uterine inversion in mioma geburt
TRANSCRIPT
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LAPORAN KASUS KAMAR OPERASI
MIOMA GEBURT DENGAN
KOMPLIKASI INVERSIO UTERI
Konsulen :
dr. Doddy SpOG
Residen :dr. Yuwono/dr. Tikal
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Ilustrasi kasusNama : Ny S
Usia :66 th
Alamat : wadasDatan k! "SUD : #6$#$%'
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Keluhan utama
Diru(uk dari dokt!r umum di "S swasta d!nan in)!rsio ut!ri lama
Ria!at Pen!a"it Se"a#an$
pasi!n m!n!luh *!n(olan di k!maluan s!(ak # tahun S+"S, *!n(olan t!rutamasaat *atuk dan *uan air *!sar dan -A, *!n(olan dapat dimasukkan, pasi!n tidakm!rasakan ny!ri, p!rdarahan p!r)ainam $, anuan saat *!rhu*unan s!ksualdisankal.
Ria!at %en!a"it dahulu dan #ia!at %en!a"it "elua#$a
D+ $0, 1T $0, asma $0, al!ri $0 p!nyakit (antun $0
Ria!at menst#uasi& #ia!at meni"ah& #ia!at o'stet#i& #ia!at"ont#ase%si
"iw m!nstruasi: m!nar2h! lupa, r!ular, #3/*ulan , s!lama 4 hari, G5 3/harip!nuh, ny!ri $0"iw m!nikah: #3"iw O*st : 56A#"iw -: pil, suntik" sos!k : I"T
Peme#i"saan (isi"
TD #'&/7& mm1, 1" 7%3/m!nit, 5 %& 3 /m!nit, S: 6& 8St. G!n!ralis: d*n
St. Gin!koloiI: )/u t!nan, p!rdarahan akti9 $0 ,tampak massa pada introitus )aina ukuran '3'2mt: t!ra*a massa % *uah, m!nyam*un s!pan(an )aina, t!ra*a tankai d!nandiam!t!r % 2m, 8UT m!n!2il, param!trium l!mas, 8D tidak m!non(ol, massa padaadn!ksa$/$
Peme#i"saan Penun)an$
La' :Dia$nosis
*B: ++&,- leu: +./+/-t#om':001#i'u- ht 213- BT 0- 4T +0-$ol da#ah O-5- *'SA$ 678- GDS+0/
USG :Tida" ada inte#%#etasi
Dia$nosis
Mioma geburt
Tatala"sanaaan
"!n2ana dianosis :"!n2ana t!rapi :
;kstirpasi mioma hinahist!r!ktomi
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Intra op
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T!rimakasih
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In)!rsio ut!ri adalah suatu k!adaandimana 9undus ut!ri t!rputar *alik
k!luar dimana s!*aianatau s!luruhnyamasuk k! dalam ka)um ut!ri, )ainaatau k!luar dari )ul)a
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Ut!rin! in)!rsion
Th!r! ar! two typ!s o9 ut!rin! in)!rsions:pu!rp!ral or o*st!tri2 and non$pu!rp!ral oryna!2oloi2
In !n!ral, non$pu!rp!ral ut!rin! in)!rsionpr!s!nts a9t!r '4 y!ars and is mostly r!lat!d to*!nin myomas and s!ldom asso2iat!d withmalinan2i!s.
+ost non$pu!rp!ral in)!rsions ar! 2aus!d *y*!nin su*mu2ous myomas, whil! oth!r 2aus!sar! l!iomyosar2oma, rha*domyosar2oma,malinant mi3!d m
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D!ra(at in)!rsio ut!ri
sta! #: th! in)!rt!d9undus r!mains inth! ut!rin! 2a)ity
sta! %: 2ompl!t!
in)!rsion o9 th!9undus throuh th!2!r)i3
sta! : th! in)!rt!d9undus protrud!sthrouh th! )ul)a
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a!tioloy
Th! a!tioloy o9 ut!rin! in)!rsion is not 2l!arlyd!=n!d. 5ossi*l! !3planations 2ould *! a thinut!rin! wall, rapid rowth o9 th! tumour, tumoursi>!, 9undi2 lo2alisation o9 th! tumour, tumouratta2hm!nt to th! ut!rin! wall with a thin p!di2l!,dilatation o9 th! 2!r)i3 *y dist!nsion o9 th! ut!rin!
2a)ity, and sudd!n !3pulsion o9 th! tumourTh! main symptoms o9 non$pu!rp!ral ut!rin!
in)!rsions ar! ana!mia 2aus!d *y irr!ular )ainal*l!!din, )ainal dis2har!, low!r a*dominal and/orp!l)i2 pain, a protrudin mass in th! )aina, and insom! 2as!s o*stru2tion o9 th! ur!thra.
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Th! mana!m!nt o9 a2ut! ut!rin! in)!rsion
tr!atm!nt o9 hypo)ol!mia/sho2k
r!pla2!m!nt o9 th! in)!rt!d ut!rus throuh th! )aina:
?on!s1!nd!rson and all!s
?honson
O@Sulli)an
A*dominal r!position :1utinton
1aultain
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8ara (on!sDalam anal!sia
Ut!rus didoron k!atas m!nunakan
(ari$(ari pada 9undusut!ri yan t!r*alik
atu pada 9ornikspost!rior
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1!nd!rson dan Alli!s S!r)iks dip!an d!nan 9ors!p 2in2in,
s!m!ntara, 9undus ut!ri didoron k!
atas atau ant!rior
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?honson
m!masukkan s!luruhtanan k! dalam(alan lahir, s!hinai*u (ari dan (ari$
(ari yan lain pada
2!r)i2al ut!ro(un2tion dan 9undusut!ri dalam t!lapaktanan. Ut!rusdiankat k!luar dan
rona p!l)is dandip!rtahankan didalam ronaa*dom!n s!tinium*ilikus
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OBSulli)an 53 dlm posisi tr!l!d!n*ur
%$4 C NS dit!mpatkan % mdr lantai
% *ush tu*! kar!tdit!mpatkan pada 9ornikspost!rior
tananop!rator m!nutupintroitus untuk m!n2!ah
k!luarnya 2airan "!posisi ut!rus *iasanya
didapatkandalam 4$#&m!ni
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1untinton
m!narik 9undus ut!ris!2ara *!rtahapd!nan *antuan9ors!p Allis. ors!pAllis dipasan E %2m
di *awah 2in2in pada,k!dua sisinya,k!mudian ditank k!atas s!2ara *!rtahap
sampai9undus ut!rik!m*ali padaposisinya s!mula.
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1aultain insisi lonitudinal
s!pan(andindin post!rior ut!rusdan m!lalui 2in2inkontriksi. ?ari k!mudiandimasukkan m!lalui insisi
k! titik di *awah 9undusut!ri yan t!r*alik dandi*!rilm t!kanan pada=mdus atau t!kanans!2ara simultan dantanan asist!n. -ilar!posisi t!lah komplit,luka insisi di(ahit d!nan
(ahitant!rputus, % lapisd!nan 2hromi2 ataud!kson no.#
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+ana!m!nto9 2hroni2ut!rin!in)!rsionainal :
Spin!lliustn!r pro2!dur!
A*dominal
1oultain pro2!dur!
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1aultain insisi lonitudinal
s!pan(andindin post!rior ut!rusdan m!lalui 2in2inkontriksi. ?ari k!mudiandimasukkan m!lalui insisi
k! titik di *awah 9undusut!ri yan t!r*alik dandi*!rilm t!kanan pada=mdus atau t!kanans!2ara simultan dantanan asist!n. -ilar!posisi t!lah komplit,luka insisi di(ahit d!nan
(ahitant!rputus, % lapisd!nan 2hromi2 ataud!kson no.#
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Spin!lli +!lalui )aina dindin ant!rior )aina di*uat
t!an *!rlawanan d!nanar2h tarikan dari r!traktor dandilakukaninsisi trans)!rsalt!pat di atas porno ant!rior.!mudian plika kandunk!mi* dipisahkan daris!r)iks
dan s!m!n *awah rahim.Insisi m!dians di*uat m!laluis!r)iks pada (am #%,s!2ara komplit m!m*ai2in2in konstriksi. Insisidilakukan pada lin!s m!dianssampai 9undus ut!ri.Ut!rus
di*alik d!nan 2ara t!lun(ukm!nait k! dalam insisi padap!rmukaan!ndom!trium yan, t!r*ukadan m!m*uat t!kanan. yan*!rlawanan d!nan i*u (uripada *aian p!riton!al
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ustn!r D!nan2ara m!m*uka
dindin post!rior ka)urndoulas. Dilakukan kolpotomitrans)!rs!trans)ainald!nan insisis!dalam k!t!*alan s!r)ilspada (am 6 sampai dindinpost!rior ut!rus. Insisidi*uat
s!pan(an aris putus$putuss!p!rti pada am*ar F.!mudian d!nanm!nunakani*u (ari ut!rusdir!)!rsi s!pan(an sisi insisi.S!t!lah ut!rus dir!)!rsi,insisi dindin post!riorut!rus
d!n s!r)ik dip!r*aiki,d!mikian (us d!nan insisitrans)!rs! d!n kolpotomipada )aina. Cul!a ditutupd!nan (ahitan t!rputus d!nut!rus dit!mpatkan k!m*alil!! dalamka)um p!l)is.
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5ada in)!rsio kronik y dis!*a*kan ol!htumor, *iasanya dilakukan hist!r!ktomi
trans)ainal, su*total atau 9und!ktomit!rl!*ih dahulu, *aru %$ *ulan *ilain)!rsio masih ada, dapat dilakukanhist!r!ktomi total
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1ist!r!ktomi )aina 2ara?uni>a9 (ahitan s!p!rti rantai m!linkari korpus, ut!rus d!nan*!nan
>!yd! no. # atau d!nan )i2ryl no.#untuk h!mostasis. sayatan m!linkar pada korpus ut!rus distal dari (ahitan s!dikit
d!mi s!dikit s!hina tidak m!n!nai oranadn!ksa yan
t!rp!rankap di kantun in)!rsio. !adaanpankal tu*a, o)arium, liam!ntum rotundum dan
(arinan lain di!)aluasi. D!nan*antuan sond! trans ur!tra diid!nti=kasi )!sika urinaria. S!lan(utnya dilakukan (ahitans!p!rti rantai m!linkari korpus
ut!rus tahap II kuran l!*ih I 2m di luar introitus )aina. S!t!lah itu dilakukan p!motonan m!lmkar lai t!rhadap
korpus ut!rus di *aian distal (ahitan tahap k!$II. Cankah s!lan(utnya k!dua liam!n rotundum dikl!m, dipotondandi(ahit d!nan 2hromi2 2atut no.%.
?ika diyakini tidak ada p!rdarahan, tunul ut!rus dimasukkank! dalarn )aina
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Te9hniue o;
a'dominalh!ste#e9tom! ;o#non7%ue#%e#alute#ine in
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-a2k round
A 4%$y!ar$old lady was admitt!d with s!)!r!low!r a*dominal pain 9ollow!d *y *l!!din p!r$)ainum and a mass protrudin 9rom h!r )ul)a o94$day duration. Sh! was a nullipara with a historyo9 myom!2tomy don! % y!ars ao.
In )i!w o9 th! pr!)ious laparotomy and a lar!
l!iomyoma, our main 2on2!rns w!r!: Any att!mpt to r!position th! ut!rus would *!
t!2hni2ally di2ult and would 2ontaminat! th!op!ratin =!ld.
Cimit!d a22!ss to th! p!l)is du! to adh!sions*!2aus! o9 pr!)ious myom!2tomy.
8los! pro3imity o9 th! ur!t!rs to th! o)arian andut!rin! )!ss!ls du! to tra2tion on th! )as2ularp!di2l!s.
8onstraints o9 mo*ilisin th! *ladd!r down du! toth! in)!rt!d ut!rus.
T!knik tanpa r!posisi t!rl!*ih dahulu
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pr!op!rati)!
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#Trans)!rs! slit
with in)!rt!d
How!rpotapp!aran2! showsth! liam!nts,tu*!s and o)ari!s
pull!d to midlin!into th! 9unn!l o92!r)i2al rim.
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%1ookin out th!
round liam!nt
out 9rom th!trans)!rs! slit *yusin th!sur!on@s ind!3
=n!r.
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-oth roundliam!nts ar! h!ld
*y -a*2o2k9or2!ps. Th! =rstst!p in)ol)!sliation and
transa2tion o9round liam!nt.
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A9t!r transa2tinth! riht round
liam!nt, th!p!riton!al in2isionis !3t!nd!dtowards th!para2oli2 utt!r to
ain a22!ss tor!trop!riton!alspa2!
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Ur!t!r was id!nti=!d onth! m!dial p!riton!al9old and tra2!d 9rom
p!l)i2 *rim downwards "iht ur!t!r is s!!n
atta2h!d to m!dialp!riton!al Hap 9or2!pspoint to th! ur!t!r0.Ur!t!r is tra2!d 9romp!l)i2 *rim downwards.
Ilia2 )!ss!ls ar! alsos!!n in th! ima!
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O)arian )!ss!ls inth! in9undi*ulo$
p!l)i2 liam!ntar! hook!d on th!sur!on@s =n!r to*! 2lamp!d sa9!ly
away 9rom th!ur!t!rs.
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Th! in2ision on th!ant!rior l!a9 o9 *road
liam!nt was!3t!nd!d 2audally on*oth sid!s to op!n th!ut!ro$)!si2al pou2ha*o)! th! 2!r)i2al rim.Th! ut!rin! art!ri!s
w!r! id!nti=!d2rossin th! ur!t!rssup!riorly 9rom lat!ralto m!dial sid! todisapp!ar into th! slit=ur! #%0. Usin a
+i3t!r 9or2!ps, th!ut!rin! )!ss!ls w!r!li9t!d away 9rom th!ur!t!rs th!n liat!dand di)id!d.
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Sur!on@s =n!r is us!d
to id!nti9y th! rim o92!r)i3, whi2h is pull!d$up and h!ld with-a*2o2k 9or2!ps.
This allow!d th! *ladd!rto *! mo*ilis!d down toi)! a #.4 2m 2l!ar)ainal marin. Th!)ault was th!n op!n!dant!riorly
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ainal )ault issa9!ly op!n!d
ant!riorly k!!pina 2l!ar marin o9)aina away 9romth! *ladd!r and
ur!t!rs.
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Th! in2ision was !3t!nd!dlat!rally takin 2ar! to k!!pth! in2ision lin! a*o)! th!l!)!l o9 th! ur!t!rs. Th!ut!rosa2ral liam!nts 2ould *!id!nti=!d in th! post!riorasp!2t o9 )ainal )ault. Th!iratta2hm!nts to th! )ault w!r!
pr!s!r)!d whil! !3t!ndin th!in2ision post!riorly =ur! #40.Th! sp!2im!n whi2h was now9r!! was push!d down into th!)aina. ainal )ault was th!n
2los!d.
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Sp!2im!n o9in)!rt!d ut!rus
with 9undal =*roida9t!r th! sur!ry.-oth th! ut!rin!)!ss!ls 2an *!
s!!n disapp!arininto th! rim o92!r)i3.