DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

OPERATING THEATRE REPORT

Monday, September 23rd 2019

Resident on Duty:

Dr. Gerry Irawan

Dr. Riyan Wira Pratama

Supervisor on Duty:

Dr. H. Irawan Sastradinata, SH, OBGYN (C), MARS

Supervisor:

Dr. H. Patiyus Agustiansyah, OBGYN(C), MARS

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

RECAPITULATION PATIENT OPERATING THEATRE REPORT

Operative
Date Fertility /
Oncology Uroginecology Obstetry
Gynecology
Monday,
September 1 - - -
23th, 2019
Tuesday,
September
24th, 2019
Wednesday,
September
25th, 2019
Thursday,
September
26th, 2019
Friday,
September
27th, 2019

TOTAL 1 - - -
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

RECAPITULATION BASED ON OPERATING THEATRE REPORT

Diagnosis ICD Procedure ICD Number
10 9 of Cases
Cyst Ovarian Neoplasm with C56.9 Adhesiolisis + Surgical 54.5 1
Solid Part Malignancy was N73.6 Staging (Ascites Cytology + 68.4
Suspected + Internal Organ Optimal Debulking + TAH- 54.4
Adhesion USO + Total Omentectomy) + 45.6
Anastomoses Resection by
Stapler on Descendent Colon
TOTAL 1
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

No Identity Diagnosis ICD Procedure ICD OP RES

10 -9
1 Mrs. ERM/ - Cyst Ovarian C56.9 - Adhesiolisis 54.5 IS SAT
52 y.o. / Neoplasm with N73.6 - Radical Surgical Staging 68.4 GER
P4A2 / RA Solid Part (Ascites Cytology + 54.4
Malignancy was Optimal Debulking + 45.6
Suspected TAH-USO + Total
- Internal Genital Omentectomy)
Adhesion - Anastomoses Resection
by Stapler on Descendent
Colon

No Date Identity Diagnosis ICD Management / ICD

10 Procedure 9
1 23/09/19 Mrs. ERM/ Preoperative C56.9 - Adhesiolisis 54.5
52 y.o. / Diagnosis : N73.6 - Radical Surgical 68.4
P4A2 / RA - Cyst Ovarian Staging (Ascites 54.4
Neoplasm with Solid Cytology + Optimal 45.6
Part Malignancy was Debulking + TAH-
Suspected USO + Total
- Internal Genital Omentectomy)
Adhesion - Anastomoses
Resection by Stapler
Recent Diagnosis : on Descendent
- Ovarian Cancer Stage Colon
IIIC Clinically
- Post Anastomose
Resection by Stapler
o.i. Colon Perforation
and Adhesion
Identity
Name Erma Suryani
Med Rec/ Reg 0001134014
Age 06-03-1968 (51 yo)
Address Banyuasin III, Banyuasin
Operator Dr. H. Irawan Sastradinata, SpOG (K),
MARS
Resident Dr. KGS. Irawan Satria Arjanggi
Dr. Gerry Irawan
Anamnesis
Chief Complaint Abdominal mass
History 4 years ago, there is a mass in abdomen,
larger, history of weight loss (+), history
of loss of apetite (-), urinary and
defacation normal, history od leucorrhea
(-), history of vaginal bleeding (-)
Past operation & Past Illness History of injection contraception 3
month (last time was 10 years ago)
Marrital 1x for 21 years
Obstetric P4A2
Menstrual Menopause since 3 years ago
Economic and nutrition status Moderate
Physical examination
General condition Good RR 20 x/m
Sens CM Pulse 84 x/m
BP 110/80 mmHg Temperature 36,1oC
Weight 48 kg Height 150 cm
Gynecology status PL: convex abdomen, tense, fundal
height hard to asses, there is a mass with
upper border in ½ processus –
symphysis, lower border in umbilicus,
right border in right LMC, left border in
left LMC, free fluid sign (-)
Insp: portio didn’t livide, OUE closed,
fluor (-), fluxus (-), E/L/P (-)
VT: portio firmed, OUE closed, both AP
tense, CD protruded
USG Uterus, shape and size in normal limit
Homogen myometrium, regular basalis
stratum
Portio and endocervix in normal limit
There is cystic mass with solid part,
probing size 16,7 x 12,9 cm ~ ovarian
cystic neoplasm with solid part susp
malignancy
Contralateral ovarium hard to assess
Hepar and both kidney in normal limit
Internal genital adhesion
C/ Ovarian cystic neoplasm with solid part
susp maligancy
Internal genital adhesion

Radiology Result There is no sign of abnormalities in torax

02-08-2019
Laboratory examanination Hb 11,2 g/dL WBC 96.600/mm3 Ht 34%
17-09-2019 PLT 320.000/L SGOT 12 U/L SGPT 8
U/L Albumin 3,6 g/dL BSS 112mg/dL
RMI 3: 3x4x445.5 = 5340 Ureum 17 mg/dL Creatinin 0,83 mg/dL
Ca 9,9 mg/dL Na 138 mEg/L K 3,8 mEg/L
RMI 4: 4x4x2x445.5 = 14,256 Cl 100 mmol/L
AFP 2,50 ng/mL CEA 28.00 ng/mL CA
125 445,5 u/mL
Diagnosis Ovarian cystic neoplasm with solid part
susp malignancy
Planning FS Laparotomy (19-09-2019)
Intraoperative
- 13.00 PM: Operation started.
- Patient on supine position and under general anesthesia.
- Aseptic and antiseptic were done on operating area.
- Operation site narrowed with sterile cloth, hen continue with mediana incision. On
exploration was found:
- Uterine and right ovarian within normal limit
- There was adhesion between mass and descendent colon and peritoneum 
adhesiolisis peritoneum and mass
- There was solid mass at left adnexa, mass size 16x15 cm, bumpy surface, fragile
 Perform left Salphingoooforectomy  clamped, cut, and stitch, left
ligamentum infundibulo pelvikum, left ligamentum ovarii proprium, and left tube
base with Chromic cut gut no.1  PA
- There was adhesion between mass and descendent colon  adhesiolisis 
perforation on descendent colon  consult intraoperative with digestive surgery
division
- Consult intraoperative with Digestive Surgery Division  performed Anastomose
Resection by Stapler  PA
- Performed TAH-USO
- 17.00 PM: Operation was finished.
- Bleeding intraoperative 500 cc, urine 200 cc clear.