lewat parasimpatetik pelvic nerve  sinyal eferen rangsang m detrusor + relaksasi
sphincter internal  kalo gak di inhibisi  miksi

Mau pipis  pons sinyal  interneuron spinal  eksitasi m detrusor  relaks

sphincter internal - pipis

Nahan pipis  serebrum  interneuron spinal  eksitasi sphincter external  tahan

ANAM

(FUN- WISE)

IPSS/AUA-SI
The severity of BPH can be determined with the International Prostate Symptom
Score (IPSS)/American Urological Association Symptom Index (AUA-SI) plus a
disease-specific quality of life (QOL) question. Questions on the AUA-SI for BPH
concern the following:
 Incomplete emptying
 Frequency
 Intermittency
 Urgency
 Weak stream
 Straining
 Nocturia
Indikasi operasi

o Tidak perbaikan setelah obat (tamsulosin)

o Retensi urin akut dan kronik
o TWOC  lepas kateter masih gak bisa
o ISK berulang
o Hematuria mikrosopik berulang
o Hematuria makroskopik  langsung tindakan RESP (resuscitation, ensuring, safe, prompt)
o Batu saluran kemih
o Penurunan fungsi ginjal obstruksi
o Peruabahan patologis bladder dan upper urinary tract
PP

- PSA (prostat specific antigen )  lihat kanker

Normal
o 40-49 : 0-2,5 ng/ml
o 50-59 : 0- 3,5
o 60-69 : 0-4,5
o 70-79 : 0-6,5
- Urinalisis
- Uroflowmetry
- Uretrosistokopi

Watchful waiting

Terapi konservatif pada BPH dapat berupa watch ful waiting yaitu pasien tidak mendapatkan terapi
apapun tetapi perkembangan penyakitnya tetap diawasi oleh dokter. Pilihan tanpa terapi ini
ditujukan untuk pasien BPH dengan skor IPSS dibawah 7, yaitu keluhan ringan yang tidak
mengganggu aktivitas sehari-hari.

Apa yang diperhatikan : 3-6 bulan kontrol

o Perubahan keluhan
o IPSS
 o Uroflowmetry
o Volume residu urin

Operasi

o TURP
TURP merupakan tindakan baku emas pembedahan pada pasien BPH dengan volume prostat
30-80 ml. 1 Akan tetapi, tidak ada batas maksimal volume prostat untuk tindakan ini di
kepustakaan, hal ini tergantung dari pengalaman spesialis urologi, kecepatan reseksi, dan
alat yang digunakan. Secara umum, TURP dapat memperbaiki gejala BPH hingga 90% dan
meningkatkan laju pancaran urine hingga 100%
o Laser
 Penggunaan laser pada terapi pembesaran prostat jinak dianjurkan khususnya pada pasien
yang terapi antikoagulannya tidak dapat dihentikan.
o TUIP
Transurethral Incision of the Prostate (TUIP) atau insisi leher kandung kemih (bladder neck
insicion) direkomendasikan pada prostat yang ukurannya kecil (kurang dari 30 ml) dan tidak
terdapat pembesaran lobus medius prostat.2,14 TUIP mampu memperbaiki keluhan akibat
BPH dan meningkatkan Qmax meskipun tidak sebaik TURP.1
o Thermoterapy
Thermoterapi kelenjar prostat adalah pemanasan >45o C sehingga menimbulkan nekrosis
koagulasi jaringan prostat. Gelombang panas dihasilkan dari berbagai cara, antara lain
adalah Transurethral Microwave Thermotherapy (TUMT), Transurethral Needle Ablation
(TUNA), dan High Intensity Focused Ultrasound (HIFU). Semakin tinggi suhu di dalam
jaringan prostat, semakin baik hasil klinik yang didapatkan, tetapi semakin banyak juga efek
samping yang ditimbulkan. Teknik thermoterapi ini seringkali tidak memerlukan perawatan
di rumah sakit, tetapi masih harus memakai kateter dalam jangka waktu lama. Angka terapi
ulang TUMT (84,4% dalam 5 tahun) dan TUNA (20-50% dalam 20 bulan).
o Stent
Stent dipasang intraluminal di antara leher kandung kemih dan di proksimal verumontanum,
sehingga urine dapat melewati lumen uretra prostatika. Stent dapat dipasang secara
temporer atau permanen. Stent yang telah terpasang bisa mengalami enkrustasi, obstruksi,
menyebabkan nyeri perineal, dan disuria.2
o Operasi terbuka
Pembedahan terbuka dapat dilakukan melalui transvesikal (Hryntschack atau Freyer) dan
retropubik (Millin).15 Pembedahan terbuka dianjurkan pada prostat yang volumenya lebih
dari 80 ml. Prostatektomi terbuka adalah cara operasi yang paling invasif dengan morbiditas
yang lebih besar. Penyulit dini yang terjadi pada saat operasi dilaporkan sebanyak 7-14%
berupa perdarahan yang memerlukan transfusi. Sementara itu, angka mortalitas perioperatif
(30 hari pertama) adalah di bawah 0,25%. Komplikasi jangka panjang dapat berupa
kontraktur leher kandung kemih dan striktur uretra (6%) dan inkontinensia urine (10%).

2. Insisi abses

Cutaneous abscesses are localized collections of pus that occur within the dermis and subcutaneous
space. They occur virtually anywhere on the body; however, common locations for an abscess to
develop are the groin, buttocks, axillae, and extremities.

Gejala:

o Eritema
o Indurasi
o Nyeri tekan
o Fluktuasi

INDIKASI
Most patients with an abscess should have incision and drainage performed, as antibiotic therapy
alone is not sufficient for treatment. In cases of small fluid collections, conservative management
with antibiotics, in addition to the manual expression of pus can be considered.

CONTRAINDICATION

o Large and deep abcess

o Pulsatile mass
o Proximity to neurovascular
o Foreign body
o Location ( palms, soles, and face, neck, periareolar, perirectal)

TEKNIK
Holding the scalpel with a steady grip, an incision is made directly over the center of the
abscess until pus is expressed. The incision should be made parallel to skin tension lines in
order to prevent scar tissue formation. A curved hemostat can then be used for blunt
dissection to further disrupt loculations within the infected cavity. Manual expression can be
used to facilitate drainage as well. After the abscess is drained, the wound should be
copiously irrigated with sterile normal saline solution. Wound packing is not recommended
for abscesses that are 5 cm or less in diameter, as it has not been shown to affect outcomes
and may contribute to increased pain.[6][7] Furthermore, packing has not been shown to
reduce the risk of abscess recurrence.[8]
The next step is to cover the site with sterile dressing and tape. A follow-up visit is advised 2
to 3 days after the procedure for removal of the packing. Wounds are then left to close by
secondary intention.
An alternative to I&D is needle aspiration, though this is much less commonly used, given
that it is both more invasive and less effective than I&D. In a randomized clinical control trial
comparing outcomes with I&D to ultrasound-guided needle aspiration, the overall success of
producing purulent drainage with needle aspiration was 26% compared to an 80% success
rate in patients who underwent I&D.[9]
Another alternative to conventional incision and drainage is the loop drainage technique,
which may reduce pain and scarring at the site of infection. Studies suggest that loop drainage
is associated with a lower failure rate than conventional therapy, although it is not yet a
widely used procedure.

3. Rozerplasty
o Nama medis : onychocryptosis/ unguis incarnatus

o Terjadi karena trauma

Operasi pada grade 3 ke atas

Non surgical

o Rendam kuku 10-20 menit dalam air sabun hangat

o Oles obat topical steroid 1-2 minggu
 Indikasi operasi
o Nyeri
o Onychogryphosis = kuku jari tumbuh lebih panjang
o Kronik/ rekuren paronikia = inflamasi kuku jari

4. Burn
o Lihat kriteria dan pengukuran luka bakar
o Terapi cairan
o Prinsip FATT
o Fluid : gunakan RL uuntuk resus.
 o Analgesia
 Appropriate initial choices include intranasal fentanyl or IV morphine

Continuous pain (experienced at rest)

 Moderate pain:
paracetamol PO + tramadol PO (see Pain, Chapter 1)
 Moderate to severe pain:
paracetamol PO + sustained release morphine PO (see Pain, Chapter 1)
In patients with severe burns, oral drugs are poorly absorbed in the digestive tract
during the first 48 hours, morphine is administered by SC route.

Acute pain experienced during care

Analgesics are given in addition to those given for continuous pain.

 Significant medical interventions and extensive burns: general anaesthesia in an

operating room.
 Limited non-surgical interventions (dressings, painful physiotherapy):
o Mild to moderate pain, 60 to 90 minutes before giving care:
tramadol PO (see Pain, Chapter 1) rarely allows treatment to be
completed comfortably. In the event of treatment failure, use
morphine.
o Moderate or severe pain, 60 to 90 minutes before giving care:
immediate release morphine PO: initial dose of 0.5 to 1 mg/kg; the
effective dose is usually around 1 mg/kg, but there is no maximum
dose.
or morphine SC: initial dose of 0.2 to 0.5 mg/kg; the effective dose is
usually around 0.5 mg/kg, but there is no maximum dose.

Note: these doses of morphine are for adults, dosing is the same in children > 1
year, should be halved in children less than 1 year, and quartered in infants less
than 3 months.

 Pain management using morphine during dressing changes at the bedside

requires:
o A trained nursing team.
o Availability of immediate release oral morphine and naloxone.
o Close monitoring: level of consciousness, RR, heart rate, SpO2, every
15 min for the first hour following dressing change, then routine
monitoring.
o Assessment of pain intensity and sedation during the intervention and
for 1 hour thereafter.
o Necessary equipment for ventilation by mask and manual suction.
o Gentle handling of the patient at all times.
 Adjustment of morphine doses for subsequent dressings:
o If pain intensity (SVS) is 0 or 1: continue with the same dose.
o If SVS score ≥ 2: increase the dose by 25 to 50%. If pain control
remains inadequate, the dressing change should be carried out in the
operating room under anaesthesia.
 Take advantage of the residual analgesia following dressing changes to carry out
physiotherapy.
  As a last resort (morphine unavailable and no facilities to give general
anaesthesia), in a safe setting (trained staff, resuscitation equipment, recovery
room), adding ketamine IM at analgesic doses (0.5 to 1 mg/kg) reinforces the
analgesic effect of the paracetamol + tramadol combination given before a
dressing change.

Chronic pain (during the rehabilitation period)

 The treatment is guided by self-evaluation of pain intensity, and utilises

paracetamol and/or tramadol. Patients may develop neuropathic pain (see Pain,
Chapter 1).
 All other associated pain (physiotherapy, mobilization) should be treated as acute
pain.

o Tubes
 Intubasi NGT + kateter untuk pantau UO (target > 0,5 cc)
 ETT jika perlu airway obstruction, hypoventilation, persistent hypoxemia
(SaO2 ≤ 90%) despite supplemental oxygen, severe cognitive impairment
(Glasgow Coma Scale ≤ 8), cardiac arrest, severe hemorrhagic shock
and smoke inhalation.
o Tests
 Rontgen  vert cervical lateral atau CT, dada, atau
 USG fast scan

Nutrition

Start feeding early, beginning at H8:

 Daily needs in adults

o calories: 25 kcal/kg + 40 kcal/% BSA
o proteins: 1.5 to 2 g/kg
 High energy foods (NRG5, Plumpy'nut, F100 milk) are necessary if the
BSA is > 20% (normal food is inadequate).
 Nutritional requirements are administered according to the following
distribution: carbohydrates 50%, lipids 30%, proteins 20%.
 Provide 5-10 times the recommended daily intake of vitamins and trace
elements.
 Enteral feeds are preferred: oral route or nasogastric tube (necessary if
BSA > 20%).
 Start with small quantities on D1, then increase progressively to reach
recommended energy requirements within 3 days.
 Assess nutritional status regularly (weigh 2 times weekly).
 Reduce energy loss: occlusive dressings, warm environment (28-33 °C),
early grafting; management of pain, insomnia and depression.

Patients at risk of rhabdomyolysis

In the event of deep and extensive burns, electrical burns, crush injuries to the
extremities:

 Monitor for myoglobinuria: dark urine and urine dipstick tests.

  If present: induce alkaline diuresis for 48 hours (20 ml of 8.4% sodium
bicarbonate per litre of RL) to obtain an output of 1 to 2 ml/kg/hour. Do
not administer dopamine or furosemide.

Infection control

Precautions against infection are of paramount importance until healing is complete.

Infection is one of the most frequent and serious complications of burns:

 Hygiene precautions (e.g. sterile gloves when handling patients).

 Rigorous wound management (dressing changes, early excision).
 Separate “new” patients (< 7 days from burn) from convalescent patients
(≥ 7 days from burn).
 Do not administer antibiotherapy in the absence of systemic infection.
Infection is defined by the presence of at least 2 of 4 following signs:
temperature > 38.5 °C or < 36 °C, tachycardia, tachypnoea, elevation of
white blood cell count by more than 100% (or substantial decrease in the
number of white blood cells).
 In the event of systemic infection, start empiric antibiotherapy:
cefazolin IV
Children > 1 month: 25 mg/kg every 8 hours
Adults : 2 g every 8 hours
+ ciprofloxacin PO
Children > 1 month: 15 mg/kg 2 times daily
Adults: 500 mg 3 times daily
 Local infection, in the absence of signs of systemic infection, requires
topical treatment with silver sulfadiazine. Not to be applied to children
under 2 months.

Other treatments

 Omeprazole IV from D1
Children: 1 mg/kg once daily
Adults: 40 mg once daily
 Tetanus vaccination (see Tetanus, Chapter 7).
 Thromboprophylaxis: nadroparin SC beginning 48 to 72 hours post-injury. High
risk dosing protocol if the BSA is > 50% and/or in the event of high-voltage
electrical injury; moderate risk dosing protocol if the BSA is 20 to 50% and/or in
the event of burns of the lower limbs.
 Physiotherapy from D1 (prevention of contractures), analgesia is necessary.
 Intentional burns (suicide attempt, aggression): appropriate psychological follow-
up.

Local treatment

o GV
o Hindari infeksi
o Stabilkan termodinamika
o Stabilkan energi
Basic principles

 Rigorous adherence to the principles of asepsis.

 Dressing changes require morphine administration in the non-
anaesthetised patient.
 The first dressing procedure is performed in the operating room under
general anaesthesia, the following in an operating room under general
anaesthesia or at the bedside with morphine.

Technique

 At the time of the first dressing procedure, shave any hairy areas (armpit,
groin, pubis) if burns involve the adjacent tissues; scalp (anteriorly in the
case of facial burns, entirely in the case of cranial burns). Cut nails.
 Clean the burn with povidone iodine scrub solution (1 volume of 7.5%
povidone iodine + 4 volumes of 0.9% sodium chloride or sterile water).
Scrub gently with compresses, taking care to avoid bleeding.
 Remove blisters with forceps and scissors.
 Rinse with 0.9% sodium chloride or sterile water.
 Dry the skin by blotting with sterile compresses.
 Apply silver sulfadiazine directly by hand (wear sterile gloves) in a
uniform layer of 3-5 mm to all burned areas (except eyelids and lips) to
children 2 months and over and adults.
 Apply a greasy dressing (Jelonet® or petrolatum gauze) using a back and
forth motion (do not use a circular movement).
 Cover with a sterile compresses, unfolded into a single layer. Never
encircle a limb with a single compress.
 Wrap with a crepe bandage, loosely applied.
 Elevate extremities to prevent oedema; immobilise in extension.

Emergency surgical interventions

 Escharotomy: in the case of circumferential burns of arms, legs or fingers,

in order to avoid ischaemia, and circumferential burns of chest or neck that
compromise respiratory movements.
 Tracheotomy: in the event of airway obstruction due to oedema (e.g. deep
cervicofacial burns). Tracheotomy can be performed through a burned
area.
 Tarsorrhaphy: in the event of ocular or deep eyelid burns.
 Surgery for associated injuries (fractures, visceral lesions, etc.).

Burn surgery

 Excision-grafting of deep burns, in the operating room, under general

anaesthesia, between D5 and D6: excision of necrotic tissue (eschar) with
simultaneous grafting with autografts of thin skin. This intervention entails
significant bleeding risk, do not involve more than 15% of BSA in the same
surgery.
 If early excision-grafting is not feasible, default to the process of sloughing-
granulation-reepithelisation. Sloughing occurs spontaneously due to the
 action of sulfadiazine/ petrolatum gauze dressings and, if necessary, by
mechanical surgical debridement of necrotic tissue. This is followed by
granulation, which may require surgical reduction in the case of
hypertrophy. The risk of infection is high and the process is prolonged (> 1
month).

5. Open fracture

Tatlak
o Antibiotic + tetanus
o Wound debridement
o Wound coverage
o Fracture stabilization

What are the 5 stages of bone healing?

Definition/Introduction
 Hematoma formation.
 Fibrocartilaginous callus formation.
 Bony callus formation.
 Bone remodeling.
  https://www.ncbi.nlm.nih.gov/books/NBK5 51678/

Klasifikasi

Gustillo :

 Type I
o wound ≤1 cm, minimal contamination or muscle damage
 Type II
o wound 1-10 cm, moderate soft tissue injury
 Type IIIA
o wound usually >10 cm, high energy, extensive soft-tissue damage,
contaminated
o adequate tissue for flap coverage
o farm injuries are automatically at least Gustillo IIIA
 Type IIIB
o extensive periosteal stripping, wound requires soft tissue coverage
(rotational or free flap)
 Type IIIC
o vascular injury requiring vascular repair, regardless of degree of soft
tissue injury

 Antibiotic indications for open fractures

o Gustillo type I and II
 1st generation cephalosporin
o Gustillo type III
 1st generation cephalosporin + aminoglycoside
 traditionally recommended, but there is controversy about
this regimen
o With farm injury / bowel contamination
 1st generation cephalosporin + aminoglycoside + PCN
 add PCN for clostridia
o Duration
 initiate as soon as possible
 increased infection rate when antibiotics are delayed > 3
hours from time of injury
 continue for 24-72 hours after I&D
o Tetanus booster if not up to date (no booster in last 5 years)

Tscheme
Anam

o Kronologi / mechanism
o Lokasi
o Onset

PF

 inspection
o assess soft-tissue damage
 the size and nature of the external wound may not reflect the
damage to the deeper structures
 neurovascular
o if concern for vascular insult, ankle brachial index (ABI) should be
obtained
 normal ratio is > 0.9
 vascular surgery consult and angiogram is warranted if ABI <
0.9
 provocative tests
o consider saline load test or CT scan if concern for traumatic arthrotomy
  some studies now show CT scan more sensitive than saline
load test for the knee

PP
 Radiographs
o indications
 obtain radiographs including joint above and below fracture
 CT
o indications
 peri-articular injuries
 evaluation for traumatic arthrotomy of the knee

Tatalaksana
 Nonoperative
o urgent IV antibiotics, tetanus prophylaxis, and extremity
stabilization and dressing
 indications
 initial treatment for all open fractures
 a soft tissue wound in proximity to a fracture
should be treated as an open fracture until proven
otherwise
 mutlidisciplinary training of open fracture
management has been associated with decreased
timing to antibiotic administration
 antibiotic type indicated by injury pattern and location
 Operative
o I&D, temporary fracture stabilization, local antibiotic
administration and soft tissue coverage
 indications
 consider I&D as soon as possible
 ideal time of soft tissue coverage controversial, but most
centers perform within 5-7 days
 outcomes
 infection rates of open fracture depend on zone of injury,
periosteal stripping and delay in treatment
 incidence of fracture-related infection range from <1% in
type I open fractures to 30% in type III fractures
o definitive reconstruction and fracture fixation
 indications
 once soft tissue coverage is obtained and an adequate
sterility is achieved
 outcomes
 definitive treatment with internal fixation leads to
significantly decreased time to union, improved functional
outcomes, and decreased time in the hospital compared
to those definitively fixed with external fixation
antibiotic
o gustillo lihat atas
Tetanus
 timing
o initiate in emergency room or trauma bay
 two forms of prophylaxis
o toxoid
 0.5 mL, regardless of age
o immunoglobulin
 < 5 years old receive 75 U
 5-10 years old receive 125 U
 >10 years old receive 250 U
o toxoid and immunoglobulin should be given intramuscularly with two
different syringes in two different locations
 guidelines for tetanus prophylaxis depend on 3 factors
o complete or incomplete vaccination history (3 doses)
o date of most recent vaccination
o severity of wound
Extremity stabilization & dressing
 stabilization
o splint, brace, or traction for temporary stabilization
o decreases pain, minimizes soft tissue trauma, and prevents disruption
of clots
 dressing
o remove gross debris from wound, do not remove any bone fragments
o place sterile saline-soaked dressing on wound
o little evidence to support aggressive irrigation or irrigation with
antiseptic solution in the ED, as this can push debris further into
wound
I&D
Irrigation and debridement
 timing
o recent meta-analysis (GOLIATH study) have recommended
debridement within 24 hours to minimize risk of infection for type III
fractures
 within 12 hours for type IIIB open tibia fractures
o staged debridement and irrigation
 perform every 24 to 48 hours as needed
technique

 incision
o extend wound proximally and distally in line with extremity to adequate
expose open fracture
 irrigation
o low-pressure bulb irrigation vs. high-pressure pulse lavage
 studies have shown that low pressure bulb irrigation is less
expensive than high pressure pulse lavage and has no
difference in infection rates or union rates
o saline vs. saline with castile soap vs. antibiotic solution
 studies have shown that saline with castile soap had decreased
primary wound healing problems when compared to antibiotic
solutions
o on average, 3L of saline are used for each successive Gustilo type (i.e
9L for type III)
 debridement : bone and debris
 temporary fracture stabilization
o technique
 performed at the time of initial debridement
 external fixation is temporary initial treatment of choice for
majority of high energy open fractures of the lower extremity
 local antibiotic administration
o indications
 significantly contaminated wounds with large soft tissue defects
 large bony defects
o technique
 beads made by mixing methylmethacrylate with heat-stable
antibiotic powder
 vancomycin and tobramycin most commonly used
 soft tissue coverage
o timing
 early soft tissue coverage or wound closure is ideal
 timing of flap coverage for open tibial fractures remains
controversial, < 7 days is desired
 increased risk of infection beyond 7 days
 odds of infection increase by 16% for each day
beyond day 7
 early studies demonstrated increased infection
with delay beyond 72 hours, however recent
studies do not support this finding (LEAP study)
  studies have not shown any statistical difference between
rate of infection when ORIF is performed before
fasciotomy closure, at fasciotomy closure, or after
fasciotomy closure
 selain ORIF
o open vs closed reduction
o internal vs external fixation

6. trauma kepala

Klasifikasi

Lesi Fokal Lesi Difus

 Klasifikasi

Kontusio fokal
Perdarahan intraserebral
Cedera otak Cedera aksonal difus
Perdarahan epidural
primer Cedera vaskular difus
Perdarahan subdural
Perdarahan subaraknoid

Edema otak fokal Edema otak difus

Cedera otak
Cedera iskemik fokal Cedera hipoksik fokal Cedera iskemik difus Cedera hipoksik difus
sekunder
Disfungsi metabolik fokal Disfungsi metabolik difus

ALTS

Primary survey

o airway
o breathing
o circulation
o disability
o exposure

secondary survey

o stabil
o anam, pf, dan pp

gejala

konkusi/ komosio

o Headache or “pressure” in head.

o Nausea or vomiting.
o Balance problems or dizziness, or double or blurry vision.
o Bothered by light or noise.
o Feeling sluggish, hazy, foggy, or groggy.
o Confusion, or concentration or memory problems.
o Just not “feeling right,” or “feeling down”.

Kontusio

o Gangguan fungsi neurologi disertai kerusakan jaringan otak tetapi kontinuitas otak masih
utuh, hilangnya kesadaran lebih dari 10 menit.

Laserasio

o Ggn neuro + luka terbuka

Hematoma intracranial
 o EDH
o Ekstradural hemorrhage = pendarahan di antara lapisan duramater dan arachnoid
o Kena arteri media meningens atau sinus venosus  CSF leak  >>> intracranial
pressure
o Khas : lucid interval
o Gejala lain : <<<< kesadaran, late hemiparesis kontrlateral, pupil anisokor, babinsky+
kontralateral, nyeri kepala, muntah projektil, cushing sign ( bradikardi, >>>>TD,
pernapasan irregular)
o PP : CT scan
 Lesi Bikonveks
 Perdarahan di antara tengkorak dan dura mater
 Meningkatkan sinus venous
 Padat dan homogen
 Fase akut → hyperdense
2-4 minggu → isodense
> 4 minggu → hypodense
o Indikasi pembedahan
o Surgical intervention is recommended in patients with:
 Acute EDH
 Hematoma volume greater than 30 ml regardless of Glasgow coma scale
score (GCS)
 GCS less than 9 with pupillary abnormalities like anisocoria
 Perdarahan > 40 cc dgn midline shifting pada temporal/ frontal/ parietal +
fungsi batang otak baik
 Perdarahan > 30 cc fossa posterior + hidrosefalus / >>> intracranial pressure
 EDH progresif

Several markers that correlate with a poor prognosis of EDH include the following:
 A low GCS before surgery, or on arrival
 Abnormal pupil examination, in particular, un-reactive pupils (unilateral or bilateral)
 Advanced age
 The time between neurological symptoms and surgery
  Elevated ICP in the post-operative period
Certain head CT findings can correlate with a poor prognosis:
 Hematoma volume of greater than 30 to 150 ml
 A midline shift greater than 10 to 12 mm
 “Swirl sign” indicating an active bleed
 Associated intracranial lesions (such as contusions, intracerebral hemorrhage,
subarachnoid hemorrhage, and diffuse brain swelling)
o SDH
o Initial management : ABCDE
o Gejala

Specific presenting symptoms may vary according to the location of the

bleeding overlying the brain structures impacted.

o ●Frontal lobe – Hemiparesis, speech impairment (dominant

hemisphere), executive dysfunction (nondominant hemisphere) [64]

o ●Parietal lobe – Speech impairment (dominant hemisphere), sensory

impairment (nondominant hemisphere) [65]

o ●Posterior fossa – Headache, vomiting, anisocoria, dysphagia, cranial

nerve palsies, nuchal rigidity, ataxia [66]

o ●Interhemispheric – Headache, paraparesis without facial weakness

(falx syndrome)

o Gejala lain : kejang, kalau acute  stupor or herniation symptom,

1/3 dari pasien bisa ada transient lucid interval dilanjutkan
neurologic decline ke koma

o Chronic : pusing , light headedness, apathy, cognitive impairment,

parkinsonism, gait ataxia, somnolence, seizure

o SDH CT scan : uniformly high-density crescentic collection

o Indikasi operasi

●Clinical features

o •Dilated pupil(s)

o •Rapid or progressive deterioration (including new drowsiness) on

examination

o •Drop of ≥2 points on Glasgow Coma Scale (GCS) score (table 2)

o •Cushing triad (bradycardia, respiratory depression, hypertension)

●Imaging features

o •Maximal clot thickness >10 mm

o •Shift of midline structures >5 mm, measured at the septum pellucidum

(image 1)

o •Hydrocephalus or brainstem compression (image 2)

 o •SDH associated with structural brain lesion (eg, skull fracture,
arteriovenous malformation)

o For other patients with acute SDH, we monitor nonoperatively with close
neurologic examinations and surveillance imaging for clinical or
radiographic deterioration.

Operasi : craniotomy, burr hole drainage

Tatalaksana CKR
o Biasanya careful watching : monitor selama 48 jam pertama
o Rawat inap
o Pasien sering mengantuk
o Gangguan orientasi
o Sakit kepala memberat
o Muntah proyektil
o Teknikal : tdk ada pengawasan atau susah Kembali
o https://www.cdc.gov/traumaticbraininjury/mtbi_guideline.html

Tatalaksana CKS

OBAT PEREDA : acetynophen atau PCT

TIDAK BOLEH : PENGENCER DARAH (alcohol atau aspirin)

7. sirkumsisi
o indikasi
o adat
o terdapat kelainan
 phimosis
  Paraphimosis
 Balanophitis rekuren ( infeksi)
 Balanitis xerotica obliterans (sclerosis + atrofi)
 ISK rekuren
 Neoplasma
o Kontraindikasi
 Hipospadia
 Hemofilia
 Kelainan darah
o Cara

Postoperative
o Aktivitas ringan  jangan olahraga berat
o Jangan mandi sampai hari kedua  sponge bathing
o Jangan pakai pakaian ketat
o Remove dressing hari ke 2  terbuka, kasih bactrin atau Vaseline di sekitar jahitan
o Analgesic jika perlu
o Kontrol 4 minggu ( infeksi, keadaan luka)

8. Nyeri perut
o Anamnesis
o Onset
o Lokasi
o Kualitas/ kuantitas nyeri
o Penjalaran
o Reffered pain
o Apakah remitten atau persisten
o Pertama atau berulang
o Factor berat ringan
o RPO
o RPD, RPK, etc
o Khusus
 Kehamilan
 Dysmenorrhea, dyspareunia
 Penurunan BB
 Perut membesar
 Nyeri pinggang
o PF

DD
Berdasarkan waktu
Berdasar lokasi, perjalanan waktu, dan PF
9. Fraktur + bidai
- Baca x ray
 Baca identitas x ray
 Kualitas x ray ( lihat jari )
 Tentukan proyeksi
 Utuh ( mencakup semua )
 Sebutkan anatomi  ditanya
 Menilai
- Soft tissue
- Alignment
- Kondisi tulang
- Kondisi tulang rawan
 Kelainan
- Fraktur
Open vs closed
Lihat derajat di atas

Osteoarthritis
- Derajat
 Stage 1 – Minor
- Minor wear-and-tear in the joints
- Little to no pain in the affected area
 Stage 2 – Mild
- More noticeable bone spurs
- The affected area feels stiff after sedentary periods
- Patients may need a brace
 Stage 3 – Moderate
- Cartilage in the affected area begins to erode
- The joint becomes inflamed and causes discomfort during normal activities
 Stage 4 – Severe
- The patient is in a lot of pain
- The cartilage is almost completely gone, leading to an inflammatory response from the joint
- Overgrowth of bony spurs (osteophytes) may cause severe pain

Operasi biasa pada grade 3-4

Injeksi pada grade 3

PF

o Look
- Shape and posture
- Skin ( color, scars, wounds, ulcers
 Feel
- Skin  suhu, kelembapan
- Jaringan  benjolan
- Tulang  outline, synovium
- Tenderness
 Move
- Gerak : aktif  pasien gerakkin; pasif  dokter gerakkin
- ROM
- Unstable movement: weird
- Provocative movement

Muscle power is usually graded on the Medical Research Council scale:

- Grade 0 No movement
- Grade 1 Only a flicker of movement
- Grade 2 Movement with gravity eliminated
- Grade 3 Movement against gravity
- Grade 4 Movement against resistance
- Grade 5 Normal power
PF lutut

Saat berdiri

- Deformity : valgus (outward), varus (inward)

- Alignment
- Gait

Saat duduk

- Pattelar alignment
- Q angle (cowo 14, cewe 17)  chondromalacia

Supinasi

Look
- Lutut simetris
- Wasting
- Edema, erythema

Feel
- Skin temp
- Outline
- Cairan lutut/ synovial thickening

Move
- Passive and active extention
- Pasif aktif flexion
- Rotation
- Crepitus
Fluid
- Cross fluctuation
- Pattelar tap
- Bulge test
- Juxtapatellar hollow

Stability
- Collateral ligaments
- Cruciate ligaments
- Complex ligamnets

Meniscal injury
- Mcmurrays test
- Thessaly test
- Apley test
- Lachman test

10. Acute scrotum

- Anatomi
o Testis dan epididymis
o Testis : dibungkus tunika albugenia. Pada sisi dorsal  epididymis +
pedikel vaskuler. Masing2 testis ada lobulus yang terdiiri tubulus
semniferus, sel Sertoli, dan sel Leydig.
o Epididymis :
 Postolateral testis, 6 cm
 Ada caput : ductus eferen  massa melingkar pada bagian
posterior
 Corpus : true epididymis  cauda epididymis
o Epididymis  menjadi vas deferens = ductus ekskretorius 
membentang vesikula seminalis  bergabung ductus ejakulatorius 
menjadi uretra
o Tunika vaginalis = kantong peritoneum yg tertutup rongga abdomen

- Ada : orkitis, torsio, hernia inguinalis

Hidrokel

- Definisi : penumpukan cairan dalam rongga tunica vaginalis

- Patofosiologi
o Communicating
 Komunikasi peritoneal cavity dgn skrotum
 Patent pros vaginalis
 genetic
o Non communicating
 Karena : infeksi, trauma, malignancy, varicoceltoctomy
 Ggn drainage
 Imbalance sekresi + absorbsi dlm tunika vaginalis
 Cairan >>>> dlm tunika vaginalis

o PF
 I : pembesaran
 P : palpasi hanya teraba 2 sisi tepi atas
 Transiluminasi +
 o PP

o Edukasi
 Anak
 < 2 thn dapat ditunggu apakah bisa menutup Kembali
 > 2 tahun harus operasi
 Komplikasi : nyeri, risk ingunal hernia, infeksi, rupture,
disfungsi sexual
 Prosedur  hydrocelectomy
 Dewasa
 Konservatif  obati etiologic
 Operasi : jaboulys, lords plication, hydrocolectomy
 Drainase
 Schleroterapy

Hernia inguinalis inkarserata

- Anak : patent pros vaginalis

- Dewasa  genetic (kolagen III> I)
- >>>> tekanan abdomen
o Batuk
o BPH
o Konstipasi
o Massa abd
o Cairan abd
o Hamil
 Herniasi : usus, ovarium, omentum, hami
- Hernia bisa repondible
- Bisa irreponible
o Inkarserata (passsase)
o Strangulate (vaskularisasi)
o Akreta = perlengketan
 - PF

VALSAVA

- PP
o Foto abdomen : AP + LLD  cari ileus utk inkarserata
 Cari pneumoperitoneum utk strangulate  udah rupture apa belum
o USG doppler
o CT utk pasien obes

Torsio testis

- Torsi spermatic cord

- Neonatal  pada saat descending testis
- Dewasa
o Bell clapper deformitiy
o Karean sports dan activity
o Pernah kejadian sebelum
o Anam : nyeri akut
 o P
 High riding testis = angel sign
 Phren sign (-) Prehn's sign is an evaluation used to
determine the cause of testicular pain. It is performed by
lifting the scrotum and assessing the consequent changes
in pain. A positive Prehn's sign indicates relief of pain upon
elevation of the scrotum and is associated with
epididymitis.
 Cremaster sign (-) The cremasteric reflex is a superficial
reflex found in human males that is elicited when the
inner part of the thigh is stroked. Stroking of the skin
causes the cremaster muscle to contract and pull up the
ipsilateral testicle toward the inguinal canal.

blue dot sign

Deming sign = testis horizontal

- PP
o Urinalisis
o USG doppler
o Hematologic  leukositosis , CRP >>>

Epididimio orchiditis

- Infeksi epididymis
- Usia muda : STD , urethritis,
Kalo tua UTI
- Anam
o Nyeri lokalisir
o Bisa demam
o Bisa LUTS
- PF : phren sign +
- PP
o Urinalisis : leukosituria
o USG doppler : >>> vaskularisasi

11. Pneumothorax
 Pakai tube dan WSD

Thoracotomy : kalau mau cabut suruh pasien napas dalam/ batuk  bubble eksperatoar

Cara pernapsan pasien  resp maksimal : niup balon ( im serious)

Bubble inspiratoar  udara masuk = ada bocor, ada fistula, atau bocor dari parenkim paru 
kayak gargle sound

Nah kalo bocor harus

- Continuous suction  suction pada botol ke 3 pada WSD  tekanan 15-20 cm H2O

WSD

- 3 sistem  1,2, dan 3 botol

- 1 botol
o Mengumpulkan cairan + segel
o Sedotan  2 cm di air garam

- 2 botol
o Botol pertama untuk mengumpulkan cairan
o Botol kedua utk seal
o Tingkat segel air tidak meningkat
o System 1 dan 2 botol tergantung gravitasi
- 3 botol
o Untuk suction
o Refasilitasi ekspansi parenkim

 Elevating the head of a person’s bed by 30–60 degrees. Someone will usually
raise the arm on the affected side above the head.
 Identifying the tube insertion site. This will typically be between the fourth and fifth
ribs or between the fifth and sixth ribs, just behind the pectoralis (chest) muscle.
 Cleaning the skin with a solution, such as povidone-iodine or chlorhexidine.
Doctors will allow the skin to dry before placing a sterile drape over the patient.
 Using local anesthetic to numb the insertion site. Once the area is completely
numb, a doctor may insert a needle more deeply to see if they can pull back fluid or
air. This will confirm that they are in the right area.
 Making an incision of about 2–3 centimeters (cm) through the skin. Using a
surgical instrument called a Kelly clamp, the doctor will widen the incision and gain
access to the pleural space. The clamp insertion should be slow to avoid puncturing
the lung.
 Inserting a gloved finger into the incision site. This is to confirm that the area is
the pleural space. The doctor will also feel for unexpected findings, such as a mass
or scar tissue.
 Inserting the chest tube through the incision site. If fluid begins to drain through
the tube, it is in the right place. It is also possible to attach the tube to a chamber
containing water that moves when a person breathes. If this does not occur, the tube
may need repositioning.
 Suturing the tube in place so that the seal is as airtight as possible.
  Covering the tube insertion site with gauze pads.
A chest X-ray can also help to confirm the tube’s placement.

12. Hemoroid
- Ada external dan internal
- Gejala : swelling + pain + bisa bleeding
- Utk internal ada grading
o 1 : no prolapse + bledding
o 2 : prolaps + reduksi spontan
o 3 : perlu reduksi manual
o 4 : gak bisa reduksi
-

- Operasi
o Konservatif gagal

- Konservatif
o Serat diet
o Sitz bath
o >>> konsumsi air
 o Topical : astringent = witch hazel, protectant= zinc oxide, decongestant =
phenylepinephrine, corticosteroid, anestesi topikal
o Supplemen bioflavonoid = hidrosimin, disomin, min min
o ardium 500 mg = flavonoid
 kronik = 2 tab / hari
 akut = 6 tab/ hari 4 hari , lalu 4 tablet/ hari 3 hari
o no ngeden atau jongkok
- surgery : ligase

13. kolelitiasis
- ada operasi atau non operasi
- no operasi
o atasi gejala
o batu <0,5-1 cm, fungsi empedu baik,
o analgesic
o pelarut batu = ursodiol atau chenodiol
 o litotripsi dari luar = dengan shockwave
o sedot jarum = ERCP
- operasi = kolestoktomi = angkat kantong empedu
o open
o keyhole = laparaskopi
- gejala
o chacot triad = fever, RUQ pain, jaundice
o Reynolds pentad = (chacot triad = fever, RUQ pain, jaundice) + alter mental status +
hypotension
- Mirrizi syndrome = komplikasi
o Impaksi batu di duct  kompresi common hep duct
o Cahcot triad
 x

14. Ca mammae
- Anatomi
- Risk
o Usia > 50 thn
o Wanita
o Riw keluarga
o Mens dini < 12 thn
o Menarche lambat > 55 thn
o No kids
o Hormone
o Obes
o Alcohol
o Radiation
- Stage
- PF
o Lokasi
o Konsistensi
o Ukuran
o Fiksasi
o Bentuk + batas
- PF = perubahan kulit,
KGB axilla, infra dan supraclavicular
- PP
o Blood
o Tumor marker
o Mamografi
o USG
o Biopsi

15. Batu ureter

- Anatomi
o Prostatic
o Membraneous
o Bulbus
- Batu
o Supersaturasi
o Presipitasi
o Kristalisasi
- Jenis batu
 o Ca oxalatw
o Uric acid
o Struvite
o Cystine
- Gejala

o Lower abdominal pain

o Pain during urination

o Frequent urination

o Difficulty urinating or interrupted urine flow

o Blood in the urine

o Cloudy or unusually dark-colored urine

- Tatalaksana

- Konservatif : Recommendation: Spontaneous passage of

stones less than 5 mm in size in the distal ureter have a
>90% chance of spontaneous passage within 40 days and
are appropriate for an attempt at conservative management
provided there are no infectious symptoms, intolerable
patient symptoms or a threat to renal function. Stones
above 5 mm in diameter are less likely to pass
spontaneously and patients should be counselled about
treatment options (Level of Evidence 4, Grade C).
- Obat : Ca blocker dan alpha receptor antagonis
- Operasi : litotripsi atau URS (ureteroscopy)
- Meatotomi
- Batu ginjal

16. Osteomyelitis
- Patof
o Inflamasi
o Supuratif
o Nekrosis
o Involucrum
o Resolusi
- PF

Lihat hijau

- PP
o X ray minggu ke 2
o USG
o CT scan
o Aspirasi
o Hematologic : CRP dan ESR meningkat
- Tatlak
o Antibiotik
o Splint + rest
o Drainase
o Suportif
17. Tiroid
- Struma = goiter = pembesaran tiroid
- Kanker karena
o Defisiensi iodine
o Autoimine (Hashimoto)
o Resistensi pituitary terhadap hormone thyroid
o Adenoma hipotalamus atau kel pituitary
o Tumor yg produksi hormone chorionic gonadotropine

- Gejala hipertiroid toksik

o BB turun , tapi nafsu makan >>>
o Intoleransi panas + >>>> keringat
o Palpitasi
o Tremor
o Anxietas
o Kelemahan otot proximal
o Alopecia
o Lemas
 - Graves ophthalmopathy sign
o Bulging eyes, redness, retracted eyelids
o Gejala
 Iritasi mata
 Kemerahan dan inflamasi kornea
 Air mata berlebih, mata kering
 Pembengkakan palpebra
 Sensitivitas cahaya
 Proptosis = bulging eye
 Double eyes
- Tatalaksana
o Bedah  thyroidectomy
o Apa yang harus diperhatikan

Whenever a person has a goiter or thyroid nodule, three questions must be

answered.

1. Is the gland, or a portion of it, so large that it is stretching, compressing, or

invading nearby structures?

Thyroid swelling can cause a sensation of tightness or, less commonly,

pain in the front of the neck. A goiter or nodule can compress the
windpipe (trachea) causing cough or shortness of breath, while pressure on
the swallowing tube (esophagus) can cause discomfort with swallowing or
even the inability to get things down. When a goiter extends down into
the chest, blood returning from the neck and head can be partially
obstructed, causing neck veins to bulge. When a goiter or nodule is due
to cancer, the tumor may actually grow into nearby structures, causing
pain, hoarseness when nerves to the voice box are invaded, or coughing up
blood when the trachea is penetrated.

2. Is the gland functioning normally, or is it overactive or underactive?

Goiter is a characteristic feature of all the common forms of

hyperthyroidism. For example, in hyperthyroid Graves disease, there is
usually a diffuse or generalized goiter; and in toxic adenomas and toxic
multinodular goiter, there are solitary and multiple nodules, respectively in
the gland. Individuals with hyperthyroidism due to either painless
thyroiditis or subacute thyroiditis also usually have a modest diffuse goiter.

Conversely, people with hypothyroidism also often have a goiter. For

example, the most common cause of hypothyroidism, autoimmune
thyroiditis, typically causes diffuse gland enlargement that is 1½ to 3-times
normal size. Consequently, thyroid function must be assessed in all
patients presenting with goiter or a thyroid nodule. The best single test
to screen for both conditions is the serum thyroid stimulating hormone
(TSH) concentration, which is suppressed to a low level in people with
hyperthyroidism, and elevated in those with hypothyroidism.
3. Third, is the goiter or thyroid nodule due to malignancy? Fortunately,
most patients with a goiter or thyroid nodule do not have thyroid
cancer. Often other findings in a patient with a goiter, such as the
 features of hyperthyroid Graves disease, make it unnecessary to do
additional tests to rule out cancer. On the other hand, almost everyone
with a thyroid nodule larger than 1.0 to 1.5 cm in diameter must be
investigated for the possibility of thyroid cancer. The approach to these
diagnostic evaluations is discussed below.

o Indikasi : suspek malignansi atau ukuran sudah besar

o Prosedur : thyroidectomy dan/atau iodine radiasi
-
18. Appendicitis
- Infeksi appendectomy

- Anatomi

o Descending type: Appendix extending into the lesser pelvis. In women it may be
closely adjacent to the ovary.
o Medial position: The appendix is enveloped by loops of small intestine.
o Lateral position: The appendix courses between the lateral abdominal wall and
cecum.
o Retrocecal position: The appendix turned craniad posterior to the cecum (65%).
o Anterocecal position: The appendix turned craniad anterior to the cecum.
o Subhepatic position: The appendix turned towards the liver and is in contact
with it.

o The appendix is a slender and hollow, blind-

ended pouch attached to the proximal cecum.
o The appendiceal orifice is always located at the
confluence of the taenia coli.
 o On average, the appendix is approximately 9 cm
long but can vary from 2 to 22 cm.
o Mesentery of the appendix:
 Called the mesoappendix
 Attaches to the cecum and
proximal appendix
 Contains the appendiceal artery and vein
o Blood supply:
 The appendiceal artery is a branch of the
ileocolic artery.
 The appendiceal vein is a tributary of the
ileocolic vein.
o Positions of the appendix:
 Retrocecal within the peritoneal
cavity (65%)
 Pelvic (30%)
 Subcecal
 Ileocecal (preileal or postileal)
 Retroperitoneal
o McBurney’s point:
 The junction between the lateral and medial
thirds of a line drawn from the anterior
superior iliac spine to the umbilicus
 Localized tenderness at this point is a
classic sign of appendicitis.
 Both McBurney’s and Rocky–Davis incisions
for open appendectomy can be performed at
this point.

Indications
 Acute appendicitis:
o Most common abdominal surgical emergency
o Appendectomy is the first-line treatment.
  Appendiceal neoplasms (0.5%–0.9% of
appendectomies):
o Most often, these are discovered
intraoperatively or postoperatively on a
pathology report after appendectomy is
performed for presumed appendicitis.
o Most common appendiceal tumors:
 Neuroendocrine tumor or carcinoid
 Goblet cell carcinoma
 Lymphoma
 Primary adenocarcinoma
 Mucinous neoplasm
o May require further surgery (right
hemicolectomy), depending on the stage of
the tumor
 Prophylactic appendectomy:
o Removal of a vermiform appendix that is
macroscopically normal, usually during surgery,
for another indication
o Prophylactic appendectomy is controversial
and is not routinely recommended.
o Sometimes this procedure is performed to avoid
future diagnostic uncertainty.
o Some conditions in which a prophylactic
appendectomy is warranted:
 During Ladd’s procedure for malrotation
 Surgery for Crohn’s disease, if cecum is
not severely inflamed
 “Chronic appendicitis” (chronic
lower abdominal pain):
The appendix may appear grossly normal
but have histologic abnormalities.
 Grossly normal appendix during surgery
for presumed appendicitis
- Diagnose
o Alvarado
 Migrasi nyeri
 Anoreksia
  Mual muntah
 Nyeri RUQ
 Rebound tenderness
 Demam  > 37,3
 Leukositosis
 Shift to the left

KONTRAINDIKASI

- Semua relative
o App perforasi dengan massa atau phlegmon
o Sdg terapi antikoagulasi
o Penyakit KV (miokard infraksi, CHF, aortic stenosis
o Penyakit pulmo
 - Jika risk >>>  kasih AB aja

Periapp mass dan abses

- Jika app perforasi  jaringan sekitar bisa abses atau phlegmon

- Phlegmon
o Jika burst  tubuh respon  peritonitis local  generalized
o Untuk phlegmon  burst nya micro  tubuh respon dengan menutupnya dgn
jaringan omentum sekitar  jika appendectomy : bisa inflamasi
o Indikasi operasi
 Autoimun
 Anak
 Lansia
o Konservatif treatment

- Periapp abses
o Mikroperforasi  respon tubuh telat  pus  omentum hanya bisa ngebungkus
pus  abses
o Jika bungkusan dibuka  infeksi

- Periapp abses dan phlegmon ( dan multicompartmental abcess)

o Antibiotic
 IV imidazole dicampur fluroquinolone cephalosporin gen III
 Untuk gen III cephalosporin
 Metronidazole + ciprofloxacin
 2 hari  ganti oral 10 hari

Preoperative preparation
 Initial supportive management:
o Fluid resuscitation
o Correct electrolytes.
 o Pain and nausea management
o Bowel rest (nothing by mouth)
 Preoperative antibiotics:
o Must be administered 30–60 minutes prior to
incision
o Should cover skin and intestinal flora
o First-generation cephalosporin or
fluoroquinolone + anaerobic coverage
(e.g., cefazolin–metronidazole, ciprofloxacin–
metronidazole)
 Anesthesia:
o General anesthesia is most commonly
used for both open and laparoscopic
approaches.
o Spinal or regional anesthesia can be used for
an uncomplicated open appendectomy.
 Foley catheter:
o Optional
o Often placed with a laparoscopic approach to
prevent trocar injuries to the bladder

Types and steps of the procedures

Both open and laparoscopic approaches are considered
acceptable. The choice should be made on the basis of
the surgeon’s expertise and the patient’s preference.
Laparoscopic appendectomies are associated with
slightly shorter hospital stays and better pain scores.
Open appendectomy:
1. The patient is placed in the supine position, with at
least a 15 degree head-down tilt (Trendelenburg
position).
o This position allows the small intestine to
separate from the right lower quadrant to
provide better exposure of
the cecum and appendix.
 2. An incision is made through McBurney’s point,
which can be:
o Oblique (McBurney’s incision)
o Transverse (Rocky–Davis incision)
3. The peritoneal cavity is entered by transecting the
following abdominal wall layers:
o Skin
o Camper’s fascia (subcutaneous fatty tissue)
o Scarpa’s fascia (membranous layer of
the anterior abdominal wall)
o External abdominal oblique fascia and muscle
o Internal abdominal oblique muscle
o Transversus abdominis muscle
o Transversalis fascia
o Preperitoneal fat
o Peritoneum

4. The mesoappendix is transected and the

appendiceal vessels are ligated.
5. The appendix is transected at the base either with
a stapler or with scissors and the stump is
ligated/oversewn.
6. The appendix is removed from the abdominal
cavity.
7. The abdominal wall is closed in layers.
Peritoneal lavage or “toilet”:
 If pus is seen in the abdomen, the peritoneal
cavity is washed out extensively with normal
saline.
 In the case of a localized abscess cavity, a
Jackson–Pratt drain is placed.
Exploratory laparotomy:
 Usually performed through a vertical midline incision
 Preferred approach in a patient with a
ruptured appendix and generalized peritonitis
 Allows better visualization, abdominal washout, and
conversion to more extensive surgery if needed
Postoperative care
 Uncomplicated appendectomy with
nonperforated appendix:
o Antibiotics should be discontinued within 24
hours.
o Diet is usually advanced rapidly.
o The patient is commonly discharged home
within 24 hours.
 Perforated appendix:
o Usually 3–5 days of postoperative antibiotics
o Diet is advanced as tolerated, depending on the
patient’s recovery.
o Discharge home occurs when the patient is
afebrile, is tolerating the diet, and has
acceptable pain levels.