No. MR

SURGERY REPORTNama : Mrs. Nunung Sex : Female Age : 41 YearsOperator Prof. Dr. H.I.O Marsis, SpOG Anesthetic dr. Widodo, SpAnAsisten Toby Hadinata W. Instrumentator

ObserverPre-surgical Diagnose : Primer Infertility + Susp. Tube occlusionPost-surgical Diagnose : Bilateral tubes patent Surgery Date : March 21th 2016

Duration time of surgery :15 minutes( 20.15 – 20.30 )

Tehnique of operation : Type of surgery1. Hydrotubation □ Emergency □ Minor

□ Poliklinik □ Medium□ Elektif □ Mayor

Operation Procedures:

I. Patient was administrated with general anesthesia in lithotomy position

II. Aseptic and antiseptic were done on genital area and the operation field was limited with sterile doek

III. Operation procedures of hidrotubation followed :

a. Applied sims speculum posterior and anterior speculum to vagina. Portio clamped with Kohel

tang at 12 hour direction.

b. Removed anterior sims speculum.

c. Sondation 7 cm anteflexion uterine.

d. Hidrotubator was inserted into uterine cavity and then 20 cc of NaCl 0,9% + Kanamycin 1 gr

was injected into the uterine cavity through the uterine canul. No leak of liquid detected in the

sims speculum and no obstruction, so the conclusion is the both fallopian tube is passable.

e. The uterine canul had been released, the Kohel tang and sims speculum had been released

IV. Aseptic and antiseptic at external genital region

V. The vagina was cleaned

VI. The operation finished

The condition of patient post operation:

General condition : Look mild sick

Consciouness : Compos Mentis

Blood pressure : 120/80 mmHg

Pulse rate : 88 x/minute

Respiration : 22 x/minute

Temperature : 36,6oC

OBSTETRIC AND GINECOLOGY DEPARTEMENTBUDHI JAYA MOTHER AND CHILDHOSPITALJL. Dr. Sahardjo No. 120 Jakarta Selatan 12960Telp. (021) 8292672, 8311722, 8312378Fax. 8301901

03 20 16

Tissue to Pathology of Anatomy :

□ Yes

□ No

Operator,

(Prof. dr. H.I.O Marsis, SpOG)