23 Mei 2010

TUMOR PAYUDARA

Dr. HKM. YAMIN ALSOPH, SpB (K) Onk

DEPARTEMEN BEDAH
RSMH/FK UNSRI
PALEEMBANG
EMBRIOLOGI
Tumbuh mulai minggu
ke 5-6 masa embrio
Sbg penebalan ektoderm
sepanjang garis susu
(mulai axilla sampai inguinal)
Pd manusia, gajah, 2/3
kaudal garis susu
menghilang
1/3 atas (dada) →
cikal bakal payudara


Polimastia (payudara tambahan ) atau politelia (nipple tambahan ) → bisa tjd bila gagal tjd regresi yg normal
Amastia ( tdk ada payudara ) bisa tjd bila mamary berhenti berkembang pd mgg ke 6 masa embrio
ANATOMI
Payudara terletak pada hemithoraks kanan dan kiri dg batas- batas sbb :

1. Batas yg tampak dr luar :
- superior : iga II atau III
- Inferior : iga VI atau IV
- medial : pinggir sternum
- lateral : garis aksilaris anterior

2. Batas yg sesungguhnya :
- superior : hampir sampai klavikula
- medial : garis tengah
- lateral : m. latissimus dorsi


STRUKTUR PAYUDARA :
- parenkim epitelial
- lemak
- pemb. Darah
- saraf
- saluran getah bening
- otot dan fascia

10-100 kelompok asini  lobulus  lobus
15 – 20 lobus, masing2 punya saluran → duktus laktiferus → papilla mamma
Dibungkus fasia pektoralis superfisialis
Lig. Cooper  penyangga




VASKULARISASI PAYUDARA

1. Arteri
a. cabang2 a. perforantes a. mammaria interna (cab. I, II, II dan IV)
b. rami pektoralis a. thorakoakromialis
c. a. thorakalis lateralis
d. a. thorakalis dorsalis

2. Vena
tdp 3 group vena
a. cabang2 perforantes v. mammaria interna
b. cabang2 v. aksilaris, tda :
- v. thorako-akromialis
- v. thorako-dorsalis
- v. thorako lateralis
c. vena-vena kecil yg bermuara pd v. interkostalis

SISTEM LIMFATIK PAYUDARA

a. Pembuluh getah bening :
1. aksila
2. mammaria interna
3. didaerah tepi medial kwadran medial

b. Kelenjar getah bening :
a. terdapat 6 group KGB aksila :
1. Mammaria eksterna :
- klp. Superior
- klp. Inferior
2. Skapula
3. Sentral (central nodes)
4. Interpektoral (Rotter’s nodes)
5. KGB v. aksilaris
6. Subklavikula




b. KGB prepektoral
c. KGB mammaria interna

HISTOLOGI
- terdiri dari kelenjar alveolar multipel
- duktus terminalis dilapisi epitel kolumner
- sinus laktiferus pd regio subareolar dilapisi epit. Skuamosa
- alveoli multipel membentuk lobulus- lobulus


FISIOLOGIS

Perkembangan dan fungsi payudara dimulai oleh berbagai hormon

- Estrogen  perkemb. Duktus mammilaris

- Progesteron  perkemb. Lobulus2 dan differensiasi epitel2

- Prolaktin  laktogenesis

- Kehamilan dan laktasi  duktus alveolaris dan lobularis proliferasi, regresi stlh masa menyusui

- Menopause  lobulus berinvolusi. Lemak mengganti parenkim


GnRH (di hypotalamus)


LH dan FSH (di hypofisis anterior)


Estrogen dan Progesteron (di ovarium)



Payudara

Remaja

Hamil


Menyusui

Menopause

DIAGNOSIS
Meliputi :
1. Anamnesis
2. Pemeriksaan fisik
3. Pemeriksaan penunjang
4. Pemeriksaan Histopatologi

ANAMNESIS
Identitas
Keluhan utama :
- benjolan
- nyeri
- cairan dr putting susu
- ekzema seiktar areola
- dimpling
- ulserasi
- peau d’orange

Perjalanan penyakit
TB/Bbdanbnafsu makan
Keluhan tambahan
Faktor2 resiko tinggi kanker payudara


Faktor-faktor resiko tinggi kanker payudara :
1. > 30 th
2. melahirkan anak I pd usia > 35 th
3. tidak kawin/nullipara
4. menarche < 12 th
5. menopause terlambat, > 55 th
6. terapi hormonal yg lama
7. kanker payudara kontra lateral
8. operasi ginekologis tumor ovarium
9. radiasi pd dinding dada
10. r/ keluarga
11. infeksi, trauma atau operasi tumor jinak
payudara


PEMERIKSAAN FISIK

Sebaiknya 1 mgg dr hari terakhir menstruasi  pengaruh hormonal minimal

a. Inspeksi
- simetri payudara kiri dan kanan
- kelainan papila :
- letak dan bentuk
- retraksi nipple
- tanda radang
- peau d’orange
- dimpling
- ulserasi
- tangan diangkat

Berbagai bentuk kelainan payudara

b. Palpasi

- berbaring  payudara tersebar rata

- jika perlu punggung diganjal dg bantal kecil

- pemeriksaan :
1. lokasi tumor  kwadran payudara
2. ukuran
3. konsistensi
4. batas tumor
5. mobilitas



- Pemeriksaan KGB regional

a. KGB aksila
- pemeriksa berada didepan dan arah samping ,posisi duduk

- aksila kanan penderita diperiksa dgn tangan kanan pemeriksa, aksila kiri penderita diperiksa dgn tangan kiri pemeriksa

- tentukan : ukuran, konsistensi, jumlah, terfiksasi atau tidak

b. KGB supra dan infraklavikuler

- Periksa organ lain  hepar, lien, tulang2, vertebrae (metastasis)




PEMERIKSAAN PENUNJANG

1. Mammografi
- dimulai di Amerika Utara thn 1960
- 2 posisi : craniocaudal dan mediolateral
oblique
- foto rontgen utk jar.lunak
- ketepatan : 83 % - 95 %
- tanda primer keganasan :
fibrosis reaktif, comet sign (stelata), mikrokalsifikasi, spikulae dan distorsi arsitektur payudara


MAMMOGRAFI

2. Termografi
- menggunakan sinar infra red
- ditemukan LAWSON th. 1956
- suhu kanker payudara > tinggi dr jar. sekitar

3. Ultrasonografi
- membedakan lesi solid dan kistik
- digunakan untuk memandu FNAB, core-
needle biopsy
- diagnosa dugaan













USG: Daerah anechoic dgn batas garis
hitam karakteristik dr kista











USG : Massa padat dgn garis/batas irreguler
kemungkinan carcinoma

4. Xerografi
- Fotoelectric imaging system
- ketepatan 95,3 %
- false positive + 5 %


5. Scintimamografi
- teknik pemeriksaan radionuklir
- radioisotop Tc 99m
- sensitifitas tinggi dlm menilai aktifitas sel kanker payudara
- deteksi lesi multipel dan keterlibatan KGB regional

STADIUM KLINIS Klasifikasi Kanker Payudara berdasarkan Sistem TNM (UICC/AJCC)


Keterangan :
T : tumor primer
Tis : karsinoma in situ
T1 : diameter tumor < 2 cm
T2 : diameter tumor 2-5 cm
T3 : diameter tumor > 5 cm
T4 : tumor telah menginvasi jar. diluar mamma
T4a : dinding dada
T4b : kulit mama
T4c : dinding dada dan kulit
T4d : tumor dg inflamasi
Tx : tumor primer tdk dpt dievaluasi

N : metastase KGB regional
No : tdk terdapat metastase KGB reg.
N1 : ada metastase KGB axilla yg mobile
N2 : ada metastase KGB axilla yg melekat
N3 : metastase KGB mammaria interna
Nx : metastase axilla tdk dpt dievaluasi

M : metastase jauh
Mo : tdk ditemukan metastase jauh
M1 : ada metastase jauh
Mx : metastase jauh tdk dpt dievaluasi
DIAGNOSIS PASTI
Dgn pemeriksaan histopatologi
Bahan pemeriksaan dari :
1. biopsi aspirasi (fine needle biopsy)
2. needle core biopsy dg jarum Silverman
3. excisional biopsy dan frozensection

potong beku  ketepatan 97,65 %, tidak ada false +, false negative 0,6 %
KANKER PAYUDARA
Insidens di AS th 1983  92 kasus baru/ 100.000 pddk
Neoplasma ganas
Infiltratif dan destruktif
Metastase  paru2, hati dan tulang
Tumbuh progresif, relatif cepat membesar




Stadium awal :
- keluhan (-), seperti FAM atau FCD yg kecil
- bentuk tidak teratur, batas tidak tegas, permukaan rata, konsistensi padat keras


Stadium lanjut :
- retraksi nipple
- peau d’orange
- satelit nodule
- ulserasi
- metastase
♀, 36 thn, FNAB: 154/A/05 Infiltrating ductal ca mamma
♀, 57 thn, FNAB : 468/AS/05 Ductal carcinoma




Klasifikasi Histopatologi (WHO 1981) :

1. Non invasive
- Intraductal carcinoma
- Lobular carcinoma

2. Invasive Carcinoma
- Invasive ductal carcinoma
- Invasive ductal carcinoma with predominant intraductal componen
- Invasive lobular carcinoma
- Mucinous carcinoma
- Medullary carcinoma
- Papillary carcinoma

- Tubular carcinoma
- Adenocystic carcinoma
- Juvenile carcinoma
- Apocrine carcinoma
- Carcinoma with metaplasia
- Carcinoma with squamous type
- Carcinoma with spindle cell type
- Carcinoma with cartilagues and osseus type
- Carcinoma mixed type

3. Paget’s disease of breast
PENGOBATAN
Early Invasive Breast Cancer (std I, IIA atau IIB)

- bersifat kuratif

- stadium I dan II :
radikal mastektomi/modified dg atau tanpa radiasi
dan sitostatika ajuvan

BCT ( Breast Conserving Treatment)
 utk std I dan II dg Ø < 3 cm





Advanced Locoregional Breat Cancer (std IIIA atau IIIB)

- bersifat kuratif

- stadium IIIA operabel :
Operasi + Adjuvan kemoterapi +
Adjuvan radiasi

- stadium IIIA inoperabel dan IIIB :
Neoadjuvan kemoterapi + operasi +
Adjuvan radiasi

Distant Metastases ( std IV)

- Bersifat paliatif

- Memperbaiki quality of life

- Th/ Hormonal dan kemoterapi

- Suppertif terapi
Prognosis
Ditentukan oleh :

- Staging  5 - 10 th
Stadium I : 90 - 80 %
Stadium II : 70 - 50 %
Stadium III : 20 - 11 %
Stadium IV : 0 %
Stadium O : 96,2 %

- Histopatologi
Ca insitu > baik daripad Ca invasif

TUMOR – TUMOR JINAK PAYUDARA

Fibroadenoma

- Gol. terbesar tumor payudara yaitu 45,28 – 50 %
(RS Dr. Soetomo, Surabaya)

- Klinis :
- padat-kenyal, mobile, bulat-lonjong, batas tegas, tidak nyeri
- pertumbuhan lambat
- usia muda (15-30 thn)
- bilateral atau multipe (15 %)
- metastase (-)
- th/  eksisi

Fibrocystic Disease

- Biasanya multipel atau bilateral
- Nyeri terutama menjelang haid

- Ukuran menjadi lebih besar, penuh dan nyeri menjelang haid. Haid berhenti, keluhan berkurang/hilang

- Batas tidak tegas kec. kista soliter
- Padat, kenyal atau kistik
- Permukaan granular
- Pengaruh hormonal
- th/  medikamentosa/operasi


Cystosarcoma philloides

- Klinis seperti FAM yg besar
- Bulat lonjong, permukaan berbenjol, batas tegas, ukuran mencapai 20-30 cm.
- Tidak melekat pada dasar atau kulit
- Kulit tegang, berkilat dan venektasi
- Tidak metastase
- Ganas  Malignant Cystosarcoma Philloides ( 27 % dr cystosarkoma)
- th/  Simple mastektomi atau mastektomi subkutan pd org muda
♀, 20 thn, PA : 541/A/2005 Malignant phyloides tumor
Cystosarcoma Phylloides

Galactocele

- Masa tumor kistik krn tersumbatnya duktus laktiferus saat masa laktasi
- Berisi air susu yg mengental
- Batas tegas, bulat dan kisteus

Mastitis

- Infeksi pada kelenjar payudara
- Biasanya saat laktasi
- Ditemukan tanda2 radang
- Sering menjadi abcess

KULIAH BEDAH DIGESTIF SUMBATAN SALURAN CERNA

SUMBATAN SALURAN CERNA / HAMBATAN SALURAN CERNA / OBSTRUKSI USUS
HAMBATAN PERJALANAN ISIS
SALURAN CERNA DARI ARAH ORAL
KE ANAL
OBSTRUKSI USUS
KLASIFIKASI ( PEMBAGIAN)
ETIOLOGI
PATOFISIOLOGI
GEJALA KLINIS
TERAPI
PROGNOSIS
KLASIFIKASI ( PEMBAGIAN)
OBSTRUKSI USUS MEKANIK
- Simple
- Strangulata
- Closed Loop
OBSTRUKSI USUS NEUROGENIC
- Pasca Bedah
- Peritonitis
- Trauma Col. Vertebra ( Medula Spinalis )
- Intoksikasi ( Uremia )
KLASIFIKASI ( PEMBAGIAN
MENURUT LETAK:
- Obstruksi Tinggi :
Yeyunum – Ileum ( Usus Halus )
- Obstruksi Rendah :
Sepanjang Usus Besar

MENURUT TERJADINYA :
- Akut ( Mendadak )
- Khronis
ETIOLOGI
TERGANTUNG UMUR
NEONATUS
Atresia Usus
Pita Kongenital
Stenosis Usus
Volvulus Neonatorum
Mekonium Ileus
Anomali Anorektal
Hirschprung Disease
ETIOLOGI
INFANT :
Invaginasi
Hernia Inkarserata
Meckel Divertikulum
Hirschprung
ETIOLOGI
DEWASA MUDA :
Hernia Inkarserata
Perlengketan
Crohn’s Disease
Kadang-kadang Carcinoma
ETIOLOGI
ORANG TUA :
Carcinoma
Skibala
Divertikulitis
Perlengketan
Hernia Inkarserata
PATOFISIOLOGI
Oleh karena obstruksi  distensi usus
proksimal dari obstruksi, kolaps distal obstruksi.
Distensi menyebabkan :
Cairan dan Gas
Odema Dinding Usus
Transudasi Plasma ke Dalam Lumen Usus & Rongga Abdomen
Strangulasi Usus  Perforasi
PATOFISIOLOGI
DALAM KEADAAN NORMAL :
Cairan 7 – 8 ltr sepanjang usus halus
90% diserap kembali
± 1 – 1½ ltr dikirim ke usus besar
DALAM KEADAAN OBSTRUKSI :
Penyerapan terganggu
Cairan hilang karena muntah, transudasi, odema

VOLUME DARAH MENURUN
PATOFISIOLOGI
Proliferasi kuman dalam usus yang
“ STANGULATED “ ( Clostridia, E. Coli)
Kuman gram negatif  endotoksin shock
GAMBARAN KLINIS
Sakit Perut ( kolik )
Muntah
Meteorismus / Distensi Perut
Kadang2 Peristaltik Usus (+) ( Steifung )
Bising Usus Meningkat dg “ Nada tinggi “
Tidak Ada Flatus & defekasi
Rectal Toucher ( colok dubud ):
Ampula Rektum Kosong
Mungkin Teraba Tumor / Skibala
DIAGNOSIS
GAMBARAN KLINIS
RADIOLOGIS :
Foto Polos Abdomen :
- Air Fluid Level ( Anak Tangga )
- Haring Bone
TERAPI
PASANG NASOGASTRIK TUBE
CAIRAN INFUS :
NaCl Fisiologis
Dextrosa 5% - 10%
Ringer Laktat
Plasma / Darah
ANTIBIOTIKA
OPERASI SETELAH “ LAYAK” OPERASI
PROGNOSIS
Makin Dini Didiagnosa
Pengelolaan Yang Benar

Dalam Keadaan Lanjut :

Dehidrasi
Syok

Tindakan Bedah Mungkin Tdk Dapat Mencegah
Kematian

General Surgery

General Surgery; Lecture 1
ABDOMINAL TUMOR
Abdominal Region, divided into 4 quadrants;
Right Upper Quadrant (RUQ)
Left Upper Quadrant (LUQ)
Right Lower Quadrant (RLQ)
Left Lower Quadrant(LLQ)
ABDOMINAL COMPARTMENT
- Intraperitoneal
- Retroperitoneal
ABDOMINAL WALL
- Skin
- Subcutaneous
- Muscles
TUMOR LOCATION
1. Abdominal Wall
2. Intraperitoneal
3. Retroperitoneal
DIFFERENTIATING TUMOR LOCATION
 Abdominal wall was tightened by;
- raising both lower limbs
- straining or blowing something
On tightened condition, we evaluate whether tumor is;
- More “obvious” à tumor is locate at abdominal wall
- “disappear“ or smaller à tumor is locate at intra- or retro-peritoneal
To differentiate between intra- and retro-peritoneal à bimanual examination, to find ballotement sign .
Ballotement (+) à retroperitoneal tumor
Ballotement (-) à intraperitoneal tumor
Sometimes ballotement sign is hard to evaluate in big tumor
WORK-UP (intra- or retro-peritoneal tumor)
1. USG
2. IVP
3. CT- Scan
4. Ba- meal
5. Ba- enema
WORK-UP (intra- or retro-peritoneal tumor)
USG:
to detect “solid” organs (kidney, spleen, liver)
IVP :
when tumor origin is kidney, there is delayed function of influence kidney
CT-Scan :
To differentiate whether the tumor origin is kidney, spleen, or liver with transverse view
Barium meal (upper gastrointestinal series):
“ filling defect” showing anomalies on digestive tract
Barium enema (lower gastrointestinal series):
Barium contrast is inserted retrograde from anus into rectum to see colorectal condition
ABDOMINAL TUMOR
INTRAPERITONEAL TUMOR
Liver
Spleen
Caecum
Transverse Colon
Sigmoid Colon
Ovarium
Stomach
RETROPERITONEAL TUMOR :
Kidney (hidronephrosis, Grawitz Tumor, Wilms’ Tumor)
Neuroblastoma
Teratoma
INGUINAL TUMOR/LUMP
Diff.Diagnosis
1. Inguinal Hernia, femoral hernia
2. Enlarge Inguinal lymph nodes (lymphadenopathy, inflamation)
3. Abscess (cold abscess, chronic abscess)
4. Skin Tumor (lipoma, atheroma, etc)
2.1 Inguinal Hernia
Reducible :
Hernia can be returned to intraabdomen
Irreducible :
Hernia cannot be returned to intraabdomen
Upper edge of the lump à diffuse, vague, indistinctive
2.2. Enlarged Inguinal Lymph Nodes
Irreducible
Pain , redness à inflamation
No Pain :
à chronic lymphadenopaty
à Lymph sarcoma
à Cancer metastasis
2.3 Cold Abscess
TB Spondylitis
Fungus Infection
2.4 Skin Tumor
Atheroma
Lipoma
Femoral Region : irreducible
Irreducible Scrotal Hernia
irreducible, upper edge is undistinctive
Testical Tumor
Irreducible
diaphanoscopy / transillumination test (-)
Hydrocele
Irreducible
Diaphanockopy (+)
Orchitis
Irreducible
Painful
Inflamation symptom (+)
HERNIA
Anatomy of Abdominal Wall :
Superficial
skin
Adipose tissue
Scarpa’s Fascia
External Abdominal Oblique Muscle
aponeurosis
Deep
Canalis Inguinalis
Internal Abdominal Oblique Muscle
Transversus Abdominis Muscle
Transverse Fascia
Peritoneum
Inguinal Canal
Surrounded by Cremaster Muscle
superior wall (roof): internal oblique muscle, transvesus abdominis muscle
anterior wall : aponeurosis of external oblique, aponeurosis of internal oblique
inferior wall (floor): inguinal ligament, lacunar ligament, iliopubic tract
posterior wall : transversalis fascia, conjoint tendon
Content : Funikulus spermatikus (spermatic vessel, ilioinguinal nerve, iliofemorale nerve, proc vaginalis, lig rotundum)


Pathophysiology
Definition :
a protrusion of a tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained
Structure :
 Hernia ring
 Hernia Sac (fundus, corpus and neck)
 Content (omentum, bowel, etc.)
Predispose à lokus minoris ressistentiae
Risk Factor à Increasing intraabdominal tension (chronic cough, ascites, urinate obstruction, straining)
Hernia Prevention mechanism on healthy people:
Oblique inguinal canal
Internal oblique muscle that always close internal ring when contracting
Firm transverse fascia that close Hasselbach Triangle
Preventive mechanism disruption à hernia
Based on pathophysiology :
1. Congenital Hernia
2. Aquired Hernia
Based on location
1. Inguinal Hernia
2. Femoral Hernia
3. Umbilical Hernia
4. Diafraphmatic Hernia
5. Hernia of Morgagni
6. Hernia through the foramen of Winslow
7. Obturator Hernia
Based on clinical symptomps
Reducible Hernia
An uncomplicated hernia which returns, either spontaneously or after manipulation, to its original site
Irreducible Hernia
A hernia that will not return to its normal position in the body cavity, even with gentle manipulation
Incarcerated Hernia
A hernia is traped in its ring, there’s risk of strangulation à necrotic tissue
Inguinal Hernia : (majority)
1. Indirect Inguinal Hernia
2. Direct Inguinal Hernia
Older Man
Rounded Lump
Long standing-high-intraabdominal-tension and weak muscle floor of Hasselbach Triangle
Rarely become incarcerated
Sometimes become a sliding hernia
Mostly affect old women
Groin lump below the inguinale ligament and medial site of femoralis vein dan at lateral site of tuberkulum pubikum
Hernia protrudes à femoralis ring à femoral canal à exit at fossa ovalis at groin
Chronic increasing of intraabdominal tension, pregnancy, obesity, connective tissue degeneration in older men
Secondary à hernioraphy’s complication (Bassini and Shouldice Procedure)
Umbilical Hernia :
Congenital, prostrution of viscera organ through umbilical ring à Increased abdominal tension
< 2cm à spontaneous regression
Adult à surgery
Incision Hernia
Usually affect on post ceilotomy wound
Nerve disruption => skin anastesia and muscle paralisis (lumbotomy incision)
Diagnosis:
Anamnesis
Reducible lump on groin which can be persisted (irreducible)
The lump usually appear on increasing intra abdominal tension
The lump can manually reduced when the patient lying
Intestinal pasase disruption à incarserated hernia
Pain in incarcerated or strangulated condition
Watch out for predispose factors
I = there is lump, without skin color alteration
P = there is palpable lump, with indistinctive upper border, the protrusion can return back to the abdominal cavity
Reducible Lump:
On inguinal region can be doubtful à “ finger-tip “ test/ Valsava’s test
Irreducible Lump:
Whether in inguinal or other region;
Accompanied obstructive bowel symptoms à incarcerated hernia
Without obstructive symptoms' à irreducible hernia only
Strangulation : tissue/bowel necrosis due to vascularization disruption
1. Testicular tumor
2. Hidrocele
3. Orchitis
4. Incarserated hernia
To differentiate:
- (1) and (2): has distinctive border
- Diaphanoscopy test : (1) negative,(2) positive
- (3) : distinctive border, negative diaphanoscopy test , pain on pressure manipulation
- (4) : indistinctive border, pain on upper part of lump, there’s possibility of obstruction symptoms
TERAPHY
Surgery is the only way :
- Herniotomy
- Hernioplasty
Time to operate :
- As soon as the diagnosis has been confirm
Emergency operation:
- Incarcerated hernia
- Incarceration à can happen anytime!
Indication of surgery:
Reducible hernia
Irreducible hernia
Incarcerated hernia
Strangulated hernia
Contraindications of surgery :
General
Spesific (increasing intra-abdominal tension : prostat hyperthrophy, lung disease)
Complication of Surgery
- bleeding
- Wound infection
- Iatrogenic trauma of bowel, bladder, vas deferen, testis
- Orchitis, atrophy of the testis
- Intrainguinal nerve trauma, ilio hipogastrik or genota femoral
Mortality
Depend on hernia condition : reducible or strangulate, patient general conditin and accompanied disease
Post Operative Care
Post operative, observe the possibility of complication that might happen (bleeding or hematom)
Follow-Up
Pasien is advised not to have heavy physical work in 6-8 weeks, to prevent recurrency
Patient on supine posistion under either general, spinal or local anesthesia
Executing aseptic and antiseptic prosedur on operating field
Narrowing operating field using sterile fabric
Executing oblique or skin crease incission paralel to inguinal ligament. Incise deeper until we found external oblique aponeurosis
External oblique aponeurosis is opened in sharp fashion.
Identify hernia sac, transect the sac transversally and return the content of hernia
Ligate the hernia sac as high as preperitoneum fat, continue with herniotomy
Stop the bleeding if there is, follow with hernioplasty close it with mesh graft
Close the operation wound layer by layer
JAUNDICE
Definition : increase level of bilirubin in the blood
Normal : < 9 mu mol/L (0,5 Mg % )
Obvious jaundice : >35 mu mol/L (2 mg %).
Based on patophysiology :
Pre-Hepatic events
Hepatic events
Post-Hepatic events
Prehepatic Jaundice
The pathology is occurring prior the liver
Increased rate of Haemolisis :
No evidence of liver disease
Sign of high hemolisis
Very high level of UCB

Hepatic Jaundice
Liver Disease ( + )
Defect of liver physiology
Increased level of UCB

Post-hepatic Jaundice
Intrahepatic obstruction;
- liver cirrhosis, liver abscess, hepatocholangitis, primary or secondary malignancy
Biliary system obstruction;
- Gall stones, ascariasis
Disruption of biliary system’s wall
- congenital atresia, traumatic strictur, biliary system tumor
Extrabiliary system pressure :
- Pancreas head tumor, ampula vater tumor, pancreatitis, secondary malignancy at hepatoduodenale ligament
Physical Examination
Family history of anemia, gall stone
Acholic stool
Urobilinuria
History of blood transfusion, drug/alkohol consumption
Jaundice without colicky pain or pain on liver palpation
à Hepatitis
Colicky pain with chill , intermittent obstructive jaundice à gallstone or cholagitis
Progressive jaundice with pain in flank area
à pancreatic malignancy
Orange skin discoloration + moderate jaundice + anemia à prehepatic jaundice
Deep color jaundice à hepatic and posthepatic events
Enlarged gallbladder, hepatomegaly, without pain on palpation à Tumor (Courvoisier’s sign)
Splenomegaly à liver cirrhosis, hematologic disorder, malaria, reticulosis.
Work Up
Laboratorium :
Liver function , bilirubin, stercobilinogen, urobilinogen, urinary bilirubin
Obstructive jaundice : high level of conj. bilirubin , low level of fecal stercobilinogen dan urinary urobilin,
Increased level of SGOT/PT ,
High level of Gamma GT
USG : gall stone, enlarge duct, mass, liver parenchimal disorder.
Work Up
Abdominal plain photo
USG
Abdominal CT
ERCP
PTC
Liver Biopsy à for non obstruktive jaundice only
JAUNDICE OBSTRUCTIVE ALGORITHM
MANAGEMENT
Paralel to the etiology
Surgery case à post hepatic jaundice
THANK YOU

HERNIA

 KULIAH BEDAH DIGESTIF
 Dr. SOERJANTO SOEDARNO, SpBKBD
 HERNIA
 DEFINISI
Hernia :
keluarnya isi suatu rongga dalam tubuh melalui defek pada dinding rongga tersebut
 HERNIA PD TUBUH
 Hernia Abdominal :
1. Hernia Inguinalis
2. Hernia Femoralis
3. Hernia Umbilikalis
4. Hernia Diafragmatika
5. Hernia Morgagni
6. Hernia Foramen Winslowi
7. Hernia Obturatoria
 Hernia Inguinalis : terbanyak
- 1. Hernia Inguinalis Lateralis / Indirek
- 2. Hernia Inguinalis Medialis / Direk
 Hernia Kongenital
 Hernia Akwisita / didapat
 Hernia insisi

 HERNIA INGUINALIS
 Defek : anulus internus / abdominal
anulus eksternus / subkutaneus
 Hernia Lateralis / kongenital / bayi / anak/ dewasa
 Hernia Medialis : orang tua
 ANATOMI DAERAH INGUINAL
 Atap / dinding depan : aponeurosis MOE
 Dasar : fasia transversa
 Batas kranial : konjoin tendon
( aponeurosis MOI dan Transversus)
 Batas inferior : Lig. Pouparti
Desensus testikulorum : intra embrional
- testis retroperitonial – derah skrotum
 STRUKTUR HERNIA
1. Pintu hernia
2. Kantong hernia
3. Isi hernia
 KLINIS
 Hernia reponibilis
 Hernia irreponibilis
- non inkarserata
- inkarserata
 DIAGNOSA
 Benjolan reponibilis : H. reponibilis
-Daerah inguinal : bila meragukan à test “ finger tip “ / test Valsava
 Benjolan irreponibel :
- Daerah inguinal / lainnya
# Disertai ileus obstruktif à hernia
inkarserata.
- # Tanpa ileus à hernia irreponibel saja
- # Strangulata : jaringan / usus nekrosis
.arena obstruksi vaskularisasi
 TERAPI
 Hanya operasi :
- Herniotomi
- Hernioplasti
 Waktu operasi :
- Segera setelah terdiagnosa
 Operasi darurat:
- Kalau terjadi inkarserasi
- Inkarserasi : terjadi sewaktu-waktu
 Angka keberhasilan terapi operasi
97% – 99%
 Penyulit residif : 1-3 %