SURGERY
CLASS
B a t c h # 1 1
P a r t 3
@dionfaisal31 X @dokterpost 21 Agustus 2021
Nama : Dr. Dion Faisal, Sp.B FICS
TTL : Balikpapan, 31 Mei 1985 Istri & anak :
Dr. Dian Manggiasih Muhammad Nabil Muhammad Dhafin Pendidikan :
S1 Kedokteran Umum FK Unmul 2009 Spesialis Bedah Umum FK Unair 2018
Fellow International College of Surgeon 2020 Pekerjaan :
Kepala SMF Bedah, Subkomite Mutu RSUD Tarakan Staf pengajar FIKES Universitas Borneo Tarakan Webinar lecturer in General Surgery
MENTOR
SHIP &
POSITIVE
ROLE MODELS
• Career success
• Job satisfaction
• Improved working relationships with colleagues &
patients
Sinclair P, Fitzgerald JE, Hornby ST, Shalhoub J. Mentorship in surgical training: current status and a needs assessment for future mentoring programs in surgery. World J Surg. 2015;39(2):303-314.
TIME
COMMITMENT
• Intense residency:
30 hour calls & four days off
in a month.
• A patient and surgeon. The patient allows the surgeon to do
something
life-altering.
The surgeon has
the responsibility
of someone’s
life in their hands.
• The complications are real, but the outcome & satisfaction is
exponential.
WHAT DO
PROGRAM
DIRECTORS
LOOK FOR IN
CANDIDATES?
• Academic performance
• Personal qualities
• Letters
1
Berikut ini yang merupakan faktor risiko terjadi trauma plexus brachialis, kecuali a. Berat badan besar
b. Persalinan dengan forsep c. Presentasi sungsang
d. Distosia bahu
2
An. J, 2 bulan dibawa ke dokter bedah setelah mendapat rujukan dari dokter umum akibat adanya kelainan pada kaki. Pada pemeriksaan fisik ditemukan kaki yang kecil, dan kaki berada pada posisi equinus, varus, cavus, dan adduksi. Pada inspeksi ditemukan gambaran sebagai berikut. Diagnosis dan tatalaksana pada pasien ini adalah a. Erb Distrophy, Neurostimulasi
b. CTEV, Metode Ponseti
c. Plexus brachial injury, Nerve graft d. Displacement hip, Open Reduction e. Dislokasi ankle, ORIF
3
Reposisi dislokasi yang terlambat dapat menyebabkan komplikasi berupa
a. Avaskular nekrosis dari kepala femur b. Osteonekrosis dari socket joint
c. Osteoartritiis d. Fraktur femur
HIP DISLOCATION:
AVASCULAR
NECROSIS
1-20%
4
Diagnosis compartement syndrome dapat ditegakkan jika terdapat tekanan diastolik kompartemen yang lebih dari a. 35 mmHg b. 5 mmHg c. 10 mmHg d. 30 mmHg e. 20 mmHg
COMPARTEMENT
SYNDROME
Diagnosis compartement syndrome atau sindroma
kompartemen ditegakkan dengan gejala klinis.
Namun pada pasien yang tidak sadar atau pasien yang
tidak kooperatif, diagnosis dapat ditegakan dengan
menusukkan jarum pada kompartemen.
Diagnosis ditegakkan jika tekanan kompartemen
melebih 30 mmHg dari tekanan diastolic.
SUMBER: Schwartz’s Principles of Surgery Halaman
1883
5
Tatalaksana reseksi pada karsinoma kolon dilakukan menggunakan prinsip a. Reseksi tumor primer dan suplai limfovaskular
b. Reseksi tumor primer c. Reseksi seluruh kolon
d. Reseksi tumor primer dan suplai vaskular
Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis. 2009 May;11(4):354-64; discussion 364-5. doi:
6
Pada pemeriksaan fisik apendisitis, ketika dokter memberikan tekanan pada kuadran kiri bawah dan pasien mengeluhkan nyeri pada kuadran kanan bawah disebut sebagai
a. McBurney sign b. Rosving sign c. Dunphy sign d. Iliopsoas sign e. Obturator sign
Rosving sign Psoas sign
Obturator sign Dunphy sign
7
Pengobatan pilihan untuk kista koledokus tipe I adalah:
A. Observasi
B. Reseksi kista dan re-anastomosis primer duktus biliaris komunis.
C. Reseksi duktus biliaris komunis, kolesistektomi, dan hepatico-jejunostomy.
D. Reseksi kista dan choledocho-duodenostomy.
8
Relaksasi sfingter Oddi sebagai respons terhadap makanan sebagian besar terjadi di bawah
kendali hormon?
A. Gastrin
B. Kolesistokinin (CCK)
C. Motilin
D. Sekretin
E. Ghrelin
9
Kolesistitis akut merupakan
A. Proses infeksi primer dengan inflamasi sekunder.
B. Proses inflamasi primer yang steril.
C. Proses inflamasi primer dapat disertai kontaminasi bakteri.
D. Proses autoimun primer.
10
Faktor risiko atau kolesistitis akalkulus termasuk:
A. Sepsis
B. Luka bakar parah
C. Nutrisi parenteral berkepanjangan
D. Trauma
11
Menurut sistem klasifikasi Bismuth-Corlette, kolangiokarsinoma perihilar yang meluas ke duktus intrahepatik sekunder kanan diklasifikasikan sebagai
A. Tipe II B. Tipe IIIb C. Tipe IIIa D. Tipe IV E. Tipe I
12
Komplikasi pankreatitis kronis yang paling umum adalah
A. Pseudokista
B. Striktur saluran dan/atau batu C. Nekrosis pankreas
D. Obstruksi duodenum E. Karsinoma
13
Insulinoma terkait dengan sindrom multiple endokrin neoplasia (MEN) 1
A. Biasanya tidak memerlukan reseksi
B. Bersifat sporadis
C. Memiliki tingkat kekambuhan yang tinggi
D. Lebih cenderung menjadi ganas
14
Manakah dari berikut ini adalah gejala yang paling umum pada pasien dengan
somatostatinoma?
A. Kolelitiasis
B. Sembelit
C. Hipoglikemia
D. Hipokalsemia
E. Kolangitis
15
Nyeri akibat pankreatitis kronis dapat disebabkan oleh:
A. Hipertensi duktal B. Penyakit parenkim
C. Pankreatopati obstruktif D. Semua Benar
16
Fraktur klavikula distal umumnya terjadi dengan komplikasi berikut a. Ruptur coracoclavicular ligament
b. Fraktur terbuka
c. Gangguan ROM yang ringan d. Kerusakan arteri karotis
CLAVICLE
FRACTURE
• Distal clavicle fractures are traumatic
injuries usually caused by direct
trauma to the shoulder from a fall in
adults
• Diagnosis: standard shoulder
radiographs and a 15° cephalic tilt
view (zanca view)
• Treatment: immobilization or
surgery, depending on the
displacement and stability of the distal
clavicle, as determined by whether
coracoclavicular (CC) ligaments
(trapezoid & conoid) are intact
TREATMENT
• Nonoperative: sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks • indications
• stable fractures (Neer Type I, III, IV)
• pediatric distal clavicle fractures (skeletally immature) • Operative: open reduction internal fixation
• indications • absolute
• open or impending open fractures • subclavian artery or vein injury
• floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement) • symptomatic nonunion
• relative
• unstable fracture patterns (Neer Type IIA, IIB, V)
• brachial plexus injury (questionable because 66% have spontaneous return) • closed head injury
• seizure disorder • polytrauma patient
17
Tn. J, 40 tahun datang dengan kecelakaan lalu lintas dan luka pada kaki kanan. Pada luka Nampak tulang yang mencuat. Panjang luka sepanjang 5 cm dengan keruasakan jaringan lunak yang sedang dan kontaminasi luka yang sedang. Fraktur terbuka pada pasien ini adalah
a. Tipe I b. Tipe II c. Tipe III d. Tipe IV e. Tipe V
GUSTILO
CLASSIFICATION
• Type I
• wound ≤1 cm, minimal contamination or muscle damage • Type II
• wound 1-10 cm, moderate soft tissue injury • Type IIIA
• wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated • adequate tissue for flap coverage
• farm injuries are automatically at least Gustillo IIIA • Type IIIB
• extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap)
• Type IIIC
• vascular injury requiring vascular repair, regardless of degree of soft tissue injury Most accurate way to grade open fratures is by intra-operative examination
18
Tn. A, 20 tahun, datang dengan keluhan kaki tidak terasa setelah tertendang kaki lawan saat bermain futsal. Pada pemeriksaan fisik Nampak adanya bengkak yang berat pada kaki kanan yang tertendang. Selain itu juga ditemukan kaki kesemutan, paralisis, dan tidak adanya pulsasi arteri. Diagnosis pada pasien ini adalah
a. Sindroma kompartemen b. Sindroma fraktur terbuka c. Fraktur tertutup
d. DVT
LEG COMPARTEMENT
SYNDROME
• Devastating condition where an
osseofascial compartment pressure
rises to a level that decreases perfusion
• may lead to irreversible muscle and nerve
damage
• Epidemiology
• location
• compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
• leg (details below) • forearm • hand • foot • thigh • buttock • shoulder • paraspinous muscles
19
An. D 14 tahun, pasien datang dengan keluhan bengkak yang mendadak pada testis setelah tertendang saat bermain bola. Pada pemeriksaan fisik Nampak testis yang membengkak, reflex kremaster pada pasien ini menghilang. Diagnosis yang paling mendekati pada pasien ini adalah a. Ca testis
b. Epididimitis c. Torsio testis d. Ca prostat e. Cowperitis
ACUTE
SCROTUM
• Acute scrotum is a paediatric urological
emergency, most commonly caused by torsion
of the testis or appendix testis, or
epididymitis/epididymo-orchitis.
• Other causes of acute scrotal pain: idiopathic
scrotal oedema, mumps orchitis, varicocele,
scrotal haematoma, incarcerated hernia,
appendicitis or systemic disease (e.g.
Henoch-Schönlein purpura).
• Trauma: post traumatic haematomas, testicular
contusion, rupture dislocation or torsion.
• Torsion of the testis occurs most often in the
neonatal period and around puberty, whereas
torsion of the appendix testes occurs over a
wider age range.
20
Diagnosis torsio testis ditegakkan dengan pemeriksaan penunjang berupa a. USG Doppler
b. MRI Testis c. CT Scan testis d. Foto polos testis e. Foto testis lateral
EAU
GUIDELINE 2016
• Doppler US is useful to evaluate acute scrotum,
with 63.6-100% sensitivity and 97-100%
specificity, and a positive predictive value of 100%
and negative predictive value of 97.5%.
• The use of Doppler US may reduce the number of
patients with acute scrotum undergoing scrotal
exploration, but it is operator-dependent and can
be difficult to perform in pre-pubertal patients
21
Tatalaksana torsio testis yang sudah nekrosis dilakukan dengan cara a. Orchiectomy
b. Orchiotomi c. Orchioplasti
d. Orchioepididimoplasti e. Epididimopolasti
EAU
GUIDELINES 2016
• Manual detorsion without anaesthesia (outwards rotation, unless the pain increases or if there is obvious resistance). Success: immediate relief of all symptoms and normal findings at physical examination (LE: 3; GR: C). Doppler US may be used for guidance.
• Bilateral orchiopexy is still required after successful detorsion (elective procedure). • Surgical treatment:
• Early surgical intervention with detorsion (mean torsion time < 13 hours) was found to preserve fertility.
• Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of symptom onset. In patients with testicular torsion > 24 hours, semi-elective exploration is necessary.
• There is still controversy on whether to carry out detorsion and to preserve the ipsilateral testis, or to perform an orchiectomy, in order to preserve contralateral function and fertility after testicular torsion of long duration (> 24 hours).
• During exploration, fixation of the contralateral testis is also performed. Recurrence after orchidopexy is rare (4.5%) and may occur several years later. There is no common
22
Berikut ini adalah faktor yang dapat menghambat fistula intestinal untuk menutup spontan, kecuali a. Benda asing
b. Infeksi c. Epitelisasi d. Neoplasma e. Ileus paralitik
ENTERIC
FISTULAS
• A fistula is defined as an abnormal
communication between 2 epithelial surfaces.
• Enteric fistulas may arise in a number of settings:
1. Diseased bowel extending to surrounding
epithelialized structures;
2. Extraintestinal disease eroding into
otherwise normal bowel;
3. Surgical trauma to normal bowel including
inadvertent or missed enterotomies; or
4. Anastomotic disruption following surgery for
a variety of conditions.
• The first 2 generally occur spontaneously, while
the latter 2 occur following surgical procedures.
GENERAL
PRINCIPLES
1. Early recognition and stabilization of patients with fistulas combined with control of sepsis and provision of nutritional support
2. Investigation of the anatomic and etiologic characteristics of each fistula, thus providing information about the likelihood of spontaneous closure or need for operative management
3. Decision making regarding the approach to management that includes the involvement of a multidisciplinary team, which will provide the best possibility of resolution of the fistula
4. Definitive surgical therapy in a controlled setting
PREDICT
FAILURE OF
23
Pendarahan intrakranial yang paling banyak disebabkan oleh aneurisma serebral adalah a. SAH
b. ICH c. IVH d. SDH e. IVDH
24
Tumor intrakarnial dapat merusak jaringan otak dengan cara di bawah ini, kecuali a. Efek masa
b. Disfungsi struktur saraf sekitar c. Edema
d. Kejang
INTRACRANIAL
MASS
EFFECT
•
Most tumors will cause mass effect
on surrounding structures and in turn
cause midline shift or hydrocephalus.
•
the skull is a fixed volume and cannot
increase in size. a lesion within the
skull will compress and/or displace
adjacent structures.
•
mass effect may be caused by:
•
tumors
•
cerebral abscess
•
infarction and associated edema
•
hemorrhage
25
Pada tumor intrakranial metastasis, reseksi kraniotomi hanya dilakukan ketika a. Semua metastasis dapat dideteksi
b. Ukuran tumor > 10 cm
c. Menyebabkan mideline shift d. Terdapat di bagian batak otak e. Berjarak 10 cm dari meningen
SURGERY FOR
BRAIN METASTASES
• Classically, surgical resection of brain metastases has been limited to palliative care. Recently,
however, several prospective studies have described a subset of patients for which surgery is highly
indicated and results in a prolonged survival.
• These patients most often have a single, surgically accessible metastatic lesion, absent or
well-controlled systemic disease, good functional status (KPS), intact neurological function, and absence of
leptomeningeal infiltration.
Yaeger KA, Nair MN. Surgery for brain metastases. Surg Neurol Int. 2013;4(Suppl 4):S203-S208. Published 2013 May 2. doi:10.4103/2152-7806.111297
@dionfaisal31
