KKLIU 1228/2010/C

i-exposure
I S L A N D

H O S P I TA L
www.islandhospital.com

Island Hospital Sdn Bhd (Co. No.: 323705 A)

Vol 12 I MAY AUG 2011

all about

EXERCISE AFTER 3
HEART ATTACK AND
HEART SURGERY
ENT SURGERY 4
KNOW
YOUR SINUSES
GYNAECOLOGICAL 5
CANCER SURGERY
NEEDS 6
& CONCERNS
OF GYNECOLOGIC
LAPAROSCOPY
PILES 9
(HAEMORRHOIDS)
ACTIVITIES OF THE
ISLAND HOSPITAL
SPINE CENTRE
UNDESCENDED 11
TESTIS
LIVER CANCER 12
GETTING TO KNOW 13
OUR CONSULTANTS
THANK YOU
DEAR READERS
HEALTH TALKS 14
PAST EVENTS
ANTE-NATAL
CLASSES 2011
PEMBEDAHAN 15
BATU EMPEDU
APPENDISITIS 16
We are ISO certified

Certificate No: KLR 0500345

SURGERIES
Nutrition Concerns
in Surgery

by Ms Supanee Sararaks

Surgery (whether minor or major) may be a necessary intervention at any

time in your life. After any surgery, a certain amount of time is required
for the body to heal itself. You can support and speed that process by
implementing a healthy nutrition regime both before and after the surgery.
Furthermore, you need to follow your doctors suggestion on activity
level and any precautions you should take to guard against complication
after surgery. Take these recommendations seriously, especially those
regarding your activity level and nutrition.
It is known that nutritional status is a very important factor in the recovery
process from all kind of surgical interventions. Many studies show that
preoperative acceptable nutritional conditions help to prevent early and
late postoperative complications. Individuals with suboptimal nutritional
parameters should be supplemented and replenished before elective
surgery.
Before surgery, patients with risk factors need to improve their
nutritional status if they have any indication stated below. By having
preoperative nutrition intervention, post-surgical outcome would
be very much better. The patient at predicted risk for surgery can be
recognized as follows:
signicant decits in muscle response to nerve stimulation or general
weakness
recent weight loss of greater than 10% body weight and /or body weight
of 80% 85% ideal body weight
serum albumin in a stable, hydrated patient of less than 3g /100ml
a history of functional impairment
In the same way that preoperative nutritional status is important,
postoperative nutrition must be considered. Successful recovery from
a surgical intervention depends on many factors and postoperative
nutritional support is one of these important factors. Postoperative
nutrition should be initiated as soon as possible. The nutrients
implemented will help in wound closure, improving immune responses,
preventing infections or sepsis and help in many other processes that
play a role in the recovering period. Delaying this support may impair the
healing process, thus putting risk in the patients life and also increase
hospital stay time and costs.

Basic Dietary
Guidelines
Depending on the type of
surgery, your surgeon or physician
may prescribe a specific diet
for you. Follow your doctors or
dieticians instructions.
If you are a
regular coffee
drinker, you
should be aware
that withdrawal
from caffeine can cause headaches
after surgery. An estimated 25%
of coffee drinkers complain of
headaches after surgery, even if
they drink as little as one cup
of coffee a day. It is a good idea
to taper off your coffee drinking
before surgery to prevent this.
Moreover, coffee do not provide
essential nutrient for wound
recovery.
During the initial period after
surgery, you may have little or
no appetite. Unless your doctor
restricts your uids, try to get
sufcient liquids to ensure
you stay well hydrated. Try to
start by taking liquids such as
broth, soup, diluted fruit juice or
complete nutritional products
such as Ensure, Nutren or Enercal
Plus depending on your medical
condition as advised by your
dietician.

cont. page 2

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MAY - AUG 2011

Allow your gastrointestinal tract to adjust to food.

Your portion should start small but frequent. Gradually
increase your intake as tolerated by you. If your
intake is too small by day 3, supplementation from
complete nutritional products may be required.
Protein need is essential after surgery to repair
and build body tissues. Furthermore, by having
sufficient protein, recovery process will be faster and
without any infection or complication. Start with easily
digestible protein such as fish, tofu and eggs (well cook
or pasteurized). Meat and chicken are more difficult to digest
and should be delayed. Dairy products should be introduced
with caution as occasionally milk intolerance may be a concern
after surgery. Using lactose free products, soy milk or oat milk
may be better tolerated.
Sufcient energy from complex carbohydrate but low in
simple carbohydrate like sugary food. Fats should be taken
low and gradually increase to moderate depending on the
type of surgery. Begin with foods that are easily digested such
as bananas, congee, rice porridge, oatmeal porridge and soft
soupy noodles. Gradually include soft boiled potatoes, bread
and biscuits and gradually work up to a regular diet. Eat whole
foods that are full of many vitamins and minerals your body
needs to heal and regain energy.
Fruits and vegetable may be introduced depending on the
type of surgery. If the surgery is related to the gastrointestinal
tract, pectin, a dietary fibre from ripe pears, apple puree, and
soft peaches can be introduced gradually to help digestion and
absorption.
Request to see a dietician prior to discharge. The dietician
can assist you in planning your nutritional needs (protein and
calories) and provide you a specific menu plan to help you cope
with the stress and to speed up recovery after surgery.
The dietician will advice on nutritional support or
supplementation if the individual: is weak and not healthy prior to surgery
has a current nutritional status that is poor with serum
albumin value less than 3g / 100ml
is an elderly patient
is unable to eat or very low intake and unlikely to resume
to normal intake soon
experience weight loss of 15% from previous weight

by Ms Supanee Sararaks
Clinical Dietitian
BSc Dietetics (Hons.)(UKM)

Other Nutritional Consideration

Beta-carotene a precursor of vitamin A can help to reduce
injury of the mucous membranes and help heal tissues. Betacarotene is generally considered safe because they are not
associated with specific adverse health effects. Their conversion
to vitamin A decreases when body stores are full. A high intake
of pro-vitamin A carotenoids can turn the skin yellow, but this
is not considered dangerous to health. Carotenoids are found
in carrots, cantaloupes, sweet potatoes, and spinach.
Vitamin C and bioavonoid will help with tissue repair and
decrease inammation.
Zinc can hasten wound and tissue healing. Always take zinc
with food to prevent stomach upset.
Vitamin E is an antioxidant nutrient and is a mild but effective
anti-inammatory. Choose a formula containing mixed
Tocopherols.
If you have had gastrointestinal surgery, taking acidophilus or
bido-bacteria supplement would be helpful.
Glutamine as a fuel for enterocytes (gut cells) has received
much attention, with several recent clinical trials. However,
in severe stress, such as bone marrow transplant, a beneficial
effect of glutamine in decreasing hospital stay, increasing
nitrogen balance and decreasing infection rates has been
demonstrated. These effects have been attributed to
improved gut barrier function, improved gut and hepatic
protein synthesis.
Nutritive solutions enriched with arginine, RNA and omega-3
fatty acids are also important fuels that inuence positively the
postoperative recovering of many plasma parameters which
reect patients recovering from surgery. People who receive the
enriched solution has the same risk of developing postoperative
infections if compared with people who receive the standard
diet, but the infections in the latter group tend to be much
more severe and difficult to treat.

It is better to use a basic multi-vitamin / mineral formulation

with as many essential ingredients as possible, but not higher
than the RDA / DRI, despite the fact that this may not provide
optimal amounts of nutrients. The reason is simply that no multiformulation will ever provide all essential nutrients in their optimal
configuration for everyone.
Requirements not only vary from one person to another, but they
vary for the same person over a lifetime. Random mega-dosing
on single nutrient creates a risk of significant imbalance in ones
system. Vitamins and minerals are necessary for post surgery but
must be administrated within the nutritional support plan and
recommended by your doctor or dietician.

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MAY - AUG 2011

Exercise after
Heart Attack and
Heart Surgery
recently had a heart attack
Iforyouve
heart surgery, exercise will play

by Ms Tan Ah Git
Physiotherapist

Dip PT(Mal), Cardiac Rehab(Aust), MMPA

an important part in your recovery.

However, it is also natural to worry
about what physical activity you can
or cant do safely.

The benets of exercise

People with heart disease get the same benets
from regular exercise as others do. If you exercise regularly
you tend to:
have a stronger heart
be less likely to have another heart attack
control your body weight better
have a healthier blood cholesterol level
have lower blood pressure
control your blood glucose level better
feel more condent and less stressful

What sort of exercise is right for me?

Aerobic (Heart-Lung) Exercise is recommended because of
its benefits to the heart. Sustained activity of large muscle
groups (legs, arms, torso) increases the bodys demand for
oxygen. This trains the heart, lungs and muscles to become
more efficient. Brisk walking, jogging, cycling, swimming,
Tai Chi, rowing, dancing, stairs climbing, playing tennis /
badminton / golf etc are good examples of aerobic exercises.

How much, how often

and how long?
Always begin your programme slowly with lighter exercise
and gradually build up your intensity over time.
There are 2 ways to monitor your exercise intensity:
1) By taking your pulse rate
The exercise should raise your pulse rate to 120 150
beats per minute, which is equivalent to 60% 85%
of your maximum heart rate (MHR).
MHR = 220 age in years
2) The talk test
If you cant talk comfortably while exercising, then you are
working too hard. If you can talk with great ease, you need
to work harder. Exercise should make you breathless but
never speechless!
Exercise should be carried out at least 3 times a week, evenly
spaced out or preferably daily.
Start off with 20 30 minutes per session and progress
gradually.

How do I know if I am doing

too much?
If you experience any of the symptoms listed below during
exercise, stop immediately.
1) Excessive fatigue
2) Chest pain / discomfort
3) Nausea, vomiting or headache
4) Excessive breathlessness
5) Irregular heartbeats
6) Unusual visual problems, dizziness or light headedness
7) Cold and clammy
Should the above symptoms persist, consult your doctor /
cardiologist.

Walking is strongly recommended for heart patients as it is

safe, easy and inexpensive. According to the Cooper Institute
for Aerobics Research, men who walk at least half an hour,
six days a week, can reduce mortality rates from heart disease
in half, compared with those who are sedentary.

Once Ive recovered

When you have recovered, keep up the regular exercise.
It has played an important role in your recovery and should
continue to be an important part of your life.

Out-patient walking programme for heart patients

Week

Duration (minute)

Distance (metre)

Frequency (per day)

Pace

5 10

250

Stroll

10 15

500

Comfortable

15 20

1000

Comfortable

20 25

1500

12

Comfortable / Stride out

25 30

1500

12

Comfortable / Stride out

30

2000

12

Comfortable / Stride out

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MAY - AUG 2011

ENT Surgery

Know Your Sinuses

4) What cause Sinusitis?
by Dr Lee Guan Telk
Consultant ENT Surgeon

MBBS (Hons)(NSW, Australia), FRCS (Glasg), AM

1) What are sinuses?

Sinuses are air-filled spaces in your skull
surrounding the nose. There are 4 pairs
of sinuses one pair over the cheeks
(maxillary), in between the eyes
(ethmoidal), forehead (frontal) and
the last pair is located deep in the centre
of the skull (sphenoidal). The sinuses are
connected and drained into the nasal
cavity by small openings called ostia.

Location of Sinuses

Sinusitis can be caused by bacterial, viral

infections, foreign bodies, cancer as
well as structural deformity of the nose
such as deviated septum of the nose.
However, the most common cause
of Sinusitis is ALLERGY. Allergic reaction
occurs due to an over-exaggerated
immune response by our body to
harmless allergens that enter our body
either from the foods we eat or through
the air we breathe. This reaction causes
the lining of the nose to swell up and
blockage of the ostia causing poor
drainage of the sinuses. As a result,
secretions build up in the sinuses which
provide an ideal medium for bacterial
growth and pus formation.

6) How is Sinusitis treated?

2) What are the functions

of sinuses?
The functions and purposes for the
presence of sinuses in the skull remain
unknown. It is thought that air filled
sinuses act as resonant organs making
human speech sounds better. Another
theory is that air filled sinuses act as a
protective buffering zones during facial
trauma and help to protect the brain
and other vital skull structures from
injuries.

3) What is Sinusitis?
Sinusitis occurs when there is an
inammation of the sinus lining as
a result of the blockage of the sinus
openings or ostia. When the opening
is blocked or closed, normal mucus
drainage from the sinuses is disrupted
and this lead to inammation and
infection of the sinuses.

Steps in using
the Balloon SinuplastyTM
Technology

5) What are the symptoms

of Sinusitis?
Common symptoms include the
following:
a) Facial pain, pressure, congestion,
forehead pain and headaches.
b) Nose blockage and discoloured
discharge which may be purulent
or blood stained.
c) Loss of sense of smell.
d) Discoloured post-nasal discharge
with thick phlegm in throat.
e) Fatigue, unwell.

Each sinus has an opening through which mucus

drains. Mucus drainage is a normal process that
keeps the sinuses healthy.

invasive key hole surgery of the

nose and sinuses using endoscope
is known as Functional Endoscopic
Sinus Surgery (FESS). Newer sinus
operative techniques in an attempt
to improve patient safely and surgical
outcome are still evolving. One of
the newer surgical devices available
is Balloon Sinuplasty devices which
represent a new technology in
the opening of blocked sinuses
by utilising inatable balloons.

Sinusitis is initially treated medically.

The medical therapy includes
nasal steroidal spray, antibiotics,
antihistamines, antiallergics.
Most patients respond well to medical
therapy. However, in those patients
who are not responding to medical
therapy, surgery forms an important
part of the management.

7) What are the types of

sinus surgery available?
a) Conventional sinus surgery like
sinus irrigation, Caldwell-Luc
operation which involves opening
the cheek through an incision
underneath the upper lip,
external ethmoidectomy, etc.
These conventional procedures are,
often ineffective but also leaves
an external facial scar.
b) With the availability of endoscope,
the surgeon for the first time is able
to see and operate with great
precision in the confined spaces of
the nose and sinuses. This minimally

Step 1
Using the Balloon Sinuplasty system,
your physician gently places a guide catheter
and a exible wire through the nostrils to
access the target sinus. Next a sinus balloon
catheter is advanced over the wire.
Step 2
The sinus balloon is positioned across the
blocked opening and gently inated.
Step 3
The Balloon Sinuplasty system is removed,
leaving an open sinus passageway and
restoring normal drainage and function.

8) What are the dos and

donts when you have
sinus surgery?
Before surgery, if you take
anticoagulants you should stop after
consulting with your prescribing
physician.
You should stop herbal medications like
gingko, omega 3 supplements which
can increase bleeding. You should
continue taking your anti-hypertensive
medications if you are hypertensives.
With FESS, recovery is normally
uneventful, shorter and faster than
conventional surgery. However, after
surgery, you still should have adequate
rest and oral hydration. Excessive,
vigourous activity is best avoided for
a few weeks. You will have some blood
stained nasal discharge and crusts in the
nostrils. Excessive blowing and picking
the crusts can cause nose bleeding and
should be avoided.

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MAY - AUG 2011

Gynaecological
Cancer Surgery
by Dr Jayanthi Karen Sokalingam
Consultant Obstetrician & Gynaecologist
MD (USM), MRCOG (Lon)

Gynaecological cancer surgery, like all

cancer surgeries, involve removing all the
cancerous areas with a good margin to
ensure clearance.
The first surgery discussed here is surgery
for stage 1B to 2A cancer of the uterine
cervix. Once the diagnosis is made,
the patient will need to undergo clinical
staging, whereby the disease is confirmed
to be conned to the cervix. This is
usually done via clinical examination
combined with a ct scan of the abdomen
and pelvis.
In contrast to surgery for ovarian cancer,
the standard bowel preparation is done
as these patients will not have any
surgery to the intestines. The standard
fasting time also applies which means
the patient will be fasted overnight.
On the day of the surgery, a transverse
incision will be made on the lower
abdomen of around 8 inches long and
the pelvis will be examined again to
ensure that the disease is still at an early
stage. Then, a radical hysterectomy
is performed, making sure that there
is adequate margin away from the
uterus to ensure clearance. It has been
commented that the dissected specimen
must come out looking like a buttery,
i.e. with enough tissue on the sides.
During this time, the urinary bladder
which is situated in front of the uterus
and vagina will need to be dissected
away with sharp dissection. This will
result in bladder dysfunction because
the nerve supply is temporarily disrupted
and the patient will not be able to pass
urine temporarily sometimes up to
a month. A suprapubic catheter
is inserted towards the end of the
operation to help drain the bladder till
the condition recovers.
The most dangerous complication would
be massive blood loss because the
next part of the surgery is the removal
of lymph nodes which are situated
ery close to the major blood vessels
of the pelvis. However, when done
with competent hands, the risk of this
complication is small.

The postoperative stay is usually

10 days because of the need to await
the restoration of bladder function,
with bladder training.
For cancer of the endometrium, there is
now gathering evidence that for locally
advanced or aggressive disease whereby
the cancer has invaded into the outer half
of the uterus or shows a more aggressive
histology, the pelvic and paraaortic lymph
nodes need to be removed. Therefore,
surgery for this group of patients will
be via a midline incision with a radical
hysterectomy performed along with
both pelvic and paraaortic lymph
node dissection. Surgery would take
approximately 6 to 7 hours. The same
risk of massive blood loss applies.
For cancer of the ovary, as the disease
often presents at a late stage, the surgery
involves the gynaecologist and
sometimes the surgeon and the urologist.
This is when the disease also involves
the intestines, or the ureters or the
bladder. Again, there has to be a proper
assessment done to ascertain the extent
of the disease so that the necessary
preoperative preparation is done.
There will be a need for proper bowel
preparation whereby the patient is given
an enema to clear out the faecal material
on the day before surgery. While the
intestines are being cleansed, the patient
will be put on clear uids and later fasted
for the surgery.
Again, the surgery is via a midline incision
to ensure the abdomen is fully explored
and the disease be cleared as much as
possible. This involves the removal of
the uterus and both the tubes and the
ovaries and any other areas where the
disease has spread. Sometimes, if the
ureters are very near, there will be a need
for preoperative stenting to minimise
injuries to the ureters. Postoperatively,
recovery will depend on the extent of
the surgery and the stay can be as short
as 3 days or longer if the intestines or
urinary system is involved.

Figure 1:
Radical lymph node dissection
exposing the obturator nerve.

Figure 2:
Lymph nodes from the para
aortic area.

Figure 3:
Advanced CA endometrium.

Figure 4:
The buttery specimen of radical
hysterectomy.

Figure 5:
Early cancer of the uterine cervix.

6 i-exposure

MAY - AUG 2011

Needs & Concerns of

Gynecologic Laparoscopy
by Mr Mah Siew Lee
Consultant Obstetrician & Gynaecologist
MBBS (NSW), FRCOG (London)

During the last 35 years, gynecologic

laparoscopy has evolved from
a limited surgical procedure used only
for diagnosis and tubal ligations to
a major surgical tool used to treat
a multitude of gynecologic indications.
Today, laparoscopy is one of the most
common surgical procedures performed
by gynecologists.
For many procedures, such as removal
of an ectopic pregnancy, treatment of
endometriosis, or ovarian cystectomy,
laparoscopy has become the treatment
of choice. Compared with laparotomy,
multiple studies have shown laparoscopy
to be safer, to be less expensive, and to
have a shorter recovery time.
As opposed to laparotomies or open
surgical techniques which require a big
incision, three to seven days in hospital
and longer recovery times, the newer
procedure is comparatively simple
for the patients.
A laparoscope which is a slim telesope
like instrument which is used to look at
the inside of a persons body while doing
minimal damage to surrounding tissue.
3 - 4 small incisions or ports, each one
0.5 to 1 centimetre in diameter are made
during a laparoscopy. A fibre-optic camera,
inserted through first port, relays images
from the abdominal cavity onto monitors,
providing surgeons with a clear and crucial
picture of their operating environment.
Tiny instruments are used to do the actual
surgery, avoiding the need for a large
surgical incision that would require a
lengthy healing period.

coming into contact with delicate tissue in

the abdominal wall may arise. Since most
surgery is done on an outpatient basis,
these complications may only appear once
the patient has left hospital, outside the
careful watch of their physician.
Laparoscopic surgery also involves complex
procedures that require a lot of training.
Laparoscopy is a hybrid surgical approach
that shares characteristics of both
minor and major surgery. To patients,
laparoscopic procedures often seem to
be minor surgery because of the small
incisions, relatively small amount of
postoperative pain, and short convalescent
period. When a laparoscopic procedure
involves minimal intra-abdominal surgery
(e.g., diagnostic laparoscopy, tubal
fulguration), both postoperative discomfort
and the risk of complications may more
closely resemble a minor procedure than
a major procedure.
At its essence, laparoscopy remains an
intra-abdominal procedure. Therefore, it
shares all intraoperative and postoperative
risks of laparotomy, including infection
and injury to adjacent intra-abdominal
structures. When major intra-abdominal
procedures are performed laparoscopically
(e.g., hysterectomy), the resultant
postoperative pain and morbidity are
still significant. However, because a large
abdominal incision is unnecessary, the
postoperative pain and morbidity are
always less significant than similar major
surgery performed by laparotomy.

The procedure doesnt come without

potential downsides.

Laparoscopic procedures have risks that

are unique to laparoscopy. These risks
are related to methods used for the
placement of abdominal wall ports and
to the pneumoperitoneum required for
laparoscopy. Pneumoperitoneum is the
process whereby the abdominal cavity
is distended with carbon dioxide thereby
allowing better visibility of the abdominal
organs. The use of energy within the
abdominal cavity likewise introduces
risk. Such energy include electrical (as
in diathermy) and laser energy. These
risks include injury to bowel, bladder, or
major blood vessels and intravascular
insufation. In addition, increased intraabdominal pressures from the articial
pneumoperitoneum increase anesthesiarelated risks such as aspiration and
increased difficulty ventilating the patient.
Although the risk of blood loss is relatively
low for most procedures, potentially
massive blood loss may occur and is
complicated by the fact that control
of blood loss may be delayed (resulting
in more blood loss) by the time taken
to perform an emergency laparotomy.
A laparotomy may become a necessity as
visibility may be obscured by the bleeding.

Though complications such as wound

infections and pneumonia are
uncommon with laparoscopy, other
potential problems such as hematomas
(internal bleeding) caused by instruments

Previous surgery is associated with a

greater than 20% risk of adhesions of bowel
or omentum to the anterior abdominal
wall. For this reason, many laparoscopists
adjust their techniques in these patients

Patients are able to get up and walk on

the day of the operation, as well as require
much less pain control. They also resume
eating and drinking on the same day as
the operation and ultimately resume their
daily activities much earlier.
One of the biggest advantages attributed
to the procedure is that it seldom requires
the use of a hospital bed, a precious
commodity always in short supply.

But the laparoscopic

option is not right for
every patient.

to minimize the risk of bowel injury.

Of special concern are incisional scars
immediately adjacent to the umbilicus
because bowel adherent underneath
the umbilicus may be at risk for injury
regardless of the technique used.
Although abdominal incisions distant to
the umbilicus (such as Pfannenstiel) may
also be associated with adhesions, these
incisions appear to represent less of
a risk than incisions near the umbilicus.
In addition to location, the width and
depth of the scar should be evaluated
because a wide or retracted scar may
suggest that a postoperative wound
infection had occurred. Postoperative
infections may be associated with an
increased risk of intra-abdominal adhesion
formation. If the dome of the bladder
is involved in the infectious process, it
may cause the bladder dome to be drawn
higher behind the anterior abdominal
wall, thus increasing the risk of bladder
injury at the time of suprapubic trocar
placement.
Although abdominal thickness correlates
with patient weight, short stature or
truncal obesity may increase abdominal
wall thickness out of proportion to
patient weight. Routine evaluation of the
abdominal wall prior to laparoscopy
is important because the success of
trocar insertion may depend on altering
the technique based on abdominal wall
thickness. Abdominal wall thickness
may increase the chance of failure to
introduce the trocar thereby necessitating
a laparotomy.
The umbilicus should be examined for
signs of umbilical hernia. Techniques for
trocar insertion should be adjusted, and
closure of the defect should be considered.
The skin over the hernia should be carefully
incised and the peritoneal cavity entered
using an open technique. Closure of
a small defect can be performed with
interrupted sutures at the completion
of the laparoscopic procedure. For ideal
cosmetic results, larger defects may require
the assistance of a surgeon experienced in
umbilical hernia repair.
The anterior abdominal wall contains
2 sets of bilateral vessels: the supercial
and the inferior (deep) epigastric vessels.
These arteries are accompanied by
a large vein in most cases. In order to
avoid injuring these vessels during lateral
trocar placement, these vessels should
be visualized by transillumination and the
inferior vessels should be laparoscopically
visualized whenever possible. The use of
conical trocars (as opposed to pyramidal
tipped trocars) can also decrease the risk
of injury to these vessels.
In gynecology, the most commonly
suggested contraindication is
hemodynamic instability resulting from
a ruptured ectopic pregnancy. However,
following appropriate uid resuscitation,
laparoscopy is a safe approach.

7 i-exposure
Another traditional contraindication was
pregnancy. Using an open technique for
laparoscopy during pregnancy has been
shown to be relatively safe.
Currently, there is no clear cut consensus
as to whether a known gynecologic
malignancy is a contraindication to
laparoscopy.
Obesity is a well-recognized factor that
increases the risk of any abdominal
surgery. For laparoscopy, increased
weight takes on a special significance.
In women who are overweight,
and even more so in those who are obese,
every aspect of laparoscopy becomes
more difficult and potentially more risky.
Placement of laparoscopic instruments
becomes much more difficult and often
requires special techniques. Bleeding
from abdominal wall vessels may be more
common because these vessels become
difficult to locate. Many intra-abdominal
procedures become increasingly difficult
because of a restricted operative field
secondary to retroperitoneal fat deposits
in the pelvic sidewalls and increased
bowel excursion into the operative eld.
This second problem is probably related
to increased volume of bowel, decreased
elevation of a heavier anterior abdominal
wall by the pneumoperitoneum,
and the inability to place many patients
who are obese in steep Trendelenburg
position (head down position) because
of ventilation considerations.
Weight loss prior to elective surgery in
patients who are overweight or obese
would be ideal. Unfortunately, significant
weight loss may take years and, more
often than not, is impossible. A more
realistic approach is to inform the
patient of the increased risk associated
with obesity and to limit the extent of
advanced laparoscopic procedures that
are attempted in patients who are obese.
Although no certain weight exists at which
laparoscopy is contraindicated, performing
surgery in patients weighing more than
136 kg (300 lb) requires skill.
Another well-described surgical risk
factor is age. As the population ages,
more women of increased age will have
indications for laparoscopy. Older patients
are at increased risk of having concomitant
disease processes that affect their
perioperative morbidity and mortality.
Probably the single most important
consideration is age-associated increase
in cardiovascular disease. Intraoperative
cardiac stress related to anesthesia and
the surgery itself may result in sudden
heart problems.
Of special importance is the increased
susceptibility of elderly persons to
hypothermia (low body temperature)
because the vast majority of patients
experience some degree of hypothermia
during laparoscopy. In older patients, even
mild degrees of hypothermia may increase
the risk of heart problems and prolong
recovery time.
As far as laparoscopic complications are
concerned, one of the most important risk
factors is a history of previous abdominal
surgery. The risk of adhesions of omentum
and / or bowel to the anterior abdominal
wall after previous abdominal surgery is

MAY - AUG 2011

greater than 20%. Because laparoscopy

requires the insertion of sharp instruments
into the abdominal cavity, a reasonable
assumption is that previous surgery would
increase the risk of bowel injury. Thus,
strategies have been developed to decrease
the risk of bowel injury in patients with
previous abdominal surgery.

of the potential risks. Not all cases

are suitable for laparoscopy. Careful
preoperative assessment and selection of
cases is vital to minimize complications
from a procedure that is supposed to
reduce morbidity.

The most common of these strategies is the

use of an open technique for laparoscopic
trocar placement. Open laparoscopy
techniques decrease the risk of bowel
injury distant to the umbilicus. In patients
with previous laparotomy in which the
scar is located at the umbilicus, use of an
alternative location for trocar insertion
(usually in the left upper quadrant) has
been recommended to avoid injury of
bowel adherent immediately beneath the
umbilicus.
Both general anesthesia and increased
intra-abdominal pressure may increase
the risk of regurgitation and resultant
aspiration. The appropriate time to wait
from the last oral intake until induction
of general anesthesia is approximately
6 hours be allowed to elapse between the
last intake of solid food and the elective
induction of anesthesia. In patients with
conditions associated with decreased
gastric emptying (e.g., diabetesinduced autonomic dysfunction) or in
the presence of predisposing factors for
regurgitation (e.g., sliding hiatal hernia,
known reux), a longer period of fasting
may be indicated.

Figure 1: Laparoscopic Instruments.

Unfortunately, in emergency cases such

as ectopic pregnancy or ovarian torsion,
general anesthesia may be required
despite a period of fasting of less than
6 hours. In these cases, steps can be taken
to decrease the incidence of aspiration
pneumonia, including administration of
agents to decrease gastric acidity, such as
antacids or histamine receptor antagonists,
or the use of drugs that increase gastric
emptying, such as metoclopramide.

Figure 2: Trocars.

Preoperative evaluation should include

a search for evidence of underlying cardiac
disease. With a positive history or physical
examination ndings suggestive of cardiac
disease, preoperative evaluation by both
a cardiologist and an anesthesiologist is
extremely important.

Figure 3: TV Monitor.

Any patient with a significant history

of lung problems should be evaluated
by both a chest physician and an
anesthesiologist prior to laparoscopy.
When given an option, laparoscopy is
preferable to laparotomy in these patients.
The relatively decreased postoperative pain
following laparoscopy may result in less
ventilatory compromise than laparotomy
and thus, fewer problems with lung
collapse (atelectasis) or pulmonary failure
in those with borderline lung function.
Special care should be taken during
laparoscopy in patients with lung disease.
In patients with compromised lung
function, even a small intravasation of
carbon dioxide could result in signicant
lung decompensation.
Surgery performed using laparoscopy has
many benefits but complications arising
from laparoscopy can carry great morbidity
and sometimes mortality. Laparoscopy
requires special skills. One must be aware

Figure 4: Laparoscopic
equipments including TV monitor,
co2 insufator and light source
and DVD recorder.

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Peak Flow Meters

Pulse Oximeters

Digital
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Support & Orthoses

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9 i-exposure

MAY - AUG 2011

Piles (Haemorrhoids)
by Mr Goh Tiong Meng
Consultant General Surgeon
MBBS (Sydney), FRCS (Edin)

Piles are very common and are swellings that appear around the anus. They are due
to congested and dilated blood vessels in the anal cushions. Piles tend to occur
in those who suffer from constipation and strain excessively when passing motion.
In the early stages, a patient would only notice bleeding (first degree) when
passing motion. This tends not to be painful and the blood is usually bright red
in colour. As the piles grow larger, they may drop outside the anus when passing
motion, some return inside the anal canal spontaneously (second degree), some
needs to be manually pushed inside (third degree) and some stays permanently
outside (fourth degree). Although most piles are not painful, sometimes a clot
forms within the piles (usually a result of excessive straining) and this can be
excruciatingly painful.

Step 2

Step 1

There are several modalities of treatment for piles. Medications can be used to
reduce the bleeding and to soften stools but are not able to eradicate the piles.
Physical treatment is the preferred method to eradicate piles. Early piles (first and
second degrees) can be treated easily by rubber band ligation, which is a simple
outpatient procedure and is relatively painless. The more severe piles (third and
fourth degrees) will require surgery.
In 1937, Dr Milligan and Morgan developed the operation for piles where the piles
masses are surgically removed from the anus, leaving the open wounds to heal
themselves from the surrounding skin. This has been the operation of choice for
many years with very good success rates, although it was associated with immense
amount of pain after surgery for up to four weeks, The pain is further exacerbated
during sitting and passing motion. This fact had made treatment of piles very
unpopular and many sufferers resisted consulting doctors for their problems.

Step 3

Step 4

Step 6

Step 5

In 1998, Dr Antonio Longo from University of Palermo, Italy first introduced

a new operation for piles, which was much less painful, allowing patients to
quickly return to their normal activities. This operation is called the procedure
for prolapsed haemorrhoids (PPH). This operation requires a stapling device,
which helps the surgeon to perform the operation from the inside of the anus,
at a place where there are no pain-sensing nerves present. The operation will
remove a portion of the piles and more importantly, disconnect the piles from their
feeding blood vessels, causing the remaining piles to shrink within several weeks.
This new operation has gained much popularity in the last decade and has become
the operation of choice for patients with third and fourth degree piles. With the
introduction of this new operation, all the modalities of treatment for piles at all
stages have become much more bearable for patients with piles today.

Activities of the Island Hospital

Spine Centre
1) Dr Oh Kim Soon, Consultant Orthopaedic & Spine Surgeon presented
the 2-year results of utilizing cervical spine artificial disc replacement at the
Cervical Spine Research Society, Asia-Pacific forum at Kobe, Japan recently.
Dr Oh spoke extensively on the ex-IDE (Food & Drug Administration) multicentric prospective trial results along with Prof Dr Todd Albert, the Richard
Rothman Professor at the Thomas Jefferson University, Philadephia, USA.

2) Dr Oh (extreme right) was invited to the 7th Asia Pacic Spine Symposium
in Brisbane, Australia to speak on artificial cervical disc replacement
techniques and results. In the picture: (from left to right) Assoc Prof
Kwan Mun Keong from Universiti Malaya, Prof Liu Zhong-Jun from Beijing
University 3rd Hospital, China and Dr Oh Kim Soon from Island Hospital.
3) Dr Malik Mumtaz (right) spoke on the utility of teriparatide hormone at
the 3rd Strong Bone Asia Congress at Pattaya, Thailand. He had worked
closely with the efforts of the International Osteoporosis Foundation to
heighten awareness and streamline treatment of bone insufficency.
4) Dr TJ Wong led a delegation to the Ikatan Dokter Indonesia Scientific
Congress in Makassar, Sulawesi. Dr Wong spoke on surgery for liver cancer
while Dato Dr Ding gave a talk on the management of Irritable Bowel
Syndrome (IBS) and Dr Oh presented on the advances in spine surgery.

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www.ymcapg.com

11 i-exposure

MAY - AUG 2011

Undescended Testis
by Dr Badrul Hisham Yeap
Consultant General & Paediatric Surgeon

MD (USM), MRCS (Edin), FRCS (Ireland), Fellowship

in Paediatric Surgery (Malaysia)

Introduction
When one or both testes is not present in the scrotum, the
condition is known as undescended testis. The medical term for
undescended testes is cryptorchidism. A testis absent from the
scrotum can be found in several locations, including the groin,
within the abdomen and even under the skin of the thigh. Less
commonly, the affected testis can be undeveloped, severely
abnormal or even vanished. This malady can affect both testes
in about 15% of cases.
A testis can also move readily between the groin and the
scrotum, a condition known as retractile testis. Furthermore,
a testis initially found to be in the scrotum can very occasionally
move back up into the groin, which is known as ascending
testis.
Undescended testis is the commonest abnormality of sexual
development in boys. Although up to 5% of newborns
are found to have undescended testis, most testes would
spontaneously descend within the first 4 months so that only
1% of 1-year-old infants have a persistent undescended testis.
Nonetheless, spontaneous descent does not occur after the age
of 6 months.
In most cases the cause of undescended testis is not known.
The condition is not hereditary, although there is a familial
tendency in that about 10% of brothers of affected boys have
also had undescended testis. Some of the other causes and risk
factors are:
1. prematurity and low birth weight.
2. alcohol use and cigarette smoking during pregnancy.
3. maternal diabetes and obesity.
4. exposure to pesticides.
5. use of painkillers including aspirin, ibuprofen, and
paracetamol especially when taken simultaneously.
6. improper surgery in the inguinal area such as hernia
repair, that can trap the testis above the scrotum (rarely).
7. various congenital malformation syndromes, including
androgen insensitivity, Prader Willi and Prune Belly
syndromes.

Routine blood tests are not usually required. Radiological

examinations such as ultrasound, CT scanning or MRI may help
to locate the undescended testis though their overall accuracy
is less than 50%. Therefore, a careful physical examination
remains the most accurate diagnostic tool. Even so, most
testes that cannot be felt in the outpatient department can be
readily located when the child is better relaxed under general
anaesthetic.
Hormonal therapy is not effective in cases of true undescended
testis, but may work in cases of retractile testis.
Therefore, the most effective treatment is surgery, known as
orchidopexy. Due to the potentially serious consequences of
undescended testis, continued observation is not advisable once
the child is over 6 months old. Crucially, recent research has
found that the earlier the treatment for undescended testis, the
lesser is the risk of testicular cancer.
The operation involves making 2 incisions, one in the groin at
the site of the undescended testicle, and another is made in the
scrotum. The testis is detached from the surrounding tissues
and pulled out of the groin incision attached to the spermatic
cord, whilst the associated hernia is repaired. The testis is then
pulled into the scrotum and stitched into place (Fig. 3).
For the truly impalpable testis, diagnostic laparoscopy becomes
the most effective and efficient investigation. It is performed at
the same sitting and in conjunction with definitive treatment to
bring the testis into its rightful location. This involves inserting
a small camera (laparoscope) via a small opening in the belly
button to look for the missing testis in the abdomen. Once
found, the testis can be moved into the scrotum either in a one
or two stage operation (Fig. 2).
In cases where the testis is poorly formed, abnormal or dead,
the remnant testicular tissue will be removed so as to prevent
the development of cancer.

Fig. 1 Absent right testis and

relative enlargement of left testis.

Fig. 2 Identification and mobilisation

of testis with a laparoscope.

Therapy
Undescended testis must be treated for the following reasons:
1. To lower the risk of testicular cancer, which can be
40-times compared to the normal population if
uncorrected.
2. To minimise the risk of infertility. In order for testicles
to develop and function normally, they need to be cooler
than body temperature. The scrotum provides this cooler
environment.
3. To preserve testicular hormonal production.
4. To repair an associated inguinal hernia.
5. To prevent testicular torsion.
6. To lessen the risk of trauma to the testis.
7. To maintain the appearance of a normal scrotum.
The presence of an asymmetrical scrotum could indicate an
absent testis. This is often associated with relative enlargement
(hypertrophy) of the opposite testis (Fig. 1).

Fig. 3 The operation of orchidopexy; and result at one week.

Aftercare
After surgery, patients should be advised to limit their activities
and refrain from straddling for one to two weeks. Only minimal
pain medication is needed in the first 1 to 2 days. Most boys
recover fully within a week. The surgical dressing is left intact
until the time of follow up about one week later. Thereafter,
regular reviews are necessary to ensure the testis develop
normally and its location remains satisfactory.

12 i-exposure

MAY - AUG 2011

by Mr T. J. Wong
Senior Consultant Surgeon

MBBS (Spore), FRCS (Edin), MMed (Surgery)(Spore)

Liver
Cancer
Liver cancer is the 5th most
common cancer but is the 3rd most
common cause of cancer deaths,
about 1.2 million annually.
Hence, its reputation as a
common & deadly cancer.

CT Scan - Large (R) Liver Cancer

(R) Liver Cancer

Anatomy of Liver

Anatomy
The liver is the
largest human organ,
1200-1600gm. It lies in
the upper (R) abdomen
under the lower ribs.
It is very vascular with
1500mls of blood owing
through it every minute.
It has many important
functions and like the
heart, brain, lungs and
kidneys, the liver is
essential to life.

Presentation
The disease is insidious
in onset and there are no
specic symptoms. As the
liver cancer grows, upper
abdominal discomfort,
weight loss & loss of
appetite come on. Pain
is not a feature of liver
cancer. Acute pain comes
only if the tumour rupture!

Ruptured Liver Cancer

Diagnosis
The diagnosis of liver
cancer is usually straight
forward. The patient
is usually a Hepatitis B
or C carrier. Blood tests
will show a high alfafetoprotein (AFP).
An ultrasound scan will
show up the liver mass.
Usually CT scan or MRI
scan is necessary to dene
the tumor and to assess
operability. Biopsy
of the liver mass is
not necessary and
in fact not advisable
because of bleeding
and tumor spillage.
Extra-hepatic disease is
a contraindication for
surgery and is a bad
prognostic sign.

Treatment

Results

The only curative

treatment is surgery.
Other forms of treatment
are only palliative.
However only about 20%
- 30% are operable at
presentation. Resections
range from segmental
resections to extended
hepatectomies depending
on the size of the liver
tumour and the patients
overall condition. Liver
resections are major
surgery but today they
are not as formidable
as they were in the past.
Mortality rates range
from 6% - 10% and
recently as low as 0.8%.

The current overall 5 year

survival rate is about 50%.
Poor prognostic factors
include large tumour size,
multiple tumours, diffuse
type (not encapsulated),
accompanying cirrhosis,
old age & portal vein
involvement.

Liver Surgery

A note about
liver surgery in
Island Hospital
Thus far more than
300 liver resections has
been done in Island
Hospital since its inception
in 1996 and Island Hospital
today is the leading liver
treatment centre outside
the Klang Valley. 70% of
the liver resections are
for primary liver cancer,
invariably in cirrhotic livers
from Hepatitis B. More
recently liver resections for
secondaries from colorectal
cancer are becoming
common. Indeed, for the
next decade it is estimated
this will become more
common.

13 i-exposure

MAY - AUG 2011

Getting to know our Consultants

CONSULTANT ANAESTHESIOLOGISTS

CONSULTANT PSYCHIATRISTS

Dr Tan Hooi Ming

Dr Heng Yen Pin

Dr Lai Fong Hwa

MD(USM), M.Med (Anaesth)(UKM)

MBBS (India), M.Med (Spore)

MBBS (Mal) MPsy (Mal)

Dr Umadevi
Vasudevan
MBBS (Manipal, India), M.Med
(Psychiatry)(USM)

Thank You
Dear Readers!
Thank you for all your wonderful
feedback. Its always a pleasure to share.
So do anticipate for our upcoming issues
as we continue to share with you more
informative articles on daily health
and medical matters. Together let us
strive for a healthier lifestyle.

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Kedah
Kulim,

A Medical Voice from Bangladesh

Dear Sir / Madam,

This is a request from Bangladesh for your

newsletter. Kindly add me to your e-mailing list.
- Dr Md Hazul Islam Golder, Bangladesh

st
Requees and
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- Dr Looi Ko
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- Iskandar W

14 i-exposure

Health Talks

MAY - AUG 2011

Dato Dr Hamzah
shares some tips
on Heart Disease

An insight into High

Cholesterol with
Dr Chiew Kean Shyong,
Consultant Cardiologist

Tips on Heart Disease and

Prevention was presented
by Dato Dr Hamzah to
the staff of Hoya Electronics
in Kulim. Dato elaborated
on the prevention with
proper diet and exercise.

Dr Narinder Singh, Obstetrician

Gynaecologist talks about
Penyakit Kanser

Dr Chiew conducted a health

talk on High Cholesterol
to the management and staff
of B.Braun Medical Industries.
The response was good with
many staff turning up to get
first-hand information on the
control of Cholesterol.

Medical Camp

Past Events

At the request of the Persatuan

Senamrobik at Bayan Lepas,
Penang, our Obstetrician &
Gynaecologist, Dr Narinder
Singh presented a health talk
in Bahasa Malaysia to keep
the members abreast on
Penyakit Kanser. The talk
was conducted at Hotel Sri
Malaysia in Bayan Baru.

In conjunction with World

Diabetes Day, a public health
camp was arranged at the
Kedah Road Complex. This is
in collaboration with the Penang
Health State Committee and
Diabetic Society of Penang.
With the assistance of the
Diabetic Society, Island Hospital
provided 200 free Blood Glucose
checks and 100 free Cholesterol
checks aside from other free tests
including blood pressure checks,
BMI, eye checks and feet checks.
Free diabetic counseling was
given on the day as well.

Dr Aaron Lim shared some

health knowledge with the
management and staff of
Integrated Device Technology
(Malaysia) Sdn Bhd. The talk
was conducted at the
companys premises with an
overwhelming turn-out.

Health Expo

Medical Conference

Visitation from a University

Students from the ACMS
University paid a visit to Island
Hospital premises to have a feel
of the hospitals environment as
well as to familiarise with the
medical technologies available
here. They were personally led
by Dato Dr Chan Kok Ewe,
Director of Island Hospital,
during their tour on the hospitals facilities.

A talk on Arthritis
of the knee
by Dr Aaron Lim,
Orthopaedic & Sports
Injury Surgeon

From left to right: Dr Asmaun Najamuddin

(Organising Committee), Dr Rasyidi Juhamran
(Organising Chairman), Prof Dr Abdul Kadir
(Chairman of IDI Sulawesi), Mr Harris Hor
(AdvantCare), Dr TJ Wong, Dr Oh Kim Soon,
Dato Dr Robert Ding and Dr Heru Budianto
(Organising Committee)

In-House Ante-Natal Classes 2011

Class 5 22 & 29 October 2011, 5 November 2011
Class 6 14, 21 & 28 January 2012
Interested in joining us? Call our customer service at 04-2288 222 ext.5043.

Island Hospital recently

participated in an in-house
Health Expo at Philips Lumiled.
Free health checks were
provided to the staff for BMI,
body fat, visceral fat, skeletal
muscle body, age, height,
weight, blood pressure and
blood sugar. Health brochures
and newsletters were also
distributed to all attending
staff.
Our consultants were invited
speakers at the Ikatan Dokter
Indonesia Scientific Congress
in Makassar, Sulawesi.
The event was hosted by
the Doctors Association
of Indonesia (IDI). Three
consultants from Island
Hospital presented the talk
namely Dr TJ Wong (General
Surgeon), Dato Dr Robert
Ding (Gastroenterologist
& Hepatologist) and Dr Oh
Kim Soon (Orthopaedic &
Spine Surgeon).

Pembedahan Batu
Empedu

15 i-exposure

MAY - AUG 2011

SUDUT INFORMASI
UNTUK PEMBACA INDONESIA KAMI

Denisi

Pemeriksaan Tambahan

Batu empedu merupakan bahan

kristalin yang dibentuk oleh tubuh yang
mengalami penimbunan. Batu empedu
dapat terjadi disepanjang sistem
empedu, meliputi kantung empedu dan
juga saluran empedu.

Pemeriksaan terbaik untuk dapat

melihat adanya betu empedu
adalah dengan pemeriksaan USG.
Pada pemeriksaan laboratorium darah,
akan terlihat pola fungsi hati (SGOT,
SGPT, bilirubin direk, bilirubin indirek,
dll) yang abnormal.

Penatalaksanaan

Gejala
Biasanya batu empedu pada awalnya
tidak memberikan keluhan apa-apa.
Namun, jika sudah berukuran lebih
dari 8mm (kemungkinan terjadi
penyumbatan saluran empedu lebih
besar) barulah akan menimbulkan
gejala. Karena pada dasarnya kantung
empedu itu berkontraksi, maka batu
yang ada di kantung empedu akan
berusaha didorong keluar, hingga pada
suatu keadaan (batu yang berukuran
besar), batu yang terdorong keluar
akan menyangkut di saluran empedu.
Keluhan utamanya berupa nyeri
(biasanya hilang timbul) yang sangat
hebat di perut kanan atas yang menjadi
semakin hebat seiring dengan waktu
(dalam beberapa jam). Dapat juga
juga dirasakan nyeri pada punggung
(diantara kedua tulang belikat) atau
pada pundak kanan.

Pengobatan: batu di saluran

empedu dapat diatasi dengan suatu
tehnik yang dinamakan Edoscopic
Retrograde Sphinceterotomy (ERS)
diikuti dengan Endoscopic Retrograde
Cholangiopancreatography (ERCP).
Pada ERCP, suatu endoskop dimasukkan
melalui mulut, kerongkongan, lambung
dan ke dalam usus halus. Lalu otot
sfingter dibuka agak lebar sehingga
batu empedu yang menyumbat saluran
akan berpindah ke usus halus. Hal yang
sering menjadi salah persepsi adalah
penggunaan gelombang ultrasound
(Extracorporeal Shock Wave Lithotripsy)
untuk memecah batu empedu.
Memang ESWL berguna untuk
memecah batu ginjal, namun tidak
untuk batu empedu.
Operasi: pengangkatan kantung

empedu merupakan tindakan yang

sangat baik dalam mengatasi batu
empedu. Namun hanya pasien yang
mengalami gejala yang boleh
dilakukan tindakan ini. Jika pasien
tidak merasakan apa-apa, maka tidak
dilakukan tindakan apa-apa. Pada
beberapa orang (5% - 40%), setelah
diangkat kantung empedunya, maka
akan timbul gejala berupa perasaan
tidak nyaman pada perut dan nyeri
yang menetap pada perut kanan
atas. Ada 2 pilihan operasi, operasi
terbuka dan operasi laparoskopi (semi
tertutup).

Pencegahan

Serangan nyeri ini biasanya timbul

setelah makan makanan berlemak
dan sering terjadi pada malam hari.
Gejala nyeri ini mirip dengan nyeri yang
dirasakan jika seseorang menderita
batu ginjal. Selain nyeri, terdapat
beberapa gejala lainnya. Seperti mual
dan muntah, kentut, dan diare.
Jika gejala yang telah disebutkan
terdahulu disertai dengan demam
(tidak terlalu tinggi), mata atau kulit
menjadi kuning, dan tinja berwarna
seperti dempul, maka sebaiknya kita
langsung berkonsultasi ke dokter.

Batu empedu sebagian besar berasal

dari kolesterol, maka dari itu sebaiknya
kita mengurangi makanan yang
mengandung kolesterol tinggi
seperti makanan berlemak, terutama
yang mengandung lemak hewani.

Karakteristik
Batu empedu dapat bervariasi
ukurannya, dari sebesar pasir hingga
sebesar bola golf. Jumlah yang
terbentuk juga bisa mencapai beberapa
ribu. Bentuknya juga berbeda-beda
tergantung dari jenis kandungannya.
Secara garis besar, batu empedu dapat
dibedakan menjadi 2 jenis:

Batu kolesterol: jenis kolesterol

ini merupakan 80% dari keseluruhan

batu empedu. Penampakannya
biasanya berwarna hijau, namun
dapat juga putih atau kuning. Batu
kolesterol dapat terbentuk jika
empedu mengandung terlalu banyak
kolesterol dibadingkan dengan
garam empedu. Selain itu 2 faktor
yang berperan dalam pembentukan
batu kolesterol adalah seberapa baik
kantung empedu kita berkontraksi
untuk mengeluarkan empedu dan
adanya protein dalam hati yang
berperan untuk menghambat
masuknya kolesterol kedalam batu
empedu. Kenaikan hormon estrogen
(kehamilan, mendapat terapi hormon,
dan KB) dapat meningkatkan
kandungan kolesterol dalam empedu
dan mengurangi kontraksinya,
sehingga mempermudah
pembentukan batu empedu.

Batu pigmen: batu jenis ini

berukuran kecil, berwarna gelap dan

terbuat dari bilirubin atau kalsium.
Berjumlah sekitar 20% dari
keseluruhan batu empedu. Biasanya
batu jenis ini dijumpai pada pasienpasien dengan keadaan/penyakit
sirosis, infeksi saluran empedu,
kelainan darah yang bersifat
menurun, dan anemis sickle cell.
Jika saluran empedu tersumbat, maka
bakteri akan tumbuh dan segera
menimbulkan infeksi di dalam saluran.
Bakteri bisa menyebar melalui aliran
darah dan menyebabkan infeksi di
bagian tubuh lainnya.

Penyebab
Biasanya batu empedu banyak
dijumpai pada wanita yang:
Berusia lebih dari 40 tahun
Kegemukan
Tidak mempunyai anak (fertil)
Mempunyai faktor keturunan
Tidak terbukti bahwa ada hubungan
antar pola makan dengan
pembentukan batu empedu. Namun
masih dipercaya bahwa makanan
rendah serat, tinggi kolesterol, dan
tinggi karbohidrat dapat berperan
dalam pembentukan batu empedu.
Faktor lain yang mungkin mempunyai
peranan dalam pembentukan batu
empedu adalah kehilangan berat
badan yang drastis, kesulitan buang
air besar, sedikit makan ikan, dan
konsumsi rendah folat, kalsium, dan
vitamin. Namun, anggur dan roti
gandum dapat menurunkan risiko
terjadinya batu empedu.

Sumber: Klikdokter

16 i-exposure

Appendisitis
Denisi
Apendisitis adalah peradangan pada
apendiks. Apendiks disebut juga
umbai cacing. Kita sering salah kaprah
dengan mengartikan apendisitis
dengan istilah usus buntu, karena
usus buntu sebenarnya adalah
sekum. Organ apendiks pada awalnya
dianggap sebagai organ tambahan
yang tidak mempunyai fungsi tetapi
saat ini diketahui bahwa fungsi
apendiks adalah sebagai organ
imunologik dan secara aktif berperan
dalam sekresi immunoglobulin
(suatu kekebalan tubuh). Organ ini
cukup sering menimbulkan masalah
kesehatan dan peradangan akut
apendiks yang memerlukan tindakan
bedah segera untuk mencegah
komplikasi yang umumya berbahaya.

MAY - AUG 2011

SUDUT INFORMASI
UNTUK PEMBACA INDONESIA KAMI

yang panjang dapat berada pada

daerah perut kiri bawah, punggung,
atau di bawah pusar. Anoreksia
(penurunan nafsu makan) biasanya
selalu menyertai apendisitis. Mual dan
muntah dapat terjadi, tetapi gejala
ini tidak menonjol atau berlangsung
cukup lama, kebanyakan pasien hanya
muntah satu atau dua kali. Dapat juga
dirasakan keinginan untuk buang air
besar atau kentut. Demam juga dapat
timbul, tetapi biasanya kenaikan suhu
tubuh yang terjadi tidak lebih dari
1oC (37.8oC 38.8oC). Jika terjadi
peningkatan suhu yang melebihi
38.8oC. Maka kemungkinan besar
sudah terjadi peradangan yang lebih
luas di daerah perut (peritonitis).

Penyebab
Kita sering mengasumsikan bahwa
apendisitis berkaitan dengan makan
biji cabai. Hal ini tidak sepenuhnya
salah. Namun yang mendasari
terjadinya apendisitis adalah adanya
sumbatan pada saluran apendiks. Yang
menjadi penyebab tersering terjadinya
sumbatan tersebut adalah fekalit.
Fekalit terbentuk dari feses (tinja)
yang terperangkap di dalam saluran
apendiks. Selain fekalit, yang dapat
menyebabkan terjadinya sumbatan
adalah cacing atau benda asing
yang tertelan. Beberapa penelitian
menunjukkan peran kebiasaan makan
makanan rendah serat terhadap
timbulnya apendisitis. Kebiasaan
makan makanan rendah serat dapat
mengakibatkan kesulitan dalam buang
air besar, sehingga akan meningkatkan
tekanan di dalam rongga usus yang
pada akhirnya akan menyebabkan
sumbatan pada saluran apendiks.

Pemeriksaan Tambahan
Penatalaksanaan

Gejala Klinis
Gejala utama terjadinya apendisitis
adalah adanya nyeri perut. Nyeri perut
yang klasik pada apendisitis adalah
nyeri yang dimulai dari ulu hati,
lalu setelah 4 - 6 jam akan dirasakan
berpindah ke daerah perut kanan
bawah (sesuai lokasi apendiks).
Namun pada beberapa keadaan
tertentu (bentuk apendiks yang
lainnya), nyeri dapat dirasakan di
daerah lain (sesuai posisi apendiks).
Ujung apendiks

Penatalaksanaan standar untuk

apendisitis adalah operasi. Pernah
dicoba pengobatan dengan antibiotik,
walaupun sembuh namun tingkat
kekambuhannya mencapai 35%.
Pembedahan dapat dilakukan
secara terbuka atau semi-tertutup
(laparoskopi). Setelah dilakukan
pembedahan, harus diberikan
antibiotika selama 7 10 hari.

Epidemiologi
Apendisitis paling sering ditemukan
pada usia 20 sampai 40 tahun.
Penyakit ini jarang ditemukan pada
usia yang sangat muda atau orang
tua.

Pada pemeriksaan laboratorium, yang

dapat ditemukan adalah kenaikan
dari sel darah putih hingga sekitar
10.000 18.000/mm3. Jika terjadi
peningkatan yang lebih dari itu,
maka kemungkinan apendiks sudah
mengalami perforasi (pecah).
Pada pemeriksaan radiologi, foto
polos perut dapat memperlihatkan
adanya fekalit. Namun pemeriksaan ini
jarang membantu dalam menegakkan
diagnosis apendisitis. Ultrasonografi
(USG) cukup membantu dalam
penegakkan diagnosis apendisitis
(71% 97%), terutama untuk
wanita hamil dan anak-anak. Tingkat
keakuratan yang paling tinggi
adalah dengan pemeriksaan CT scan
(93% 98%). Dengan CT scan dapat
terlihat jelas gambaran apendiks.

Meskipun terdapat beberapa

pemeriksaan tambahan seperti diatas
yang dapat membantu
menegakkan diagnosis
apendisitis, namun
gejala klinis sangat
memegang peranan
yang besar.
,
ew
Ch
uah Chong
Ch
,
oi
id
O
e
am
H
tin
g,
a
ris
, Ch
eng Sian
Puan Nor
Amelia, Carol Lim Tan, Lim Chee Boon, Loh Ch
CHAIRMAN
atron Christine
n
M
ia
Siva,
g
Lil
SN
tin
g,
in
g,
Ac
H
Lin
r
Sumber: Klikdokter
E
g
Ang Foon
COMMITTE
Lim, Leong Ka
SN
ce
g,
ra
on
G
H
h,
k
ai
Lo
G
or
Dylin
Kh
er
st
Si
aron Peh,
P. Sarasvathy, Sh
ks
ra
ra
Sa
Supanee

NEWSLETTER

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