Duty Report

Wednesday, August 10th 2016

Surgery Team
Consultant in charge : dr. Theddeus OHP, SpBP-RE(K)
Team : dr. Wulan/dr. Adra/dr. Tama - dr. Fejo/dr. Kiki - dr. Diana
dr. Utok - dr. Pimu - dr. Dullah - dr. Wira
dr. Oka-dr. Endrika
dr. Dilla - dr. Jo
dr. Juno - dr. Ucup - dr. Alvin
dr. Faisal

Intervention Patient
Operation 1
Inpatient 0
Outpatient 14
Total 15

Signature Consultant
 Operation
Girl Natha Larissa, 1 year 8 months, 413-07-26
Preoperative diagnosis: Mechanical bowel obstruction due to suspected invagination
Postoperative diagnosis: Ileocolocolica invagination

Supporting data:
History of present illness:
- Blood and mucus in the patients stool since 4 days before admission.
- Vomited several times after she was fed.
- Fever was noticed.
- Patient seemed to be in pain, restless and cranky.
- Persisting intermittent pain despite medication & hospitalization.
- History of cough and flu 1 week ago.

Physical Examination:
General Appearance: irritable
General Status
Alert, HR 110x/min, RR 24x/min, T 38oC
Abdomen:
I: distended, bowel contour (+), bowel movement (-)
A: decreasing bowel sound
P: firm, tenderness (+), palpable mass on the left side of the abdomen
P: tympanic, liver dullness (+)
Digital rectal examination: anal sphincter tone normal, ampulla was not collapse, smooth
mucosa, pseudoportio (+), stool (-), blood (+), mucous (+)

Supporting Examination:
Laboratory 10/8/2016
CBC 11,4/36,6/8870/544000

Plan:
Laparotomy release of the invagination, with the possibility of resection &
anastomosis/stoma formation
Informed consent
NPO
IVFD
NGT insertion
Foley catheter insertion
Urine output monitoring with the target of 1-2 cc/kgBW/h
Antibiotic
Analgetic
Preoperative consultation to Pediatric and Anesthesiology Department

Intraoperative findings:
1. When peritoneum was opened, serous fluid came out.
2. Intestine dilated, invagination was found on left side of the abdominal cavity.
3. Performed milking, invagination was released; the intussusceptum consisted of ileum,
caecum, appendix, ascending colon, and transverse colon.
4. There was swelling of the bowel walls, multiple mesenterial lymph node enlargement,
and white streak on transverse colon, 20 cm anal of the ileocaecal junction, 3 cm long.
Seromuscular suture along the white streak was performed.
5. Appendectomy was performed.
Postoperative diagnosis:
Ileocolocolica invagination

Todays condition:
POD 1
 Operation
Girl Natha Larissa, I year 8 months, 413-07-26
History of Illness
Chief complaint:Blood and mucus in patients stool since 4 day before admission
History of present illness:
4 day before admission, blood and mucus was found in the patients stool. Patient also
vomited several times after she was fed (containing milk and food). Fever was found.No
history of diarrhea. Patient cries more often than usual. Previously patient was getting treated
in Cilincing Hospital, and nasogastric tube was inserted and intravenous medication was
given, but there was no improvement. The pain still existed. There was history of cough and
flu 1 week ago Patient then referred to Cipto Mangunkusumo Hospital because lack of
facility.

History of pas illnesses:

No history of congenital anomaly, no previous gastrointestinal problem.
Physical Examination
General Appearance: irritable
General Status
Compos mentis, HR 110x/min, RR 24x/min, T 38oC
Eye : conjunctiva was not pale, sclera was not icteric
Neck : no palpable lymphnode
Chest : vesicular +/+, rales -/-, wheezing -/-
Heart : 1st and 2nd heart sounds were normal, no murmur nor gallop
Abdomen:
I: distended, bowel contour (+), bowel movement (-)
A: decreasing bowel sound
P: firm, tenderness (+), palpable mass on the left side of the abdomen
P: tympanic, liver dullness (+)
Digital rectal examination: anal sphincter tone normal, ampulla was not collapse, smooth
mucosa, pseudoportio (+), stool (-), blood (+), mucous (+)
Extremity : warm, CRT <2
Supporting Examination
Laboratory 10/8/2016
CBC 11,4/36,6/8870/544000
Ureum/Creatinin 9,4/0,265
AST/ALT 30/8
Random blood glucose 75
PT 1,1x/APTT 1,1x
Electrolyte 135/3,8/102
Albumin 4,18

Two positional Abdominal X-Ray (10/8/2016):

Radioopaque findings on the central and left side of the abdomen. No signs of obstruction.
No pneumoperitoneum.

Abdominal USG (10/8/2016):

Consistent with invagination on colocolica level
Minimal free fluid in hepatorenal fossa

Chest X-Ray (10/8/2016) :

Lung and heart within normal limit
 Diagnosis
Ilecolocolica invagination
Plan
Laparotomy exploration
Informed consent for the possibility of resection &anastomosis and stoma
Fasting
IVFD
NGT insertion
Foley catheter insertion with urine output target of 1-2 cc/kgBW/h
Antibiotic
Analgetic
Surgical tolerance from Pediatric and Anesthesiology department

Operation Report
Consultant in Charge: dr. Ahmad Yani, SpB, SpBA
Surgeon: dr. Rizky, SpB
Assistant Surgeon: dr. Wulan, dr. Adrian
Pre operative diagnosis: Mechanical obstruction due to suspected ileocolica invagination
Post operative diagnosis: Ilecolocolica invagination
Surgical Management: Laparotomy, release of the invagination, seromuscular suture,
appendectomy

Description of Surgery:
1. Patient in supine position under general anesthesia
2. Asepsis, antisepsis, draping
3. Supraumbilical transverse incision through skin, subcutaneous tissue, fascia, and
muscles
4. When peritoneum was opened, serous fluid came out
5. Small bowel was dilated, invagination was found on left abdominal cavity
6. Performed milking, invagination was released; the intussusceptum consisted of ileum,
caecum, appendix, ascending colon, and transverse colon.
7. There was swelling of the bowel walls, multiple mesenterial lymph node enlargement,
and white streak on transverse colon, 20 cm anal of the ileocaecal junction, 3 cm long.
Seromuscular suture along the white streak was performed.
6. Appendectomy was performed.
7. Abdominal cavity was cleansed
8. Operation wound was sutured layer by layer
9. Operation complete
Post-Op Instruction
Vital signs observation
IVFD
Antibiotic
Analgetic
Follow Up