A/M/68yo

72.87.54
Chief complaint : can not defecate
It has been suffered since 4 days before admitted to Adam
Malik Hospital. Flatulence (-) for the last 2 days. Nausea
(+), Vomiting (+), fever (-).
Patient also complaint lump in the scrotal since 4 months
ago,lump came out and enter again but persistent in these
5 days. patient has had the same complaint in December
2012 and had undergone herniorraphy with mesh in
hospital. In 2014, the former surgical site was inflamed and
removal of the mesh was conducted. Pain (+). History of
heavy work (+), history of chronic cough (-). History of
difficult to urinate (-)
Present State :
• Awareness : Alert
• BP : 130/80 mmHg
• HR : 80 beats/minute
• RR : 20 times/minute
• Temp : 37,5 0 C
• VAS :4
Generalized State
• Head : No abnormalities was found
• Neck : No abnormalities was found
• Chest : No abnormalities was found
• Abdomen : In localized state
• Genital : Male, In localized state
• Extremity : No abnormalities was found
Localized state:
• Abdomen I : symmetrical , distention (+), visible bowel
movement (-)
P : smooth, muscular rigidity (-),
P : hypertympany
A : peristaltic (+) increase,
borborigmi(+), metalic sound (+)

• (L) Inguinal :
scar operation on the left inguinal (+)
Lump (+) 35 x 25 x 20 cm in size, hypereremic (-), transilumination test
(-), bowel sound (+), pain (-)

• DRE :
Perineum normal, tight anal sphincter tone , mucosal layer smooth,
ampula recti collapsed, mass (-). Gloves : blood (-), feces (-),mucous (-).
Laboratory Finding
• Hb/Ht/Wbc/Plt : 10.5/37/16540/510.000
• Na/K/Cl : 132/4.5/101
• Ur/Cr : 107/3.59
• Random blood Glucose : 161
Working Diagnosis :
Incarcerated (L) Recurrent Lateral Inguinal Hernia
Management at Emergency Department :
• Fasting
• Insertion of NGT  clear fluid 50 cc
• Insertion of urinary catheter  clear yellow urine
200 cc
• IVFD Crystalloid
• Inj.Antibiotic
• Inj.Analgetic
• Plan for (L) Herniorraphy
 Operation Theatre
• Patient in supine position under Epidural Anesthesia, aseptic and antiseptic procedure was
done.
• Incision o/t (L) inguinal oblique cutis, subcutis, aponeurosis was opened
• Sac was identified and opened. Sac content was small bowel, 280 cm long and omentum.
• Ring was cut, identification of wedge area.
• Small bowel 170 cm-240 cm from ileocaecal junction was found bluish  Compressed with
warm saline  small bowel still bluish, tactile stimulation  no peristaltic and bluish (+), and
serosal layer was sharply sliced  hemmorhage (-)  small bowel not viable
• Small bowel was resected and performed end to end anastomoses simple interupted with
long absorbable material 3.0 rb
• Sac content returned to abdominal cavity.
• Proximal and distal sac were separated and the proximal sac was ligated until free peritoneal
fat.
• The operation wound was rinse with normal saline. Bleeding control
• Identify the spermatic cord and the mesh was applied and fixated to tuberculum pubicum,
conjoint tendon, inguinal ligament.
• The operation wound was closed layer by layer.
• Operation finished.