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Identity
• Name : Mrs. R
• Age : 26 years old
• Address : Padang
• No. MR : 51 25 18
Chief complaint
Abdomen:
Inspection : Seem no enlarge
Palpation : No mass was palpable
Tenderness (-), Rebound tenderness (-), Defans muscular (-)
Percussion : Tympani
Auscultation : Normal peristaltic sound
Ginekology
Inspeksi : V/U within normal limit, bleeding (-)
Inspeculo:
Vaginal : a little bit short, tumor (-), laceration (-)
There is no cervix and external uterine ostium (-)
USG
• Uterus size and shape a little bit small with
size 4,9 x 3,08
• Both of ovary was normal
• Cervix/portio (-)
• Impression : cervical agenesis
Laboratory:
No Parameter Results Normal range
5. EL 99 pg/ml 25-75
Attitude
• Control GA, VS,
• Informed consent
• Consult to anesthesiologist
• Report to operation room
Plan
• Laparoscopy and vaginal approach for utero-vaginal anastomosis
07-09-2017 (08.00 a.m)
Laparascopy performed
Theres are massives adhesive adhesiolysis
Separation of plica vesicouterina until lower segment of uterine
With Sondage from vaginal, the uterine push to upward
Make longitudinal incision in lower segment of uterine
Until penetrate to uterine cavum. Then make incision in vaginal
area, sondage replaced with silicon cathether no 16. The silicon
catheter was discharged from vagina until uterine cavum anad
the ballon cathether expanded.
Between uterine and vaginal was sutured
Diagnosis
Utero-vaginal anastomosis with laparoscopy and vaginal
approach + adhesiolysis
Plan
Control after operation