"A Man can't make a mistake can't make anything"

Wednesday, 29 February 2012

Diagnosis and management of kidney stone (Nephrolithiasis)

To commemorate the fallen world kidney day on March 1, it is reviewed on a case Nefrolithiasis is one of the causes of the destruction of the kidneys, so we need to know and understand about the mechanism of occurrence of stones in the urinary tract, especially the kidneys so that we can anticipate and prevent (lower morbidity) of nefrolithiasis which may indirectly increase the quality of kidney health.

In Indonesia, cases of urinary tract stone disease is common. In Asian countries such as Indonesia, the Middle East, China and India is mentioned in the literature as the countries with the number of cases of urinary tract stones are high.
Urinary tract stones are common in the urine is sterile. It is estimated that the increased incidence of stones associated with plant-based diet low in protein and phosphate. The change of lifestyle to a modern style, which among other marked by increasing consumption of animal protein, the incidence of urinary tract stones tend to increase. Foods that affect stone formation is a variety of foods that contain calcium, but low.
Urinary tract stones is actually nothing more than the minerals in the water that had precipitation and compact. Dehydration due to weather, the hot tropical climate and circumstances diarrhea can complicate kidney stones or urinary tract stones that have previously occurred. In addition, urinary tract stones often recur, so have the nature of the threat of a lifetime for patient.
In developing countries, many found bladder stone patients, whereas in developed countries the disease is more prevalent upper urinary tract stones, because of the influence of nutritional status and daily activities of patients Kidney stones or nefrolithiasis hari.2 affects about 4% of all population, the ratio of male: female is  4: 1, and nefrolithiasis illness accompanied by greater morbidity due to pain. 3

Definition Nefrolithiasis
Nefrolithiasis or kidney stones are solid objects that occur in the kidney is formed through a process fisikokimiawi of substances contained in the urine. Kidney stones are formed endogenously from the smallest elements, mikrolith-mikrolith and can grow to be large. Mass is soft at first, for example jendalan blood, can also experience.

Etiology Nefrolithiasis

Tuesday, 28 February 2012

Diagnosis and Management Tuberculosis Peritonitis with Intestinal Obstruction

Tuberculosis is still an endemic disease that is quite worrying in Indonesia. From the existing data that Indonesia occupied the position-3 in the world after China and India. However, for the discovery of new cases in recent years Indonesia occupied the fifth position after China, India, Philippines and Thailand. This does not necessarily indicate that tuberculosis has been declining in Indonesia, probably many factors that cause yain. Because of Indonesia's total population is pretty much (pulmonary tuberculosis), then the extra-pulmonary tuberculosis were also many in Indonesia, especially nutritional status in Indonesia is still not good.

A. Definition
Peritoneal tuberculosis is an inflammation of the parietal or visceral peritoneum caused by the bacteria Mycobacterium tuberculosis, and the disease is also frequently seen on the entire peritoneum, gastrointestinal system tools, mesentery and internal organs genetalia

B. Incidence
Peritoneal tuberculosis is more common in women than men with a ratio of 1.5:1, and more often decades to 3 and 4. Peritoneal tuberculosis found 2% of all pulmonary tuberculosis and 59.8% of abdominal tuberculosis. In the United States this disease is the sixth largest among extra pulmonary disease, while other researchers found that only 5-20% of patients with peritoneal tuberculosis who have active pulmonary TB. At this time it was reported that cases of peritoneal tuberculosis in developed countries is increasing and this increase is in accordance with the increasing incidence of AIDS in developed countries. 1
She Asia and Africa where tuberculosis is still prevalent, peritoneal tuberculosis is still an important issue. Manohar et al reported on King Edward III Hospital Durban South Africa found 145 cases of peritoneal tuberculosis over a period of 5 years (1984-1988) while peritonoskopi way. Daldiono find as many as 15 cases at Cipto Mangunkusumo Hospital in Jakarta during the period 1968-1972 and Solomon in the same hospital period 1975-1979 found a total of 30 cases of peritoneal tuberculosis was also Sibuea et al reported there were 11 cases of peritoneal tuberculosis in hospital for a period Tjikini Jakarta 1975 to 1977. Whereas in Medan Zain LH reported there were 8 cases during the period 1993-1995.

C. Pathogenesis
Peritoneal tuberculosis can be subjected by a number of ways:
A. Through haematogenous spread mainly from lung
2. Through the intestinal wall of infected
3. From mesenteric lymph nodes
4. Through the fallopian tubes are infected
In most cases of peritoneal tuberculosis occurs not as a result of the spread perkontinuitatum but often due to reactivation of latent processes that occur in the peritoneum obtained through previous haematogenous spread of the primary process (latent infection "Dorman infection"). As is known to have tuberculosis lesion suppression and healing. Still in the latent phase of infection where it can persist throughout life, but latent infection can develop into tuberculosis had at any time. If the organ was started bermutiplikasi intrasseluler quickly.

DIAGNOSIS,MANAGEMENT OF LEPROSY DISEASE AND SURGICAL RECONSTRUCTION / diagnosa dan penataksanaan kusta serta rekontruksi bedah


On the day of leprosy worldwide was falling on January 25, Indonesia was in the position of the 3rd world for new leprosy cases. The position of the two major populated by India and Brazil. The public stigma of leprosy is still not good where leprosy is a curse or karma disease. Leprosy recorded in Indonesia in 2010 showed as many as 17 200 new cases of leprosy and of that number as many as 1882 or about 10% in the second level of disability or handicap that is not visible, whereas in India the same year there were 126 600 new cases of leprosy sufferers, while Brazil there are 34 849 the new lepers. It is worried thing is as much as 1904 cases of leprosy in Indonesia suffered by children. This indicates that the transmission of leprosy still exists in society and the discovery of new cases there was delay. Ironic. The leaders scramble position and seat, while the people still continue to pick up from the development of leprosy.Here will be presented regarding the disease and how to handle and reconstruct the defect that caused the disease in the surgical field.


2.1. Definition of Leprosy. Leprosy is a chronic disease caused by the bacterium Mycobacterium leprae in the skin and peripheral nerves. Clinical manifestations of the disease varies greatly with the spectrum in between the two clinical forms of the lepromatous and tuberculoid. In patients with lepromatous leprosy attacks the type of upper respiratory tract and skin disorders-shaped nodules, papules, macules and in large quantities. In patients with tuberculoid type of leprosy skin lesions are usually single and rarely, the limit firmly lesions.

2.1.1. History of Disease Eradication Leprosy
According to the history of the eradication of leprosy in the world we can share in the three days are:
A. AncientLeprosy is known nearly 2000 years BC. It can be known from historical relics such as in Egypt, 1400 BC in India, the term leprosy was known in the Vedas, in China 600 BC, 400 BC in Mesopotamia.In the ancient times it has happened spontaneously exile people feel inferior and ashamed, as well as the public away from people because they feel disgusted and afraid.
2. Middle AgesAfter about the 13th century with the constitutional order and the prevailing feudal system in Europe resulted in the community is very obedient and fearful of the authorities and human rights do not receive attention. Similarly happened in the lepers who is usually a commoner. At that time the cause of diseases and drugs have not been found then the patient is more stringent and enforced exile living in Leprosaria / leper colony settlement for a lifetime.
3. Modern AgeWith leprosy germs ditemukannnya Amaeur by Gerhard Hansen in 1873, then begin a new era for the development of anti-leprosy drug seeking and mitigation efforts.Similarly in Indonesia dr. Sitanala has pioneered the treatment system changes that had been done in isolation, is gradually carried out by treatment of the road. Development of subsequent treatment were as follows:a. In 1951 used diamino Diphenyl sulfone (DDS) as a treatment for leprosy patients.b. In 1969 the eradication of leprosy began to be integrated in the clinic. c. Since 1982 Indonesia began using the drug combination of Multidrug Therapy (MDT) as recommended by WHO.

Thursday, 23 February 2012

Hydrocele and hernia at a Glance (etiology,sign, symptoms,diagnosis and management)

Generally hernia is a protussion the content of the cavity through  defect or the weakness of the cavity wall in question. On abdominal hernia, abdomenal content protunding  through a defect or weakness of the musculo-aponeurotik layer of the abdominal wall. Based on the occurance, congenital hernia or hernia are divided into congenital and acquired hernia. Hernia are named according to its location, eg diaphragm, inguinal, umbilical and femoral

By their very nature, can be called a hernia hernia when the hernia contents can reponibel jeluar entry. Out when standing or straining, and came back when sleeping or pushed into the stomach. When the contents of the bag can not be repositioned back into the abdominal cavity, called a hernia hernia ireponibel. This is usually caused by adhesions in the peritoneal pouch bag hernia. This is called a hernia hernia accreta. There is no pain or signs of intestinal obstruction.

Inkarserata called hernia or hernia strangulate when it squashed by the hernia ring so that the bag can not be caught and returned to the abdominal cavity. As a result, frequent passage or vascular disorders. Inkarserata hernia clinically more intended for hernia ireponibel with passage disturbance, whereas vascular disorder known as Strangulated hernia.
External hernia is an abnormal protrusion of intra-abdominal organs through the abdominal wall defect in the fascia. Hernia which often happens is inguinal, femoral, umbilical, and paraumbilikal.

Inguinal hernia is the protrusion viscus (organ) from the peritoneal cavity into the inguinal canal.

All hernia occurs through slit weak or potential weakness in the abdominal wall that is triggered by an increase in intra-abdominal pressure that repeated or continuous.

Seventy-five percent of all abdominal hernias occur in the inguinal (groin). Others may occur in the umbilicus (navel) or other abdominal area. Inguinal hernias are divided into two, namely the medial inguinal hernia and inguinal hernia lateralis. If the bag reaches the lateral inguinal hernia scrotum (testicles), called a hernia hernia skrotalis. Lateral inguinal hernia occurs more frequently than the medial inguinal hernia with a ratio of 2:1, and among men it was 7-fold more frequently affected than women. The more we age, the greater the possibility of a hernia. This is influenced by the strength of abdominal muscles that have been weakening.

Hernias that arise in the crease and the inguinal hernia abdominokrural is arising below the fold is a femoral hernia. Inguinal canal is an oblique line passing through the lower anterior abdominal wall. This channel allows the structures to pass to and from the testis to the abdomen in the male. In women, the channel is crossed by ligaments rotundum uteri, magi from the uterus to the labium. In addition, the channel is bypassed Ilioinguinalis nerve in both sexes.
            The length of the inguinal canal in adults is approximately 4 cm, formed from the profundus inguinal annulus / annulus inguinali internal to the superficial / external. Inguinal canal is located parallel to and just above the inguinal ligament. In neonates, the internal inguinal annulus is located almost directly posterior to the external inguinal annulus so that the inguinal canal is very short at this age. Then, the internal annulus moves toward the lateral growth effect.
            Internal inguinal annulus is an oval hole in the fascia transversalis, located about 3 cm above the inguinal ligament, midway between the Messiah and symphisis pubis.Medial to the internal annulus there is av. inferior epigastric. Edge of the annulus is the origin of the internal spermatica fascia in the male or the inner wrapper rotundum uteri rotundum ligaments in women.
            Externa is an annular shaped defect in the inguinal triangle (Hesselbach's triangle) on the aponeurosis. Obliquus externus abdominis and essentially formed by the crista pubica. Edge of the annulus is the origin of the fascia spermatica externa. Lateral boundary is the inferior epigastric artery, the medial border of the m. rectus abdominis lateral part, and the inferior border of the inguinal ligament.
            Inguinal canal is formed on the wall of the anterior, posterior, superior, and inferior.Anterior wall formed by the aponeurosis m. Obliquus externus abdominis is amplified at 1/3 by the lateral fibers of m. Obliquus internus abdominis. The entire length of the posterior wall of the inguinal canal is formed by the fascia transversalis tendon reinforced cojoint in 1/3 medial. Cojoint tendon is the tendon insertion combined m. Obliquus internus abdominis and m. transversus abdominis is attached to the crista pubica and linea pectinea. Basic or inferior wall of the inguinal canal is formed by the inguinal ligament, while the roof is formed by m. Obliquus abdominis internus abdominis and m.transversus.

Figure 1. Hesselbach's triangle
Inguinal hernias can be directly (direct) and can also indirectly (indirect). Indirect inguinal hernia bag of walking through the deep inguinal ring, lateral to the inferior epigastric vessels, and finally towards the scrotum. Pockets of directors inguinal hernia protruding directly through the base of the inguinal canal, medial to the inferior epigastric vessels, and rarely go down towards the scrotum. Femoral hernia is almost always seen as a mass irredusibel, although pockets more kososng, because fat dam of femoral canal lymph nodes around the bag. Single, enlarged lymph nodes can mimic femoral hernia very quickly.
Indirect hernia bag is actually a process vaginalis persistently dilated. Hernia was walking through the deep inguinal ring and follow the sheath into the scrotum. At the deep ring, bag filling anterolateral side of the cord. Properitoneal fat pockets often associated with indirect and is known as a lipoma of the cord, although the fat is not a tumor.
Retroperitoneal organs such as the sigmoid colon, cecum and ureter can be slipped into a pocket indirect. In the bag, these organs become part of the pouch wall and are susceptible to injury during repair.
Inguinal hernia pouch directors come from the bottom of the inguinal canal, the Hesselbach triangle; protruding hernia bag directly and does not contain obliqus externus muscle aponeurosis. Only in rare circumstances, the hernia is so intense that it pushes out through the annulus superficial and descend into the scrotum. The bladder is often a component of the bag is empty hernia director.
Bags from the femoral hernia femoral canal through a defect on the medial side of the femoral sheath (femoral sheath). Femoral canal contains one or two lymph nodes, which are scattered called Cloquet. Lymph-nodes are pushed out of the femoral canal by a protrusion of peritoneal and often form a palpable mass.

Phylloid Tumor (Mamae) / Cystosarcoma phylloides Mamae ( etiology,sign, symptoms,diagnosis and management)

                                                                     CHAPTER I

It is a benign neoplasm that is locally infiltrate and possibly malignant (10-15%). Used to be called Cystosarcoma phyllodes are benign tumors that occur almost exclusively on women's breasts. Its name comes from the Greek word sarcoma, which means the fleshy tumor, and phyllo, meaning leaf. So called because the tumors display characteristics of a large, malignant sarcomas, such as display-leaves when cut, and the epithelium, cyst-like space when viewed histologically. Because most of the tumor was benign tumor is also called filoides.
Although metastatic tumors are not benign, but they have a tendency to grow locally aggressive and recurrent. Similar to sarcoma, malignant tumor hematogenous metastasis. Filoides tumor pathological picture is not always predict the clinical behavior of neoplasms, hence in some cases there is uncertainty about the classification level of the lesion.
The characteristics of malignant tumor filoides are as follows:
· Recurrent malignant tumors are more aggressive look than the original tumor.
· Pulmonary metastasis is the place most frequently, followed by bone, heart, and liver.
· The symptoms for metastatic involvement can occur immediately, until a few months and no later than 12 years after initial therapy.
· Most patients with metastases died within 3 years of initial therapy.
· There is no treatment for systemic metastases occurred.
· Roughly 30% of patients with malignant tumors filoides died of the disease.

            Filoides tumor etiology is not known, it is estimated associated with fibroadenoma in some cases, because patients may possibly have a second histological lesions in the same tumor. However, if the tumor develops filoides of developing fibroadenoma or both together, or whether the tumor can arise de novo filoides, is still unclear
This tumor has a smooth texture, sharply bounded and usually move freely. This tumor is relatively large tumor, with an average size of 5 cm. However, lesions> 30 cm have been reported.
Haagensen reported roughly one for every 40 filodes tumor fibroadenoma. Distribution of age according to Haagensen majority occur between the ages of 35 and 55 years.Bilateral tumors are very rare and rarely also occur in patients under age 20, first appeared benign react.
Mammography and ultrasound examination (Figure II.03) are generally important in the diagnosis of breast lesions, but they are notoriously unreliable in differentiating benign tumor from filoides malignant form of the condition or of fibroadenoma. Thus, the findings on imaging studies is not a definite diagnosis. Open excision biopsy of breast lesions smaller or incisional biopsy for larger lesions is a surefire method for diagnosing tumor filoides.

 image 03. Mammography image of the tumor filoides

Tuesday, 21 February 2012


(Library research)


Dr.Herry Setya Yudha Utama, SpB, MHKes, FInaCS




         The hospital is an organization that is very different and very unique compared to other institutions. Hospital organization is very complicated, because the set of all policies and activities which consist of different work units in the role, duties and responsibilities, but shall cooperate in conducting comprehensive health care in hospitals [1] . Doctors and hospitals play a role as provider of healthcare services, while patients act as recipients of healthcare services. Implementation of the relationship between doctors, patients and hospitals are always governed by certain rules to implement the harmony in the relationship occurred. These rules are set forth in rules established in a special hospital for the benefit of the hospital in question [2] .
The physician and patient, physician and hospital relationships and relationships with hospital patients, visits from his legal relationship is mutually agreed to bind themselves in carrying out the treatment which is known as the engagement (Verbentenis). Engagement generally used as the legal relationship on the engagement effort ( inspanning verbentenis ) which is an attempt to achieve optimum health care for the patients treated, not a result of the engagement ( resultaat verbentenis ).
To protect patients and the public in need of treatment and to avoid violations, negligence of duty of care by doctors and hospitals.
Hospitals should have rules to protect patients from that hospital practices are not feasible to operate, to protect health workers from the dangers posed by the hospital, to protect the public from the impact of the hospital environment, controlling the functions of the hospital in the right direction, improving the quality of hospital , harmonize services at the hospital with government programs in health and other - other.
Regulations hospitals must meet various criteria, among others, can answer all the challenges that arise in the practice of medicine in the era of globalization, can answer all the challenges that arise in the management of hospitals, forms a well-integrated setting, monitoring and built it clear shape and to optimize performance in empowering potential of the profession as well as related institutions [3] . 
Therefore, home-sick is the existence of a guideline as regulations to carry out the internal rules berlaku.di hospitals there are three functional units like the so-called three pillars representing the owner or owners, directors and medical staff, it must exist is set properly so that hospitals can have good governance between Corporate Governance and Clinical Governance [4] , the government issued a regulation of the Minister of Health 772/Menkes/SK/VI/2002 number of Hospital Internal Regulation Code (Statute of the House-Pain or the Hospital bylaws ). Also Minister of Health of the Republic of Indonesia Number 631/MENKES/SK/IV/2005 on Guidelines for Internal Regulations Medical Staff (Medical Staff bylaws ) in the hospital [5] .

         A decade back, confusion and sense of understanding of the term hospital bylaws in Indonesia is still much beloved, so let alone have all the hospitals in Indonesia have had a hospital bylaws, which really just do not understand much. At the hospital bylaws are very important in the life cycle weakly layperson.
            Now the layperson, sickly man had enough to understand the terminology hospital bylaws so they no longer understood as ambiguous as all forms of internal regulations that exist in or are made ​​by the hospital, but was limited to the basic rules or statutes alone.Therefore, the terminology of hospital bylaws need to be distinguished by the term rule and regulation in many ways, among others in terms of matter (substance) and body (authority) who has the authority to authenticate it.

If material hospital bylaws still contains principles that are common (general principles) then the rule and regulation has begun to load things that are more specific to the needs of the implementation of the general principles contained in the hospital bylaws .When the hospital bylaws must be approved by the g overning board [6] or an equivalent body (as the highest authority representing the owner) then the rules and regulations aresufficient by the executive (ie the hospital component which is responsible for daily management). Like the hospital bylaws that a law is the rule and regulation is an implementing regulation to the law (which is abstract, general and passive) become more operational in order to complete various tasks and real problems in the hospital.
Concretely, when in the hospital bylaws written provision which authorizes the executive to establish the right hospital clinic (clinical privileges) [7] to every member of staff who joined the clinic in the hospital coupled with other rules and code of ethics to fit a standard [ 8] , the provisions in the basic rule was to be followed up by the executive to make rules and regulations about the procedure of granting it to be used as operational guidelines. And of course, rule and regulation pertaining to the clinic staff must not conflict with the provisions of the hospital bylaws to remember the rules is the latter that will be won when there is conflict between the parties concerned.
In addition the material must not be contradictory, making management of rule and regulation itself must also not violate the existing guidelines for the manufacture of thehospital bylaws . Therefore, in the hospital bylaws should also be noted that the articles contain general principles that must be complied with by the executive in making rules and regulations; example of anyone who may submit a draft (draft) and who is authorized to authenticate it, when to take effect , for how long each is reviewed and revised as well as anyone who may propose amendments.
The question now is, how to formulate bylaws hospital is good and right so that the basic statutes or regulations from the point of formal juridical- effective? Of course, makinghospital bylaws not as easy as we want, a lot of "wound twists" it. [9]
            Health services in hospitals continue growing with the increasing variety of medical specialties. This is when it is not set correctly will lead to a sharp intersection between the owners, management, medical staff, other health professionals and patients that can degrade the image of health care in the hospital.
            Internal regulations of the medical staff, and other internal regulations in the hospital should be made ​​to avoid the problems that will arise from all aspects of the functional unit of the good relationship with the directors, the medical staff, other health professionals and patients, of course, must refer to the parent legislation the Hospital bylaws. In Indonesia developed a variety of hospitals with different ownership status. Broadly speaking hospitals in Indonesia can be divided by 2 is a hospital run by the Government and the hospital staff and are operated by private parties.  Of course there are differences between the Hospital bylaws in government hospitals [10] with private hospitals, not of the material in legeartis but the difference of the substance that is because:
A. Factors and hospital ownership status of the Agency statute.
2. Model Governing Board or the Governing Body [11] or the Board of supervisors / Trustees.
3. Vision and mission.
4. Differences in organizational structure and Corporate Culturnya.
5. Committee of Medical Model organization formed, role, duties and authority.
6. Employment Status of Medical staff (doctors).                                                  
7. House-type illness

A. Is there a difference between hospital Bylaws in government hospitals to private hospitals?
2. What are the factors causing the difference between the hospital Bylaws in government hospitals to private hospitals?
3. Why the difference between the hospital Bylaws in government hospitals to private hospitals?

To get an idea Hospital bylaws are good and right so as to be a reference to hospital-similar hospitals so as to improve the quality of layperson weakly in Indonesia.



[1] . White, The Hospital Medical Staff, Delmar Publishers,Albany New York, 1997.

[2] Sofwan Dahlan, " Health Law, beacons for the Profession Doctor ", ed. 3, the Agency Publisher Dipenogoro University, Semarang, 2005.

[3] C. Vincent et All, Medical Accidents,Oxford University Press,London, 1993.
[4] Samsi Jacobalis, Model Formulation Hospital Bylaws for the RS in Indonesia, Workshop on Hospital Bylaws I, PERSI cab. Central Java,Semarang , March 2002.
[5] See Regulation of the Minister of Health 772/Menkes/SK/VI/2002 number of Hospital Internal Regulation Code (Statute of the Home-Hospital or Hospital bylaws ). Also Minister of Health of the Republic of Indonesia Number 631/MENKES/SK/IV/2005 on Guidelines for Internal Regulations Medical Staff ( Medical Staff bylaws ) in the hospital.
[6] Cyril O. Houle, Governing Board, Jossey-Bass Publishers,San Francisco, 1997

[6] Herkutanto, workshop Hospital Bylaws II, Directorate General YanMed Ministry of Health, Jakarta, July 2002.

[7] Saint John's Hospital, Bylaws, rules and regulation of the medical staff,Santa Monica, 1985

[8] Yan Apul, Efficacy and Mechanism of the Code Enforcement Doctors and Medical Profession,Seminar on Hospital Management & Health Law Issues, Universitas Pelita Harapan in Siloam Gleneagles Hospital, Karawaci, juli1997
[9] Trisno Karmadji,Experience set Hospitalbylaws in health care ST. Carolus, DG Seminar bylaws Yan Med Hospital, Jakarta, 2001
[10] Aulia Sani, Medical Staff Bylaws in RS Government , Hospital Bylaws Seminar and Workshop II, Directorate General YanMed Ministry of Health,Jakarta, July 2002.

[11] The definition of the board, is an organized group of people with the authority to control and foster Collectively an institution is usually administered by That a qualified executive and staff.