DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

FERTILITY ENDOCRINOLOGY REPRODUCTIVE REPORT

Tuesday, August 18th 2020

Resident on Duty:
Dr. Aprian Ilhami

Doctor Incharge :
DR. Dr. H. Kms Yusuf Effendi , OBGYN (C)

Supervisor :
Dr. A. Abadi, OBGYN (C)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Diagnosis ICD 10 Procedure ICD 9 Number

of Cases

Endometriosis ASRM grade I (Score 4, N80.9 Leuprolide Acetate V07.59 1

EFI score 6) Injection 3 series

TOTAL 1
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
FER OUTPATIENT REPORT
Monday, August 10th 2020
No Identity Analysis Diagnosis Procedure
1. Mrs. YUL/ 38 yo/Control Post Laparoscopy Endometriosis ASRM leuprolide acetate
1163083/ RA/ IS- Operative grade I (Score 4, EFI injection 3 series
IAN/ P1A1 score 6)
Normal vital signs ICD 10 ICD 9
N80.9 V07.59
Abdomen
Flat abdomen , supple, sym
metrical, uterine fundal not
palpable, tenderness (-), free
fluid sign (-), mass (-)
Speculum examination
Non-livide portio, closed
OUE, fluor (-), fluxus (-),
E/L/P (-)
Vaginal toucher
Firmed portio, closed OUE,
CUT ~ normal, both of AP
supple, douglas pouch not
bulging.
Rectal Toucher
TSA was normal,Intraluminal
mass (-), Ampulla was
normal,endometriotic nodul
(-),left AP and right AP were
normal, douglas pouch not
bulging
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

ANAMNESIS
Identification Mrs. YUL/ 38 yo/ 1163083/ RA/ IS-IAN/ P1A1
Chief Complain Control Post Laparoscopy Operative
History Patient was referred to Moh Hoesin Hospital after patient had laparotomy
cystectomy on 23/07/20 with PA result 2071/A/2020: endometriosis cysts.
dysmenorrhea (-), dyschezia (-), dysuria (-), leuchorrhea (-), weight loss (-),
loss appetite (-) abdominal enlargement (-), defecation and urination
normal.
Menstrual Status Menarche at 15 y.o. regular menstrual, last 5 days, LMP: 05/07/2020
Marital Status 1x, 14 years
Obstetric status P1A1
Physical Examination
General TD: 120/70 mmHg N: 82 x/mnt RR: 20 x/mnt T: 36.6 C
Examination BB: 68 Kg TB: 163 cm IMT 30.0
Abdominal Flat abdomen ,supple, symmetrical, uterine fundal not palpable, tenderness
(-), free fluid sign (-), mass (-)
Inspeculo Non-livide portio, closed OUE, fluor (-), fluxus (-), E/L/P (-)
Vaginal Toucher Firmed portio, closed OUE, CUT within normal limit, both of AP supple,
CD not bulging.
Diagnosis Endometriosis ASRM grade I (Score 4, EFI score 6)

Planning Inj. Leuprolide acetate 6 series

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

LAPORAN Bangsal : Enim 2 Nomor : 06/EL-FER/XII/2019

OPERASI MR : 1154499
LAPAROSKOPI Nama : Ny. Yulita Sari Umur : 43 tahun
Ruang Operasi 02 OK Graha Spesialis
Cito/ Elektif: Elektif Tanggal : Rabu 22 Januari 2020
DPJP : Asisten I: Perawat instrument:
Dr. Awan Nurtjahyo, SpOG(K) / Dr. H. Dr. Ceza Kautsar Lasera Kartina, Am. Kep
Patiyus Agustiansyah, SpOG(K),MARS Asisten II:
Dr. Octaria Saputra
Nama Ahli Anestesi : Jenis Anestesi : Obat- obat anestesi :
Dr. Aidyl Sp.An General Anestesi Propofol, Fentanyl, atrakurium,
Sevoflurane, O2
Diagnosa Pre-Bedah : Indikasi Operasi :
 Suspek Kista Endometriosis Bilateral Diagnostik dan terapetik
 Perlengketan genitalia interna
Diagnosa Pasca Bedah: Jenis Operasi :
 Endometriosis ASRM Grade IV  Laparoskopi operatif
(ASRM Score 124 EFI Score 3)  Kistektomi
 Post kistektomi perlaparoscopy ai kista  Adhesiolisis
endometriosis bilateral  Ablasi endometriosis
 Post Adhesiolisis a.i perlengketan  Salpingektomi
genitalia interna
 Post Ablasi endometrium
 Post salpingektomi bilateral

Disinfeksi kulit dengan : Jaringan yang diambil :

Alkohol 70% + Povidon iodine 10% Kista endometriosis bilateral, salpingektomi bilateral

Jam operasi Jam operasi selesai Lama operasi Jenis bahan:

dimulai berlangsung Yang dikirim untuk pemeriksaan :
Pukul 15.00 WIB Pukul 16.00 WIB 1 jam Patologi anatomi

Cara Operasi (Bila perlu dengan Gambar) Keterangan :

TROKAR 1

TROKAR 2
TROKAR 3

TROKAR 4

Singkatan kelainan yang ditemukan dengan gambar ( Laporan lengkap lihat di sebelah )
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

RUMAH SAKIT UMUM PUSAT PALEMBANG

Pukul 15.00 WIB Operasi dimulai
 Pasien terlentang dalam narkose.
 Dilakukan aseptik-antiseptik dengan alkohol dan povidon iodine 10% pada daerah abdomen.
 Lapangan operasi dipersempit dengan doek steril.
 Dilakukan pengosongan kandung kemih dengan kateter FR 16.
 Dilakukan pemasangan sondase, didapatkan uterus antefleksi dengan sondase 7 cm, dipasang uterine manipulator
Tindakan dilanjutkan dengan laparoscopy
 Dilakukan insisi intraumbilikal memanjang sambil melakukan elevasi dinding abdomen
 Dilakukan insersi trochar 10 mm dengan teknik direct trochar entry, setelah yakin masuk di rongga abdomen dengan
pandangan teleskop, dimasukkan gas untuk dilakukan pneumoperitoneum.
 Dilakukan pemasangan trokar kerja 5 mm, trokar I dipasang di kuadran kanan bawah, trokar II kuadran kiri bawah dan trokar
III 5 jari di bawah umbilical.
 Dilakukan laparoskopi diagnostik, dalam lapangan pandang laparoskopi didapatkan :
- Tampak Uterus dalam batas normal
- Tampak perlengketan antara adneksa kanan, tubo ovarian, dengan dinding pelvic  adhesiolisis berhasil. Tampak
massa kistik pada ovarium kanan  kista dipecahkan  cairan cokelat  kista endometriosis  dilakukan kistektomi
 jaringan di PA kan
- Tampak perlengketan antara adneksa kanan, tubo ovarian, dengan massa kistik  adhesiolisis berhasil. Tampak
massa kistik pada ovarium kiri  kista dipecahkan  cairan cokelat  kista endometriosis  dilakukan kistektomi 
jaringan di PA kan
- Tampak nodul endometriosis pada dinding pelvic, corpus uterine anterior  ablasi endometriosis
- Dilakukan salpingektomi bilateral
- Dilakukan pencucian cavum abdomen dengan aquades
- Setelah diyakini tidak ada perdarahan aktif, alat laparaskopi dilepaskan
 Trokar kerja kedua dan ketiga dilepaskan dengan visualisasi langung
 Saluran gas dilepaskan dengan mematikan insuflator gas terlebih dahulu
 Pneumoperitoneum dihilangkan, teleskop dan trokar kerja utama dilepaskan.
 Luka insisi pada dinding abdomen dijahit secara terputus dengan Vicryl no.3.0
 Luka operasi ditutup dengan softratulle dan opsite
Pukul 16.00 WIB. Operasi selesai

Komplikasi :
Tidak Ada
Ada

Jumlah perdarahan : 50 cc
Cairan masuk: Cairan keluar:
RL : 500 cc Darah : 50 cc
Darah : - cc Urine : 100 cc
Jumlah : 500 cc Jumlah : 150 cc

Diagnosis prabedah : Suspek kista endometriosis bilateral dengan perlengketan genitalia interna
Diagnosis pascabedah : Endometriosis ASRM Grade IV (ASRM Score 72 EFI Score 5) + Post kistektomi
perlaparoscopy ai kista endometriosis bilateral + Post Adhesiolisis a.i perlengketan genitalia interna + Post Ablasi
endometrium + Post salpingektomi bilateral

Jenis tindakan : Laparoskopi operatif + Kistektomi + Adhesiolisis + Ablasi endometriosis + Salpingektomi

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Instruksi Pasca bedah :

1. Observasi TVI (TD, N, RR, T, perdarahan) 7. Obat – obatan
2. IVFD RL gtt xx/m  Asam Tranexamat 500mg/8jam IV
3. Kateter menetap 24 jam  Ketorolac amp/8jam IV
4. Diet bertahap bila bising usus (+) normal dan pasien  Inj Ceftriaxon (bila leukosit post op > 15.000)
sadar penuh
5. Mobilisasi bertahap setelah pasien sadar penuh
6. Bila ada keluhan, lapor dokter jaga/dokter ruangan

DPJP / Operator Pembuat laporan

Dr. Awan Nurtjahyo, SpOG(K) /

Dr. H. Patiyus Agustiansyah, SpOG(K), MARS Dr. Ceza Kautsar Lasera
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Ny Yulita Sari
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

ANAMNESIS
Identification Mrs. REN/ 34 yo/ 1179839/ UA/ HE-IAN
Chief Complain Control Post Laparotomy Cystectomy (outside) with PA result
History Patient was referred to Moh Hoesin Hospital after patient had laparotomy
cystectomy at BARI hospital on 23/07/20 with PA result 118/PA/BA/2020:
endometriosis cysts in left ovary. dysmenorrhea (-), dyschezia (-), dysuria
(-), leuchorrhea (-), weight loss (-), loss appetite (-) abdominal enlargement
(-), defecation and urination normal.
Menstrual Status Menarche at 15 y.o. regular menstrual, last 5 days, LMP: 05/07/2020
Marital Status 1x, 17 years
Obstetric status P3A0
Physical Examination
General TD: 110/70 mmHg N: 82 x/mnt RR: 20 x/mnt T: 36.6 C
Examination BB: 60 Kg TB: 155 cm IMT 30.0
Abdominal Flat abdomen ,supple, symmetrical, uterine fundal not palpable, tenderness
(-), free fluid sign (-), mass (-)
Inspeculo Non-livide portio, closed OUE, fluor (-), fluxus (-), E/L/P (-)
Vaginal Toucher Firmed portio, closed OUE, CUT within normal limit, both of AP supple,
CD not bulging.
Diagnosis Endometriosis ASRM grade IV ( ASRM score 56 EFI score 7 )

Planning Inj. Leuprolide acetate 6 series

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Reni Novita Sari

56
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG