Académique Documents
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Surgery
BIMBEL UKDI MANTAP
dr. Andreas W Wicaksono
dr. Anindya K Zahra
GENERAL SURGERY
Lap belt marks: Correlate with small intestine rupture
Kehr’s sign
• Kehr’s sign : pain in
the left tip shoulder
cause by irritation of
peritoneum that
covers inferior
surface of left
diaphragm >> a sign
of rupture spleen
HistoryRetroperitoneal
& Physical: Hematoma
Hematom penis
Butterfly
Hematome
Ruptur Uretra Posterior
0 1 2 3 4
Eritem < 3cm 3-12cm >12-25cm >25cm > ekstremitas
(dalam
12jam)
Gejala - - Mual, Shock, Gagal ginjal
Sistemik pusing Petechie, akut, coma,
echymosis perdarahan
DIGESTIVE SURGERY
Migrating pain–
Acute Appendicitis
appendicitis
• Rovsing’s sign :
palpation in the left
lower quadrant of
abdomen increase the
pain in the right lower
quadrant
Obturator sign
Alvarado Score: MANTRELS
Pathophysiology
Radiology– Ileus
Ileus
Screening Test:
• FOBT
• Colonoscopy
• CEA (Carcinoembryonic Antigen). Normal <2,5ng/ml
• Genetic analysis
DUKE’s Staging
Hemorrhoid
• Asymptomatic
Gallstone in CBD • Biliary colic
(choledocholithiasis) • Obstructive jaundice
– Surgery :
• Laparoscopic cholecystectomy
• Open cholecystectomy
Choledocholithiasis
• 10-15% pasien cholelithiasis
• Penyebab :
– Gallstone (pigmented stone)
– Sering pada pasien dgn kronik
hemolytic disease
• Sign & symptom :
– Asymptomatic
– Biliary colic
– Obstructive jaundice
• Px lab (mirip dgn cholelithiasis) :
– Serum bilirubin (++)
– Alkaline phospatase (almost always elevated in biliary obstruction)
• Komplikasi :
– Cholangitis
• Terjadi akibat ascending infection dari bacteria di duodenum. Bisa
terjadi krn bile duct sudah terobstruksi oleh gallstone.
• Medical emergency
• Sign & symptom : jaundice, fever, malaise, rigor & abdominal pain
(severe : hypotension & confusion)
• Gambaran duktus : dilated, sclerosed & strictured ducts
• Initial Tx : IV fluid & antibiotik
– Pancreatitis
cholangitis
• Px penunjang :
– Cholangiography
– ERCP & MRCP
– USG
• Tx :
– Choledocholithotomy
– ERCP (Modalitas intervensi: endoscopic sphincterotomy,
stone removal, insertion of stent, dilation of stricture)
ERCP
Alat Dx sekaligus Tx
• SHIFTING DULLNESS
– For ascites
500ml
Hernia
Trigonum hasselbach
Dibentuk tepi MRA, a.
epigastrica inferior, lig.
Inguinalis
• Screening test :
PSA ( Prostat
Specific Antigen),
normal value <4
ng / ml
• Rectal toucher:
–Suspect
malignancy IF
hard, nodular,
irregular
PENANGANAN / PENGOBATAN BPH
Dulu: Mencegah / menurunkan angka
kematian karena BPH
IPSS: WISE & FUN Sekarang: Meningkatkan kualitas hidup
W eak stream
ALTERNATIF PENANGANAN BPH
I ntermittensi
• IPSS <8 Watchful Waiting
S training • IPSS 8-18 Pemberian obat
E mptying incomplete • Alpha1 adrenergik blocker
F requecy (Prazosin)
U rgency • 5 Alpha reductase inhibitor
(Finasterid)
N octuria
• IPSS >18 Operatif
Invasive: open prostatecomy
Less Invasive: TURP
WATCHFUL WAITING
• Sebagian besar tanpa keluhan
• Tanpa penyulit / gejala
• Kualitas hidup tetap baik
INDIKASI
• BPH dengan IPSS ringan (<8)
• Baseline data normal
• Flowmetri : non obstruktif
FOLLOW-UP
• Tiap 3-6 bulan
• Ulangi :
• IPSS
• Flow (6 bulan)
• PSA (6-12 bulan)
Prostate
TERAPI BPH DENGAN BLOCKER
INDIKASI :
• IPSS ringan dan sedang
SYARAT :
• Normotensi / hipertensi ringan
• Urin normal
• Faal Ginjal Normal
• PSA 4 ng%
• Miokard Infark (-), CVA (-)
KONTRAINDIKASI
• Hipotensi postural / ortostatik
• Alergi terhadap bloker
TERAPI PEMBEDAHAN BPH PEMBEDAHAN BPH
Di Amerika : 300.000 – 400.000/tahun • TUR Prostat: 90 – 95%
Di Urologi RS Dr. Soetomo • Open prostatektomi
Ke 2 terbanyak setelah urolithiasis : 5 – 10 %
150/tahun
• BPH yang besar
INDIKASI TERAPI PEMBEDAHAN BPH (>50 – 100 gram)
• Retensi urin akut Tidak habis
• Retensi urin kronis (selalu > 300 ml) direseksi dalam
• Residual urin > 100 ml 1 jam
• BPH dengan penyulit
• Disertasi :
• Terapi medikamentosa tidak berhasil
• Flowmetri obstruktif • Batu buli besar
(> 2.5 cm)
INDIKASI KONTRA TERAPI PEMBEDAHAN BPH • Multipel
• Infark miokard Akut • Fasilitas TUR tidak
• CVA Akut
ada
Batu Saluran Kemih
Nephrolithiasis
Ureterolithiasis
Vesikulolithiasis
Uretrolithiasis
Urinary Tract Reffered Pain
Lokasi Gejala
GINJAL Nyeri regio flank, dapat berupa
- Nyeri kolik akibat aktivitas peristaltik otot polos sistem kalises, atau
- Nonkolik akibat peregangan kapsul ginjal, hidronefrosis, atau infeksi
pada ginjal
• menyerupai tanduk rusa.
URETER Nyeri pinggang kolik dan menjalar, tergantung letak batu:
• rektum.
- Proksimal pinggang setinggi pusar (T10)
- Medial medial paha/skrotum (L1-3)
- Distal ujung penis (S2-3), +disuria
VESICA Gejala iritasi, miksi tiba-tiba berhenti dan menjadi lancar kembali
dengan perubahan posisi tubuh.
Nyeri berkemih pada ujung penis, skrotum, perineum, pinggang, atau
kaki. Anak sering mengeluh enuresis nokturna, sering menarik-narik
penisnya (laki-laki) atau menggosok-gosok vulva (perempuan)
URETHRA Miksi tiba-tiba berhenti retensi urin. Batu pada uretra - Anterior
benjolan keras di penis, atau tampak di meatus uretra eksterna. Nyeri
pada glans penis.
- Posterior nyeri pada perineum atau rektum
Jenis-jenis batu
Diagnosis –Px Penunjang
Urinalisis
• Hematuria, kristal, tanda infeksi
Radiologi
• BNO hanya untuk batu radioopak (kalsium, sistin)
• IVP bisa untuk batu non-opak (urat, struvit)
• USG aman untuk ibu hamil dan yang KI IVP
• Pyelografi antegrad/retrograd bila fungsi voiding terganggu
Struvite Stones
• >> women
• Struvite (magnesium ammonium phosphate) stone
• Infection with urease producing bacteria (e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter), resulting in
hydrolysis of urea into ammonium and increase in the
urinary pH 6,10.
• They can grow very large and form a cast of the renal pelvis
and calices resulting in so-called staghorn calculi. The
struvite accounts for approximately 70% of these calculi,
and is usually mixed with calcium phosphate thus
rendering them opaque. Uric acid and cystine are also
found as minor components.
Staghorn
Faktor Risiko –Batu Kalsium (70-80%):
• Hiperkalsiuri
– absobtif
– renal (reabsorbsi turun)
– resorptif (kalsium tulang) pada hiperparatiroidisme
• Hiperoksaluri
– post operasi usus atau banyak konsumsi makanan yang kaya oksalat (teh, kopi
instan, soft drink, dll)
• Hiperurikosuria
– asam urat bertindak sebagai inti batu/nidus untuk terbentuknya batu kalsium
oksalat.
• Hipositraturia
– Di dalam urine, sitrat bereaksi dengan kalsium membentuk kalsium sitrat
cegah ikatan kalsium dengan oksalat atau fosfat.
• Hipomagnesuria.
– Di dalam urine magnesium bereaksi dengan oksalat menjadi magnesium
oksalat cegah ikatan kalsium dengan oksalat.
Prevensi Batu Kalsium
• Menurunkan konsentrasi kalsium dan oksalat
• Meningkatkan konsumsi sitrat minum jeruk nipis/air
lemon sesudah makan malam
• Meningkatkan asupan cairan
• Hindari soft drink (>1 L/minggu)
• Batasi asupan protein (1 gr/kgBB/hari).
– Protein tinggi ekskresi kalsium & asam urat, sitrat
• Batasi asupan natrium reabsorpsi kalsium
• Pembatasan asupan kalsium tidak dianjurkan
Tatalaksana
Bladder Carcinoma
• Cancer age
• Painless gross
hematuria all along
micturition, reccurent
• Risk factor
– Male
– Cigarette
– Amine aromatic
substance exposure
(paint, textile)
– UTI
• 90%: Transitional Cell
Carcinoma (TCC)
Retrograde Urethrography
4. Continuous: fistula 5. functional: paralysis, cognitive impairment
Urinary Incontinence
Scrotal Swelling
Disorders Etiology Clinical
Testicular torsion Intra/extra-vaginal Sudden onset of severe testicular pain followed by
torsion inguinal and/or scrotal swelling. Gastrointestinal
upset with nausea and vomiting.
Hidrocele Congenital anomaly, accumulation of fluids around a testicle, swollen
blood blockage in the testicle,Transillumination +
spermatic cord
Inflammation or
injury
Epicondylus medial
Claw hand
N. Ulnaris
Drop hand
N. Radialis
Preacher’s Hand
N. medianus
Orbita
Management of Fracture
• 4R :
– 1. Recognition
– 2. Reduction
– 3. Retention
– 4. Rehabilitation
Recognition
• Anamnesis
– History of trauma?
– Mechanism of injury?
– Localized pain, aggravated by movement
– Decreased function
– “heard the bone break”
– “feel the ends of the bone grating”
Physical Examination
LOOK (Inspection)
Symetricity right-left
Swelling, wound, deformity (angulation, rotation,
shortening), abnormal movement, discoloration
(ecchymoses)
Bone exposure
FEEL (Palpation)
Localized tenderness
Distal neurological status (S&M), pulsation
Aggravation of pain and muscle spasm during even the
slightest passive movement
Feeling and listening the crepitus unnecesary!
Reduction
• Restore a fracture to correct allignment
• Closed Reduction
– Traction : Skin traction, skeletal traction
• Open Reduction
– ORIF
– OREF
Traction
Skeletal Traction
Femur fracture managed with skeletal traction and use of a Steinmann pin in the
distal femur.
ORIF vs OREF
Indications for External Fixation
• Open fractures that have
significant soft-tissue
disruption (eg, type II or III
open fractures)
• Soft-tissue injury (eg, burns)
• Pelvic fractures
• Severely comminuted and
unstable fractures
• Fractures that are associated
with bony deficits
• Fractures associated with
infection or nonunion
• Closed reduction is needed if the fracture is significantly displaced or
angulated. Indications for surgical intervention include the following:
– Failed nonoperative (closed) management
– Unstable fractures that cannot be adequately maintained in a reduced
position
– Displaced intra-articular fractures (>2 mm)
– Patients with fractures that are known to heal poorly following
nonoperative management (eg, femoral neck fractures)
– Large avulsion fractures that disrupt the muscle-tendon or ligamentous
function of an affected joint (eg, patella fracture)
– Impending pathologic fractures
– Multiple traumatic injuries with fractures involving the pelvis, femur, or
vertebrae
– Unstable open fractures or complicated open fractures
– Fractures in individuals who are poor candidates for nonoperative
management that requires prolonged immobilization (eg, elderly patients
with proximal femur fractures)
– Fractures in growth areas in skeletally immature individuals that have
increased risk for growth arrest (eg, Salter-Harris types III-V)
– Nonunions or malunions that have failed to respond to nonoperative
treatment
Retention / Immobilization
Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi
bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku
(rigid)
• Plaster slab adalah lempengan gips untuk imobilisasi sendi atau
daerah cidera sehingga terjadi penyembuhan. Sebagian besar
fraktur dislab untuk 24-48 pertama untuk mengakomodasi
pembengkakan, sebelum dipasang gips sirkuler.
• Lempengan Gips/CAST → Dapat Digunakan Pada
– Imobilisasi Fraktur
– Imobilisasi pada penyakit tulang dan sendi
– Pencegahan deformitas muskuloskeletal
* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan
traumatologi, 2006. hal 2-6
GIPS/CAST
Supracondylar Fracture of Humerus
Open Reduction To Prevent
Arm Sling
Brachial Artery Injury!
U Slab
• Humeral shaft
fracture
Volar Slab
Compartment Syndrome
• 6 P of Compartment
Syndrome
– Pain
– Pallor
– Pulseless
– Paresthesis
– Paralysis
– Pressure
• Tx : Fasciotomy
Compartment Syndrome
• Fasciotomy
• Casts and tight
bandages
–remove or
loosen any
constricting
bandages
Muscle of Calf
Artery of Calf
Paget’s Disease
• Paget disease is a localized disorder of bone
remodeling that typically begins with
excessive bone resorption followed by an
increase in bone formation. This osteoclastic
overactivity followed by compensatory
osteoblastic activity leads to a structurally
disorganized mosaic of bone (woven bone),
which is mechanically weaker, larger, less
compact, more vascular, and more susceptible
to fracture than normal adult lamellar bone.
• Sign and Sympton including the following:
– Bone pain (the most common symptom)
– Secondary osteoarthritis (when Paget disease
occurs around a joint)
– Bony deformity (most commonly bowing of an
extremity)
– Excessive warmth (due to hypervascularity)
– Neurologic complications (caused by the
compression of neural tissues)
• Skull involvement may lead to the following:
– Deafness
– Vertigo
– Tinnitus
– Dental malocclusion
– Basilar invagination
– Cranial nerve disorders
Multiple Myeloma
Level Definition
Normal Bone density is within 1 SD (+1 or −1) of the young adult mean.
Severe
Bone density is more than 2.5 SD below the young adult mean,
(established)
and there have been one or more osteoporotic fractures.
osteoporosis
Incidence of osteoporotic Fx
Vertebral
Fracture
Forearm
Fracture
Hip
Fracture
Osteoporosis
ATLS
Shoulder Dislocation
Anterior Shoulder
Subluxation/Dislocation
• Radiographs:
Axillary View
True AP
Y view
Anterior Shoulder Subluxation/Dislocation
• Dislocation: • Mechanism:
– Complete separation of articular
surfaces – Forced extension, abduction,
external rotation
• Subluxation:
– Direct blow to posterior or
– Abnormal translation of humeral
head on glenoid without posterolateral shoulder
complete separation of articular – Repeated episodes of overuse
surfaces (subluxation)
• Humeral head can dislocate • Physical Exam:
anteriorly, posteriorly or – Intense pain
inferiorly – Arm held in adduction & external
• Anterior dislocation most rotation
common – Humeral head palpable anteriorly
– Unable to completely internally
rotate or abduct the shoulder
– Thorough neuro exam (close
relation of axillary nerve)
Hip Dislocation
Posterior Anterior
(flexi, adduksi, endorotasi) (flexi, abduksi, exorotasi)
Osteosarcoma
• X-rays of area of suspected infection would
not demonstrate darkened areas typical of
osteomyelitis.
• Conventional features
– Destruction of normal trabecular bone pattern
– a mixture of radiodense and radiolucent areas
– periosteal new bone formation
– formation of Codman's triangle (triangular
elevation of periosteum)
No osteoblastic appearance, Notice the osteoblastic-
fracture can be seen osteolytic appearance
Codman triangles (white Osteosarcoma of the distal femur,
arrow); and the large soft demonstating dense tumor bone formation
tissue mass (black arrow) and a sunburst pattern of periosteal reaction.
Periosteal reactions
• Radiographs of the primary
tumor usually show a large,
destructive, mixed lytic and
blastic mass. The tumor
frequently breaks through the
cortex and lifts the periosteum,
onion-skin "sunburst" and "hair-on- resulting in reactive periosteal
(Ewing’s sarkoma) end" periosteal reaction bone formation. The triangular
shadow between the cortex
and raised ends of periosteum
is known radiographically as
Codman triangle and is
characteristic, but not
Codman's triangle
diagnostic of this tumor.
The Canadian Journal of Diagnosis / May 2001
Ewing’s Sarkoma
• Annual
incidence at
birth to 20 y.o
(teenagers and
young adult)
• Most common
site : pelvis
• Radiologic :
onion peel
Ewing’s Sarkoma
Acute Achilles Tendon Rupture
• Adults 40-50 y.o.
primarily affected (M>F)
• Athletic activities,
usually with sudden
starting or stopping
• “Snap” in heel with pain,
which may subside
quickly
Acute Achilles Tendon Rupture
Diagnosis
• Weakness in plantar flexion
• Gap in tendon
• Palpable swelling
• Positive Thompson test
Open Fracture
Vertebral Fracture
ONCOLOGIC SURGERY
The Breast
Tumors Onset Feature
Breast cancer 30-menopause Invasive Ductal Carcinoma , Paget’s disease (Ca Insitu),
Peau d’orange , hard, Painful, not clear border,
infiltrative, discharge/blood, Retraction of the
nipple,Axillary mass
Fibroadenoma < 30 years They are solid, round, rubbery lumps that move freely in
mammae the breast when pushed upon and are usually painless.
Fibrocystic 20 to 40 years lumps in both breasts that. increase in size and
mammae tenderness just prior to menstrual bleeding. occasionally
have nipple discharge
Mastitis 18-50 years Localized breast erythema, warmth, and pain. May be
lactating and may have recently missed feedings.fever.
Philloides 30-55 years intralobular stroma . “leaf-like”configuration.Firm,
Tumors smooth-sided, bumpy (not spiky). Breast skin over the
tumor may become reddish and warm to the touch.
Grow fast.
Duct Papilloma 45-50 years occurs mainly in large ducts, present with a serous or
bloody nipple discharge , mass ussually small, not always
palpable
Benign Breast Lumps
Breast Cancer
Biopsy
Excisional or incisional biopsy
• In this type of biopsy, a surgeon cuts through the skin to remove the entire tumor
(called an excisional biopsy) or a small part of a large tumor (called an incisional
biopsy).
Enucleation
• surgical removal of a mass without cutting into or dissecting it. Eg: eye, oral pathology,
uterine fibroids (without hysterectomy)
FNA
• does not require an incision
Core biopsy
• uses needles that are slightly larger than those used in FNA
• Local anasthesia
• Sometimes uses a special vacuum tools to get larger core biopsies from breast tissue
Epidermoid Cyst
• Benign cyst underneath
skin that arise with
ruptured pilosebaceous
follicle
• Associated with trauma
(piercing-needle)
• Common location :
auricular lobe, plantar
Demoid Cyst
• An abnormal growth
(teratoma) containing
epidermis, hair follicles,
and sebaceous glands,
derived from residual
embryonic cells.
• Common site :
– Periorbital
– Ovarian
– Spinal
Atheroma
• Cause by blockage of
the duct of
sebacceous gland
• Also known as
Retention Cyst
• Puncta (+)
Callus & Clavus
• Galaktokel
merupakan massa
berisi susu yang
tersumbat apada
duktus laktiferus.
• Px :
– Solid mass
– Tanda radang (-)
TERIMA KASIH
Brief Introduction