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OBSTETRIC AND GINECOLOGY DEPARTEMENT

BUDHI JAYA MOTHER AND CHILD HOSPITAL

JL. Dr. Sahardjo No. 120 Jakarta Selatan 12960

Telp. (021) 8292672, 8311722, 8312378Fax. 8301901

 No. MR

OPERATION REPORT

 Nama : Mrs. Carolyne Dewi Anggraini Sex : Female Age : 40 Years

Operator Prof. Dr. H.I.O Marsis, SpOG Anesthetic dr. Widodo, Sp An

Assistant 1 Daniel Matius Instrumentator Bd. Lathifa

Assistant 2 dr. Benhur Sibuea Observer Melati Pratiwi

Pre-operation Diagnose : Cephalopelvic disproportion +

Previous sectio caesarea one times + Enough Children +History of secondary infertility at 38th weeks in gestation

with Gravid 2, Para 1, Abortus 0 

Post-operation Diagnose : Cephalopelvic disproportion +

Enough Children + History of secondary infertility

Date of operation : July 11t  2013

Duration of operation : 1 hours 30

minutes

Tehnique of operation :

1. Sectio caesarea trans peritoneal profunda

2. Tubectomy

3. -

Type of operation

□ Emergency 

□ Poliklinik  

 Elektif  

□ Minor  

□ Medium 

  Mayor 

Operation Procedures:

I.  Patient slept in supine position with spinal anastesia on operation table

II.  Aplied inside the dower catether

III.  Aseptic and antiseptic on abdomen adjacent regio until 1/3 proximal upper leg and the

operation field was limited with steril doek

IV.  Pfanenstiel incision was made around fibritio tissue and the skin fold in down

abdomen regio was thrown, the incision was made deeper slice by slice from cutis,

subcutis, fascia with sharp technique. Then musculus rectus abdominis it separated to

lateral section with dull technique, bleeding was taken care off.

V.  Peritoneum parietal was opened upside and downside so we can see uterine

gravidarum, and 2 curavors were put inside the right and left abdomen cavity for

seperating the uterine and the other organ

VI.  Opened plica versico uterine and continued incision to left and right lateral and put

aside to lower.

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VII.  Transversal incision was made on lower segment of uterus, extend to right and left

until we can saw liquor amnii membran and then the operator brook the liquor amnii

membran, liquor amnii was clear and we could saw baby’s head 

VIII.  We saw the baby’s head upper from the pelvic inlet.

IX.  Then the baby’s head was pulled out by forcep extraction and with mild pressure on

the fundus uterine by assistance. Then the deliver step by step from head, front

shoulder, back shoulder, backward trochanter anterior, trochanter posterior, breech

and extremitas inferior was delivered with a sort umbilical cord coil attached to the

 baby.

X.  The baby was crying, umbilical cord was clamped on 2 place ± 5 cm and 7 cm from

the umbilical cord, then it was cut between 2 clamp and the baby was delivered to

 perinatologi

XI.  The new born baby was delivered at 6.33 am, with male gender, body weight birth

4000 gr, length birth 50 cm, Apgar Score 9/10, anal (+) and didn’t saw major

congenital disorder

XII.  Plasenta was completely born in manual, cavum uterine was cleaned from the

residual plasenta tissue. Bleeding was controlled. After that the uterine tissue was

sewed and over hecting with “chromic cat gut” no 2.

XIII.  Suture was done on lower segmen of uterine at two pole with “Chromic cat gut” no. 1

and then the miometrium tissue was suture by continue and overhecting

-  First slice of miometrium tissue with “Chromic cat gut” no. 2 by continue

-  Second slice of miometrium tissue and serosum was suture by continue with

“Chromic cat gut” no. 2 

-  Reperitonisation by sutured plica vesica uterine with “chromic cat gut” no. 2.0 by

continue.

XIV.  Operative procedures of tubectomy :

-  The middle of right fallopian tube lifted then its base was tied by “siede” no 2.0. 

-  0,5 cm under the tying, tied by “chromic cat gut” no 2.0.

-  Cut the tuba and cautered.

-  The same procedure is done on the left fallopian tube.

XV.  The abdomen cavity was cleaned and 2 curavors was pulled out from the abdomen

cavity

XVI.  Before the abdomen cavity sewed, it was giving cortisone asetat 25 mg/10ml into

 peritoneal cavity

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XVII.  After sure it’s no bleeding, abdomen cavity was objed slice by slice

a.  Peritoneum parietal was sutured with “Plain cat gut” no. 2.0 by continue 

 b.  M. Rectus abdominis was sutured with “Chromic cat gut” no. 1.0 

c.  Fascia was sutured with “vicryl” no. 1 by simpl suture

d.  Subcutis was sutured with “Plain cat gut” no. 2.0 by simple suture

e.  Cutis was sutured with “Chromic cat gut” no. 3.0 by subkuticuler

XVIII. Bleeding approximately 200 cc

XIX.  Cavum uterine was cleaned pervaginam

XX.  The operation wound was cleaned by cleaning stole cell from the vagina, the

operation wound was cleaned with Nacl 0,9 % and then it was given antibiotic zalf

and then was closed by sufratulle, sterill cassa and tegaderm

XXI.  The operation finished

The condition of patient post operation:

General condition : Look mild sick

Blood pressure : 140/80 mmHg

Pulse rate : 88 x/minute

Respiration : 21 x/minute

Temperature : 36,3 oC

Tissue to Pathology of Anatomy :

□ Yes  : Type of tissue ..........................................

□ No 

Operator,

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