SURGERY CLASS Batch #4 Part 1

SURGERY

CLASS

Batch #4 Part 1

C

urriculum

V

itae

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

DO

YOU

WAN

T

TO

BE

LIKE

THIS

?

MENJADI

AHLI BEDAH

• PERJALANAN PANJANG

• PENGORBANAN TIADA HENTI

• DUKUNGAN KELUARGA SANGAT PENTING

• USAHA, DOA, ORANG DALAM???

KOMPONEN

TES MASUK

• PERSYARATAN UMUM, KHUSUS, AFIRMATIF

• TES AKADEMIK: sesuai bidang, jurnal reading, case

report

• TES PSIKOLOGI & MMPI

• TES KESEHATAN: lab darah & urine, narkoba, radiologi,

treadmill

• WAWANCARA: motivasi, dukungan keluarga,

pembiayaan/beasiswa, alasan memilih prodi atau

universitas

• REKOMENDASI: pimpinan RS, SMF bedah, IDI, Dekan,

Walikota, Gubernur, izin BKD

Fraktur klavikula distal umumnya terjadi dengan komplikasi berikut a. Ruptur tendon coracoclavicular

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

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

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

Pathophysiology

• Etiology • trauma • fractures (69% of cases) • crush injuries • contusions • gunshot wounds

• tight casts, dressings, or external wrappings • extravasation of IV infusion • burns • postischemic swelling • bleeding disorders • arterial injury • Pathoanatomy

• cascade of events includes

• local trauma and soft tissue destruction • bleeding and edema

• increased interstitial pressure

• vascular occlusion (decreased venous outflow relative to arterial inflow)

Diagnosis sindroma kompartemen dibuat Ketika terdapat tekanan kompartemen diastolic yang lebih besar daripada

a. 5 mmHg b. 10 mmHg c. 15 mmHg d. 20 mmHg e. 30 mmHg

Compartment Pressure

Measurement

According to Mubarak and

Hargens, an absolute pressure

measurement of 30 mm Hg in the

compartment should be the

“critical pressure” for

recommending fasciotomy.

However, even though this tissue

pressure is abnormal and

corresponds to the onset of pain

and paresthesias, it does not

necessarily precipitate a

compartment syndrome in the

absence of other factors.

Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978 Dec. 60

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.

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

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

Rekonstruksi ekstremitas paska kejadian trauma harus dilakukan dengan prinsip utama

a. Minimalisasi jaringan parut b. Maksimalisasi fungsi

c. Maksimalisasi estetika d. Flap jauh

Sistem skoring yang bisa digunakan pada rekonstruksi ekstremitas paska traumatic untuk memudahkan pemilihan opsi terapi adalah sistem skoring a. New York

b. James c. Gustillo

d. Hanifin Rajka e. Maxwell

Fistula iatrogenic enterocutaneous dapat muncul setelah post op dengan manifestasi klinis di bawah ini, kecuali

a. Demam

b. Leukositosis c. Ileus

d. Infeksi luka post op e. Diare

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.

Fistula intestinal pada usus halus dengan jenis fistula enterovesikular dapat menyebabkan

a. Infeksi kolon berulang

b. Infeksi saluran kemih berulang c. Keganasan

d. Obstruksi saluran cerna e. Ileus

Berikut ini merupakan prinsip yang benar pada penanganan fistula intestinal usus halus

a. Lanjutkan dengan terapi pembedahan

b. Terapi medis 1 minggu lanjutkan pembedahan c. Observasi selama 2-3 bulan

d. Observasi selama 5-6 bulan

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 5. Postoperative care including physical rehabilitation

and emotional support, which together help patients return to their premorbid condition.

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

PREDICT FAILURE OF

SPONTANEOUS

Keganasan usus halus kasus yang paling sering ditemukan adalah a. Adenoma b. Lipoma c. Limfangioma d. Hemangioma e. Neurofibroma

Berikut ini merupakan pernyataan yang tepat mengenai neoplasma usus halus, kecuali

a. Umumnya menyebabkan obstruksi

b. Ditemukan pada pemeriksaan esophagogastoduodenoskopi c. Dapat berupa fibroma

d. Umumnya jinak

Indikasi reseksi secara endoskopi pada keganasan usus halus umumnya dilakukan pada lesi di bawah

a. 2 mm b. 5 mm c. 10 cm d. 2 cm e. 1 cm

EMR

Kakushima, Naomi & Yoshida et al (2020). Present Status of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Epithelial Tumors. Clinical Endoscopy. 53. 10.5946/ce.2019.184.

Berikut ini yang dapat menyebabkan icterus neonatorum kecuali a. Gangguan obstruksi b. Gangguan darah c. Gangguan metabolic d. Infeksi kongenital e. Fistula bilier

Temuan terbaru dari patogenesis atresia bilier menunjukkan adanya hubungan kuat pada infeksi … selama kehamilan

a. Rotavirus b. Hemophilus c. Hepatitis d. HIV

*Billiary atresia and splenic malformation syndrome

An. D 5 hari datang dengan keluhan kuning sejak 4 hari yang lalu. Orang tua juga mengeluhkan adanya tinja yang berwarna akholik. Pada

pemeriksaan fisik Nampak anak lemas, icterus seluruh tubuh, serta adanya tinja berwarna abu pucat. Diagnosis yang paling mungkin pada pasien ini adalah a. Atresia duodenum b. Atresia esopahgus c. Atresia bilier d. Invaginasi e. intususepsi

Pada kasus kecurigaan atresia bilier, eberapa titer infeksi perlu untuk diperiksa. Selain TORCH, infeksi apalagi yang juga harus diperiksa? a. Hepatitis viral

b. HIV

c. Leptopsira d. Haemophilus e. Streptococcus

Pendarahan intrakranial yang paling banyak disebabkan oleh aneurisma serebral adalah a. SAH b. ICH c. IVH d. SDH e. IVDH

Berikut ini adalah modalitas tatalaksana yang dapat dilakukan pada malformasi arteriovenosus serebral, kecuali

a. Microsurgical excision b. Interventional radiology c. Endovascular embolization d. Stereotactic radiosurgery e. I-323 embolization

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

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

Life only has one rule:

Never

quit

. – Unknown

@Surgery Class Februari 2021

SEMOGA

BERMANF

AAT