OPERATING THEATRE

REPORT
Wednesday, November
Supervisor :

Dr. H. Rizal Sanif, SpOG(K), MARS

30th, 2016
Doctor in charge:

Dr. Amirah Novaliani, SpOG(K)

Dr. Hj. Hartati, SpOG(K)

Residents on duty :
Dr. Fitri Yulianti, Dr. Ratih Sari Putri
Dr. Fachrul Irsan, Dr. Iman Ruanssa

OPERATING THEATRE REPORT

Wednesday, November 30th, 2016
No

Operation

Total

1.

Radical hysterectomy + bilateral pelvic

lymphadenectomy

2.

LSCS + tubal ligation

OPERATING THEATRE REPORT

Wednesday, November 30th, 2016
COT
No

Identity

Preop Diagnosis

Post op
diagnosis

Procedure

Present
status

Mrs.
RUS/47/AM
/P5A0

cervical cancer stage IB2

cervical cancer
stage IB2

radical hysterectomy +
bilateral pelvic
lymphadenectomy

Stable
in ward

Mrs.
YAN/34/HI

G3P2A0 38 weeks
gestational age not inlabor
with prior CS 2x SLF
cephalic presentation

P3A0 post
LSCS due to
prior CS 2x +
post tubal
lgation

LSCS + tubal ligation

Stable
in ward

Procedure
radical
hysterectomy +
bilateral pelvic
lymphadenectomy

No Case
1

Mrs.
RUS/47/AM/P5A0

ICD 10
C53.9

Preop diagnosis:
cervical cancer stage
IB2

ICD 9-CM
68.9
40.5

Post op diagnosis:
cervical cancer stage
IB2

Dr. Amirah
Novaliani,
SpOG(K)

Intraoperative
09.30 AM
Patient on general anesthesia
mediana incision
uterine corpus was in normal limit
cervical mass size 7 x 6 cm without
parametrium invlvement
perform radical hysterectomy
perform bilateral pelvic lymphadenectomy
Abdominal was close
01.00 PM
Operation was over
All tissues send to pathology

Identity

Mrs. RUS/47/AM/P5A0

Chief complain

vaginal bleeding

History

7 months ago, patient complained about vagina bleeding. H/post coital

bleeding (+) H/ leuchorrea (+), H/ biopsy with pathology result poorly
differentiated cervical cancer

Marital status

P5A0

Reproduction history

Menarche 15 y.o, reguler cycle, 28 days, LMP forget

Gynecology
examination

PL : enlargment of abdomen, symetrical, uterine fundal was not palpable ,

mass (-), pain (-), free fluid sign (-)

Physical examination

Insp : bumpy portio, mass (+) 6 x 7 cm, weak, easy to bleed.

VT : bumpy portio, mass (+)6 x 7 cm, easy to bleed

Diagnosis

Cervical cancer stage IB2

07/11/16

07/11/16

Procedure
LSCS + tubal
ligation
ICD 10
O34.21
ICD 9-CM
669.7 + V26.51
Dr. Hj. Hartati,
SpOG(K)

No Case
2

Intraoperative

02.15 PM
Patient on supine position, on spinal
anasthesia
Preop diagnosis:
mediana incision
G3P2A0 38 weeks
02.20 PM
gestational age not
Female life baby was born with BW 3100
inlabor with prior CS gram , Bl 49 cm, A/S 8/9 FTAGA
2x SLF cephalic
02.22 PM
presentation
placenta was delivered completely
Uterine low segment was closed
Post op diagnosis:
03.15 PM
P3A0 post LSCS due
to prior CS 2x + post Operation was over
tubal lgation
Mrs. YAN/34/HI

Identity

Mrs. HEN/26/AF

Chief complain

Plan for abdominal delivery

History

Fullterm pregnancy with prior CS2x. H/ of contraction (-), H/ rupture of

membrane (-), bloody show (-).

Marital status

1x, 11 years
1. 2002, female, 3500 g, RSMH, CS oi obstructed labor
2. 2010, male, 3100 g, RS benteng, CS oi prior CS

Reproduction history

LMP 07/03/16

Gynecology
examination

FUT : 3 finger below xiphoid processus, 31 cm, EFW 2790 gram

Diagnosis
07/11/16

G3P2A0 38 weeks gestational age not inlabor with prior CS 2x SLF

cephalic presentation

THANK YOU