SURGERY CLASS #3 Part 3

SURGERY CLASS #3 Part 3

23 Januari 2021

Curriculum Vitae

Nama : Dr. Dion Faisal, Sp.B FICS

TTL : Balikpapan, 31 Mei 1985

Istri & anak :

Dr. Dian Manggiasih

Muhammad Nabil

Muhammad Dhafin

Pendidikan :

S1 Kedokteran Umum FK Unmul 2009

Spesialis Bedah Umum FK Unair 2018

Fellow International College of Surgeon 2020

Pekerjaan :

Kepala SMF Bedah, Subkomite Mutu

RSUD Tarakan

Webinar lecturer in General Surgery

PEMBAHASAN

BUKU BEDAH GRATIS???

KLIK https://t.me/joinchat/H98ar0DCkng16V57nkxD-w

Tatalaksana pada necrotizing enterocolitis berikut ini yang benar adalah, kecuali

a. Pemasangan NGT

b. Resusitasi cairan

c. Pemberian antibiotik

d. Pemberian ionotropic jika dibutuhkan

e. Memulai ASI dengan diet 5x20 cc.

NEC

An infant with NEC. Note the abdominal wall ecchymosis extending from the suprapubic region to above the umbilicus and laterally to the flanks.

NEC AXR

Pneumatosis intestinalis Portal venous gas

TATALAKSANA NEC

Aschraft Pediatric Surgery 5th edition

An. J, 5 hari dikonsultasikan pada Anda akibat tidak BAB sejak hari pertama lahir. Pasien nampak lemas, letargis, dan perut pasien nampak distended. Saat dilakukan colok dubur ditemukan feses yang menyemprot. Jika dokter mendiagnosis Hirschprung’s disease, maka pemeriksaan baku emas yang bisa dilakukan adalah

a. Biopsi rektal

b. Barium enema

c. Fleet enema

d. BOF

e. BOF LLD

Penyakit Hirschsprung

Harold Hirschsprung (1886) di Berlin Society of Pediatrics

ETIOLOGI • Kegagalan neuroblas bermigrasi ke segmen usus yang

lebih distal

• Kegagalan maturasi neuroblas. • Terjadi perkembangan normal tetapi oleh karena suatu

hal menyebabkan degragdasi dan destruksi sel-sel ganglion.

Gejala klinis

• Pada prenatal didapatkan ibu dengan polyhidramnion.

• Keterlambatan keluarnya mekonium pertama ( >24 jam) 80% kasus

• Pada neonatus : gejala sama dengan penderita obstruksi tengah, kalau segmen yang aganglionernya panjang. (46% terdiagnosis pada masa neonatus)

• Fecal vomiting.

• Kalau khronis : menyebabkan malnutrisi.

Gejala pada usia lebih besar : • Gangguan defekasi.

• Pemakainan laxantia kronik, kadang manipulasi anus setiap buang air besar.

• Bila disertai komplikasi enterokolitis : biasanya gangguan defikasi dengan disertai diare yang berbau.

• Sering kali disertai malnutrisi.

Pemeriksaan fisik

• Status lokalis : Abdomen distensi, kadang didapatkan contour usus dan darm steifung. Bising usus meningkat.

• Pada colok dubur : khas, yaitu saat dilepas, dari anus akan menyemprot udara dan feses cair.

PENUNJANG

• BOF : gambaran ileus.

• Barium enema :

1. Rektosigmoid yang dilatasi.

2. Fekal material yang banyak

3. Rektum yang menyempit disebut Rat Tail.

4. Zona Transisional : Daerah transisi antara segman yang ganglioner dengan aganglioner.

Pemeriksaan Tambahan

• Biopsi : Swenson (1948), full thickness rectal biopsy

• Biopsi isap (Suction biopsi) : Cara Noblett yaitu teknik pemeriksaan histokimia asetilkolonesterase. (asetilkolinesterase meningkat)

• Pemeriksaan elektromanometri

A, Anorectal manometry without Hirschsprung’s disease, the rectoanal inhibitory reflex is normal. Note the drop in the

internal sphincter pressure with rectal distention. B, Hirschsprung’s disease, abnormally increased contraction of the anal canal and no relaxation of the internal sphincter with rectal distention.

Aschraft Pediatric Surgery 5th Ed

A, This biopsy specimen of normal ganglionated bowel has been stained with hematoxylin and eosin. A ganglion cell (arrow) is seen in the submucosa. B, This rectal biopsy specimen in a neonate with Hirschsprung’s disease has been stained with hematoxylin and eosin. Ganglion cells cannot be found in the wall of the rectum. Also, the submucosal nerve trunks (arrow) are noted to be greater than 40 μm in diameter, which strongly correlates with aganglionosis. C, This rectal biopsy specimen in a neonate with Hirschsprung’s disease has been stained with acetylcholinesterase. The increased staining in the mucosa and submucosa (arrows) is diagnostic of Hirschsprung’s disease. (Courtesy of Dr. D. Kelly, Children’s Hospital of Alabama, Birmingham, AL.)

Tatalaksana definitif dari penyakit Hirschprung adalah

a. Fleet enema

b. Urus-urus

c. Laksatif

d. Pull through

e. Duodenojejunostomi

Terapi dan perawatan

• Dekompresi

• IV line, puasa.

• Pasang rectal tube, kemudian irigasi dengan normal salin hangat hingga segmen usus yang dilatasi menjadi normal.

• Tindakan bedah :

• Diversi : colotransversostomy, sigmoidostomi

• Definitif: Duhamel (retrorectal pull through), Swenson (rectoanal pull through), Soave (endorectal pull trough)

PULLTHROUGH

- KOMPLIKASI

- Dini: perdarahan, infeksi, bocor (leakage)

- Lanjut : stenosis, enterokolitis.

Tn. D, 50 tahun, datang dibawa ambulans ke rumah sakit akibat sebuah kecelakaan lalu lintas. Petugas ambulans mengatakan bahwa terdapat kecurigaan berat trauma servikal, setelah diceritakan mengenai kronologis kecelakaan oleh saksi mata. Pada pameriksaan foto polos ap lateral terdapat burst fracture dari spine servikal. Tatalaksana untuk fraktur ini adalah

a. Dekompresi anterior

b. Dekompresi posterior

c. Cervical brace dan splint

d. Gips

e. Dekompresi lateral diikuti dengan rekonstruksi

CERVICAL FRACTURE BY MECHANISM

• compression fracture • compressive failure of

anterior vertebral body without disruption of posterior body cortex and without retropulsion into canal

• often associated with posterior ligamentous injury

• burst fracture

• characterized by • fracture extension through posterior

cortex with retropulsion into the spinal canal

• often associated with posterior ligamentous injury

• prognosis • often associated with complete and

incompete spinal cord injury

• treatment • unstable and usually requires

surgery

• flexion teardrop fracture

• characterized byanterior column failure in flexion/compression

• posterior portion of vertebra retropulsed posteriorly

• posterior column failure in tension

• larger anterior lip fragments may be called 'quadrangular fractures’

• prognosis • associated with SCI

• treatment • unstable and usually requires

surgery

• extension teardrop avulsion fracture

• characterized by • small fleck of bone is avulsed of

anterior endplate • usually occur at C2 • must differentiate from a true

teardrop fracture

• mechanism • extension

• prognosis • stable injury pattern and not

associated with SCI

• treatment • cervical collar

TREATMENT • Nonoperative

• collar immobilization for 6 to 12 weeks

• indications

• stable mild compression fractures (intact posterior ligaments & no significant kyphosis)

• anterior teardrop avulsion fracture

• external halo immobilization

• indications

• only if stable fracture pattern (intact posterior ligaments & no significant kyphosis)

• Operative

• anterior decompression, corpectomy, strut graft, & fusion with instrumentation

• indications

• compression fracture with 11 degrees of angulation or 25% loss of vertebral body height

• unstable burst fracture with cord compression

• unstable tear-drop fracture with cord compression

• minimal injury to posterior elements

• early decompression (< 24 hours) has been shown to improve neurologic outcomes compared with delayed (>/ 24 hours) decompression

• posterior decompression, & fusion with instrumentation

• indications

• significant injury to posterior elements

• anterior decompression not required

Burst fracture pada spine thorakal ditandai dengan gambaran sebagai berikut pada posisi AP dari foto polos spine

a. Pelebaran lamina

b. Pelebaran pedikel

c. Penyempitan pedikel

d. Penyempitan lamina

e. Pembesaran kauda ekuina

VTh ANATOMY

https://radiologyassistant.nl/musculoskeletal/spine/tlics-classification

Berikut ini merupakan indikasi untuk melakukan pembedahan pada hernia nucleus pulposus

a. VAS 3-4

b. VAS 5-6

c. Gejala bertahan hingga 4 minggu

d. Gejala bertahan hingga 6-8 minggu

e. Diikuti dengan kekakuan otot

HNP Non Operative Management

• Rest and physical therapy, and antiinflammatory medications

• indications • first line of treatment for most patients with disc herniation (90% improve without

surgery)

• technique • bedrest followed by progressive activity as tolerated • Medications: NSAIDS, muscle relaxants (more effective than placebo but have

side effects), oral steroid taper

• physical therapy: extension exercises extremely beneficial, traction, chiropractic manipulation

• Selective nerve root corticosteroid injections

• indications • second line of treatment if therapy and medications fail

• technique • epidural

• selective nerve block

• outcomes • leads to long lasting improvement in ~ 50% (compared to ~90% with surgery)

• results best in patients with extruded discs as opposed to contained discs

HNP Operative Management

Laminotomy and discectomy (microdiscectomy)

indications:

• persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections)

• progressive and significant weakness

• cauda equina syndrome

Technique: can be done with small incision or through "tube" access

Rehabilitation: patients may return to medium to high-intensity activity at 4 to 6 weeks

Outcomes

• outcomes with surgery compared to nonoperative: improvement in pain and function greater with surgery

• positive predictors for good outcome with surgery: leg pain is chief complaint, positive straight leg raise, weakness that correlates with nerve root impingement seen on MRI, married status, professional athletes

• negative predictors for good outcome with surgery: worker's compensation have less relief from symptoms and less improvement in quality of life with surgical treatment

Far lateral microdiscectomy

• Indications: for far-lateral disc herniations

• Technique: utilizes a paraspinal approach of Wiltse

Tumor intrakranial dapat menyebabkan cedera otak melalui mekanisme berikut, kecuali

a. Efek masa

b. Disfungsi dari sel saraf sekitar

c. Pembengkakan

d. Kejang

e. Hipoglikemia lokal

Berikut ini merupakan lokasi paling sering berasalnya tumor otak metastasis adalah

a. Paru

b. Payudara

c. Ginjal

d. Saluran cerna

e. Melanoma

Fraktur ZMC atau Zygomaticomaxillary complex umumnya mengenai bagian-bagian berikut, kecuali

a. Zygomatic arch

b. Inferior orbital rim

c. Lateral orbital wall

d. Zygomaticofrontal buttress

e. Superior orbital rim

ZMC Fracture

SURGICAL ANATOMY

Fraktur nasoorbithaletmoid (NOE) umumnya mengenai bagian-bagian berikut,

kecuali

a. Orbita medial

b. Tulang nasal

c. Processus nasalis

d. Processus frontalis maksila

e. Processeus lateralis maksila

Trauma ureter paling banyak terjadi akibat sebab berikut

a. Kecelakaan lalu lintas

b. Trauma seksual

c. Iatrogenik

d. Komplikasi keganasan

e. Proses melahirkan

Ureteric Injury

Causes

External Trauma (20%)

- After external violence are rare (<1%)

- 10 - 28% have associated renal injuries

- - 5% have associated bladder injuries

Surgical Injury (80%)

- Pelvic surgical procedure – TAH

- Endoscopic manipulation, etc.

Treatment

Repair when injury occurs.

Tension-free spatulated anastomosis, closure, ureteral stenting, RP - drainage.

Primary closure of partial transection of the ureter. Direct ureter to ureter anastomosis.

Reimplantation of the ureter into the bladder (ureteroneocystostomy), either using a psoas hitch or a Boari flap.

Transureteroureterostomy.

Permanent cutaneous ureterostomy.

Trauma buli harus dicurigai ketika ada gross hematuria dengan latar belakang trauma yang akut. Trauma buli paling sering disertai dengan gejala berikut

a. Fraktur kollum femur

b. Fraktur pelvis

c. Fraktur femoral head

d. Trauma ginjal

e. Trauma uretra

Berikut ini merupakan ketidakseimbangan elektrolit yang menyebabkan ileus, kecuali

a. Hipokalemia

b. Hipomagnesemia

c. Hypermagnesemia

d. Hiponatremia

e. Hipernatremia

ILEUS/ ADYNAMIC ILEUS/ PARALYTIC ILEUS

CAUSES

A. Abdominal trauma

B. Abdominal surgery

C. Serum electrolyte abnormality: hypokalemia, hyponatremia, hypomagnesemia, hypermagnesemia

D. Infection, inflammatory or irritation (bile, blood)

• Intrathoracis: pneumonia, lower rib fracture, myocardial infarction

• Intrapelvic: PID

• Intraabdomen: appendicitis, diverticulitis, nephrolithiasis, cholecystitis, pancreatitis, perforated duodenal ulcer

E. Intestinal ischemia

F. Skeletal injury: vertebral fracture

G. Medication: narcotics, phenothiazines, diltiazem or verapramil, clozapine, anticholinergic

Motilitas normal dari kolon setelah sebuah pembedahan abdomen umumnya mulai terjadi pada waktu

a. 12 jam

b. 18 jam

c. 24 jam

d. 36 jam

e. 48 jam

Kehlet H, Holte K. Review of postoperative ileus. Am J Surg. 2001 Nov;182(5A Suppl):3S-10S. doi: 10.1016/s0002-9610(01)00781-4. PMID: 11755891.

• Each segment of the gastrointestinal tract recovers activity at a different rate after surgical manipulation. The small intestine recovers motility within several hours, the stomach within 24 to 48 hours, and the colon in 3 to 5 days.

• However, in postoperative period, some patients experience a prolonged inhibition of coordinated bowel activity that causes accumulation of secretions and gas, resulting in nausea, vomiting, abdominal distension, and pain.

Livingston EHPassaro EP Postoperative ileus. Dig Dis Sci. 1990;35121- 131

• In postoperative ileus, inhibition of small-bowel motility is transient, and the stomach recovers within 24 to 48 hours, whereas colonic function takes 48 to 72 hours to return.

Pada kasus ileus berkepanjangan post op, pemeriksaan radiologi manakah yang menjadi standar untuk mendeteksi adanya abses atau sepsis peritoneal

a. BOF

b. BOF LLD

c. CT scan abdomen

d. USG Abdomen atas

e. Barium enema

Tatalaksana ileus paralitik di bawah ini yang benar adalah

a. Resusitasi cairan

b. Pasang pipa nasogastrik

c. Koreksi cairan elektrolit

d. Spasmolitik

e. Total parenteral nutrition

ILEUS MANAGEMENT

• Nasogastric Intubation

• Early postoperative feeding

• Laparoscopic Procedures

• Local epidural anesthetic/analgesic

• Pharmacologic Agents (NSAID, laxative, neostigmine, metoclopramide hydrochloride, cisapride)

• Gum chewing

• Water & salt balance

Luckey A, Livingston E, Taché Y. Mechanisms and Treatment of

Postoperative Ileus. Arch Surg. 2003;138(2):206–214.

doi:10.1001/archsurg.138.2.206

Short bowel syndrome umumnya terjadi ketika reseksi usus halus melebihi … % dari total panjang usus

a. 10

b. 20

c. 30

d. 40

e. 50

SHORT BOWEL SYNDROME

• a condition in which your body is unable to absorb enough nutrients from the foods you eat because you don't have enough small intestine.

• Portions of the small intestine have been surgically removed: Crohn's disease, cancer, traumatic injuries and blood clots in the arteries.

• Portions of the small intestine are missing or damaged at birth.

• Symptoms: Diarrhea, Greasy, foul-smelling stools, Fatigue, Weight loss, Malnutrition, Swelling (edema) in the lower extremities

• The average length of the adult human small intestine is approximately 600 cm, as calculated from studies performed on cadavers.

• According to Lennard-Jones and to Weser, the range extends from 260 to 800 cm. Any disease, traumatic injury, vascular accident, or other pathology that leaves less than 200 cm of viable small bowel or results in a loss of 50% or more of the small intestine places the patient at risk for developing short-bowel syndrome.

Weser E. Nutritional aspects of malabsorption: short gut adaptation. Clin

Gastroenterol. 1983 May. 12(2):443-61.

Tatalaksana medis untuk short bowel syndrome dapat dengan obat-obat berikut, kecuali

a. PPI

b. Histamine 2 reseptor antagonist

c. Ocreotide

d. Loperamide

e. N asetil sistein

SBS TREATMENT

• Surgery

• TPN: administered concurrently with enteral nutrition

• Fluid and electrolyte management

• Growth hormone 0.03-0.14 mg/kg/day subcutaneously for 4 weeks

• Parenteral (0.16 g/kg/day) or enteral (30 g/day) glutamine supplementation

• High-carbohydrate diet with 55-60% of calories coming from carbohydrates versus 20-25% from fat and 20% from protein.

• Decreasing gastric hypersecretion : PPI or H2 blockers.

• Decreasing diarrhea: when the patient is on nothing by mouth (NPO), codeine (60 mg IM q4hr) may be helpful. When enteral intake is resumed, Imodium (4-5 mg q6hr) or Lomotil (2.5-5 mg q6hr) is useful. In refractory cases, tincture of opium (5-10 mL q4hr) may be tried

• Somatostatin analogue octreotide: 100 μg subcutaneously three times a day. This can reduce stool output by as much as 50%. Short-Bowel Syndrome Treatment & Management.

https://emedicine.medscape.com

An. D, 2 bulan datang dengan keluhan beberapa kali muntah, dan berak yang berdarah seperti jelly berwarna merah. Pada pemeriksaan fisik ditemukan Dance’s sign. Diagnosis pada pasien ini adalah

a. Intususepsi

b. Apendisitis

c. Hirschprung’s

d. IBD

e. Crohn’s disease

INTUSSUSEPSI/ INVAGINASI

• TRIAD: colicky pain, abdominal mass, currant jelly stool

• Radiology findings: abdominal mass, doughnut/ target sign, pseudokidney

ALGORITMA

Rule of 3 Hydrostatic Reduction

• 3 attempt, 3 feet, 3 minutes each

Tatalaksana pasien intususepsi yang stabil yang juga merupakan metode diagnostic adalah

a. Enema udara

b. Laktosa

c. Laktulosa

d. Laparotomi

e. Kolonoskopi

Berikut ini yang merupakan komplikasi yang dapat muncul dari duplikasi intestinal pada bayi baru lahir kecuali

a. Muntah

b. Hematochezia

c. Obstruksi

d. Ileus paralitik

e. Ulserasi

Gastrointestinal (GI) duplications

• Rare congenital malformations that may vary greatly in presentation, size, location, and symptoms.

• In 1937, Ladd introduced the term duplication of the alimentary tract with the following three characteristics: 1. A well-developed coat of smooth muscle is present 2. The epithelial lining represents some portion of the

alimentary tract 3. Duplications are frequently intimately attached to

some portion of the GI tract • Most common site of duplication is the jejunum and

ileum followed by the colon, stomach, duodenum, and esophagus.

Pathophysiology

• Alimentary tract duplications are uncommon and may present as solid or cystic tumors, intussusception, perforation, or GI bleeding.

• Symptoms are often related to the location of the duplication; oral and esophageal lesions can create respiratory difficulties, whereas lower GI lesions may cause nausea, vomiting, bleeding, perforation, or obstruction.

• Patients with cervical esophageal duplications or thoracic/thoracoabdominal duplications may present with respiratory distress that is caused by compression of the airway; this can be life-threatening.

• The presence of heterotopic mucosa (eg, gastric mucosa) in a duplication can lead to peptic ulcerations, bleeding, and perforation with peritonitis.

• Neoplastic changes have been reported in GI duplications.

Tatalaksana kista mesenterika yang ekstensif dan tidak bisa dieksisi sepenuhnya, dapat diterapi dengan

a. Eksisi parsial + marsupialisasi

b. Eksisi parsial

c. Observasi

d. Pendekatan laparoskopi

e. Eksisi komplit + donor organ

MESENTERIC CYST

• A rare, benign intra-abdominal lesions found in the intestinal mesentery.

• The aetiology is unclear, but the most accepted theory to date describes a benign proliferation of ectopic mesenteric lymphatic tissue failing to communicate with the core lymphatic system.

• In almost all reported cases, the management approach for a symptomatic mesenteric cyst is acute surgical resection, often performed laparoscopically, or in some cases using marsupialisation to avoid extensive bowel resection. Surgical drainage is avoided due to infection and recurrence

An. H, 1 hari dirujuk oleh Bidan pada Anda akibat temuan berikut ini. Diagnosis pada pasien ini adalah

a. Hirchprung’s Disease

b. Congenital Adrenal Hiperplasia

c. Malformasi anorectal

d. Hydrocele

e. Megatestis

MALFORMASI ANOREKTAL

BATASAN

Kelainan bawaan yang mengenai laki-laki dan

perempuan dimana didapatkan kegagalan pertumbuhan

normal rektum dan / atau anus

INSIDEN : 1/5000 kelahiran

♂ : ♀ = 2 : 3

ETIOLOGI

Faktor Genetik

Suatu autosomal recessive.

Faktor Lingkungan

- Multi para.

- Usia ibu hamil.

- Thalidomid

- Contraceptive oral ?

- Faktor mekanik pertumbuhan janin.

GAMBARAN KLINIS

Jelas, cukup dengan inspeksi.

Apakah disertai dengan tanda obstruksi.

Sedimen urine harus diperiksa, khusus penderita laki, pada makros ditemukan meconium, mikros ditemukan squamous cell

Pada wanita, inspeksi introitus vagina.

- Satu lubang : Cloaca

- Dua lubang : Atresia ani, rektovaginal fistula.

- tiga lubang : anovestibular, rectovestibular.

Jangan lupa mencari kelainan penyerta yaitu VACTERL

PEMERIKSAAN TAMBAHAN

• Foto polos abdomen (babygram).

• Invertografi :

- Wangensteen and Rice (1930)

- Narashima Foto: Knee chest position, cross table lateral view

- Morogaso: Sangat invasive.

TERAPI

Tergantung tinggi rendah anomalinya.

Tunggu Law of over ten.

Letak rendah langsung dilakukan tindakan pembedahan. : - Cutback incision.

- Dilatasi dengan bouginasi

Letak tinggi : diversi dengan initial colostomy (colotransversostomy atau sigmoidostomy)

Terapi definitive : Postero Sagital Anorekto Plasty (PSARP)

Tutup colostomy

Defek yang paling sering muncul bersamaan dengan malformasi anorectal adalah

a. Anencephaly

b. Spina bifida

c. Atresia esofagus

d. Defek traktus urinarius

e. Akalasia

KELAINAN PENYERTA

Genitourinary

• 81% perempuan dengan kloaka.

• 52% laki-laki dengan bladder neck fistula.

Refluk nephropathy pyelonephritis sampai fibrosis parenchym.

USG ginjal dan voiding cystourethrogram (VCUG).

Tatalaksana malformasi anorektal tipe “Low” adalah dengan

a. Kolostomi

b. Operasi perineal

c. Pull through

d. Pull through + kolostomi

e. Perineal + kolostomi

PSARP

@dionfaisal31

Life only has one rule:

Never quit. – Unknown

Surgery Class

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