A middle aged man was admitted for elective operation due to carcinoma of the caecum, based on clinical pattern and colon in loop radiograph. On admittance, there is a mass on the supraumbilical area which is mobile. There is a consideration of error in previous diagnostic, since now it is suspected that the carcinoma was on the transverse colon. The patient under go surgery, and intraoperative findings shows an invagination (ileo-colo-colical invagination) up to transverse colon (hence the mobile mass). There is also a carcinoma on the ileocecal junction as the lead point of the invagination. A right hemicolectemoy was performed and the patient was discharged after 6 days. There were no further complaint in the follow up.10112009214resize.jpg

A middle age man was admitted to the emergency departement due to inability to defecate for 4 days. There is no history of change of bowel habit. The only significant history is contact with a jelly fish while fishing at sea, leaving a burning sensation and ulcer on the left fore arm. Physical examination reveals a distended abdomen with contours of bowel visible at the abdominal wall. Bowel sound is increased. Plain abdominal x rays in two position showed “coiled spring” appearance of the small bowel, but colon is visible up to the transverse part. The patient was treated conservatively, and at the second day spontaneus defecation returns, with the improvement of all signs and symptoms. He was discharged from the hospital aferward.



A 27 years old male patient came to the ED because of fever, and pain in the left side of the abdomen. The patient also complained about his defecation which he refers as “black and jelly-like” for almost 1 week. Little is consumed since he felt sick. On examination, there is sign of muscular guarding on the left side of the abdomen, and painful when palpated. The patient shows septic condition. An emergency celiotomy was performed. After the abdomen was opened, the omentum was thickened and stick over the ascending colon. When carefuly removed, under the omentum there is an accumulation of pus about 200 cc and the whole anterior wall of the ascending colon until the hepatic flexure was completely necrotic. The posterior wall shows signs of necrosis and was filled with sticky pus. A right hemicolectomy was performed with double barreled stoma of ileum and transverse colon.

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A 37 years old women was admitted to the emergency ward complaining of abdominal pain. History reveals a 1 week fever and abdominal pain which worsen overtime. She can not defecate for 3 days. On physical exam, the abdomen was tender to pressure and there is a muscle guarding over all area of the abdomen. Laboratory shows leukopenia (4100/microliter). Serology test for thypoid fever shows strong positive results. Abdominal plain x rays in left lateral decubitus shows a possible free air in the abdominal cavity. Celiotomy was performed, and we found a ruptured of abcesses of the salphinx, which was consulted and further managed by obgyn.

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A middle age woman was admitted for surgery because of a single mass on the right side of the neck posterior of the sternocleidomastoid muscle. The mass was fixed, felt cystic, single, 2,5 cm in diameter and painful especially when palpated, but did not show any sign of inflammation. It is not compressible, and according to the patient , the mass existed about 2 years and enlarged very slowly. Fine needle biopsy results was hemangioma, which is incongruent with the clinical features. An excisional biopsy was planned and performed with general anaesthesia. During operation, the mass was situated posterior to the internal jugular vein,and under the brachial plexus nerves. The accesorius nerve was crossing near the posterior border. These nerves was extended by the tumour, which may explain the pain felt by the patient. A careful excision was performed preserving the nerves and the tumor was completely excised in toto. The tumor was a mixed cyst and solid part. The pathological examination shows a branchial cyst. Post operative the patient complained of tingling sensation on her lower arm, which subsided with time.

A 10 years old male child was consulted by internal medicine departement due to abdominal pain and mass. On evaluation, the pain seems to be colicky in nature, are moderate to severe (the patient can not sleep if the pain is felt), partially resolve to NSAID medication, and located in the middle upper abdomen. There is a history of abdominal trauma due to martial art practice. The patient was slightly icteric, and there is an increase of both direct and indirect bilirubin. Physical examination found a solid mass in the right hypochondriac and epigastrium area.USG reveals a right renal cyst 9 cm in diameter and a small pancreatic cyst. The patient was diagnosed as obstructive jaundice which may be caused by enlarged pancreatic cyst of the pancreatic head or cyst of the choledochal duct.

Abdominoscrotal Hernia

October 31, 2009

10 years old boy was admitted for operation with the diagnosis of hydrocele of right testis. There was a mass on the lower right abdomen. The mass was visible but palpation is equivocal for specific mass. During the operation, it was found that there is a peritoneal sac inside the testis filled with peritoneal fluid and omentum. On further evaluation, there is a second peritoneal sac which advanced into the retroperitoneal space over the inguinal ligament, contained omentum. The content was reduced into the abdomen, the sac divided and peritoneum closed. The two left over of the peritoneal sac was marsupialized to prevent future hydrocele.

Tuberculous Appendicitis

October 31, 2009

A 20 years old male patient came complaining pain in the right lower quadrant of the abdomen for 5 days. Previously, there is a diffuse dull pain over the whole abdomen which subsided after oral antibiotic therapy. Patient had antibiotic and analgetic therapy previously. The laboratory shows hemoglobin concentration of 10,5 and leucocyte 7500. Physical examination reveals the abdomen is slight distended, with pain on pressure at the left lower quadrant. Digital rectal exam found pain on the upper right area. Clinical diagnosis was acute appendicitis.
On operation, with gridiron approach, there is an inflammed appendix 0,5×5 cm,oedematous, but there is also small nodules (0,1-0,2),white, on the ileum, caecum and peritoneum. The omentum is thickened and was attached to the anterior peritoneum on the right lower quadrant. Clinically, the appearance was of abdominal tuberculosis with acute appendicitis. Appendectomy and biopsi of the omentum was performed.

A middle age woman was consulted by obgyn to the surgical department because of clinical symptoms of bowel obstruction. She complained can not defecate for around 2 weeks. Previously, there was a suspicion of pelvical mass from the adnexa. On observation, the bowel obstruction becomes worse, and the nasogastric tube was fecal. A celiotomy was performed with the diagnosis of total bowel obstruction. There was a serous fluid around 1,5 l intra abdomen upon entrance to the abdominal cavity. The Small bowel was dilated up to the ileocecal juction, and there are small white nodules scattered on the serosal surface of the bowel and omentum. Approaching the ileocecal juction, there was a heavy adhesion with loops of ileum trap within the adhesion, which can not be safely freed without damaging the intestine and much hemorrhage. Large intestine was collapsed. Mesenterium of the small bowel was contracted, fragile and hard. Because no ileum can be mobilized for proper stoma, a distal yeyunostomy (90 cm from Treitz ligament) was performed.Biopsy of the omentum was performed. The patient was put under partial parenteral nutrition to prevent malnutrition.

Male 64 years old was admitted with incarcerated inguinal hernia. Based on interview, the hernia could not be reduced less than 24 hour before admission. Vital signs was normal expect high blood pressure 170/90 mmHg. Upon operation using inguinal incision, the content of the hernia sac was a necrotic terminal ileum, caecum and part of ascending colon. Proximal to the mark of the hernia ring (at ileum), the bowel was also necrotic. A celiotomy was performed, and on examination there is a necrosis of ileum 80 cm proximal of ileocecal juction up to all ascending colon. There is a thrombus on the ileocolical artery, which may explain the extensive necrosis. A resection was performed and an ileostomy-colostomy double barreled was created.


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