No.

MR

05

28

16

OBSTETRIC AND GINECOLOGY DEPARTEMENT

BUDHI JAYA MOTHER AND CHILD HOSPITAL
JL. Dr. Sahardjo No. 120 Jakarta Selatan 12960
Telp. (021) 8292672, 8311722, 8312378
Fax. 8301901

SURGERY REPORT
Name : Mrs. Sari Gumilang
Operator
Prof. Dr. I.O. Marsis, SpOG
Asisten
dr. Reza Marsis
Asisten 1
Ramot Arif Banamtuan

Sex : Female
Anesthetic
Instrumentator
Observer

Age : 27 Years
Dr. Widodo, SpAn
Zr. Ida Tupa
Anggun Valensia Manja

Pre-surgical Diagnose : Ectopic Pregnancy

Post-surgical Diagnose : Tubal Ectopic Pregnancy
Tehnique of operation :
1. Hysteroscopy Diagnostic
2. Curettage
3. Laparoscopy Diagnostic / Laparoscopy Operative

Surgery Date : October 23rd 2014

Duration time of surgery : 1 hours 30
minutes
Type of surgery
Emergency
Minor
Poliklinik
Medium
Mayor
Elective

4. Adhesiolysis
5. Salphingectomy Sinistra

Operation Procedures:
I.

Patient was administrated with general anesthesia in lithotomy position

II.

Aseptic and antiseptic were done on abdominal region, external genital region, internal genital, and
around.

III.

Applied sims speculum at posterior vagina continue with sims speculum at anterior vagina.

IV.

Anterior portio clamped with kohel tang at 12 hour direction. Put off anterior sims speculum.

V.

Doing sonde uterus to determine the length to the uterus, uterine length 8 cm anteflexion.

VI.

Doing the curettage of the uterine cavity, clockwise direction starting at 12.00 with currete tang 0 to 3

VII.

The hysteroscopy diagnostic procedure as followed :

1.

Dilated cervical canal with hegar busion number 6,7,and 8.

2.

Insertion of hysterocopy to see the endometrial wall and ostium tubae internum dextra et
sinistra. Do exploration :
a. The mucosa of cavum uteri is looked pink and normal
b. The ostium tubea internum dextra : bubble (+), sinistra : bubble : (-)

3.

Conclusion :
a. Left fallopian tube is occlusion

VIII.

Planning : LD/LO

IX.

Operation procedures of laparoscopy diagnostic/laparoscopy operative followed :

1.

Patient made in tredelenburg position or the head lower than pelvic area

2.

Skin on the left and right of umbilicus were clamped using two doek tissue clamped made
incision 1 cm below the umbilicus using scalpel

3.

Abdominal wall was lifted and the Verees needle inserted into umbilical area to intraperitoneal
space.

4.

Pneumoperitoneum procedure or the abdominal cavity is filled with CO2 gas help move
abdominal wall and any organs way out, creating a larger space to work.

5.

Incision 0,5 cm was made on the right and left ilioinguinal region using scalpel, and then the
trocar was inserted into the incision.

6.

Laparoscope was inserted into the main trochar and the gasper was inserted into the small
trochar.

7.

Uterus wall, pelvic cavity, ovaries, fallopian tubes and the abdominal cavity were inspected
(explored) :
a. Corpus uteri is looked pink, slippery surface, as big as pears.
b. The right ovarian looks white with slippery surface, as big as egg.
c. The left ovarian adhesion with the right fallopian tube.
d. The right fallopian tube normal.
e. The left fallopian tube looks a mass, as big as egg.

8.
9.

X.

Conclusion
a. The left ovarian is adhesion to the right fallopian tube.
b. Ectopic Pregnancy.
Planning :
a. Adhesiolysis
b. Salphingectomy Sinistra

Operation procedures of laparoscopy operative followed :

1.

Adhesiolysis, Salphingectomy sinistra

a. Left ovarian cyst was cauterized and separated of the tube fallopian.
b. Resection using laparoscopic scissors to the left ovarian.
c. The rest of the left ovarian was cauterized to stop bleeding.
d. Doing incision in the left fallopian tube to remove the product of conception, and it was
ready to send to the pathological anatomy.
e. The bleeding was controlled by using the cauter.

XI.

Abdominal cavity washed by RL solution still in tredelenburg position and suctioning, and it was
given hidrocortisone asetat 25 mg/10ml into peritoneal cavity and abdominal cavity was given

XII.
XIII.
XIV.

dextrose.
After clean, removed all the trocar and the laparoscope.
Patient in supine position and three holes in cutis was sewed by simple suture with Prolene no.3.0
The operation wound was cleaned with NaCL 0,9% and then it was closed by sufratulle sterill cassa

XV.
XVI.
XVII.
XVIII.

hipafix.
Aseptic and antiseptic at external genital region
The vagina was cleaned
The sample send to pathologist anatomy for the further diagnostic
The operation finished

The condition of patient postn operation:

General condition

: Look mild sick

Consciouness

: Compos Mentis

Blood pressure

110/70

mmHg

Pulse rate

98 x/minute

Respiration

22 x/minute

Temperature

36,7 oC

Tissue to Pathology of Anatomy :

: Date, October 23rd 2014

Yes

Type of tissue :
No

Operator,

(Prof. dr. H.I.Oetama Marsis, SpOG)