Preskas Mutia Bedah Hil Dextra
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Transcript of Preskas Mutia Bedah Hil Dextra
CASE PRESENTATION
I. IDENTITY
No medical records : 894 582
Date of hospital entry : October 5th, 2015
Name : Mr. M
Age : 43 years
Gender : Male
Occupation : Labor
Address : Gegesik Kulon
Religion : Islam
Marital status : Married
II. ANAMNESIS
Main Complaint
Patients complain of a lump in the groin right since 5 months ago.
History of Disease
Patient came to RSUD Arjawinangun with complain of a lump in the groin right since
5 months ago. At first the patient felt a lump arise when standing and heavy lifting,
then disappear at rest. But over time the lump getting bigger and can not be put back.
Oval-shaped lumps and no pain when pressed. No complaints of fever, nausea,
vomiting, and bloating. Urinating dan defecating in the normal range.
History of Past Disease
Patient said he had never experienced the same symptoms before. Patients had no
previous operating history. Patient denied any history of diabetes, hypertension,
asthma, heart disease, and hemorrhoids.
History of Family Disease
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Patients said that no family members with the same disease as patients. There is no
family who suffer diabetes, hypertension, asthma, and heart disease.
History of Habits and Socio-Economic
The patient was a man with enough nutritional status. Patients are active smokers.
Patients have a lower economic status.
III. PHYSICAL EXAMINATION
a. Present Status
General Condition : Mild Pain
Awareness : Compos mentis
Blood Pressure : 140/80
Pulse : 90 x/minute
Breathing : 24 x/minute
Temperature : 36,8 ºC
Head
Form : Normocephale, Symmetrical
Hair : Black, No hair fall
Eye : Anemic Conjungtivas (-/-), Icteric Schleras (-/-),
Light Reflexes (+/+), isochore pupil right = left
Ear : Normal form, cerumen (-), thympany membrane
intact
Nose : Normal form, no septum deviation, epitaxis (-/-)
Mouth : Normal
Neck
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Enlargement of lymph nodes (-)
Trachea is in the middle
No mass found
Thorax
Lungs - pulmonary
Inspection : The chest shape is symmetrical both left and right
Palpation : Fremitus and vocale tactile both symmetrical left
and right, crepitation (-), tenderness (-), rebound
tenderness (-)
Percussion : Resonance sound in both lung fields
Auscultation : Vesicular and bronchial sound in the entire lung
field, rhonchi (-/-), wheezing (-/-)
Abdomen
Inspection : Flat, symmetrical, mass (-)
Palpation : Tenderness (-), rebound tenderness (-) a/r iliaca
dextra,
Percussion : Tympanity sound in four quadrants
Auscultation : Bowel sound (+)
Extremities
Upper
Muscle Tone : normal
Movement : active / active
Mass : - / -
Strenght : 5/5
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Oedema : - / -
Lower
Muscle Tone : normal
Movement : active / active
Mass : - /-
Strenght : 5/5
Oedema : - / -
Genitalia
No abnormalities
b. Localized Status
Regio : Inguinalis Dextra
Inspection : mass appears elliptical with ± 7x5 cm size, same
color as the surrounding skin, and there are no signs
of inflammation.
Palpation : palpable masses with flat surfaces, supple and can
not be entered manually using the finger. Finger tip
test: palpable lump in the fingertips.
Auscultation : there is no intestinal peristalsis sound.
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c. Laboratory Examination
Routine Blood
Test Result Unit
WBC 5,1 10e3/µL
RBC 4,71 10e6/
µL
HGB 13,7 g/dL
HCT 40,7 %
MCV 86,4 fL
MCH 29,1 Pg
MCHC 33,7 g/dl
RDW 12,6 %
PLT 171 10e3/
µL
Neut 56,6 %
Lymph 34,6 %
Mono 8,8 %
Eos 0 %
Baso 0 %
Test Result Unit
Ureum 25,5
Creatinin 0,66
Test Result Unit
HbsA
g
0,02
Anti
HIV
Non
Reaktif
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IV. DIAGNOSIS
Hernia Inguinalis Dextra Ireponible.
V. DIFFERENTIAL DIAGNOSIS
Hernia Inguinalis Medialis Dextra
Limfadenopati Inguinal Dextra
VI. TREATMENT
Operative
Hernioraphy
Medicamentosa
Inj. Ceftazidin 2x1 gr
Inj. Ranitidin 2x1 amp
Inj. Ketorolac 2x1
Post operative education
Total bed rest and fasting until the bowel sounds (+)
VII. PROGNOSIS
Ad vitam : ad bonam
Ad sanationam : ad bonam
Ad fungsionam : ad bonam
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LITERATURE REVIEW
I. DEFINITION
A hernia is a protrusion or protrusion of the contents of a cavity through a defect or weak parts of
the wall in question. Abdominal hernia, abdominal contents protrude through a defect or weak
parts of the musculo-aponeurotik layers of the abdominal wall. Hernia consists of rings, bags,
and fill hernia.
II. EPIDEMIOLOGY
Seventy-five percent of all cases of a hernia in the abdominal wall appears around the groin.
Hernias occur more often the right side than the left side. Hernia more indirect than direct hernia
is 2: 1, the ratio of male: female in indirect hernia is 7: 1. It happened femoral hernias less than
10% of all hernias but 40% of the emergency cases appear to inkaserasi or strangulation.
Femoral hernias are more common in older people and men who have undergone hernia inguinal
surgery.
III. ETIOLOGY
The cause of hernia is :
a) The weakness of the abdominal cavity wall. Can be from birth or acquired later in life
b) As a result of previous surgery
c) Congenital
Perfect Congenital Hernias
Baby has a hernia due to a defect in certain places.
Imperfect Congenital Hernias
Babies are born normal (abnormalities not visible) but have a defect in certain places
(predisposition) and a few months (0-1 years) after birth will occur through a defect is
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due to be affected by the increase in intra-abdominal pressure (straining, coughing,
crying).
d) Akuisital is a hernia which is not due to a congenital defect but due to other factors of human
experience, among others:
Intra-abdominal pressure is high, namely in patients with frequent straining during bowel
movement or urination.
Constitutional body. On the thin hernia because the network binding slightly, while in
obese people due to fatty tissue much so that adds to the burden of connective tissue
backers.
Distension of the abdominal wall due to increased intra-abdominal pressure.
Diseases that weaken the abdominal wall.
Smoking.
Diabetes mellitus.
IV. PART OF HERNIA
Parts of the hernia by:
a) The bags hernia. In the form of the parietal peritoneum abdominal hernia. Not all hernias
have a bag, for example, incisional hernia, adipose hernia, hernia internalizers.
b) Fill hernia: in the form of an organ or tissue out through the hernia bag, for example, gut,
ovaries and intestines buffer network (omentum).
c) Door hernia: a part minoris resistance locus through which the hernia bag.
d) Neck hernia: hernia bag narrowest part.
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V. CLASSIFICATION OF HERNIA
According to the nature and circumstances of the hernia can be divided into three:
a. Hernia reponibel: if the hernia contents can be out. Gut out when standing or straining
and enter again when lying down or pushed in the stomach, no pain or symptoms of
intestinal obstruction.
b. Hernia ireponibel: if the contents of the bag can not be repositioned back into the
abdominal cavity. This is usually caused by the contents of the bag attachment on
peritoneal hernia bag.
c. Incarcerated hernia or Strangulated: when it sandwiched by hernia ring so that the bag
is trapped and can not get back into the abdominal cavity. As a result, interference
occurs vascularization. Bowel resection should be done immediately to remove parts
that might necrosis.
According to Erickson (2009) in Muttaqin 2011, there are several hernia classifications are
divided based on the regio, namely: inguinal hernia, femoral hernia, umbilical hernia, and hernia
skrotalis.
a. Inguinal Hernia, namely: prostrusi conditions (protrusion) intestinal organs into the
cavity through a defect or parts of the walls are thin or weak of the inguinal ring.
Incoming material more often is the small intestine, but can also be a tissue or
omental fat. Predispose to inguinal hernia defect or abnormality is found in the form
of partial cavity wall is weak. The exact cause of inguinal hernia lies in the weakness
of the wall, as a result of changes in the physical structure of the wall cavity (old age),
an increase in intra-abdominal pressure (obesity, chronic cough strong and, straining
due to constipation, etc.).
b. Femoral Hernia, namely: a protrusion of intestinal organs that go through funnel-
shaped femoral canal and out of the fossa ovalis in the groin. Causes of femoral
hernia as inguinal hernia.
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c. Umbilical hernia, namely: a protrusion (prostrusi) when the contents of an abdominal
organ in through the anterior canal bordered by the linea alba, posteriorly by the
fascia umbilicus and lateral rectus. A hernia occurs when tissue fascia of the
abdominal wall at the umbilicus area experienced weakness.
d. Hernia Skrotalis, namely: lateral inguinal hernia contents into the scrotum complete.
This hernia should be carefully distinguished from the hydrocele or elevantiasis
scrotum.
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VI. PATOPHYSIOLOGY
Inguinal canal in the normal channels to the fetus. On the 8th month of pregnancy, there
desensus vestikulorum through the canal. Testicular descent will attract the peritoneum into the
scrotum causing the bulge area peritoneum called the processus vaginalis pritonea. When the
baby is born generally processes have undergone obliteration, so that the contents of the
abdominal cavity can not pass through the canal. But in some ways often not closed, because the
left one down first from the right, then the right inguinal canal are more often exposed. Under
normal circumstances, this open canal will close at 2 months.
When the process of the open portion, then the resulting hydrocele. When the canal is open
continuously, because rosesus not berobliterasi will arise lateral congenital inguinal hernia.
Hernia in adults usually happens because the bartambahnya age, the body's organs and tissues
undergo a process of degeneration. In older people the canal has been closed. Namuan because
this region is the locus minoris resistance, then the circumstances that led to increased intra-
abdominal pressure such as chronic coughing, sneezing strong and lifting heavy items, push.
Channel that has been closed can be reopened and the lateral inguinal hernia arises due to the
body's tissues and encouraged something and out through the defect. Finally punched in the wall
cavity which has been weakened as a result of trauma, prostatic hypertrophy, ascites, pregnancy,
obesity, and congenital anomalies and may occur at all.
Men more than women, because of the differences in the process of development of male and
female reproductive organs during fetal. Potential complications of adhesions occur between the
contents of the hernia hernia pouch wall so that the hernia contents can not be put back.
Suppression of the hernia ring, due to the increasing number of incoming rings intestinal hernia
becomes narrower and cause interference distribution of intestinal contents. The incidence of
edema in case of necrosis. If there is a blockage and bleeding will occur flatulence, vomiting,
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constipation. When incarcerated left, then over time there will be edema resulting in suppression
of blood vessels and necrosis.
VII. DIAGNOSIS
Physical examination
1. Finger Test
Using a finger or fingers into 2 to 5, inserted through the
scrotum through the external annulus into the inguinal
canal, the patient was told to cough. When the tip of the
finger impulse means ingunalis lateral hernia, when the
impulse in addition to finger inguinal hernia medialis.
2. Ziemen Test
Lying position, if there is a bump first insert, right hernia
checked with the right hand, the patient was told to
cough when stimulation of the finger-2 ingunalis lateral
hernia, 3rd finger medial inguinal hernia, 4th finger
femoral hernia.
3. Thumbs Test
Annulus is pressed with the thumb and the patient was
told to push, when out bumps mean medial inguinal
hernia, if not out bumps mean lateral inguinal hernia.
Supporting examination
a. Leukocyte> 10000-18000 / mm3
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b. Serum electrolyte rise
c. Radiological examination
d. Ultrasound is also useful to distinguish between hernia incaserata of a pathological
lymph nodes or other causes of a palpable mass in the groin.
e. CT scans can be used to evaluating pelvis to find the obturator hernia.
VIII. DIFFERENTIAL DIAGNOSIS
a. Malignancy: lymphoma, retroperitoneal sarcoma, metastasis, tumor testicular
b. Primary testicular disease: varicocele, epididymitis, testicular torsion, hydrocele, ectopic
testis, testicular undescenden
c. The femoral artery aneurysm
d. Lymph nodes
e. Lymph cyst
f. Sebaceous cysts
g. Psoas abscess
h. Hematoma
i. Ascites
IX. PENATALAKSANAAN
Elective surgery is done to reduce the symptoms and prevention of complications such as
inkeserasi and strangulation. Non-operative treatment is recommended only in asymptomatic
hernia. The main principle of operation is herniotomy hernia: open hernia and cut the bag.
Herniorraphy: repair the posterior abdominal wall canal ingunalis.
Herniotomy
Incision of 1-2 cm above the inguinal ligament and aponeurosis external obliqus opened all
external inguinal canal. Hernia pouch separated from m.creamester carefully up to the internal
inguinal canal, hernia pouch is opened, check the contents and return to the abdominal cavity
then the hernia is cut. In children quite simply do herniotomy and does not require herniorrhapy.
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Herniorrhapy
Dinding posterior di perkuat dengan menggunakan jahitan atau non-absorbable mesh dengan
tekhnik yang berbeda-beda. Meskipun tekhnik operasi dapat bermacam-macam tekhnik bassini
dan shouldice paling banyak digunakan. Teknik operasi liechtenstein dengan menggunakan mesh
diatas defek mempunyai angka rekurensi yang rendah.
X. PROGNOSIS
Depending on the age of the patient, the size of the hernia and the condition of the contents of the
hernia bag. The prognosis is good if the wound infection, bowel obstruction immediately
addressed. Post-surgical complications such as postoperative pain herniorraphy, testicular
atrophy and hernia recurrence can generally be overcome.
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BIBLIOGRAPHY
A. Mansjoer, Suprohaita, W.K Wardhani, W. Setiowulan. Kapita Selekta Kedokteran. Edisi III,
jilid II. Penerbit Media Aesculapius, Fakultas Kedoktern Universitas Indonesia. Jakarta.
2000.
Brian W. Ellis & Simon P-Brown. Emergency Surgery. Edisi XXIII. Penerbit Hodder Arnold.
2006.
Nicks, BA. Hernia. http//www.emedicine.com
R. Sjamsuhidrajat & Wim de Jong. Buku Ajar Ilmu Bedah. Edisi I. Penerbit buku kedokteran
EGC. Jakarta. 1997.
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