HYSTERECTOMY

BAG./ SMF OBSTETRI GINEKOLOGI FAKULTAS KEDOKTERAN / RUMAH SAKIT UMUM FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA JL. Mayjen Sutoyo No. 2 Cawang, Jakarta Timur 13630 Telp.8099217 ext. 108 / 205

OPERATION REPORT

Name : Mrs. Sri Mulyani	Sex : Female	Age : 47 years	MR : 33 22 00 00
Operator : Prof. dr. I. O. Marsis, SpOG	Assistant : dr. M.Reza		Anesthesiologist : dr. Machir Siagian SpAn
Co-Assistant : Hardina Krisetyani	Observer : Juli Novika, Irwandi		Instrumentator : Zr. Erlina
Pre-operation Diagnosis : Menormetrorrhagia e.c hiperplasia endometrium			Date of operation : July 29th 2010
Post-operation Diagnosis : Hiperplasia endometrium			Duration : 2 hours 30 minute
Technique of operation : Total Abdominal Hysterectomy			Type of Surgery :  Emergency  Minor  Clinic  Medium √ Elective √ Major

Operation procedures :

I. Patient was administered with general analgesia in supine position

II. Methylen blue 10 cc was inserted intravaginal

III. Dower catheter was inserted into external urethral ostium

IV. Aseptic and antiseptic were done on abdomen region and it’s surroundings down to 1/3 of proximal upper legs and the operation field was limited with sterile doeck

V. Opened the abdominal wall; Pfanenstiel incision was made approximately 12 cm on the lower abdomen region, the incision was made deeper, layer per layer, from cutis, subcutis, fascia, m.rectus abdominis, and then it separated to lateral side, bleeding was controlled. Peritoneum viscerale was opened upside and downside by sharp technique, so uterus can be seen.

VI. Explored the abdominal and pelvic cavity :

a. Identified :

· Uterus as big as adult hand and looked smooth

· Right and Left ovary was looked normal

· Right fallopian tube and left fallopian tube was looked normal

b. Planning : total hysterectomy

VII. Operation procedures of total hysterectomy as followed :

a. The right round ligament were clamped on two sides, approximately 1 cm and 1,5 cm from uterus and cut in between, ligated at medial and lateral dissection, then was sutured by “chromic cat gut no” no. 2

b. The proximal of right fallopian tube was clamped on two sides and was cut in between.

c. The right broad ligament was clamped on two sides, approximately 1 cm and 1,5 cm, cut in between, ligated each medial and lateral, and then sutured with “Vycril” no 1.

d. The right uterosacral ligament was clamped on two sides, approximately 1 cm and 1,5 cm from uterus, cut in between, ligated each medial and lateral, and then sutured with “Vycril” no 1. Controlled bleeding.

e. The right uterine vasa were clamped on two sides, cut and ligated with “Vycril” no 1.

f. The right cardinale ligament was clamped on two sides, cut in between, ligated in medial and lateral, then sutured.

g. Plica vesicouterina was opened and continued incision was made to the left and right lateral and was put downward.

h. The upper vagina was cut off and sutured with “Vycril” no 1. by overhecting suture. The round ligaments, uterosacral ligaments and proximal of fallopian tubes were hung.

i. Reperitonealization was done with sutured plica vasicouterina with “Chromic Cat Gut” No. 2.0

VIII. Before reperitonealization was done, blood cloth was pulled out and the abdominal wall was closed then with layer by layer suture after no obvious bleeding was found.

a. Parietal peritoneum was sewed bastes with “Plain Cat Gut” No. 2.0 after the infusion of 25 mg/10 ml cortisone acetate.

b. M.Rectus abdominis was sutured with “Chromic Cat Gut” No. 2.0 by simple suture.

c. Fascia was sutured with vicryl no: 1 by continous suture

d. Subcutis was sutured with “Plain Cat Gut” No. 1.0 by simple suture

e. Cutis was sutured with “Chromic Cat Gut” No. 3.0 by subcuticuler

IX. Post-surgical wound was treated with cemicetine zalf, then closed by using the curapor.

X. The vagina was cleaned.

XI. The operation finished.

Post-operation condition :

- General condition : Moderate illness

- Consciousness : Somnolent

- Blood pressure : 130/90 mmHg

- Pulse rate : 88 x/minutes

- Temperature : 36 ⁰C

- Respiration rate : 24 x/minutes

Tissue for Pathological Anatomy examination :

√ Yes : Date, July 29^th 2010

Type of tissue :

1. Uterus

 No

Operator’s signature

(Prof.dr. I.O.Marsis, SpOG)