ICS Material Book A5

1
Opening Speech
All praise and gratitude we say to the presence of

Almighty God for all His graces and gifts, so that we can still
work in the Faculty of Medicine Udayana University until now.
The International College of Surgeons Meeting 2022
will be held in a hybrid seminar conference with the theme Rising
Together For Better Surgical Services in New Era, this will be
attended by general surgeons, other specialists, general surgery
residents, general practitioners from around the world to share
their expertise and knowledge in the latest updates in the field of
surgery and surgical health services around the world.
In this regard, I would like to express my appreciation
and gratitude to the committee for compiling this Material Book
well. I hope this book can be our commitment to be able to work
together in advancing Medical Education at Udayana University.
Hopefully this joint effort will always receive protection and
blessing from Almighty God.
Astungkara.
Best regards,
Prof. Sri Maliawan, MD, PhD, FICS

Neurosurgeon.
Chairman of Committee
2
Opening Speech
Prof Paul L Tahalele
President of ICS Indonesia Section
Bali, 13-14 August 2022
Good Morning Ladies and Gentlemen,

For those who does not know me yet, my name is Prof
Paul Tahalele, MD, PhD, FICS. Currently, I am associated with
International College of Surgeons from Indonesia Section. I am
also a President of Indonesian Association of Cardiothoracic and
Vascular Surgeons, as well as a Dean in Faculty of Medicine
Widya Mandala Surabaya Catholic University.
First of all, thank you to each and every one of you for
being here with us today. We are very pleased to be able to
welcome those of you that have been with us for a long time now
as well as those who are new to the International College of
Surgeons.
Before we get started, I would like to express my sincere
appreciation to all of you who generously helped us make this
event come together to become a success. I also would like to
thank you the honourable guest today, World President of ICS
Global, Prof Aij-Lie Kwan, MD, PhD. Thank you also to the
Clement Chen, MD, PhD, FICS, a Corporate Secretary from the
Global International College of Surgeons. Thank you to
Federation Associate Secretary Dr. Roberto C. Vasquez. From
the USA, Executive Director of ICS Global – Mr. Max
Downham. I also feel very grateful for my friends to be here, Prof
Sri Maliawan MD, PhD, FICS, currently a Chairman of
Committee ICS Pacific Federation Conference, also I Komang
Januartha, MD, PhD, a Dean of Faculty of Medicine Udayana
University Bali. Also many important people attending this event
today, I would like to say thank you as well, although I cannot
mention the names one by one.
3
Today marks our Pacific Federation Meeting, and
International College of Surgeons and Indonesia Section are in
conjunction with Faculty of Medicine Udayana University. We
are proud to be able to host it today here at this wonderful place
with all of you. Our theme in this meeting is Rising Together for
Better Surgical Services in New Era.
In today’s gathering, I would like to focus on reporting
many cases from COVID-19, especially how it happens in
Indonesia. The government of Indonesia, by its Health Ministry
applied many efforts to prevent the spread of COVID-19. In the
following presentation, I also would like to show statistics of
daily new cases, daily mortality, and vaccination report.
As the health organization in Indonesia, ICS mobilized
more than 100 volunteer qualified as surgeons to our
humanitarian activities around Indonesia. In August 2021, ICS
Indonesia Section also received donations from ICS Taiwan
Section, to facilitate Surabaya city hospital in combating
COVID-19. In the same year, ICS Indonesia Section also giving
donation to the Surabaya’s Mayor. With these donations, ICS
Indonesia Section seek to continue humanitarian actions, by
current goal is to stop the spread of COVID-19.
Please enjoy today’s events, although this meeting filled
much with health-related cases, I do expect some of the input to
improve humanitarian actions we do along the way. Thank you.
4
Foreword
May we thank God for the making of this ICS Bali

Meeting 2022 Material Book. This is possible, thankfully
because of the support from Professors, Doctors, teachers, our
fellows, and other promoters.
This book was written for The International College of
Surgeons Pacific Federation Meeting in Conjunction with
Faculty of Medicine Udayana University and ICS Indonesia
Section with the theme “Rising Together for Better Surgical
Services in The New Era” as the compilation of the presentations
that the speakers give in the seminar.
The COVID-19 pandemic may dramatically change how
people view our healthcare system and how the healthcare givers
change their system to give services to patients. Modern
technology advances in information technology should be an
advantage that we have to use to benefit our patient's health. Not
only in the healthcare service system but also in how we share
our knowledge in different countries without borders. Thankfully
it’s happens because of the pandemic and modern information
technologies.
We are thankful for the participants' enthusiasm and look
forward to support from the participants so that this book may
become a resource for updates in surgery. We also hope this book
may improve our skills in this new era of healthcare services.
Sincerely,
The committee of ICS Bali Meeting 2022
5
The Committee
Director : Komang Januartha Putra Pinatih, MD, PhD

Person In Charge : I Made Mulyawan, MD, PhD
Protector : I Made Darmajaya, MD
Chairman : Prof. Sri Maliawan, MD, PhD, FICS
Vice Chairman : Gede Eka Rusdi Antara, MD
Secretary : Putu Astri Novianti, MD
Treasurer : Made Agus Dwianthara Sueta, MD
Steering Committee
I Gede Hendra Wijaya, MD
Ivor Wiguna Hartanto Wilopo, MD
Giovani Fatrio Odo, MD
Putu Chandra Wibawa, MD
Secretary and Treasurer

Jessica Benedick, MD
Event Division
I Putu Ari Gunawan, MD
Desak Ketut Nari Swari Pramegia, MD
Elika Larasati, MD
Oki Prima Gotama, MD
Ida Ayu Dwi Oka Putri, MD
Gde Ary Putra Kamajaya , MD
I Gede Aditya, MD
Febria Valentine Aritonang, MD
Aditya Permana Adriyanto, MD
Stephen William Soeseno, MD
6
Publication and Documentation Division
Hendry Irawan, MD
Bismantara Aditya Putra, MD
I Putu Mana Nitia, MD
Ida Bagus Putra Ambara, MD
Komang Abdi Baskara Mayun, MD
Pande Ayu Kirana Dewi, MD
Nyoman Pramudita, MD
Tomy Anditia Tarigan T, MD
Licensing and Spiritual Division

I Ketut Sudartana, MD, PhD
Hartanto, MD
Maria Melita Lake, MD
I Dewa Gede Agung Purwakatamayasa, MD
Gede Adi Reza Andika, MD
I Wayan Satwika Adhikara, MD
Accessories and Consumption Division

I Made Mahayasa, MD
Oki Prima Gotama, MD
I Komang Botha Wikrama, MD
Thomas Sentanu, MD
Krishna Murprayana, MD
Salomo Mahaputra Messakh, MD
I Made Anggita Chandra, MD
I Putu Ardinata, MD
Scientific Division
I Wayan Niryana, MD, PhD
Andy Michael, MD
Made Ayu Laksmi Ratmayanti, MD
I Nyoman Karya Kariayasa, MD
7
Felicia Adelina Shannen, MD
Gede Nyoman Jaya Nuraga, MD
Stephen Utama Candinegara, MD
Transportation Division
I Komang Weka, MD
Ida Bagus Wisnu Parbawa Kusuma, MD
Made Agus Praktyasa, MD
I Wayan Mahendra, MD
I Made Oka Wahyantara, MD
A A Kade Ari Sanjaya, MD
Dadek Biakta Pradnyana, MD
Zadrak Christian Wariaka, MD
8
List of Contents
Opening Speech ........................................................................ 2
Opening Speech ........................................................................ 3
Foreword ................................................................................... 5
The Committee .......................................................................... 6
List of Contents ......................................................................... 9
List of Figures ......................................................................... 15
List of Tables .......................................................................... 19
CHAPTER 1: MANUSCRIPT FROM SPEAKER ................. 20
Gut Microbiota and Gastrointestinal Tract Surgery ................. 21

Fransiscus Arifin, MD; Kuntaman, MD
The Ethical Concern in Surgery .............................................. 34

Peter Johannes Manoppo, MD, FICS
Bariatric Strategies Post COVID-19 Pandemic ....................... 39

Gede Eka Rusdi Antara, MD
Overview Management Of Cerebrovascular Accidents In Bali41

Robotic And Minimally Invasive Cardiac Surgery ................. 52

I Komang Adhi Parama Harta, MD
Head and Neck Infection, The Sequalae and Its Reconstruction

................................................................................................ 60
I Nyoman Putu Riasa, MD, PhD, FICS
Horse-Shoe Flap Reconstruction Technique in Breast Surgery:

From The Smallest Defect to The Biggest—A Case Series..... 69
9
Ida Bagus Made Suryawisesa, MD, PhD; I Nyoman Wawan
Tirtha Yasa, MD; Prof. Ida Bagus Tjakra Manuaba,MD, PhD;
Kelvin Setiawan, MD
Endoscopic Third Ventriculostomy For Pediatric Obstructive
Hydrocephalus, 20 Years Experiences .................................... 87
Prof. Sri Maliawan, MD, PhD, FICS; Dewa Putu Wisnu
Wardhana, MD
The Challenges of Performing Surgeries During The New

Normal Era ............................................................................ 101
Ida Bagus Putra Pramana, MD
Ksatria Airlangga Hospitalship,Voyage The Ocean To Save The

Forgotten ............................................................................... 111
Agus Harianto, MD.
Add-On Benefits Through The Collaboration Among

Federations ............................................................................ 116
Prof. Aij-Lie Kwan, MD, PhD, FICS
Ageing Population In World And Singapore – New Directions

In Surgery? ............................................................................ 118
Clement K. Chan, MD, PhD, FICS; Chwee Eng Tan,MD
Humanitarian Medical Care 2022 ......................................... 120

Izabela Chudzicka-Strugala, MD, PhD, MBA
Role Of ICS Indonesia Section In The Post COVID-19 Era: An

Opportunity And Solutions For Achieving Health, Welfare,
And Economic Development To Build Back Better .............. 122
Prof. Paul L. Tahalele, MD, PhD, FICS; Fransiscus Arifin, MD
10
Functional Endoscopic Sinus Surgery In Patients With Chronic
Rhinosinusitis ........................................................................ 132
Sari Wulan Dwi Sutanegara, MD, PhD, FICS
Cisternostomy, An Emerging Surgical Technique For

Traumatic Brain Injury: An Experience Of Two Cases ......... 141
Nyoman Golden, MD, PhD
Neuroendoscopic Surgery For Hemorrhagic Stroke .............. 148

Dewa Putu Wisnu Wardhana, Made Bhuwana Putra, Dede
Frisky Wianjana, Rohadi Muhammad Rosyidi
Acupuncture Role in ICS Humanitarian Health Services and

Treatment of Post-Surgery Pain and Residual Complication . 160
Choo Aun Neoh, MD, PhD, FICS
CHAPTER 2: ABSTRACTS FROM PARTICIPANTS ........ 163
Burn Patients in Regional Public Hospital: Profile and

Treatments Options in Regional Public Hospital Dr. Djasamen
Saragih, Pematang Siantar From Period 2017-2019 .............. 164
Case Report: A 55th Year Old Man With Long Total Occlusion
Of Left Axillary Artery Due Chronic Use Of Crutch At The
Left Armpit ........................................................................... 166
Perforator Flap For Giant Keloid On The Deltoid Region: A

Case Report ........................................................................... 168
Management of Accidental Foreign Body (Headscarf Pin)

Aspiration at The Brochial Segment: A Case Report ............ 170
11
Surgical Reconstructive Procedure For Diabetic Patient With
Grade IV Pressure Ulcer at Peripheral Hospital: Case Series 172
Characteristics of Elderly Medical Problems of Social Services

Program in Celuk Village, Bali ............................................. 174
Pancreatolithiasis: A Case Report ......................................... 176
Lobectomy In A 3 Weeks Neonate With Congenital Cystic

Adenomatoid Malformation (Ccam): A Rare Case ............... 181
Manougian Aortic Root Enlargement Procedure: Surabaya’s

First Experience And Success On Short-Term Follow Up .... 183
Cancer Clinicopathologic Characteristics Patient in Udayana

University Hospital ............................................................... 188
A Bayesian Network Meta-Analysis in Comparing Biliary Stent

Types’ Outcome and Complications in Unresectable Malignant
Biliary Obstructions .............................................................. 190
Case Report: Open Amputation And Negative Pressure Wound

Treatment In Severe Necrotizing Fasciitis, Life Or Limb
Saving?.................................................................................. 192
Successful Surgical Management Of Gunshot Wound To The

Right Chest Causing Traumatic Hematothorax, Lung
Parenchymal Laceration And Bullet Trapped Between The
Superior Vena Cava And Right Pulmonary Artery : Case Report
.............................................................................................. 194
Simultaneous Surgery of Pectus Excavatum and Tetralogy of

Fallot: A Case Report ............................................................ 196
12
Geriatric’s Vision Disturbance In Social Services Program At
Celuk Village, Bali ................................................................ 198
Primary Breast Lymphoma: A Case Report .......................... 200
Laparoscopic Cholecystectomy During The COVID-19

Pandemic In A Tertiary Care Hospital In Germany .............. 201
Recurrent Abdominal Liposarcoma infiltration to Gallbladder:

A Case Report ....................................................................... 203
Endoscopic Surgery Considerations During Covid-19 .......... 205
Ovarian Serous Cystadenoma Finding During Laparoscopy

Surgery .................................................................................. 208
D-Dimer Coagulation Activation On Septicaemia ................ 210
Ultra Low Anterior Resection Laparoscopy Post Chemotherapy

.............................................................................................. 213
Virtual Reality-Based Rehabilitation For Spinal Cord Injury: A

Systematic Review ................................................................ 216
Vertex Epidural Hematoma : Operative Considerations ........ 218
Severe Translational Atlantoaxial Dislocation With Type Iii

Odontoid Fracture Stabilization Management: A Case Report
.............................................................................................. 220
Spontaneous Resolution Of Traumatic Acute Subdural

Hematoma: A Case Report ................................................... 222
13
Needlefish Bite Wound To The Left Pelvic Region; A Case
Report ................................................................................... 223
Giant Primary Adult Retroperitoneal Teratoma: A Case Report

.............................................................................................. 225
Gastric Sleeve Twisting Post Laparoscopy Gastric Sleeve: A

Case Report ........................................................................... 227
Safe Endoscopy In Pandemic Covid 19 : Literature Review . 230
Ventricular Septal Rupture As A Result Of Acute Myocardial

Infarction : A Case Report..................................................... 232
Repair Ventricular Septal Defect (Vsd) With Infective

Endocarditis Post Pulmonary Artery Banding Using Monocusp
Implantation In Pediatric Patient: A Case Report .................. 234
Subaortic Stenosis With Ventricle Septal Defect : A Case

Report ................................................................................... 236
Cholangiocarcinoma : The Latest Advances In CCA ............ 238
Management of Esophagogastric Junction Adenocarcinoma: A

Case Report ........................................................................... 240
Nutritional Management In Patients With Gastric Cancer After

Gastrectomy Surgery: A Case Report ................................... 242
Infantile Hemangioma of The Unilateral Breast .................... 245

Bardach Two Flap Palatoplasty In Submucous Cleft Palate
Patient: A Case Report .......................................................... 247
14
List of Figures
Figure 1 Timeline of Surgical technologies development ....... 52
Figure 2 The Evolution of five generation of surgical robotics 53
Figure 3 Development in Cardiac Surgery Technologies ........ 54
Figure 4 Advancement in Cardiac Surgeries ........................... 54
Figure 5 Meta analysis of comparative studies of RCAB versus
C-CABG (on) .......................................................................... 57
Figure 6 COVID-19 impact on robotic surgery technology .... 58
Figure 7 Anatomy of the head and neck,3 and diagram of
masseteric space consist of proper submasseteric space,
temporal space and pterygoid space. ....................................... 62
Figure 8 Sub-masseteric abscess affecting female, 53 years old
after dental procedure with discoloration of the neck (right). On
CT-scan the masseteric space become enlarged (middle right)
and the pus collecting to the submandibular space (middle-left
and upper-left). The molar tooth was the source of infection
(lower-left) .............................................................................. 62
Figure 9 Anatomy of head and neck,3 and the location of
abscess in relation to the anatomy: above and below geniohyoid
muscle which connected on the posterior part (green circle) and
the easier access for drainage incision (green arrow). ............. 64
Figure 10 Acute phase of noma affecting a boy, 6 years old with
right mandible destruction. ...................................................... 65
Figure 11 Noma sequelae on the right ginggivo-labialis area
with malposition teeth Design of inner lining using scarred
tissue and composite RFF flap with palmaris longus tendon as
sling for modiolus. .................................................................. 66
Figure 12 Donor and recipient after microvascular anastomosis
(right) and the results 3 years post operation with satisfactory
results. ..................................................................................... 67
Figure 13 The horse-shoe flap’s concept with circular shape
pattern. .................................................................................... 73
15
Figure 14 Surgical steps on performing horse-shoe flap using
outer ........................................................................................ 74
Figure 15A 45-year-old patient with small phyllodes tumor on
her right breast underwent horse-she flap reconstruction using
120-degree angle from the center circle and 2-cm defect radius.
................................................................................................ 75
Figure 16 A 36-year-old patient with a bigger phyllodes tumor
underwent wide excision and reconstruction with horse-shoe
flap, 120 degree angle from the center circle and 4-cm defect
radius....................................................................................... 77
Figure 17 A 55-year-old patient with invasive breast cancer
underwent radical mastectomies with 11-cm diameter of
primary defects, 5.5 cm of adjacent tissue radius was used to
close the defects using a horseshoe flap. ................................. 77
Figure 18 A 52-year-old patient with 21 x 17 cm of the primary
defect after radical mastectomy underwent a horse-shoe flap
using 10 cm of skin outside the defect for closure. .................. 79
Figure 19 A 55-year-old patient with the largest defect in this
study underwent horse-shoe flap using 13-cm adjacent tissue
below the defects. Marginal necrotic skins were found after
surgery, and reexcision of necrotic skin was necessary, followed
by stitching both edges for closure. ......................................... 80
Figure 20 Anatomic variations and steps during ETV
(Maliawan & Wisnu Wardhana, 2017) .................................... 90
.Figure 21 Location of Fenestration ........................................ 92
Figure 22 Anatomical variations Liliequist membrane; normal
and thick. ................................................................................. 93
Figure 23 the Anteroom is located between the Operating Room
Theatre and Corridor ............................................................. 104
Figure 24 The Air Handling Unit/AHU or Heating, Ventilating
and Air Conditioning/HVAC in the operating rooms in
Udayana University General Hospital where the air from the
16
outside through 3 filters and HEPA filters before entering the
operating room. ..................................................................... 105
Figure 25 The Flow Chart and the Design of an Operating
Room in Udayana University General Hospital in the New
Normal Era. There is a Red Zone where people who wear a
level-3 PPE can enter the room, there are two anterooms with a
negative pressure to prevent the spread of Covid-19 infection.
The figure above shows the workflow for handling Covid-19
and non-Covid-19 patients. It can be seen from the figure that
there are two different workflows. ........................................ 106
Figure 26 The Team .............................................................. 112
Figure 27 Archipelago of Indonesia ...................................... 112
Figure 28 Number throughout our journey ............................ 113
Figure 29 RSTKA on the news ............................................. 114
Figure 30 Our Story .............................................................. 115
Figure 31 Foundation Accounts ......................................... 115
Figure 32 ............................................................................... 123
Figure 33 ............................................................................... 123
Figure 34 ............................................................................... 124
Figure 35 ............................................................................... 124
Figure 36 ............................................................................... 124
Figure 37 ............................................................................... 126
Figure 38 ............................................................................... 127
Figure 39 ............................................................................... 127
Figure 40 ............................................................................... 128
Figure 41 ............................................................................... 128
Figure 42 ............................................................................... 129
Figure 43 ............................................................................... 129
Figure 44 ............................................................................... 130
Figure 45 ............................................................................... 130
Figure 46 Paranasal sinus anatomy8 ...................................... 133
Figure 47 Nasal and paranasal sinus anatomy 8 ...................... 133
17
Figure 48 A. Sinus cycle with open ostium, B. Sinus cycle with
closed ostium15 ...................................................................... 135
Figure 49 A: Intraoperative nuances of case 1 showing
exposure of Liliequist membrane; B: Postoperative Non
contrast head CT scan of case 1 on first day after CS. ........... 143
Figure 50 Photograph of case 1 taken 4 months after injury . 144
Figure 51 A: Preoperative head CT scan of case 2; B:
Intraoperative nuances of case 2. The Liliequist membrane had
been sharply dissected. .......................................................... 145
Figure 52 Photograph of case 2 taken 7 months after injury. 145
18
List of Tables
Table 1 Robotic Cardiac Surgical Procedures ......................... 55
Table 2 What the Young Surgeon Should Know? ................... 59
Table 3 Calculations of the ETVSS based on age, etiology and
previous Shunt ........................................................................ 96
Table 4 Complications of ETV Procedure in Sanglah General
Hospital (2005-2016) .............................................................. 96
Table 5 The Interventions that are Classified into Aerosol
Generating Procedure (AGP) ................................................ 108
19
CHAPTER 1
MANUSCRIPT FROM SPEAKER
20
Gut Microbiota and Gastrointestinal Tract
Surgery
Fransiscus Arifin, MD1; Kuntaman, MD2
1. Digestive Surgeon. Ph.D. Program Student of Airlangga University
2. Clinical Microbiologist, Consultant, Professor of Microbiology. Faculty
of Medicine Airlangga University
Introduction
Successful surgery requires knowledge of many aspects
of medicine. These commonly include the mastery of anatomy
and physiology of the human body. However, current knowledge
of medicine shows that a "forgotten organ" is involved closely
with almost all aspects of human metabolism, and therefore
influences the physiology and pathophysiology of the human
body. The "organ" in question is the microbiomes of the human
body. While the role of skin microbiota is well known to be
involved in surgical site infections, the study of gut microbiomes
is less recognized. This is due to the complex and various
numbers of microbiota, and the previous limitation of the ability
culture and grows these microbiotas.
With the advancement of microbiology, we now have the
tools to study microbiotas and their interactions with the human
body. We now recognized that this complex world inside our gut
is playing a very important role in metabolism. Our gut contained
approximately 100 trillion bacteria not including viruses and
fungi1. They have been shown to influence neurological,
metabolic, and digestive tract functions.
On the other hand, surgery is a traumatic intervention.
The more extensive and longer the surgery, the more disruption
occurs on the patient's homeostasis. Digestive surgeons have
long recognized that their procedures may inflict more damage
to the already diseased individuals, therefore we stressed
perioperative preparation to optimized the patients and assist
21
their recovery. On cancer surgery, this had been aptly put by
Blake Cady in his speech which emphasized the importance of
biology and case selection in successful surgery: “Biology is the
king, case selection is the queen, and the technical maneuvers
undertaken are the princes and princesses of the realm.’’
The manipulation and/or resection of gastrointestinal
tract organs certainly brings about changes in normal anatomical
structure and physiology. This change is now recognized to affect
the microbiome in the gut, and in turn, the gut microbiome
change will affect the metabolism. In the short run, immediate or
early surgical complications may occur due to the imbalance and
changes microbiome.
Realizing this, this paper aimed to review the effects of
the gut microbiome on gastrointestinal tract surgery focusing on
their impact on surgical complications and their potential
management.
Surgical Complication in GI Tract Surgery

Definition
As a commonly used term, complications are less
properly defined. Patients may classify all unwanted results of
surgery as "complications", while surgeons limit the scope of
complications to only unpredicted results of the properly done
procedure. One useful definition is proposed by Clavien 2, which
differentiate negative outcomes of procedures to 1)
complications;2) sequelae and;3) failure to cure. Complications
are defined as any deviation from the normal postoperative
course. Sequelae, on the other hand, is the inherent effect of
surgery. "Failure to cure" means that that the original purpose of
surgery had not been achieved. Therefore, complications may be
predicted or unpredicted while always a negative outcome. Some
of the authors then followed up their paper with the classification
of post operative complications in 2004 3. Of note, many others
22
had tried to classify complications (and negative outcomes) for
specific organs or procedures that had been proposed, e.g. in a
gynecological, coronary artery, sinus. urology or cervical spine
surgeries4-9. Gastrointestinal tract surgeons commonly use
Clavien-Dindo classification as a generic complication
classification due to its universal (systemic) approach which does
not require a specific procedure or organ to use.
Based on this classification, a single/same type of
problem (e.g. an anastomosis leak) may be of different grade. If
it does not manifest with systemic dysfunction, such as a low
output enterocutaneous fistula, it may grade 1. But if it requires
relaparotomy, it is classified as grade 3b or even grade 4. A
superficial surgical site infection is classified as grade 1, but
orthostatic pneumonia is classified as grade 2. The classification
allowed for "d" suffix (for "disability) if the patient is discharged
but required to follow up on the complication (e.g. low output
enterocutaneous fistula with no systemic complications managed
as the outpatient case is classified as grade 1d).
Gastrointestinal Tract Surgery Complications

Hemostasis and Bleeding
Hemostasis is determined by vascular integrity,
hemolysis, and blood coagulation factor. We usually consider
intrinsic and extrinsic coagulation pathways to determine
whether the hemostasis is normal or not. Surgeons usually check
for Prothrombin Time for extrinsic pathways defect and
Activated Partial Thromboplastin Time for intrinsic and common
pathways defect before a major operation or on patients with
coagulation disorders. In collaboration with the cardiologist,
some anticoagulants may be stopped several days before the
operation or switched to other types.
Fecal microbiota transplant had been shown to delay the
onset of thrombin generation in metabolic syndrome patients 10.
23
While this finding had not suggested any change in clinical
practice, it shows that microbiota composition, which other
studies showed had reduced diversity on metabolic syndrome
patients, affected coagulation pathways11. The terminal ileum is
the place for the absorption of lipid-soluble vitamins (A, D, E,
and K), while some of the vitamin K is produced by the gut
microbiome. Germ-free mice have low prothrombin levels and
are prone to hemorrhage12. Jackel et al showed that germ-free
mice and toll-like receptor 2 deficient mice had lower plasma
levels of von Willebrand factor, and results in lower thrombus
formation13. So, two possible defects may be postulated for
coagulopathy induced by gut microbiota dysbiosis: the rapid
degradation of factor VIII due to lack of von Willebrand factor,
and inactivation of vitamin K dependent factors of coagulation
(factor II, VII, IX, and X). Both increased the risk of hemorrhage,
especially in major surgeries.14
Postoperative Infections
Postoperative infections can include infections directly
or indirectly related to the procedure performed. Direct infections
usually involve surgical site infections, which will be discussed
later. Indirect infections such as pneumonia is a common
postoperative cause of fever, mainly due to less effective
breathing pattern and immobilization. High/upper abdominal
surgery may increase the likelihood of pulmonary atelectasis and
subsequent pulmonary infection, due to pain on breathing effort
causing short breaths. Patients who underwent major
gastrointestinal surgery also needed intravenous access for fluid
and electrolytes replacements and almost always needed urinary
catheters to monitor the urine production. This instrumentation
may be a source of indirect infections.
Colorectal surgical patients even in laparoscopic
procedures had reduced microbial diversity including
24
Bifidobacteria and Lactobacilli, but increased
Enterobacteriaceae, Pseudomonas, Clostridium, Staphylococcus,
and Candida, common genus found in surgical infections 15-17. It
has been shown that the dysbiosis of gut microbiomes from
diverse patterns to single patterns and then to depleted pattern
correlated with the incidence of bacteriemia, and subsequently to
sepsis18,19. Furthermore, a study on pancreatic surgery showed
that a subgroup of patients with an increase in Akkermansia,
Aeromonas, Enterobacteriaceae, and Bacteroidales and a
decrease in Lachnospiraceae, Prevotella, Faecatitalea, and
Bacteroides had higher CRP, leukocytosis, and prolonged
hospital stay20. These studies showed that changes in gut
microbiota, especially induced by surgical procedure, increase
the probability of infections.
Wound Complications / Surgical Site Infections

Traditionally, the field of surgery develops rapidly
because of the development of anesthesia and aseptic/antiseptic
methods. Before the development of germ theory, the mortality
of surgical procedures is very high, mainly due to sepsis. Current
"simple" surgical infections such as abscesses may become a
source of infection and lead to death. Even a simple surgical
incision can be life-threatening. Due to this historical
development, surgeons are typically wanted to avoid as much
microbial contamination as possible. These lead to the
development of an antiseptic procedure that aimed to eliminate
or reduce as much as microbes as possible. In gastrointestinal
surgery, opening the gut lumen almost always results in
contamination of the surgical field, so several practices develop
to minimize the intraluminal bacteria, such as bowel
cleansing/preparation before surgery, or applying antiseptic
(povidone-iodine) to margins of anastomosis sites.
25
However, mechanical bowel preparation also eliminates
non-pathogenic microbes and induce dysbiosis. Several meta-
analyses showed that mechanical bowel preparation (MBP) only
increases the incidence of surgical site infections, but mechanical
bowel preparation plus oral antibiotics decrease the
incidence21,22. In contrast, a meta-analysis published in The
Lancet showed no benefits of MBP plus oral antibiotics did not
reduce the incidence of SSI for colectomies 23. Some studies
show that applying antiseptic (povidone-iodine) to margins of
anastomosis sites may contribute to less anastomotic leak and
improved healing, possibly due to reduction of mucin degrading
Lachnospiraceae24, but this practice had not been properly
studied, due to possible reduction of microbial diversity which is
also correlated to anastomotic leak.
Post Operative Ileus

A study performed at the Mayo Clinic covering 101
participants who underwent colon or rectal resection showed that
the group with postoperative ileus had a different microbiome
compared to the group that did not, even after accounting for
diversion stoma25. Groups that developed ileus showed increased
abundance of Bacteroides spp., Parabacteroides spp., and
Ruminococcus spp which is associated with inflammation and
carcinogenesis25,26.
Anastomosis Leak
Anastomosis leak is the most fearsome complications in
gastrointestinal surgery. It can lead to dire consequences up to
Clavien Dindo classification stages 4 and 5. Despite modern
surgical practice in creating anastomosis (such as stapling), the
leak rate is more or less the same in recent years. Colonic
anastomosis leak rate varies between 6% to 30% dependent on
many factors such as malnutrition, drugs, diabetes, and
26
radiation27. This section adds the consideration of gut microbiota
in anastomosis leak.
An increasing number of Lachnospiraceae with
Bacteroidaceae and reduction of microbial diversity contributed
to anastomotic leak28, specifically the Ruminococci family 29.
These families represent the mucin degrading groups of bacteria,
which suggested a correlation of mucous optimal wound healing
with the presence of an intact mucous layer.
While a recent multicenter RCT showed that the
anastomotic leakage rate between mechanical bowel preparation
plus oral antibiotics versus no bowel preparation showed that
there is no significant difference between the groups23, rat models
show that inoculation of the anastomotic site with P aeruginosa
and E. faecalis with high collagenases activity have a
significantly higher leakage rate26. Possible mechanism of
anastomotic leakage with microbiota may include: 1) surgical
stress and tissue damage may change local microbiome
population and phenotype; 2) local inflammatory response due to
reduced diversity and selective pressure of pathogenic
microorganisms;3) Enzymatic breakdown of collagen by
collagenases producing strains; and 4) degradation of protective
mucin due to microbial dysbiosis26,28,30.
Specials Considerations in Bariatric Surgery

Bariatric surgery is a part of gastrointestinal surgery
primarily aimed to reduce weight. Recently, it is recognized that
the surgery also improves metabolic disease conditions, such as
diabetes mellitus. It is previously thought that this metabolic
effect is due to weight reduction and increased insulin sensitivity
as a result of weight loss, but currently, we have a better
understanding of the role of the microbiome in this special type
of surgery.
27
The most common procedure performed on bariatric
surgery is sleeve gastrectomy and gastric bypass. In the first
procedure, sleeve gastrectomy reduces the gastric volume
(restrictive procedure), so the patient is less tolerant of a large
volume of food or fluid. It creates less disturbance to the
gastrointestinal tract as food and fluid still followed the
physiological route. The second procedure, gastric bypass,
basically reduced the gastric volume and redirected the gastric
output to the jejunum (restrictive and malabsorptive), bypassing
the duodenum. In this case, the duodenum and proximal jejunum
will not be passed by food boluses. The second procedure had
more metabolic and physiologic effects.
It is shown that after bariatric surgery there are changes
in gut microbiota31,32. We think that there are reciprocal
interactions between weight loss and microbiota changes,
modulated by diet, metabolic changes, and neurohormonal axis.
The bile acid cycle is expected to play an important role as an
intermediary since bile acid metabolism is altered in gastric
bypass, and bile acid modulated the type of microbiota in the
gut33. Bile acid importance in modulating gut microbiome and
gut mucosa is also noted in post cholecystectomies patients,
although the whole mechanisms are not yet clear34-37.
Conclusions
The gut microbiome plays an important role in
gastrointestinal surgery, especially in modulating surgical
complications. It is important to reconsider the current practice
of surgery in the light of findings in the microbiome study, so a
further reduction in complications can be possible.
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Büller HR, Versteeg HH, et al. The intestinal
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12. Rowland I, Gibson G, Heinken A, Scott K, Swann J,
Thiele I, et al. Gut microbiota functions: metabolism of
nutrients and other food components. European journal
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13. Jäckel S, Kiouptsi K, Lillich M, Hendrikx T, Khandagale
A, Kollar B, et al. Gut microbiota regulate hepatic von
Willebrand factor synthesis and arterial thrombus
formation via Toll-like receptor-2. Blood.
2017;130(4):542-53.
14. Formes H, Reinhardt C. The gut microbiota – a
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15. Liu Z, Qin H, Yang Z, Xia Y, Liu W, Yang J, et al.
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probiotic treatment on barrier function and post-
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surgery - a double-blind study. Alimentary
pharmacology & therapeutics. 2011;33(1):50-63.
16. Komatsu S, Sakamoto E, Norimizu S, Shingu Y, Asahara
T, Nomoto K, et al. Efficacy of perioperative synbiotics
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after laparoscopic colorectal surgery: a randomized
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17. Ferrie S, Webster A, Wu B, Tan C, Carey S.
Gastrointestinal surgery and the gut microbiome: a
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18. Stavrou G, Kotzampassi K. Gut microbiome, surgical
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Ulrich A, et al. Gut microbiome patterns correlate with
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22. Toh JWT, Phan K, Hitos K, Pathma-Nathan N, El-
Khoury T, Richardson AJ, et al. Association of
Mechanical Bowel Preparation and Oral Antibiotics
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Klintrup K, Ehrlich A, et al. Mechanical and oral
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2019;394(10201):840-8.
24. Ho KM, Kalgudi S, Corbett J-M, Litton E. Gut
microbiota in surgical and critically ill patients.
Anaesthesia and Intensive Care. 2020;48(3):179-95.
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Krull K, et al. Alterations of the Rectal Microbiome Are
Associated with the Development of Postoperative Ileus
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2016;29(2):138-44.
28. van Praagh JB, de Goffau MC, Bakker IS, van Goor H,
Harmsen HJM, Olinga P, et al. Mucus Microbiome of
Anastomotic Tissue During Surgery Has Predictive
Value for Colorectal Anastomotic Leakage. Annals of
surgery. 2019;269(5):911-6.
29. van Praagh JB, de Goffau MC, Bakker IS, Harmsen HJ,
Olinga P, Havenga K. Intestinal microbiota and
anastomotic leakage of stapled colorectal anastomoses:
a pilot study. Surgical endoscopy. 2016;30(6):2259-65.
30. Guyton K, Alverdy JC. The gut microbiota and
gastrointestinal surgery. Nat Rev Gastroenterol Hepatol.
2017;14(1):43-54.
31. Sanmiguel CP, Jacobs J, Gupta A, Ju T, Stains J,
Coveleskie K, et al. Surgically Induced Changes in Gut
Microbiome and Hedonic Eating as Related to Weight
Loss: Preliminary Findings in Obese Women
Undergoing Bariatric Surgery. Psychosom Med.
2017;79(8):880-7.
32. Kaplan LM. What Bariatric Surgery Can Teach Us
About Endoluminal Treatment of Obesity and Metabolic
Disorders. Gastrointestinal endoscopy clinics of North
America. 2017;27(2):213-31.
33. Albaugh VL, Banan B, Ajouz H, Abumrad NN, Flynn
CR. Bile acids and bariatric surgery. Molecular aspects
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34. Wang W, Wang J, Li J, Yan P, Jin Y, Zhang R, et al.
Cholecystectomy Damages Aging-Associated Intestinal
Microbiota Construction. Frontiers in microbiology.
2018;9:1402.
35. Ohlsson B, Axelson J, Rehfeld JF, Ihse I.
Cholecystectomy in hamster and mouse: Trophic effects
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Microbiota: A Case-Control Study. Journal of clinical
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37. Cortés V, Amigo L, Zanlungo S, Galgani J, Robledo F,
Arrese M, et al. Metabolic effects of cholecystectomy:
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through G-protein coupled bile acid receptor Gpbar1-
dependent mechanisms in mice. PloS one.
2015;10(3):e0118478-e.
33
The Ethical Concern in Surgery
Peter Johannes Manoppo, MD, FICS
General Surgeon, Bioethicist. ICS - Indonesia Section
Abstract
Ethically and clinically appropriate surgery is the destiny
of performing surgeons. Therefore, the surgeon should be
prudent in preparing the patient before the surgery with the good
procedures and mutual communication with the surgical team
and the patient, doing the surgery properly and proceed to
postoperative care securely. All parts of these procedures should
be done on the proper ethical deliberation. Some issues could be
challenging in surgery, like severe cases, multiple trauma,
surgical complications, bad prognosis, scarcity of human
resources or equipment. Those situations would inflict some
ethical concerns, during pre-operative preparation, surgical
intervention and post-operative care, among others: autonomy,
informed-consent, beneficence, non-maleficence, justice,
vulnerability, dignity, confidentiality.
Key-words: ethically and clinically appropriate surgery, ethical

deliberation, pre-operative care, surgical intervention, post-
operative care.
Background
Ethics is multi-disciplinary, inter-disciplinary, trans-
disciplinary, critical & scholarly study on morals, virtues, norms,
and values, as the ground of how to behave in a context. Ethics
in surgery is the ethical deliberation for education, training, care
delivery, and research, in the context of surgery. Ethics judges
the law, but law does not judge ethics. Working in operating
theatre is working in ethical theatre, based on ethical concerns-
dilemmas-tensions. Without ethics, there is no profession.
34
Objectives
• Understanding appropriate ethical deliberation for
surgery.
• Creating ethical problem solutions.
• Protecting care-receiver dignity and promoting care-
giver competency & responsibility.
• Providing ability for casuistry ethical deliberation in
surgical education and training.
• Promoting ethical clearance in surgical research &
avoiding unethical or questionable research practices
(wrong authorship, falsification, fabrication,
plagiarism).
Methodology
• Ethical approach-based deliberation: autonomy,
beneficence, non-maleficence, justice, vulnerability,
dignity, attentiveness, caring-for, competency,
responsibility.
• Questioning ethical problem: stake-holders, facts,
conflicts, norms (ethical, legal, institutional,
professional, social).
• Justification assessment: interference, proportionality,
necessity, suitability, rule of double effect (RDE).
• Conclusion: acceptable, unethical, advice.
Facts and Figures

• Primum non nocere (Hippocrates, 370 BC).
• Deontology (Immanuel Kant, 1804).
• Utilitarianism (Jeremy Bentham & JS Mill, 1832).
• Human experimentation (Nuremberg Code, 1947).
• Human subjects research (Belmont Report, 1976).
• Principlism (Beauchamp & Childress, 1983).
35
• Ethics of care (Joan Tronto, 1993).
• Declaration of Helsinki (WMA, 1964).
• CIOMS (WHO & UNESCO, 1949).
• 15 ethical contexts (UNESCO, 2005)
Taking Into Account

• Ethical concerns: acceptable or unethical, best interest
choice.
• Justice: equals to be treated equally, unequals to be
treated unequally.
• Surgical practice: experiential & individual case, raising
inevitable tensions with evidence-based medicine
(community based clinical research).
• Virtues: moral & intellectual, integrity, compassion,
self-effacement, self-sacrifice, empathy, care.
• Surgeon: competent, humble, realistic, self-critical.
Elaborating
• The extent of ethical approaches for avoiding and
mitigation of unethical behavior and consequences.
• Casuistry: case-based reasoning, ethical deliberation
incorporated with case bed side teaching.
• Surgeon life: competitive, science & art, second opinion
acceptable, when to quit, incompetent surgery, business
issues, up-to-date, withholding & withdrawing in end-
of-life care, paternalism, RDE.
• Ethical education & training: all behavioral sciences,
medicine, law, philosophy, anthropology, sociology,
from the beginning until completed.
36
Case 1
Respect for autonomy or privacy, informed
consent/reconsent/assent/dissent, confidentiality, truth-
telling, disclosure.
Case 2
Difficult surgery, severe illness, unexpected situation,
surrogate witness, informed reconsent, consulting
Case 3
Transplantation surgery, ethical approach on donor, recipient,
altruistic, compensated, reverse condition
Case 4
Unexpected result, end-of-life care, withholding,
withdrawing, when to quit, surrogate informed consent
Case 5
Hospital ethics committee, independent lay persons,
bioethicist, lawyer, GP, nurse, intensivist, pharmacist
Conclusion
• Ethical deliberation and surgery are indivisible.
• Ethics in surgery education is needed since early medical
student until completed.
• Surgical informed consent/reconsent, truth-telling,
decisional capacity, patient understanding,
voluntariness, surrogate decision, should be clear.
• Capacity building to figure-out & to fix the ethical
dilemmas should be sustainable.
• Focus on patient’s autonomy, best interest, quality of
life, patient-safety.
• Surgeon should behave ethically, to any extent possible
37
References
1. Anji Woll et al. Ethics in Surgery. Current Problems in
Surgery 50, 2013, pp 99-134.
2. G. M. Stirrat. Ethics and Evidence Based Surgery.
Journal of Medical Ethics 30, 2004, pp 160-165.
3. James W. Jones et al. The Ethics of Surgical Practice:
Cases, Dilemmas, and Resolutions. Oxford University
Press, New York, 2008, p 354.
4. Joan Tronto et al. An Ethic of Care. Ethics in
Community Based Elder Care, 2001, ch 5, pp 60-68.
5. Tom L. Beauchamp et al. Principles of Biomedical
Ethics, 5th ed, Oxford University Press, 2001, pp 57-
224.
38
Bariatric Strategies Post COVID-19 Pandemic
Gede Eka Rusdi Antara, MD
Digestive Surgeon. Faculty of Medicine, Udayana University.
Background
The ongoing "coronavirus disease 19" (COVID-
19) pandemic has had a strong effect on the delivery of surgical
care worldwide. Elective surgeries have been canceled or
delayed in order to reallocate resources for the treatment of
COVID-19 patients. Currently, the impact of the COVID-19
pandemic on bariatric and metabolic surgical practice remains
unclear.
The Impact of Pandemic in Bariatric Surgery

The majority of surgeon postponed pre operative
endoscopies. Appointments in outpatient clinic and bariatric
operations are postponed. Most surgeons performed video calls
for follow up appointments. Laparoscopy was still preferred
treatment. COVID-19 screening is a must. A wide variance
occurred regarding precautions and personal protection
equipment.
The Impact of Pandemic in Obesity

A survey done by the American Psychological
Association (APA) in March 2021 found that 42% of Americans
said they had gained weight about 30 pounds in extra weight. It’s
not only adults who are gaining extra pounds. Another study
showed obesity rates in 5-to-11-year old’s have also gone up
during the pandemic from around 36% to just over 45%. In
total,16 states currently have obesity rates of at least 35% or
higher. The number of obesities increases that become
homework for bariatrician and burden for the government.
39
Benefit of Delaying Bariatric Surgery in Pandemic
The implementation and delivery of enhanced bariatric
protocols, thereby minimizing health care system burden and
improving bariatric delivery. Optimizing patient selection.
Implementing Bariatric Enhanced Recovery After Surgery
protocols. Minimizing unnecessary postoperative investigations
to allow most patients to be discharged on postoperative day 1.
Strategies of Bariatric Post COVID-19 Pandemic

Implementation of daring initial consultation and long
term follow up. Using digital media for educating and explaining
about obesity and bariatric. During and after pandemic, people
tend to search and read digital information, which is very easy
and reachable, hence we should use this opportunity to educate
people about obesity, what options do they have, where they can
find help, the cost, the risk, any changing in their eating and
lifestyles. Determine suitable candidate for bariatric surgery
selectively. Arrange better protocol for bariatric surgery. Better
preparation of pre-bariatric surgery. Routine COVID-19
screening pre-surgery. Exercise indoor or outdoor. Build support
group for patients with obesity.
40
Overview Management Of Cerebrovascular
Accidents In Bali
Neurosurgeon. Faculty of Medicine, Udayana University.
Introduction
Due to the improvement of the treatment of ischemic
heart disease over ischemic or hemorrhagic brain disease over the
last 10 years, more and more patients can benefit from non-
surgical and surgical intervention. The nineties have been called
the decade of the brain in developed countries where brain attack
has been treated as aggressively as heart attacks. Thus, it is now
the time for all developing countries to follow the same pathway.
Next to heart disease and cancer, cerebrovascular disease
is the most frequent cause of death in the western world. And at
least one-half of all neurological patients in general have some
type of cerebrovascular disease. The term cerebrocvascular
disease denotes any abnormality of the brain resulting from a
pathologic process of blood vessels, be they arteries, arterioles,
capillaries, veins, or sinuses. The pathologic change in the
vessels takes the form of occlusion by thrombus or embolus, or
of rupture, and the resulting abnormalities in the brain are of two
types: ischemia, with and without infarction, and hemorrhage.
Rarer forms of cerebrovascular disease are those due to altered
permeability of the vascular wall and increased viscosity or other
changes in the quality of blood. The latter changes underlie the
strokes that complicate diseases such as sickle-cell anemia and
polycythemia and account for the headache, brain edema, and
convulsions of hypertensive encephalopathy.
Surgical treatment for stroke can be classified into acute
(emergent) or non-acute. Acute interventions, initiated within
hours of stroke onset, are aimed at reestablishing cerebral blood
flow, restoring lost neurologic function, and preventing
41
permanent tissue damage. Non-acute surgical therapies focus on
reducing secondary injuries resulting from brain swelling or
preventing recurrent stroke. The effective surgical management
of stroke requires continuous and immediately available
treatment by dedicated personnel specializing in complex
cerebrovascular interventions. These requirements may be best
accomplished in facilities with a dedicated neurovascular center
and stroke program.
A. Hemorrhagic Stroke (Intracerebral haematoma)

From all of Cerebrovascular accidents 25% present with
intracerebral haematoma (ICH) and account for 2-4% of all
deaths. They are twice as common as SAH. Over two thirds are
known to be fatal. The patients are usually middle aged or over,
with a male preponderance. The incidence is about 1 per 10,000
with a 30-day mortality of 44%.
Etiology
There are two categories, primary and secondary.
1. Primary ICH:
It is associated with hypertension and distinct from
hemorrhagic infarcts. It has been suggested that hypertensive
changes in the arterial wall, such as, hyaline degeneration, and
micro aneurysms are at fault. Another suggestion is the thin-
walled vessels (such as lenticulostriates), originating directly
from the main vessel are subjected to higher intravascular
pressure than the cortical vessels and tend to rupture. Eighty
percent of them are supratentorial. Mostly, the location is
central and deep.
42
2. Secondary ICH:
It is associated with a medical condition other than
hypertension, representing about 20% of all ICHs. They may
be due to:
• Coagulopathies (10-15%)-Among these, platelet
disorders are important. About 5% of those receiving
heparin, irrespective of the dosage, develop
thrombocytopenia. The platelet defects may be
hereditary (Von Willebrand’s disease) or acquired
through drugs (Aspirin, penicillin, or new
cephalosporin’s) or through disease (myeloproliferative
and dysplastic disorders, uremia, cirrhosis, SLE,
multiple myeloma).
• Arterio Venous Malformations (AVMs (7%) represent a
heterogeneous group with different histological types
(cavernoma, AVMs, venous angioma and capillary
telangiectosis).
• Vasculopathies (5%), such as cerebral amyloid
angiopathy, polyarterites nodosa and necrotizing
vasculopathy in drug abusers, tend to produce multiple
subcortical haematomas.
• Tumors (2%) such as glioblastoma and metastasis
tumors such as, melanoma, choriocarcinoma, renal cell
carcinoma and bronchogenic carcinoma, are the most
frequent tumors in producing ICH.
Pathophysiology
The haematomas may be massive (>5cm) with extension
into the ventricles or may be small (<1.5 cm). The extravagated
blood forms a roughly circular or oval mass which grows in
volume for a brief period. Adjacent brain tissue is displaced and
43
compressed resulting in extensive edema and ischemia. Ischemic
area may be much larger than the area of clot. Cerebellar and
brainstem ICH may produce obstructive hydrocephalus which
may add to the problems. In large hemorrhage, there is midline
shift and the vital centers are compromised. Rebleeding is rare.
Resolving haematomas may develop into a cyst over a period of
months, with a gliotic wall which may be orange colored due to
haemosiderin laden macrophages.
Clinical features:
It depends on the site and size of the hematoma. Sudden
headache, vomiting with depressed level of consciousness and
focal signs is the usual mode of presentation. Absence of neck
stiffness may help to exclude SAH. The large ones are usually
associated with LOC. In putaminal ICH, the patient develops
sudden hemiplegia with conjugate horizontal gaze deviation
towards the clot. Speech may be involved if the dominant
hemisphere is involved. In thalamic ICH, the findings are as in
putaminal ICH; in addition, there may be neck retraction,
paralysis of vertical gaze with upward gaze palsy, inequality of
pupils, and skew deviation with the contra lateral eye being
displaced downward and medially.
Cerebellar ICH presents with severe headache, nausea
and vomiting and imbalance and depressed level of
consciousness. Pontine ICH present with coma, pin point pupils
and decerebrate rigidity. Cortical ICH may present with
headache and seizures.
Investigations:
CT Scan will reveal the clot and other associated features
such as midline shift and hydrocephalus. A contrast CT may
suggest a vascular problem, which may necessitate an
angiography. MRI gives a better delineation of the above; in
44
addition, the age of the hematoma can be guessed. MRI may
suggest an associated AVM. Angiography (CT Angiography
(CTA), MR Angiography (MRA), Digital Substraction
Angiography (DSA) should be carried out whenever there is a
suggestion of vascular malformation, in the absence of previous
hypertension or coagulopathies before a lifesaving clot
evacuation. When surgery is not planned, the angiography can
wait for few weeks to avoid a false negative angiography.
Coagulation studies must be done as a routine in addition
to ECG, chest X-ray and other general investigations.
Management:
Supportive care control of hypertension, reduction of
ICP without compromising the CPP and prevention of
complications are the mainstay. Fluid and electrolytes and tissue
oxygenation must be closely monitored. The aim is to avoid
secondary events. An aggressive decrease of high BP may lead
to cerebral ischemia. Ideally, it should not be lowered below
150mm Hg systolic and 100 mm of Hg diastolic.
Should generally measures to control the raising ICP fail,
hyperventilation may help; but must be employed with careful
watch on pCO2, arterial blood pressure and preferably with ICP
monitoring as well. The CPP should not be compromised.
Osmotherapy with mannitol may help only when the serum
osmolality is lower than 300 mosm/kg.
Prophylactic anti-convulsant therapy is advised by most
physicians with no supporting evidence.
The role of surgical intervention is controversial.
Neurosurgeons and neurologists advocate that large cerebellar
hemorrhages with compression of the brain stem or obstruction
of the fourth ventricle should be surgically removed as soon as
possible. Surgical removal of large lobar hemorrhages in young
patients who are clinically deteriorating has also been
45
recommended based on anecdotal experience. On the other hand,
the results of such surgery in hematomas within the basal ganglia
and other deep structures are unacceptable. Standard craniotomy
for surgical removal of primary brain stem or thalamic
hemorrhages has been all but abandoned because of the
extremely poor outcomes in almost all patients.
Craniotomy
Craniotomy and evacuation of the clot has been the
standard approach for removal of intraparenchymal hemorrhage.
In addition, a decompressive craniectomy with a duraplasty is
preferred by some. Its major advantage is adequate exposure to
remove the clot. It is not difficult or time-consuming. The major
disadvantage of a more extensive surgical approach is that it may
lead to further brain damage, particularly in patients with deep-
seated hemorrhages. In addition, the effectiveness of clot
removal by craniotomy is far from ideal.
Nonrandomized treatment series of patients with
cerebellar hemorrhage report good outcomes for surgically
treated patients who have large (>3 cm) cerebellar hemorrhages
or cerebellar hemorrhages with brain stem compression or
hydrocephalus. In these patients, medical management alone
often results in bad outcomes. Smaller cerebellar hemorrhages
without brain stem compression that are managed medically do
reasonably well.
Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage (A Guideline for Healthcare
Professionals from the American Heart Association/American
Stroke Association) Stroke. 2015; 46:000-000.
Outcome
The natural course of spontaneous ICH leads to a 30-day
mortality rate of 45%. The patient's initial level of consciousness,
46
hemorrhage size, and intraventricular extension of blood has
proven to be accurate predictors of outcome. Less commonly,
age, sex, hypertension, and mass effect may indicate harmful
effects on outcome in patients with ICH.
The author recommends that patients with smaller
hematomas who are alert, stable, or improving should be treated
medically and the patients with larger hematomas who show
progressive neurological deficit, prolonged functional
impairment, and intracranial hypertension should be treated
surgically. Patients with a GCS score <4 should also be treated
medically because they uniformly die or have extremely poor
functional outcome that cannot be improved by surgery. Easily
accessible supratentorial hematomas with mass effect, especially
in the young and in those with a GCS score >5, must be
evacuated. The aim of surgery should be the removal of as much
of the clot as possible, with minimal disruption of surrounding
brain tissue. If possible, surgery should also remove the
underlying cause of hemorrhage, such as an arteriovenous
malformation, and prevent complications of ICH such as
hydrocephalus and mass effect of the blood clot. More complete
clot removal may decrease elevated ICP and local pressure
effects of the blood clot on the surrounding brain. Stereotactic
aspiration may be associated with better outcomes than standard
craniotomy; but this hypothesis has yet to be tested in a
randomized study. Ultra-early removal of ICH by localized,
minimally invasive surgical procedures is promising but
untested. Further study of the dynamics of hemorrhage and
additional results are needed prior to making a decision on how
to divide patient management into the two categories of surgical
and nonsurgical treatment.
47
B. Ischemic Stroke ( Stroke Non Hemorrhagic)
Although some strokes are hemorrhagic, the majority
(75%) are ischemic due to insufficient cerebral blood flow
secondary to occlusion or flow limiting stenosis. Brain tissue is
exquisitely sensitive to ischemia, and an estimated 1.9 million
neurons die every minute that blood flow is not restored. Time is
brain.
Decompressive Hemicraniectomy
Despite acute interventions such as IV-tPA and
embolectomy, up to 10% of ischemic strokes result in large areas
of infarction. This can lead to significant brain swelling, raised
intracranial pressure (ICP), and in severe cases, life-threatening
herniation syndromes. These conditions are associated with
worse outcomes, as they promote further reductions in cerebral
blood flow leading to additional ischemic tissue damage
(secondary brain injury).
Significant edema that occurs in the supratentorial space
after a stroke is referred to as malignant infarction of the middle
cerebral artery (MCA). This condition is associated with CT
evidence of infarction involving at least 50% of the MCA
territory or an infarct volume of greater than 145 cm3 on
diffusion weighted magnetic resonance imaging (MRI). Despite
aggressive medical management including hyperventilation,
barbiturates, hyperosmolar therapy, and corticosteroids,
malignant MCA infarctions have been associated with an 80%
fatality rate. However, recent multi-center trials and pooled
analyses strongly support the role of surgical intervention,
consisting of a decompressive hemicraniectomy (DHC), in
reducing mortality and disability after malignant MCA infarction
in select patients. The surgical procedure involves removal of a
large bone flap, followed by insertion of a dural patch. This
48
results in reduced constriction of the injured brain and culminates
in lower ICP and reduced risk of brain herniation.
Current evidence suggests a role for DHC in patients
younger than 60 with malignant infarction of the MCA
associated with altered consciousness who are treated within 48
hours of stroke onset. For patients older than 60, surgical
decompression is controversial. There are notable improvements
in mortality, but many of the surviving patients have severe
disability.
Carotid Endarterectomy and Carotid Stenting

Carotid artery stenosis causes up to 10% of all ischemic
strokes. The risk of recurrent stroke is significantly higher in
patients who have previously suffered an initial stroke or
transient ischemic attack (TIA). It is estimated that 25% of
patients presenting with a stroke are suffering from a recurrent
ischemic episode. The risk of stroke is particularly high in
symptomatic patients who have severe narrowing of the
extracranial internal carotid artery, and several large randomized
studies have demonstrated the effectiveness of carotid
endarterectomy (CEA) in reducing future stroke risk in these
patients. The North American Symptomatic Carotid
Endarterectomy Trial (NASCET) reported that in symptomatic
patients with greater than 70% carotid stenosis who undergo
CEA, the absolute risk of future stroke is reduced by 17%
compared to medical therapy alone, which has been confirmed
by other large studies. Pooled analysis of three large trials of
CEA versus medical therapy has shown a 16% absolute risk
reduction when CEA was performed in patients with
symptomatic stenosis of 70% or more. For patients with 50–69%
stenosis, there was still a benefit but to a lesser degree. Patients
with less than 50% narrowing of the carotid artery do not appear
to benefit from surgical intervention.
49
Despite the proven effectiveness of CEA, carotid artery
stenting (CAS) has been promoted as an attractive, less invasive
option for revascularization. Potential advantages of CAS
include decreased patient discomfort and a shorter recuperation
period. Early studies indicated a higher procedural risk during
CAS compared to CEA, but these studies have been criticized for
inadequate and non-uniform operator experience. Furthermore,
advances in endovascular techniques and devices used for CAS
have made the procedure safer.
Extracranial to Intracranial Arterial Bypass

Extracranial-intracranial (ECIC) bypass surgery has not
been shown to provide any benefit for patients with
atherosclerotic carotid occlusion or carotid artery narrowing
distal to the carotid bifurcation. However, in patients with
moyamoya disease or syndrome, ECIC bypass has been shown
to be effective at reducing stroke risk.
Moyamoya can occur in children and adults and is a
cerebrovascular condition that predisposes affected patients to
stroke due to progressive stenosis of the intracranial internal
carotid arteries and their branches. Genetic factors play a role,
and moyamoya can be associated with other conditions such as
Down’s syndrome, sickle cell disease, neurofibromatosis, or
previous cranial irradiation. If the disease is unilateral, or is
associated with one of these conditions, it is called moyamoya
syndrome. Moyamoya disease is bilateral and is not associated
with other risk factors. Most patients present with stroke or
ischemic symptoms with 50 –75% of known moyamoya patients
experiencing ischemic stroke.
It has been estimated that up to two-thirds of patients
with moyamoya have symptomatic progression over a 5-year
period with poor outcomes without treatment. Medical therapies
have not been shown to be beneficial in reducing stroke risk and
50
surgical revascularization (ECIC bypass) is the primary
treatment for moyamoya. This procedure utilizes extracranial
arterial supply (usually the superficial temporal artery) which is
either directly or indirectly anastomosed to an intracranial
cortical artery. Following ECIC bypass, there is a 96%
probability of remaining stroke-free over the subsequent 5 years,
and a meta analysis concluded that 1003 of 1156 patients (87%)
derived symptomatic benefit from surgical revascularization.
51
Robotic And Minimally Invasive Cardiac
Surgery
I Komang Adhi Parama Harta, MD
Cardiothoracic Surgeon. Faculty of Medicine, Udayana
University.
History
The development of robotic systems for surgery started
in the 1980s, motivated by the US army’s requirement of surgical
procedures in combat areas with the surgeon in a distant place
(telepresence)
Figure 1 Timeline of Surgical technologies development
Surgical Robotic System

Defined as “a computer-controlled manipulator with
artificial sensors that can be reprogrammed to move and position
surgical instruments aiming at performing surgical tasks.
Surgically robots in most practical can be divide in two
categories: passive and active. A ‘passive’ robot would be used
to correctly position a fixed instrument and then be turned off,
with the surgeon inserting the other instruments thereafter. They
are particularly useful in surgeries that depend more on the
production of imaging, such as laparoscopic procedures.
Examples of these passive robots are AESOP, Fips endoarm, and
Endoassist.
52
An active robot is capable of moving the instruments
utilized in the surgery, accurately transmitting the movement of
the hands, filtering and eliminating the natural shaking and
increasing surgical precision. The surgeon manipulates an
electronic hand that captures his movements and controlling the
robot. Referred to as telemanipulating, as it permits the remote
control of the instrument by the surgeon. There are The ZEUS
(Computer motion, Goleta, California, USA) and da Vinci
(Intuitive Surgical, Sunnyvale, California, USA). Da Vinci
model probably more utilized in ‘total’ robotic surgeries.
Figure 2 The Evolution of five generation of surgical robotics
53
Figure 3 Development in Cardiac Surgery Technologies
Figure 4 Advancement in Cardiac Surgeries
Left Internal Mammary to LAD Artery Still Rules the

Roost in Revascularization for Proximal LAD Disease because
no differences in all-cause mortality, major adverse cardiac and
cerebrovascular events (MACCE) higher in the PCI, relative risk
of recurrent angina was 2.5 times higher in the PCI, and repeat
TVR occurs significantly more frequently (2x) after PCI.
54
Table 1 Robotic Cardiac Surgical Procedures
Procedures Details
Coronary artery bypass Robotically-assisted
grafting minimally invasive direct
coronary artery bypass
Totally endoscopic coronary
artery bypass
Mitral valve repair or Resection versus non-
replacement resection repair techniques
Biological and mechanical
valve replacement
Atrial septal defect closure Primary closure of secundum
type defects
Patch closure of all types of
atrial septal defects including
coronary sinus type defects
Ablation for atrial fibrillation Radiofrequency ablation of
cryoablation procedures
Anomalous partial Right upper pulmonary veins
pulmonary venous return to the superior vena cava or
right atrium
Left atrial appendage closure With mitral valve surgery
Partial atrioventricular septal Primum septal defect and
defects mitral cleft closures
Intracardiac tumor resection Right or left atrial and left
ventricular myxomas
Fibroelastoma of the mitral
valve
Left ventricular pacemaker Arrhythmia surgery
lead implantation
Patient selection criteria for robotic surgery

Ideal patients’s characteristics
• Body mass index less than 30 kg/m2
• Age less than 70 years old
• Left ventricular ejection fraction above 50%
• Isolated cardiac pathology
55
• Forced expiratory volume in 1 second above 80%
• Creatinine less than 1 mg/dL
• Femoral artery diameter above 7 – 8 mm
Relative contraindications for robotic surgery

• Chest deformity
• Obstructive or restrictive lung disease
• Previous pericarditis or pleuritis
• History of cardiothoracic operations
• History of chest trauma
• Previous rib fracture, pneumo/hemothorax, tube
thoracostomy
• Peripheral artery disease
• Elevated diaphragm level
• History of radiotherapy to chest
The benefits of robotic hybrid coronary revascularization
• Less pain: smaller incisions than surgeries that access the
heart through the breastbone
• Lower risk of complications
o Less risk of bleeding
o Less risk of infection
o Potentially less risk of atrial fibrillation, an
irregular, often rapid, heart rate that can be
trigerred by heart surgery
o Reduced need for blood transfusions
o Lower risk of stroke because the heart-lung
machine isn’t generally needed
o Faster return to daily activities: less time in
intensive care unit, less time in the hospital,
fewer restrictions on driving and lifting
56
• Better appearance: smaller incisions leave less visible
scarring
Figure 5 Meta analysis of comparative studies of RCAB versus

C-CABG (on)
57
The total hospital cost associated with robotic mitral
valve repair has become similar to that for a conventional open
approach, while facilitating quicker patient recovery and
diminished utilization of in-hospital resources.
Figure 6 COVID-19 impact on robotic surgery technology
Robotic surgery technologies are now in Indonesia, for

example in RS Bunda Jakarta, RSUP Hasan Sadikin Bandung,
and RSUP Dr. Sardjito Yogyakarta. Next robotic surgery
technologies may come are Coronary Artery Bypass Graft
Surgery, Coronary Stents, and Hybrid Coronary
Revascularization.
58
Table 2 What the Young Surgeon Should Know?
59
Head and Neck Infection, The Sequalae and Its
Reconstruction
I Nyoman Putu Riasa, MD, PhD, FICS
Plastic Surgeon. Faculty of Medicine, Udayana University.
Infection affecting the head and neck area is one of the

challenging infection problems encountered by clinician. It is due
to the need of proper emergency management in preventing life
threatening spreading of infection and also adequate
reconstruction for its disfiguring long-term sequalae. The
pathogenesis of head and neck infection is a complex interaction
between microbial, host and environment factors. Microbial
factors including pathogenicity and virulence of the
microorganism as the agent of infection. Host factors including
age, genetic, nutritional status, local and general host defenses
(immune system). The environment factors mostly related to
oral, gum and dental hygiene. Dental procedure and dental
fracture accompanying facial trauma is also can cause spreading
of the bacteria from the root of the teeth.
Alveolo-dental abscess is a circumscribe pus cavity
located at the apex of the tooth; it is usually caused by the death
of the pulp. The infection in the pulp cavity invades the space
between the root and the socket and may progress until it reaches
the compact tissue on the alveolar surface of the jaw. The pus
from the abscess generally escapes through the surface offering
least resistance, namely, the lateral alveolar plate, lateral to the
apex of the affected tooth. In the process may lift up the
periosteum for a sufficient distance to cause considerable
necrosis of underlying bone. The pus finally going through a
sinus remote from the point of origin. In the lower jaw the force
of gravity and the pressure of accumulating pus may create a path
between the periosteum and bone, then finally discharge on the
neck beneath the chin and the jaw. An abscess in connection with
60
the third lower molar may penetrate the lateral tissues at the
mandibular angle, or occasionally may burrow downward into
the neck, forming large pus cavities in the submandibular region.
Abscess are less likely to occur in the upper jaw, where
there is an abundant blood supply. The pus from abscesses in the
upper jaw may extend into the nasal cavity or perforate the
maxillary sinus and established an establish an empyema.
The principle of treatment is the opening and draining of
the pus cavity. Trephine of the alveolar plate or extraction of the
teeth is intended to limit destruction of the tissue and to reach the
focus of infection. Tooth extraction in the acute abscess may
developed an extensive sepsis. Treatment of abscess which have
burrowed downward into the neck is evacuation by external
incision.
Among many types of infection affecting head and neck
region, we highlighted here only the common case encountered
in our hospitals serve a mixed of global and local population, the
sub-masseteric abscess and Ludwig`s angina.
Sub-masseteric Abscess
Masseteric space consists of three spaces: the
submasseteric space, temporal masseteric space and pterygoid-
mandibular masseteric space (Fig 7.). The space lying below the
superficial layer of the deep cervical fascia that encloses masseter
muscle and the mandible. The potential space for collection of
abscess is the space lateral to mandibular ramus on the area
between the insertion of middle part and deep part of masseteric
muscle. Odontogenic infection is the primary cause of
submasseteric abscess including impacted molar tooth. Trismus
and painful swelling of masseteric or submandibular area are the
primary symptoms. Neck discoloration indicating progressive
spreading of the infection (Fig 8.). Panoramic view and CT scan
will help in identifying the source and site of infection. Antibiotic
61
should be administered and surgical drainage of the abscess
could be done through extraoral or intraoral approach by
avoiding injury of the marginal branch of facial nerve. 2
Figure 7 Anatomy of the head and neck,3 and diagram of

masseteric space consist of proper submasseteric space,
temporal space and pterygoid space.
Figure 8 Sub-masseteric abscess affecting female, 53 years old

after dental procedure with discoloration of the neck (right). On
CT-scan the masseteric space become enlarged (middle right)
and the pus collecting to the submandibular space (middle-left
and upper-left). The molar tooth was the source of infection
(lower-left)
62
Ludwig`s Angina
This term is use to cover a variety of serious
predominantly streptococcal infection involving the floor of the
mouth. The primary infection is commonly one of the inner
aspects of the lip, the lower gingivae or teeth.
The infection often spread rapidly from its origin to the
adjacent tissue and become massive life-threatening cellulites. It
could extend along the lymphatic system, fascia and muscle
planes to the sub-mandibular space and sub-mental areas and
down the neck and more importantly moving posteriorly to
involve the larynx. Airway obstruction may result as the infection
and swelling spreads to supraglottic tissues. Interference with
respiration then occurred, so that deaths from pulmonary
infection were once common. Elevation of the tongue up and
back, redness and edema of the floor of the mouth, and brawny
induration of the upper neck were the clinical characteristics.
Dull pain in the mouth, drooling or difficulty in swallowing or
speaking clearly. Not infrequently, pus accumulated in the
sublingual area both above and below the geniohyoid muscle
(Fig 9.).
The quick use of antibiotic brings about a rapid
resolution of an early infection, so that full-blown Ludwig`s
angina is rarely seen. Intravenous antibiotics which were active
against streptococci and oral anaerobes (e.g.,
ampicillin/sulbactam 3 gram every 6 hour or high dose penicillin
plus metronidazole should be followed by oral antibiotic therapy,
with a total treatment duration of 14 days). If an abscess forms,
which is not common with adequate therapy, incisions and
drainage should be carried out through a transverse incision made
at the dependent point of the submandibular triangle or the most
safety and easily accessed sites of accumulating pus. Airway
monitoring is also essential and intubation or tracheostomy may
be necessary.
63
Figure 9 Anatomy of head and neck,3 and the location of
abscess in relation to the anatomy: above and below geniohyoid
muscle which connected on the posterior part (green circle) and
the easier access for drainage incision (green arrow).
Noma
Noma or cancrum oris or gangrenous stomatitis is a
fulminant gangrenous opportunistic infection of the oral and
facial tissues that occurs in severely malnourished and debilitated
patients and is especially common among children below 12
years old (Fig 10.). It results from complex interaction between
infection, malnutrition and compromised immunity. Noma is
very rarely affecting the adults. Disease that commonly preceded
noma was severe diarrhea, measles, malaria, necrotizing
ulcerative gingivitis.
Beginning as a necrotic ulcer in the gingiva of the
mandible, noma is caused by oral anaerobes, especially
fusospirochetal organism (e.g., Fusobabterium nucleatum or
Fusobacterium necrophorum). Other suspected bacteria
including Borrelia vincentii, Staphylococcus aureus and
Prevotella intermedia.
64
The complications of the disease including dehydration,
sepsis, airway obstruction, facial deformity and psychological
stress. The response to antibiotic (high-dose penicillin) is very
well during acute phase, simultaneously with debridement, and
correction of dehydration and the underlying malnutrition.
Figure 10 Acute phase of noma affecting a boy, 6 years old with

right mandible destruction.
Noma Sequalae Reconstructions

The defect and deformity as the end result of tissue and
bony destruction of Noma infection need reconstruction for
functional and aesthetic reasons. Functional reconstruction goal
is achieving orofacial competence as well as masticatory
function. Aesthetic goal is aimed in relieving the psychological
distress and recovered the social life, integration to the school or
academic life and productive life job.
Proper defect analysis and a well-planned reconstructive
surgery will be easily executed during surgery. Analysis of the
missing skin and soft tissue will help in reconstruct the important
structural tissue landmark with special consideration of the
aesthetic units of the face. Preliminary treatment of malposition
teeth by tooth extraction will facilitate the next reconstruction in
achieving oral competence. The magnitude of bony destruction
will affect the choice for its reconstruction. Analysis of the
useable scar tissue to reconstruct the inner lining should be put
65
into consideration. Local and regional tissue should be selected
according to the proximity, thickness and similarity of skin
quality, texture and color. Nasolabial flap is a good choice for
alar reconstruction. Abbe flap is a good option for columellar
base and philtrum reconstruction. Lips reconstruction especially
the modiolus mostly need muscle reconstruction and could be
replace wing fascial or tendon sling to prevent drooling.
Radial forearm free flap which is consist of relatively
thin and hairless skin could be design as a composite flap by
including the long palmaris tendon,4 in order to cover the defect
and create modiolus labial tendon sling (Fig 11.).
Figure 11 Noma sequelae on the right ginggivo-labialis area

with malposition teeth Design of inner lining using scarred
tissue and composite RFF flap with palmaris longus tendon as
sling for modiolus.
The long pedicle of the radial forearm free flap could

reach the upper part of the neck and thyroid superior artery could
be used as recipient artery with external jugular vein as drainage
of the veins. Flap viability was easier to be monitor using thermal
patch monitor or using other non-invasive methods or clinical
66
judgements. In setting the flap, the aesthetic unit of the face
should be respected to achieve satisfactory aesthetic outcome.
Figure 12 Donor and recipient after microvascular anastomosis

(right) and the results 3 years post operation with satisfactory
results.
Summary
Infection of the head neck region mostly originating
from alveolar-odontogenic infection which spreading to the
masseteric space or submandibular space. Laryngeal spreading
or mediastinum spreading could offer a very life-threatening
situation including airway obstruction and sepsis. In severe
malnutrition, immune compromised and poor oral hygiene,
gangrenous stomatitis could result in soft tissue and bone
destruction. Adequate drainage and proper antibiotic treatment
was mandatory during acute stage. Long term functional and
aesthetic defect due to noma infection need adequate
reconstruction using local, regional and free flap modalities.
67
References
1. Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odontogenic
infections: Microbiology and management. Contemp Clin
Dent [serial online] 2014 [cited 2022 Aug 1]; 5:307-11.
Available from:
https://www.contempclindent.org/text.asp?2014/5/3/307/13
7921. Odontogenic Infection: Microbiology and
management.
2. Moon-Gi Choi. Modified drainage of submasseteric space
abscess. J Korean Assoc Oral Maxillofac Surg 2017; 43:197-
203 2016. Source:
https://doi.org/10.5125/jkaoms.2017.43.3.197pISSN 2234-
7550·eISSN 2234-5930
3. Netter FH, Atlas of Human Anatomy, 4th Ed. Saunders-
Elsevier, USA, 2003.
4. Strauch B, Chen ZW, Yu HL, Liebling R. Atlas of
microvascular surgery, anatomy and operative approach.
Thieme, New York, 1993.
68
Horse-Shoe Flap Reconstruction Technique in
Breast Surgery: From The Smallest Defect to
The Biggest—A Case Series
Ida Bagus Made Suryawisesa, MD, PhD1; I Nyoman Wawan
Tirtha Yasa, MD1; Prof. Ida Bagus Tjakra Manuaba,MD,
PhD1; Kelvin Setiawan, MD2
1. Oncology Surgeon. Faculty of Medicine Udayana University.
2. General Surgery Department. Faculty of Medicine Udayana University
Abstract
Chest wall resections and reconstructions are routinely
performed to close defects after primary breast tumor resections.
Depending on the size of primary breast tumors, the
reconstructive technique requires more challenging approaches.
In this study, we would like to introduce a novel technique which
can be applied as a method in covering various sizes of skin
defects after mastectomy termed as “horse-shoe flap technique.”
We conducted a series of case reports of patients who underwent
chest wall coverage after primary breast tumor resections
between October 2018 and November 2019 and selected five
cases of breast cancer patients. These patients were treated with
the horse-shoe flap technique which relies on shape as its main
concept. All chest defects must form a circular shape, based on
the principle that adequate safe tumor margins are best achieved
with a circular incision. The donor flap was drawn and taken
from the outer circle area with a larger arc, depending on the
defect’s diameter size. Five postmastectomy chest wall defect
cases had been successfully closed with this technique. Patients
were all female, ranging from 36 to 55 years of age. The smallest
chest defect was 4 cm in diameter, and the largest was 26 cm. All
the defects were closed using a 120-degree horse-shoe flap
design. One patient experienced marginal necrotic skin, and one
case had formed postoperative seroma. The horse-shoe flap
69
technique proves to be an excellent option for closing chest skin
defects which can be applied for various sizes of skin defects
with minor complications.
Keywords
• horse-shoe flap
• breast cancer
• breast reconstruction
Published online on: Asian J Oncol. DOI https://doi.org/10.1055/s-

0042-1748861. ISSN 2454-6798.
Introduction
Surgical science has improved for the past decades,
allowing the development and refinement of reconstruction
techniques, particularly in chest wall areas. Along with
improvements in many surgical fields, such as anesthesia and
critical care medicine, chest wall reconstructions can be
performed with decreased morbidity, mortality, and better
outcomes.1
Chest wall resections and reconstructions are routinely
performed nowadays; the most common reasons are primary
breast tumors. Some chest wall resections leave large skin
effects, depending on how large the size of primary breast
tumors, and could result in more difficult reconstructive
approaches.2 Nowadays, the large skin defects secondary to large
primary breast cancer tumors had proven to be challenging
problems for surgeons.
There are numerous reconstruction techniques available
which have previously been conducted to cover chess wall
defects. These reconstruction techniques are generally divided
into two main categories: soft tissue reconstructions with or
without prosthetic materials.3 Chest wall soft tissue
reconstructions, such as latissimus dorsi (LD) muscle flap,
70
pectoralis major muscle flap, serratus anterior muscle flap, and
rectus abdominis muscle flaps were commonly used for chest
skin defect coverage; however, some techniques cause
complications.4
In this literature, we would like to introduce a new
technique which can be used as a method in covering a large skin
defect. It has a perfect perforator supply due to its design which
resulted in minimal damage and defect to the donor site and more
importantly, it is easy to perform. We will now introduce our
novel design flaps reconstruction for big circular defect: a
“horse-shoe flap technique” which has been applied particularly
in chest wall reconstruction cases in our center. This method
perfectly achieved a minimal-tension wound edge which ensured
dermal perfusion. In this study, we reported several post-
mastectomy with large chest skin defects coverage using our new
horse-shoe flap technique. This report aims to introduce a new
approach in covering skin defects secondary to mastectomy.
Methods
In this study, we conducted a series of case reports of
patients who underwent chest wall soft tissue coverage after
mastectomy or breast-conserving therapy due to breast
malignancies or primary breast tumors. The duration of this
retrospective study is 1 year, from October 2018 to November
2019. All of the operations and chest wall reconstructions were
performed by our oncology surgeons in Sanglah General
Hospital in Denpasar, Bali. Sanglah General Hospital, located in
West Denpasar, is the biggest referral hospital in Bali, receives
numerous patients from all around Bali, Nusa Tenggara Islands,
and other areas in East Java, particularly breast cancer patients
for curative and palliative approaches. Sanglah General Hospital
is also the main teaching hospital for Udayana University,
Faculty of Medicine, including our Department of Oncology
71
Surgery. All patients included in this study were informed and
have provided their consent to be included in the study.
We selected five representative cases of breast cancer
patients with various sizes of primary breast tumors. These
patients were all candidates for radical mastectomy and breast
reconstruction. Our study sample’s inclusion criteria are patients
who underwent breast conserving operation and mastectomy
which left a decent size of soft tissue defects. There are no
limitations in tumor or defect size, as we would like to prove the
availability of this technique which can be applied for the size of
every defect, as long as the adjacent skin length would suffice for
coverage. Patients with tumors or operative approaches affecting
the surrounding thoracic structure, such as ribs, sternum, and
clavicles, were excluded from our study samples. All clinical
variables were recorded and presented, including age, diagnosis
of breast diseases, methods, defects size, defect’s location, flap
design and length of adjacent skin needed for closure.
Horse-Shoe Flap Technique

The horse-shoe flap is one of the reconstruction
techniques that rely on shape as its main concept. Shape
reconstruction techniques are basically easier to perform but this
shape concept technique appears to be abandoned as surgeons
prefer to use the anatomy-based flap. For this horse-shoe flap
technique, all chest defects must be formed into a circular shape
defect a circular shape. This is also based on the principle that
adequate safe tumor margins can be achieved with the use of a
circular incision.5 For that reason, before the wide excision or
mastectomy is performed, a circular pattern must be drawn and
note the length of defects diameter, as it will determine the length
of the adjacent donor flap. The donor flap is drawn and taken
from the outer circle area with a larger arc, depending on the
defects diameter size. A mathematical formula is created to
72
determine the length of secondary defect size or donor area,
which needs to be dissected (Fig. 13). Prior to surgery, the
dimension of the potential defect after tumor ablation is
estimated and outlined.
R: Donor flap length (in cm) or radius of the outer circle area.
r: Radius of the circular defect (in cm).
u: Central circle angle.
Figure 13 The horse-shoe flap’s concept with circular shape

pattern.
Note the angle from the center circle and the defect’s radius,
which will determine the size of adjacent flaps needed for closure.
To facilitate determining the length of the donor flap,

there are three basic choices of central circle angle and the length
of donor flap needed for closure. The three central circle angles
mentioned before are 180, 120, and 90 degrees. If we use 180
degrees as our circular center angle, we only need 73% of defect
radius as donor flap length. If we used 120 degrees as our circular
center angle, we need the length of defect radius as donor flap
length. For the closure, both ends of the larger arc of the keystone
flap are closed by Y suture, leaving only a small defect in the
middle part. The end of the donor flap that meets at the center of
the defect will be stitched in a straight line in the middle to obtain
73
a good cosmetic reconstruction (Fig. 14). This flap viability
depends on its perforator vessels, taken together with adjacent
neural components to improve flap’s perfusion, making this
horse-shoe flap defined as one of the musculocutaneous flaps.
Figure 14 Surgical steps on performing horse-shoe flap using

outer
circle adjacent tissue as donor flap.
Results
Five post-mastectomy chest wall defect cases were
successfully closed with our new “horse-shoe flap techniques.”
Our study samples were all female patients aged between 36 to
55 years of age; the smallest chest defect was measured 4 cm in
diameter and the largest was 26 cm. One patient had marginal
necrotic postreconstruction after 5 days of follow-up, which
required a reexcision. Two patients were diagnosed with
phyllodes breast tumor, and three other patients were diagnosed
with breast malignancies. Two patients underwent breast tumor
excision, while the other three were treated with radical
mastectomy. All of these chest wall defects were closed using
120-degree skin flap reconstruction from the primary defect
center circle, using half of the diameter of the skin defect for
closure. All patients were also satisfied with the post
74
reconstruction result, with minimal postoperative wound
treatment.
Case 1
A 45-year-old patient (patient A) presented to our
oncology surgery polyclinic with a solid mass in her right breast.
She had already done an excision biopsy on her breast, and the
histopathology result revealed a phyllodes tumor on her right
breast. The patient did not feel any pain in her breast. Wide tumor
excision was done, and a 4-cm post excision defect was left. We
used 120-degree angle for skin reconstruction, and 2-cm skin
radius was needed for defect closure (Fig. 15). Chest defects were
successfully closed within 2 hours of operative duration. The
patient was discharged from the hospital after 4 days of
treatment. No postoperative complications were observed from
1-month follow-up in our clinic.
Figure 15A 45-year-old patient with small phyllodes tumor on

her right breast underwent horse-she flap reconstruction using
120-degree angle from the center circle and 2-cm defect radius.
Case 2
A 36-year-old patient (patient B) presented to our
surgery polyclinic with a large mass located in the lower medial
75
quadrant of her left breast. An excision biopsy was done before
admission from another hospital, and the histopathology result
showed a phyllodes tumor, similar to the previous patient but
bigger in diameter size. She was offered a choice to remove her
left breast entirely, including her solid mass from her previous
hospital, but the patient refused and wished to preserve her left
breast while removing the tumor.
Thus, the patient was referred to our care and we decided
to perform wide excision of the tumor and close the chest wall
defect with horse-shoe flap reconstruction to preserve the left
breast. Wide tumor excision was done, and a defect of 8 cm was
left as a result. Using the 120-degree angle from defect center
circle, 4-cm length of adjacent skin outside the primary defect
was needed to close the primary defect itself. Primary tumor
removal and chest reconstruction using horse-shoe flap technique
were successfully done, completely removing the entire tumor
and preserving the left breast with only a small section of breast
subcutaneous fat tissue removed (Fig. 16). We continued our
follow-up examination after the patient was discharged, and the
result was satisfactory after 1 month of wound care.
76
Figure 16 A 36-year-old patient with a bigger phyllodes tumor
underwent wide excision and reconstruction with horse-shoe
flap, 120 degree angle from the center circle and 4-cm defect
radius.
Case 3
A 50-year-old patient (patient C) was presented with
multiple palpable masses in her right breast. She was diagnosed
with invasive breast cancer, ductal carcinoma with triple negative
molecular type. Six series of neoadjuvant chemotherapy were
done but did not seem to show any improvement clinically. A
horse-shoe flap design was planned for reconstructing the chest
wall after we dissected the remaining tumor on her right breast.
We shaped and designed a circular defect with 11-cm diameter.
This length was considered necessary and expected to leave a
safe margin. With 11 cm of primary site defects and 120-degree
angle from the center of circular defects, 5.5 cm of adjacent tissue
outside the primary defect was sufficient to cover the defect. We
removed all tissue from the circular area and preserved the
pectoralis minor muscle. The reconstruction was successfully
done, leaving with minor scar tissues (Fig. 17). The patient was
followed-up until 1 month after discharge, and there were no
surgical complications.
Figure 17 A 55-year-old patient with invasive breast cancer

underwent radical mastectomies with 11-cm diameter of
primary defects, 5.5 cm of adjacent tissue radius was used to
close the defects using a horseshoe flap.
77
Case 4
A 52-year-old female (patient D) was our patient who
routinely came to our clinic for regular monthly examination. She
was diagnosed with T4N2M0 malignant breast cancer, ductal
carcinoma, and triple-negative molecular type. Six series of
neoadjuvant chemotherapy were delivered with no improvement
and clinical response. A large solid mass dominated her left
breast, with an open ulcer on her upper lateral quadrant. There
were granulation tissues on the ulcer edges with infections, pus,
and devitalized tissue on the center. Radical mastectomy was
planned, with a horse-shoe flap technique for defect closure. We
drew a circular pattern around the breast which measured around
21 x 17 cm of primary defect expected after the radical
mastectomy. The entire primary tumor and breast tissues were
removed with preserved pectoralis muscle. We used a 120-
degree angle from the center circular defect, half of the diameter
defect length (around 10 cm) of adjacent tissue inferior to the
primary defect (Fig. 18). The patient was followed-up until 2
months after successful reconstruction. There were some serous
fluid formations below the reconstruction site but the result was
satisfactory after a few routine aspirations. 2
78
Figure 18 A 52-year-old patient with 21 x 17 cm of the primary
defect after radical mastectomy underwent a horse-shoe flap
using 10 cm of skin outside the defect for closure.
Case 5
A 55-year-old female (patient E) with luminal-type
T4N1M0 malignant breast cancer, presented with a large breast
tumor on her left breast. Twelve series of neoadjuvant
chemotherapy were given, with the aim to downsize the tumor,
but no significant response was seen in post chemotherapy
clinical evaluation. Radical mastectomy and horseshoe flap
technique were planned as operative approach and soft tissue
coverage. A circular pattern was needed for horse-shoe flap
coverage, and it was estimated around 26 cm of defect diameter
size as a result to achieve safety tumor margin. Adjacent tissue
of 13 cm below the primary defect was needed for chest wall
coverage, as we used 120-degree angle from the center defect.
There were no complications shortly after surgery. Five days
after surgery, marginal necrotic skins were found around the
interrupted surgical stitches and did not seem viable and
irreversible. Re-excision of necrotic skin was required, and only
small parts of necrotic skin were removed. After stitching both
edges where necrotic skins were removed, the patient’s follow up
examination was continued for 1 month, and there were no other
complications afterward (Fig. 19).
79
Figure 19 A 55-year-old patient with the largest defect in this
study underwent horse-shoe flap using 13-cm adjacent tissue
below the defects. Marginal necrotic skins were found after
surgery, and reexcision of necrotic skin was necessary, followed
by stitching both edges for closure.
Discussion
In several cases of large breast tumors, extensive chest
wall resections are needed to reassure free margins, thus leaving
massive defects that require closure approaches. Several
techniques have already been introduced; some are widely used,
such as latissimus flap, abdominal flaps, and other donor sites,
such as superior gluteal artery perforator flaps or using
contralateral healthy breast for chest wall defects, that did not
cross the midline. Chest wall closures are necessary for patients
with large primary breast tumors, recurrent breast tumor with
radiation therapy (some patients with radiation-induced
angiosarcomas are indicative for wide skin resections), and in
patients with inflammatory breast cancers. Closing the chest
defects after wide tumor resections only using primary simple
skin closure is sometimes insufficient, and additional techniques
for chest wall closure are obligatory. 6 The easiest way, but no
longer used by many experts, for chest skin coverage is split-
thickness skin grafts (STSG). STSGs are widely known and best
80
used for relatively minor and small skin defects with sufficient
vascular beds. However, STSG for chest wall closure takes
longer to heal (in some cases more than 6 weeks), unstable skin
coverage which left sloughing of the grafted skin, contracture of
the skin graft, and other complications that may emerge,
particularly after post closure radiation therapy. This technique
is not a suitable option for large chest wall defects. 6
The horseshoe flap technique proved that it could be
applied from small defects into large defects with minor
complications. The largest diameter which had already been
tested was a 26-cm skin defect. We assured that this technique is
applicable in variable sizes but further trials are needed along
with defining indications and contraindications in utilizing the
horse-shoe flap. LD muscle flap is one of the most frequent
techniques used for chest wall coverages. The LD muscle is the
largest muscle located throughout the chest area.3 LD flap is often
used as a choice for autologous breast reconstruction and to
salvage previous failed breast reconstruction. LD can be safely
applied for patients who underwent radiation therapy prior to
breast conservation therapy. LD can also be applied for multiple
breast sizes which can leave various size defects post-
mastectomy. Some LD flaps can cause complications; one of the
most common is seroma formation, particularly in patients with
extended LD flaps. Other common complications include wound
separations and dehiscence, skin flap necrosis, shoulder
weakness, restricted affected arm movements, and dorsal hernia. 7
The horse-shoe flap reconstruction can facilitate patients with LD
flap, particularly patients with large primary defects, to
completely cover all resected areas. Combined with LD flaps, all
defects from large radical mastectomies or even secondary
defects, taken from extended LD reconstruction can be safely
covered. Further trials and reports for these combined
reconstruction techniques are needed.
81
For almost 40 years, pedicled transverse rectus
abdominis musculocutaneous flaps have been widely used and
performed in breast cancer patients, routinely performed by
plastic surgeons and oncologists worldwide. This autologous
chest wall reconstruction can be offered to patients with a body
mass index below 30 kg/m and with enough adipose tissue on
their abdominal area.2,7 It can be divided into two techniques,
pedicled transverse rectus abdominis musculocutaneous
(TRAM) flap which maintains superior epigastric vessels as its
vascular supply or free TRAM flap. This TRAM technique
leaves an additional scar in the abdominal area while also
requiring longer operating time and hospitalization. Partial flap
necrosis, breast asymmetry, and hernia are the most common
complications found from this technique.8
One of the complications mentioned above from horse-
shoe flap is also partial flap necrosis, but it can be easily managed
by removing it partially by removing the necrotic edges and
stitching all the edges back with a simple suture. For the next 30
days, the flap was still viable after necrotic skin removal. This is
due to the fact that horse-shoe flap has multiple perforator
vessels, bringing more vascular supply needed for flap safety and
larger area coverage. Some authors mentioned about the
development of local recurrence following mastectomy and
autologous breast reconstructions in patients with malignant
breast cancer. One observation study by Wu et al revealed 11
patients (of 397 samples) with local recurrence after autologous
breast reconstruction, with most of them were reconstructed
using LD flap. The median time needed for local recurrence to
develop was 2.9 years.9 Other retrospective study by Mirzabeigi
et al also reported a total of 41 patients with locoregional
recurrence after mastectomies and breast reconstructions, 13 of
them used implant reconstruction, and 17 patients underwent
autologous breast reconstructions.10
82
This particular topic is the main focus of the study, as we
have not done any survival analysis in our patients with horse-
shoe flap. Although other risk factors contributed to locoregional
recurrence events, we would like to investigate whether this
reconstruction technique can be one of the protective factors
related to locoregional recurrences. One of the newest
breakthrough methods, which is widely and frequently used, is
adjacent tissue coverage where local tissues are rearranged as
flaps to cover skin defects as an alternative to skin grafts and free
flaps.6 It can be used in patients with larger defects and is much
simpler than mentioned above. The most common adjacent tissue
flap and the most famous is the keystone flap, widely used in
dermatologic surgery. It relies on musculocutaneous and
vascular perforators and flaps base, increasing its reliability, as
blood flow is the key factor for flap’s tenacity. 11 Keystone flap,
as one of the adjacent tissue coverages, has many advantages. It
can be applied in almost every body region, has a simple design,
and is easy to master.12
Similar to the keystone flap, the horse-shoe
reconstructive technique also has a simple design and is easy to
perform. We have not tried this flap technique for defects in other
body regions. Further study and trials are needed to verify its
application for other defect closure. Visually, the major
difference between the keystone island flap and our horse-shoe
flap is the design. Keystone flap can be applied by creating an
elliptical shape defect, while the horse-shoe flap is designed from
a circular shape. Both designs are easy to create but theoretically,
circular shape defects are safer since it removes more adequate
tumor margins than elliptical shape defects. Based on the
author’s knowledge, there are no case reports regarding the usage
of keystone flaps for post-mastectomy chest skin defects or
breast-conserving therapy. One interesting advantage of this
circular shape adjacent flap reconstruction is the availability of
83
surrounding healthy tissue that can be taken as a flap. Keystone
flap only relies on the skin under the elliptical incision, and the
flaps below will be advanced upward to close the defect.
The horse-shoe flap offers variable options, where it can
use all of the surrounding tissues, depending on the defect’s
diameter and angle from the center circle. Based on these factors,
the adjacent flap can be taken from under the incision and can be
taken from any direction around the defects. Based on the
author’s experience and knowledge, there is not any
reconstruction technique, especially the adjacent flap technique
which provides every angle of surrounding skin as an available
flap to date.
Conclusion
Our novel horse-shoe flap technique proved to be an
excellent option for closing chest skin defects. It can be applied
for variable defect sizes with minor complications. The
horseshoe flap, as mentioned above, has multiple perforators,
leading to better flap viability and a broader coverage area. As
one of the adjacent tissue coverages, this reconstruction
technique is easy to apply and perform. It offers freedom to every
surgeon, as this technique can provide all surrounding skin to be
a usable flap. This simple method of breast reconstruction breaks
every boundary and limitation that surgeons have faced before.
It opens new paths regarding safer and fewer complications
breast reconstruction. Several trials are needed to evaluate the
strengths and weaknesses of our flap technique. Further study
regarding this technique will be expected in the future.
Conflict of Interest
None declared.
84
References
1. Mansour KA, Thourani VH, Losken A, et al. Chest wall
resections and reconstruction: a 25-year experience. Ann
Thorac Surg 2002;73(06):1720–1725, discussion 1725–
1726
2. Billington A, Dayicioglu D, Smith P, Kiluk J. Review of
proceduresfor reconstruction of soft tissue chest wall
defects following advanced breast malignancies. Cancer
Contr 2019;26(01): 1073274819827284
3. Merritt RE. Chest wall reconstruction without prosthetic
material. Thorac Surg Clin 2017;27(02):165–169
4. Hamdi M, Craggs B, Stoel AM, Hendrickx B, Zeltzer A.
Superior epigastric artery perforator flap: anatomy,
clinical applications, and review of literature. J Reconstr
Microsurg 2014;30(07): 475–482
5. Alvarado A. Reciprocal incisions for closure of circular
skin defects. Plast Reconstr Surg 1981;67(04):482–491
6. Mehrara BJ, Ho AY. Breast reconstruction. In: Harris
JR, Lippman ME, Morrow M, Osborne CK, eds.
Diseases of the breast. 5th ed. Philadelphia, PA: Wolters
Kluwer Health; 2014: 536–549
7. Bailey CM, Pu LQ. Breast reconstruction with the
pedicled transverse rectus abdominis musculocutaneous
(TRAM) flap. In: Pu LQ. Karp NS, eds. Atlas of
Reconstructive Breast Surgery. Edinburgh, Scitland:
Elsevier; 2020:1–15
8. Vasconez LO, Cerio DR. Autologous reconstruction
TRAM flap. In: Bland KI. Klimberg VS, eds. Master
Techniques in General Surgery: Breast Surgery.
Philadelphia, PA: Wolters Kluwer Health; 2011:439–
441
9. Wu S, Mo M, Wang Y, et al. Local recurrence following
mastectomy and autologous breast reconstruction:
incidence, risk factors, and management. OncoTargets
Ther 2016;9:6829–6834
10. Mirzabeigi MN, Rhemtulla IA, Mcdonald ES, et al.
Locoregional cancer recurrence after breast
reconstruction: detection, management and secondary
85
reconstructive strategies. Plast Reconstr Surg
2019;143(05):1322–1330
11. Wysong A, Higgins S. Basic principles in flap
reconstruction. In: Flaps and Grafts in Dermatologic
Surgery. 2nd ed. Edinburgh, Scotland: Elsevier;
2019:16–17
12. Einstein A. Design principles and the keystone
technique. In: The Keystone Perforator Island Flap
Concept. Sydney, Australia: Elsevier; 201228
86
Endoscopic Third Ventriculostomy For
Pediatric Obstructive Hydrocephalus, 20 Years
Experiences
Prof. Sri Maliawan, MD, PhD, FICS; Dewa Putu Wisnu
Wardhana, MD
Neurosurgeon. Faculty of Medicine, Udayana University.
Abstract
Background: Paediatric obstructive hydrocephalus is a
relatively prevalent condition that may cause significant social
and financial burdens. Current standard management is
ventricular shunting with implantation of various
ventriculoperitoneal (VP) shunt devices. This procedure is costly
and has high complication rate. Endoscopic third
ventriculostomy (ETV) is available as an option and considered
to be superior to VP shunt.
Methods: All of the paediatric obstructive hydrocephalus cases
admitted to Sanglah General Hospital between 2005 until 2016
that were treated by ETV were described.
Results: In 184 cases of ETV procedure in Sanglah General
Hospital for paediatric obstructive hydrocephalus we have 92.6%
of success rate. The complications are quite low, one patient
(0.5%) died because of bleeding; two patients (1%) suffered
wound infection, one person (0.05%) had meningitis and
Cerebrospinal Fluid (CSF) leakage on three patients (1.6%). ETV
cannot be done in eight patients (4.3%) due to the unidentifiable
third ventricle.
Conclusion: ETV is a simple yet effective procedure for
paediatric obstructive hydrocephalus. Knowledge about
intraventricular anatomic variations is very important in order to
provide high success rate and low risk of complication.
87
Keyword: ETV, VP shunt, Congenital Hydrocephalus
Introduction
The incidence of congenital hydrocephalus is around 2
cases per 1000 live births. There are 812 cases of congenital
hydrocephalus in Bali and Nusa Tenggara from 1992-2006 with
an average of 4 patients per month. Most of the patients (80%)
are categorized as obstructive (non-communicating)
hydrocephalus due to the blockade on CSF flow. Without proper
treatment, most patients will either die or severely disabled.1
Implantation of ventricular shunt systems such as VP
shunt and ventriculoatrial shunt is the conventional therapy for
hydrocephalus. It has several possible complications such as over
or underdrainage, shunt malfunctions, and infections.2
Complications could not entirely be prevented. Endoscopic Third
Ventriculostomy (ETV) showed its superiority compared to
ventricular shunting, by avoiding shunt-related
2,4,5,19,20
complicatons. It is conducted by creating CSF diversion
through basal cistern and subarachnoid spaces thus bypassing the
cerebral aqueduct. ETV procedure is cost less. 2,3,4,7,16
The success of the ETV is very dependent on the
selection of patients. Complications occur only in those who
work on the first 100 cases of the procedure. After that, the
possibility of complications is minimal so that ETV is currently
the first-choice therapy for obstructive hydrocephalus. 2,4,5,16 This
article was based on our personal experiences in treating 184
hydrocephalus patients using ETV.
History of Ventriculostomy
Ventriculoscopy was first introduced by Walter E.
Dandy in 1900 for the therapy of hydrocephalus.18,19 He is the
first person using the first plexectomy in order to perform
endoscopy in patients with communicating hydrocephalus. He
88
also developed the basic subfrontal approach to open the base of
the third ventricle.19
This procedure was accompanied by high mortality and
morbidity rate. In 1923, William Mixter worked on ETV using
urethroscope. Tracy J. Putnam modified so that it met
requirements as ventriculoscope which could be used to cauterize
the choroid plexus in children with hydrocephalus.19
However; valve regulated shunt system was then
discovered and considered simpler. This new technique was
deemed a huge success, causing ETV techniques did not progress
for the next 30 years. In 1947, H.F. McNickle introduced
percutaneous ETV technique which lowered the number of
complications and increase the success rate. The 1970s
leukotome was added to widen the perforation at the base of the
third ventricle without resulting in trauma to the surrounding
structures. Development of manufacturing technology and fiber
optic lenses allowed the development of small neuroendoscope
with arrange possible edges and excellent optical resolution. As
a result, ETV became the first-choice procedure for treating
obstructive hydrocephalus with the success rate of 50-94%.19
Applications of currently developed ETV techniques are
very broad nowadays. They includes obstructive hydrocephalus
due to aqueduct stenosis, hydrocephalus with
myelomeningocele, hydrocephalus associated with Dandy-
Walker malformation, communicating hydrocephalus, normal
pressure hydrocephalus, hydrocephalus secondary from
intracranial hematoma, secondary hydrocephalus due to
posterior fossa tumours, hydrocephalus after shunt malfunctions,
hydrocephalus associated with fasiocraniosonostosis,
hydrocephalus in patients with tuberculous meningitis and
combination of the Choroid Plexus Cauterization (CPC) with
ETV.7,9
89
Patients candidate
Clinical and radiological investigations are important in
influencing the success rate of ETV. 4 The investigations will
show right and left lateral ventricle widening. The sagittal slices
are needed to confirm that there is enough distance between the
clivus and basilar artery (AB) from the base of the third ventricle
so that the endoscope can enter safely into the third ventricle,
allowing it to move safely without risking injury to the lateral
wall of the third ventricle. Age, etiology of hydrocephalus,
previous installation of VP shunt and meningitis are the relative
contraindication for ETV. 14
It is possible to perform ETV on small or slit-like
ventricular system caused by the previous installation of a VP
shunt. Consideration should take on infants less than six months,
the slit-like ventricle form, thin cerebral mantle and
communicating hydrocephalus because of the low success
rate.10,17
Figure 20 Anatomic variations and steps during ETV

(Maliawan & Wisnu Wardhana, 2017)
Endoscopic Anatomy of the Ventricles
90
Being accustomed to the anatomy of the ventricle system
is crucial.2,4,7,8 Foramen of Monro is the most often first seen
structure. It is a pair of foramen that connects the lateral ventricle
with the third ventricle. The head of the caudate nucleus is
located on the lateral side, while septum pellucidum is located on
the medial side. If followed on top of choroid plexus, it will lead
to the foramen of Monro. Vein of septum pellucidum is
positioned at the anteromedial, delivering venous blood to
thalamostriate vein located on the posterolateral side of posterior
edge foramen of Monro, then to the internal cerebral veins that
run on tela choroidea of the third ventricle. A pair of Fornix
shaped like the letter C is an efferent-output bundle that connects
the hippocampus with mammillary bodies. 4
When the endoscope enters the third ventricle, there is a
landmark, lateral wall that is consist of the two third of the
anterior thalamus and hypothalamus related to the gray matter at
the base of the third ventricle. The edges of the leb and right
lateral third ventricles connect to intermediate mass by a band of
gray matter. The posterior edge consists of the pineal body,
habenular commissural, posterior commissural and cerebral
aqueduct. Cerebral aqueduct is a channel connecting the third and
fourth ventricles. The fourth ventricle is approximately 15 mm in
length and 1 mm in diameter. The base of the third ventricle is
formed primarily by the hypothalamus. There are some recess
and prominence for the landmark: optic recess, chiasma
opticum, infundibulum, tuber cinereum, and mammillary
bodies. In the majority of cases, the base of the third ventricle
(tuber cinereum) is thin and translucent. The location of
interpeduncular fossa (pons cistern) is below the base of the third
ventricle. CSF streamed from the third ventricle to the
interpeduncular fossa with endoscopy guidance. 4 Variations in
the anatomy of ventricles are found in more than one-third of
the cases. Variations of the thickness of the floor and its position
91
are the most common.4 Etus et al. (2016) reported
intraventricular anatomical variations that includes thick and
prominent intermediate mass, narrow tuber cinereum, hollow or
thick floor of the third ventricle, small anterior chamber of the
third ventricle, existence of interhypothalamic adhesions,
vascular floor of the third ventricle, and existence of adhesions
or bridges between mammillary bodies.8
Instruments
There are various devices for ETV procedure.4 We
emphasizes for using one type or brand of the instrument only
until the operators are comfortable with those tools. The tools
consist of rigid rod lens endoscope with a diameter of 4.2 mm, a
disposable endoscope with 13 cm rigid shaft and 2.1 mm working
channel, 30-degree optic lens, control panel (contains a video
camera, an optical coupler, a xenon light source, video recorder,
and printer), 2 French ventricular cannula, Bugbee wire,
monopolar cautery, No. 4 Fogarty balloon catheter. Warm ringer
used for irrigation during the procedure.
.Figure 21 Location of Fenestration
92
Figure 22 Anatomical variations Liliequist membrane; normal
and thick.
(Maliawan & Wisnu Wardhana 2017)
The Procedure
The success of the ETV depends primarily on
recognition and understanding of ventricular system anatomy
and its variations on hydrocephalus state. After general
anaesthesia, the patient is placed in the supine position with the
head about neutral position laying on the doughnut-shaped
pillow. The head is then elevated 30 degrees, and position of the
burr hole should be at the highest point to prevent excessive
drainage of CSF, anatomical distortion and air influx during the
procedure.1,3,4
A single 6-10 mm burr hole is placed 3 cm from the
midline (about the mid pupillary line), 1 cm anterior to the
coronal suture (Kocher point) where the normal lateral ventricle,
foramen of Monro projected.1,3,4 Dura mater is opened
curvilinearly followed by insertions of 14 French peel-away
catheters for cannulation of the lateral ventricle. The insertion is
directed, on anterior to posterior projection, towards the medial
canthus of the ipsilateral eye and, on lateral projection, towards
the external acoustic meatus.1 Endoscopy was directed into
lateral ventricle with gentle traction, without causing trauma to
the brain. The average distance from dura mater to the foramen
of Monro is 6 cm in adults. Some neurosurgeons choose the
flexible endoscopy to maximize manoeuvrability, but we prefer
rigid endoscope.1,3
93
Next step is the identification of foramen of Monro.
Subsequently, the endoscope is directed to enter the third
ventricle. The base of the third ventricle is approximately 9 cm
from the dura mater. The length is highly variable depending on
age and severity of hydrocephalus. Next is the identification of
mammillary bodies and the infundibulum. Sometimes basilar
artery (BA) can be seen clearly through the thin and translucent
base of the ventricle.3,4
At this point, the neurosurgeon should perform
fenestration using Bugbee wire without or with monopolar
electrocoagulation in front of the BA at the base of the third
ventricle, between the mammillary bodies and the infundibulum.
After that, the Bugbee wire is removed, followed by insertion of
no. 4 Fogarty balloon catheter into the stoma. The balloon is
inflated very gradually using 0.2-0.4 ml of normal saline to widen
the stoma. Balloon dilatation will expand the stoma to achieve
about 5 mm in diameter. Incorrect balloon placement during
inflation can lead to uncontrolled bleeding.3
The thick Liliequist membrane may prevent the flow of
CSF even after fenestration of the base of third ventricle. Ensure
there is no obstructing arachnoid membrane. Do not be too
aggressive in exploring the prepontine cistern because it could
damage the perforating artery or its branches. Identify the BA,
stalk hypophysis sometimes visible.1,4,17
Undulation (flappy movement) from the edges of the
stoma indicates adequate CSF flow. There is one case of redo
ETV in Sanglah General Hospital. The stoma was intact, but the
Liliquist membrane was not opened. Aber conducting further
fenestration, the patient did not need any shunt. Fenestration of
the base of ventricles may use the endoscope itself, laser, or
monopolar and bipolar cauterization. Once the endoscope
removed, foaming gel is used to cover brain parenchyma
corticotomy continued with galea closure using absorbable
94
suture, and the skin with nonabsorbable interrupted suture or skin
staples.3
If there is significant intraventricular haemorrhage,
placement the EVD (external ventricular drainage) maintained
for 1-2 days is mandatory. The shunt that was previously
implanted is removed, and clinical observation must be
performed during 3-5 days.3
If there are still signs of increased intracranial pressure,
consider performing a lumbar puncture. Withdraw
approximately 10-20 cc of CSF. It can be repeated two times for
two weeks. If there is no clinical improvement, ETV is
considered failed, and the patient is classified as shunt
dependent.4
Postoperative care
The patient should be observed in intensive care unit for
at least one day. The patient can usually be discharged on the
second or third day after the procedure. Head CT scan
performed during early post-ETV period showed that ventricle
size does not decrease significantly in the most of the patients,
compared with shunting procedure.4,5,12 When discharged, the
patient should be free from the pain of the head without major
fontanelle bulging. Patients who had previously undergone VP
shunting sometimes takes up to 10 days to adjust to the new CSF
absorption system. Sometimes external ventricular drain (EVD)
is needed.3 Ideally after two months, MRI or CT scan may show
the narrowing of the ventricular system and the disappearance of
periventricular edema. Cine-phase contrast MRI may reveal the
patency of the stoma directly, so it could be useful as an indicator
of favourable outcome following the third ventriculostomy. 4,6,12
An elastic bandage is arranged on the head so that the
shape of the head is not flat. If regularly adjusted, it may help
shrinking head circumference significantly. Treatment failure is
95
considered if after two weeks the symptoms of high intracranial
pressure persist and after two times lumbar puncture performed.
Table 3 Calculations of the ETVSS based on age, etiology and

previous Shunt
Table 4 Complications of ETV Procedure in Sanglah General

Hospital (2005-2016)
Outcome and Predictors

The success rate of third ventriculostomy procedure is
71-85% on obstructive hydrocephalus cases.2,4,6 Gorayeb et al.
(2004) demonstrated lower success rate (64%) in children under
one-year-old.13 Higher success rates already reported for patients
with stenosis of the aqueduct.6,7 Secondary ETV proved to be a
viable option in the management of shunt malfunction with a
success rate of 66% which is comparable to primary ETV. 3
Endoscopic third ventriculostomy success score (ETVSS) can
be used to predict the outcome of the procedure. 14
The ETVSS ranged from 0 to 90. The sum of the score
roughly shows the success rate of ETV after six months post
96
surgery. Patients are classified based on high ETVSS (80-90),
moderate ETVSS (50-70) and low ETVSS (score under 40).14,15
Analysis of 15 articles regarding ETV showed success rate
ranged from 31.3%-92.3%. Incorporation of these data with
predicted ETVSS revealed that the result is significant with
success score is between 41.3% to 85.4%. 15
Possible complications
Potential complications of ETV includes leakage of CSF
from the location of the incision, injury to fornix, thalamus,
hypothalamus or basilar artery (causing Intraventricular
bleeding), obstruction of a previous patent stoma, upward brain
herniation, and infection. The mortality rate of ETV ranged 1.1-
1.8%.2,5,6,11,14 Most significant complications of ETV are only
transient. The rate of major complications varies around 7% of
the cases with only one-sixth of them leading to permanent
neurological damages.4,7 The third ventriculostomy-related
complications usually occurs during the initial 3-6 months after
procedure, comparable with life-time risk of shunt-related
complications.14
In 184 cases of ETV in Sanglah General Hospital for
obstructive hydrocephalus, we experienced very low
complications rate (Table 1). ETV procedure cannot be done in
eight patients (4.3%) due to unidentifiable third ventricle.
Intraventricular bleeding usually occurs in the first 100 cases
(related to operator’s experiences and learning curve).
Postoperative complications are known to be minimal in
experienced hands.2
Shunting procedure carries a higher risk of postoperative
infection compared with ETV. There are significant lower
amount expression of CSF proinflammatory markers (IL-1ß, IL-
6, and Neural Growth Factor/NGF) on seven days after ETV
97
compared with VP shunt on children with obstructive
hydrocephalus.16
Conclusion
ETV should be considered as the first option on all
obstructive hydrocephalus and most of the nonobstructive
hydrocephalus to avoid shunt-related complications. Correct
patient selection and precise intraventricular orientation are very
important for the preoperative planning and during the
procedure. In our experiences, ETV has a small percentage of
failures and complications. This procedure can be the first choice
treatment for pediatric obstructive hydrocephalus.
References
1. Rincon-Torroella J, Chaicana KL, Quinones-Hinojosa
A. 2017. Endoscopic approach to the ventricles. In:
Quinones-Hinojosa A, editor. Video atlas of
neurosurgery. Contemporary tumor and skull base
surgery. First edition. Elsevier Inc. p93-100.
2. Ali M, Usman M, Khan Z, Khan KM, Hussain R,
Khanzada K. 2013. Endoscopic third ventriculostomy
for obstrutive hydrocephalus. J Coll Physicians Surg
Pak.,40:338-341
3. Negm HM, Habib HA. 2015. Secondary endoscopic
third ventriculostomy for shunt malfunction. Egyptian
Journal of Neurosurgery., 30:13-18.
4. Di Rocco C, Cinalli G, Massimi L, Spennato P,
Cianciulli E, Tamburrini G. 2006. Endoscopic third
ventriculostomy in the treatment of hydrocephalus in
pediatric patients. Adv Tech Stand Neurosurg., 31:121-
219.
5. Vinchon M, Rekate H, Kulkarni AV. 2012. Pediatric
hydrocephalus outcomes: a review. Fluids Barriers
CNS., 9:18
6. Salvador SF, Oliveira J , Pereira J,Barros H,Vaz R. 2014.
Endoscopic third ventriculostomy in the management of
98
hydrocephalus: Outcome analysis of 168 consecutive
procedures. Clin Neurol Neurosurg., 126:130-136.
7. Cinalli G and Spennato P. 2014. Controversies in the
endoscopic management of various forms of
hydrocephalus. In: Sgouros S, editor.
Neuroendoscopy.,First edition. Springer- Verlag Berlin
Heidelberg. p47-56.
8. EtusV,GulerTM,KarabagliH.2016.The ventricle or
variations and abnormalities in myelomeningocele-
associated hydrocephalus: our experience with 455
endoscopic third ventriculostomyprocedures. Turk
Neurosurg.,1-4.
9. Rajshekhar V. 2009. Management of hydrocephalus in
patients with tuberculous meningitis. Neurol India.,
57:368-374.
10. Ndoumbé A, Motah M, Takongmo S. 2015. Endoscopic
third ventriculostomy for nontumor obstructive
hydrocephalus in children under two years of age.
Journal of Modern Neurosurgery., 5:100-105.
11. Ndoumbé A, Simeu C, Motah M. 2015. Non-tumor
obstructive hydrocephalus treated with endoscopic
third ventriculostomy in Cameroon. Journal of Modern
Neurosurgery., 5:137-143.
12. Nikas DC,Post AF, Choudhri AF, Mazzola CA, Mitchell
L, Flannery AM. 2014. Pediatric hydrocephalus:
systematic literature review and evidence-based
guidelines. Part 10: Change in ventricle size as a
measurement of effective treatment of hydrocephalus. J
Neurosurg: Pediatrics (suppl)., 14:77-81.
13. Gorayeb RP, Cavalheiro S, Zymberg ST. 2004.
Endoscopic third ventriculostomy in children younger
than 1 year of age. J Neurosurg (Pediatrics 5).100:427–
429.
14. Kulkarni AV, Drake JM, Kestle JRW, Mallucci CL,
Sgouros S, Constantini S and The Canadian Pediatric
Neurosurgery Study Group. 2010. Predicting who will
benefit from endoscopic third ventriculostomy compared
with shunt insertion in childhood hydrocephalus using
99
the ETV Success Score. J Neurosurg Pediatrics., 6:310–
315.
15. Kulkarni AV, Riva-Cambrine J, Browd SR. 2011. Use
of the ETV Success Score to explain the variation
in reported endoscopic third ventriculostomy success
rates among published case series of childhood
hydrocephalus. J Neurosurg Pediatrics., 7: 143-146.
16. Maliawan S, Mahadewa T, Islam AA, Bakta IM. 2008.
Comparison of Endoscopic Third Ventriculostomy
(ETV) and ventriculoperitoneal shunting techniques in
obstructive hydrocephalus: The significance of clinical
finding and cerebrospinal fluid interleukin-1B,
interleukin-6 and neural growth factor. J Peny Dalam.,
9:1-10.
17. Fritsch MJ, Kienke S, Ankermann T, Padoin M,
Mehdorn M. 2005. Endoscopic third ventriculostomy in
infants. J Neurosurg (Pediatrics 1)., 103:50-53.
18. Jallo GI, Kothbauer KF, AbboM IR. 2005. Endoscopic
third ventriculostomy. Neurosurg Focus., 19:E11.
19. Rachel RA. 1999. Surgical treatment of hydrocephalus:
A historical perspective. Pediatr Neurosurg., 30:296-
304.
20. Limbrick DD, Baird LC, Klimo P, Riva-Cambrin J,
Flannery AM. 2014. Pediatric hydrocephalus:
systematic literature review and evidence-based
guidelines. Part 4: Cerebrospinaluid shunt or endoscopic
third ventriculostomy for the treatment of hydrocephalus
in children. J Neurosurg Pediatrics (Suppl)., 14:30-34.
21. Li C, Gui S, Zhang Y. 2017. Compare the safety and
efficacy of endoscopic third ventriculostomy and
ventriculoperitoneal shunt placement in infants and
children with hydrocephalus: a systematic review and
meta analysis. Int J Neurosci., 1-30.
100
The Challenges of Performing Surgeries
During The New Normal Era
Ida Bagus Putra Pramana, MD
Urologist. Faculty of Medicine, Universitas Udayana.
The world has determined that Covid-19 is a pandemic

disease, while the Indonesian government announced that Covid-
19 is a non-nature-related disaster on March 13th, 2022. As a
result, the Covid-19 pandemic situation gives numerous
challenges to the National Health System to continue serving a
high-quality healthcare facility while preventing health workers
from being exposed to the infection transmission. Surgeons will
be exposed to Covid-19 by inhaling aerosol particles and having
contact with patients’ blood and body liquid during the surgical
intervention. Nosocomial infection occurred in surgeons and
other health workers through surface contact, droplets, or aerosol
spray causes changes in the implementation of surgical
intervention regularly.
The previous study that was conducted in Indonesia
compared the surgical interventions performed 3 months before
lockdown and 3 months after lockdown. It was found that there
was a decreasing number of surgical interventions performed in
the following units: oncological surgery, digestive surgery,
pediatric surgery, cardiothoracic surgery, plastic and
reconstructive surgery, neurosurgery, orthopedics and
traumatology, and urology. The study that was conducted in
America found a decreasing number of surgical interventions
from January to December 2020 if it was compared to the number
before the COVID-19 era in the same period, January to
December 2019. The average decrease was 10.2 %.
However, in this new normal era, there is an increasing
number of surgical interventions in 11 major categories of
procedures and 25 sub-categories by comparing the period of
101
October 2020 to January 2021 and the period of March to May
2020. This shows that our health system has adapted to the
existing pandemic condition with the improvement in the
regulations and infrastructures.
Patients of Outpatient Facility

The initial examination was performed at the triage to the
patients who visit the healthcare facility, and a special clinic is
provided for patients who have fever as their complaint. The
option “reducing the polyclinic visit” is not the best option as it
may cause the patients to come with progressive disease. The
initial polyclinic screening includes a temperature check and
requires the visitors to wear a mask. The doctors who perform
the examination in the unit are required to wear an N95 mask and
face shield. CDC has recommended the use of telemedicine for
patients in an outpatient facility. The patients of an outpatient
facility are also recommended to keep a safe distance and only
be accompanied by one person (wearing a mask), minimize the
document exchange, and arrange a specific time for a visit for the
patients with a high risk, such as parents, children, and pregnant
women.
Surgical Intervention
Surgeons will be exposed to Covid-19 infection during the
intervention performed in the operating room. The duration to
complete a specialist education is quite long, so finding a
replacement specialist becomes more difficult. The screening
process that is vital to be performed during the pandemic is the
PCR test. The area with high transmission is required to perform
the following actions:
• All patients who will have a surgical intervention are
required to have the Covid-19 screening test
102
• All patients are required to have a PCR test before the
surgical intervention; in some regions where the PCR
test cannot be performed, the antigen test can be done
instead.
• For patients who will have an elective surgical
intervention, the surgery needs to be delayed until they
recover from Covid-19.
The actions that need to be performed in the area with a low
transmission include:
• All patients must perform a screening test for the
COVID-19 symptoms.
• The patients with the Covid-19 symptoms are required
to have additional/supporting tests besides PCR or
Covid-19 antigen tests.
Several things that need to be considered by health workers in
the operating room are as follows.
• There are still several possibilities of the covid-19 virus
transmission during open surgery, laparoscopic, and
robotic surgery.
• Be careful of aerosol particles.
• There is a possibility of an increasing number of
migrating viruses.
Operating Room
Health protocols for surgeons and the staff are needed to
improve the safety in the operating room to prevent coronavirus
transmission. Not only the operating room but also the outside
needs to be maintained to prevent virus transmission among
health workers. The operating room should need more than 25
air exchange cycles per hour. The Air Handling Unit (AHU) or
Heating, Ventilating and Air Conditioning (HVAC) is crucial to
minimize the risk of virus infection risk. The operating room is
usually designed to have a positive pressure to prevent the
103
occurrence of intraoperative contamination. The size of
coronavirus is 125 nm and can be filtered using a High-
Efficiency Particular Air (HEPA) filter. This Air Handling
Unit/HVAC can be combined with a high-frequency air
exchange to decrease the possibility of coronavirus transmission.
The current system of an operating room that is adapted to
the pandemic era can be seen in Figure 1. As far as we know, an
operating room has a positive pressure and has no possibility to
change the condition of the operation room that has been built
before the pandemic era. Therefore, the thing that can be done is
to add an anteroom before entering the operating room.
Anteroom has a negative pressure that can take the air out to
prevent the Covid-19 infection.
Figure 23 the Anteroom is located between the Operating Room

Theatre and Corridor
104
Figure 24 The Air Handling Unit/AHU or Heating, Ventilating
and Air Conditioning/HVAC in the operating rooms in
Udayana University General Hospital where the air from the
outside through 3 filters and HEPA filters before entering the
operating room.
105
I
Figure 25 The Flow Chart and the Design of an Operating

Room in Udayana University General Hospital in the New
Normal Era. There is a Red Zone where people who wear a
level-3 PPE can enter the room, there are two anterooms with a
negative pressure to prevent the spread of Covid-19 infection.
The figure above shows the workflow for handling Covid-19
and non-Covid-19 patients. It can be seen from the figure that
there are two different workflows.
American College of Surgeons issued a guideline in

determining a surgical intervention based on the local prevalence
condition, namely depending on the number of Covid-19
patients, the resources at a hospital, and the availability of a
ventilator in the ICU.
The number of staff in the operating room is fully
protected to minimize the risk of being infected. Performing a
surgical intervention using a set of PPE is a difficult condition
and can increase the error risk and medical errors. The Covid-19
screening can be done by distributing questionnaires, checking
the temperature, and RT-PCR for Covid-19 and thorax images.
Emergency patients with several Covid-19-related symptoms
will be treated as patients with suspected Covid-19.
106
The surgery with the aerosol risk should be equipped with
complete personal protective equipment without seeing the RT-
PCR result. The informed consent should be revised and updated
based on the informed consent filled out by the Covid-19
patients. Besides Covid-19 screening for the patients, the hospital
needs to perform a regular Covid-19 screening for the doctors
and other health workers to prevent infection transmission from
happening among the hospital staff.
Challenges of Performing Surgeries during the Pandemic

Era
The number of health workers is declining as they are
infected with Covid-19 which requires them to be isolated. The
operating room will be extremely different for several conditions,
such as a minimum number of staff, uncomfortable PPE, the
surgery that needs to be led by a consultant doctor, and the use
of level-3 PPE, which will result in a more difficult
communication among staff, unavailability of non-verbal
communication using facial expressions.
These actions aimed to minimize the risk of health
workers being exposed to Covid-19, fulfill the health workers’
needs, and arrange a backup plan if there is an escalating number
of cases. The use of good communication in a team can prevent
the occurrence of job duplications and keep the team members
continuously receiving the information.
107
Table 5 The Interventions that are Classified into Aerosol
Generating Procedure (AGP)
The staff should get access to PPE. The regular

procedures, such as replacing feeding tubes, tracheostomies, and
general stomas (related to the high risk of transmission), need to
be performed by experienced staff. The use of PPE is an
unpleasant thing to be experienced by surgeons as it will make
them feel uncomfortable during the surgical intervention and
may increase technical errors.
The regular screening conducted towards health workers
needs to be performed through the committee of the
Occupational Health and Safety division in their hospital.
However, this may cause a problem, especially for asymptomatic
health workers with a positive result in the swab test. They will
be required to perform self-isolation and cause a decreasing
number of health workers who work in the hospital.
This pandemic condition also challenged the process of
residencies, such as many cancellations of elective surgical
intervention, the surgery performed by consultant doctors, a
limited number of PPE, and the procedure to minimize the
number of surgical staff who enter the operating room.
108
Conclusion
• The need for starting to adapt to the new normal era
amidst the Covid-19 condition
• A good screening process for patients using both PCR
and Antigen must be performed on patients who will
have a surgical intervention.
• The new regulation on the management of screening up
to the surgical intervention towards the Covid-19
patients’ needs to be performed.
• A good screening process in distinguishing Covid-19
patients and non-Covid-19 patients can increase the
efficiency and the effectiveness of surgical intervention.
References:
1. Wisni, A., 2021. Operating Room Management in the
Pandemic Era. Budapest International Research and
Critics Institute (BIRCI-Journal), 4(4), pp.13307-
13312.
2. Huda, F., Kumar, P., Singh, S., Agrawal, S. and Basu,
S., 2020. Covid-19 and surgery: Challenging issues in
the face of new normal – A narrative review. Annals of
Medicine and Surgery, 60, pp.162-167.
3. Wielogórska, N. and Ekwobi, C., 2020. COVID-19:
What are the challenges for NHS surgery?. Current
Problems in Surgery, 57(9), pp.1-23.
4. Milone, M., Carrano, F., Letić, E., Shamiyeh, A.,
Forgione, A., Eom, B., Müller-Stich, B., Ponz, C.,
Kontovounisios, C., Preda, D., Ignjatovic, D.,
Cassinotti, E., Yiannakopoulou, E., Theodoropoulos,
G., Faria, G., Morelli, L., Gorter-Stam, M., Markar, S.,
Arulampalam, T., Velthoven, T., Antoniou, S. and
Francis, N., 2020. Surgical challenges and research
priorities in the era of the COVID-19 pandemic: EAES
membership survey. Surgical Endoscopy, 34(10),
pp.4225-4232.
109
5. Sandhu, H., Rai, A., Huda, F., Ravi, B., Basu, S. and
Mammen, K., 2020. Post COVID-19 return to “new
normal” in surgical care: joining the dots. International
Journal of Surgery: Global Health, 4(1), pp.1-5.
6. Muhammad David Perdana Putra , Kristanto Yuli Yarso
, Ikhdin Saadhi , Yohanes Adinugroho. Surgery
Department during Coronavirus Disease 2019 Virus
Lockdown: Multidepartment Experiences from
Universitas Sebelas Maret. Open Access Macedonian
Journal of Medical Sciences. 2021 Jun 12; 9(E):437-
442.
7. Aviva S. Mattingly, Liam Rose, Hyrum S. Eddington,
Amber W. Trickey, Mark R. Cullen, Arden M. Morris,
Sherry M. Wren. Trends in US Surgical Procedures and
Health Care System Response to Policies Curtailing
Elective Surgical Operations During the COVID-19
Pandemic. AMA Network Open. 2021;4(12):e2138038.
doi:10.1001/jamanetworkopen.2021.38038
110
Ksatria Airlangga Hospitalship,Voyage The
Ocean To Save The Forgotten
Agus Harianto, MD.
General Surgeon. Ksatria Terapung Airlangga Hospital.
Facts
The sad reality is there are so many people in remote
islands who are: neglected, forgotten, left out.
Profile
Yayasan Medika Ksatria Airlangga is a not-for-profit
organization set up 10 January 2017 by the alumni of the Medical
Faculty of Airlangga University. The foundation operates a
floating hospital service called Rumah Sakit Terapung Ksatria
Airlangga.
The floating hospital is purpose-built from scratch in
Galesong-South Sulawesi in the form of a 27-meter by 7-meter
traditional wooden Phinisi ship equipped with modern medical
facilities, including two operating rooms on board.
We conduct comprehensive medical services for the
people who live in remote islands in Indonesia. We send the
floating hospital as well as specialist doctors and the team to try
and alleviate the health problems in their islands for FREE.
111
Figure 26 The Team
Why Phinisi?
● Proven for centuries
● Can reach shallow waters & ports
● Simpler maintenance
● The masterpiece of traditional craftsmen
● Handcrafted from scratch by skillful craftsmen in
Makassar
● Iconic
What do we solve?
Indonesia is a massive archipelagic country with over 17
thousands islands. People in the remote islands may have some
basic medical services through government medical services
called Puskesmas. However, once they need to be referred to
specialists or a hospital, oftentimes, they are either too far; the
travelling and services are too expensive; or it may not even be
possible because of the hazardous sea conditions due to their
remote locations. Hence, we go to their homes in those remote
islands.
Figure 27 Archipelago of Indonesia
112
Figure 28 Number throughout our journey
A Picture of Our Surgery

• 1.400 general surgeries were held
• 1.270 eye surgeries were held
• 110 oral and maxillofacial surgeries were held
Not only Medical Services

RSTKA collaborate with some faculty at Airlangga University
and another campus to take a sustainable community
development program for remote island.
1. Faculty of Advanced Technology and Multidiscipline
Airlangga University
We provide electric bicycles to health professional on the
Gili Iyang island to support environmental sustainability on
the second-best oxygen quality’s island in the world.
2. Faculty of Pharmacy Airlangga University
We plant a medicinal plant based on their benefit at Gili
Iyang as a pilot garden of medicinal plants.
3. Institut Teknologi Sepuluh Nopember and Universitas
Negeri Surabaya
113
Student from ITS and UNESA take an observation in order
to mapping a problems and potency at island. Also to making
a disaster mitigation procedure with the community.
What are the challenges we are facing?

● How to increase awareness. We still face problems with
comprehensive health services in the remote islands. The
lack of health and logistic infrastructures, and the
difficulties to get the service of specialist doctors.
● How to make the foundation more professional, by
defining a clear vision and mission, proper organization
structure, having the right people in the right place, and
control mechanisms;
● How to reposition the foundation from almost 100%
donation-based to become a more social enterprise that
is not 100% donation-dependent?
● We need approximately 300-400 million rupiah per
island in a week to bring some surgeries for FREE.
Figure 29 RSTKA on the news
114
Figure 30 Our Story
We don’t pretend that we are solving the complex health

problems that exists in this vast archipelagic nation, but:
Do to them what you want them do to you
Always help people, you may be the only one who does. Do the
least what you can do now, because the least you can do might
turn out to be the most significant for others” – Lucielle Hanane
Tarejad as quoted by TP Rachmat
We invite the ICS to collaborate this mission
Do you know something inside this hospitalship? Nothing, but

love.
Figure 31 Foundation Accounts
115
Add-On Benefits Through The Collaboration
Among Federations
Prof. Aij-Lie Kwan, MD, PhD, FICS
Neurosurgeon. ICS World President.
World International College of Surgeons (WICS) has

been established for 87 years and subdivided into 6 federations.
Each federation is playing an active role in managing their
relevant programs. Given a few examples of the Collaboration:
European Federation has been working closely with Africa
Federation for years in the surgical mission organized by Dr.
Peter Nussbaumer from ICS Switzerland section. Humanitarian
surgical mission was targeted and became one of the major
policies of WICS during the Presidency of Professor Yikhong Ho
from Australia federation.
Professor Aij-Lie Kwan from Taiwan section advocated
the key success of humanitarian surgery based on the
collaboration among Federations! Ten years ago she initiated to
launch an invitation to Dr. Izabela Chudsizka Strugala (European
Federation), Professor Paul Tahalele (Asian Pacific Federation)
and Professor Aij-Lie Kwan with Dr. Chih-Lung Lin (Asia
Federation). We consolidated our collaboration not only in
humanitarian surgery, but also extended our service with the
inclusion of Health education and Medical Student education.
After 4 years’ field experience of surgical mission in
Ambon, Indonesian, in the meantime America Latin federation
join us since then. We are proud to say that 4 federations have
been working together tightly now. Collectively we had sent one
medical mission in Perú, 3 surgical missions in Indonesian, one
in China, one in Swaziland and one in Paraguay. Totally our data
collected was almost 400 operations done with standard
performances. We are encouraged to broaden the collaboration,
including local health government, organizations and hospitals
116
We, WICS believe team-up together with ICS teams,
local health government and facilities are preponderance for the
success of the Humanitarian Surgical Mission!
117
Ageing Population In World And Singapore –
New Directions In Surgery?
Clement K. Chan, MD, PhD, FICS; Chwee Eng Tan,MD.
Obstetrician and Gynecologist. ICS World Corporate Secretary.
Abstract
Population ageing is a global phenomenon: Virtually every
country has similar ageing population growth. For those aged 65
or above, it was around 6% world population in 1990, rising
to703 million (9%) in 2019 and expected to be 1.5 billion (16%)
in 2050.
Population ageing fastest in Eastern & South-Eastern Asia, and
Latin America & Caribbean. For E & SE Asia, it was around 6%
of the population in 1990 rising to 11% in 2019. For Latin
America & Caribbean, it was around 5% in 1990, rising to 9% in
2019. From 2019 to 2050, share of elderly projected increased to
2 folds in E & SE Asia, Central & S Asia, N Africa & W Asia,
& Latin Am. & Caribbean.
Population ageing will put increased financial pressure on old-
age support systems. Population ageing does not lead inevitably
to macroeconomic decline—with well-chosen policies, opposite
may be true.
In Singapore, the increase in life expectancy plus decrease in
birth rates leads to an aging population with unfavorable old aged
support ratio. In 2018, Singapore is one of highest life
expectancies in world. In 2017, Singapore showed lowest fertility
rate in world (0.83 children/woman). In 2035, it is estimated that
32 % Singaporeans will be aged 65 or above. The median age is
39.7 in 2015 increasing to 53.4 in 2050. The demographic shift
in Singaporean society means there is decreased workforce to
support the ageing population and less support from the family
as young generation tends to live away from parents
118
Problems of Surgery in Elderlies
While there are many reasons for increased risks of
surgeries in terms of mortality, complications, morbidities and
long-term ill consequences, there are 3 prominent ones: frailty,
polypharmacy, and comorbidities
New Directions in Surgeries for elderlies:

While the increased risks are well recognized, a good
surgical team should never be scared to take up the challenge and
adopt an attitude of avoidance. Instead, special and SEPARATE
MODE of management should be directed to surgeries in
elderlies. The lecture would discuss under 4 areas: preoperative
of perioperative management, anesthesia, surgery, and
postoperative management
119
Humanitarian Medical Care 2022
Izabela Chudzicka-Strugala, MD, PhD, MBA
Medical Microbiologist. ICS European Federation Secretary.
So far, humanitarian aid has been associated with

bringing aid to the people in need from poor countries with
meager socio-economic conditions. For many years, together
with Prof. Ajli Kwan, I have organized many similar missions
both in Asia and South America. Their main goal was to provide
medical help. For many years, as part of my charitable activity, I
have been taking care of the social emergency in which I treat the
homeless. This point of view has changed when the war in
Ukraine broke out on February 24, 2022. The whole world was
shocked by the situation that is happening in Europe, just outside
Poland. It is estimated that almost 5 million Ukrainians came to
Poland in just 5 months. They are mostly women and children. It
seems that the largest wave of refugees took place in February
and March, but every day around 20,000 Ukrainians cross the
Polish border in the hope of receiving help. As medical doctors
and volunteers, we help refugees in a wide range. I support them
at reception points, offering also individual assistance in medical
practice care of a family doctor, internist and pediatric
consultations, I assist in the organization of preventive
vaccinations. Every person looking for health care is received by
us, guided to appropriate diagnostics and properly treated. Apart
from medical assistance, we try to organize the necessary social
support: housing and living, food products, milk mixes for
infants and young children, hygiene products, assistance in
obtaining the necessary documents etc. Thanks to the
cooperation and support from Taiwan (especially professor Ajli
Kwan) and the Hospital in Czarnków (director Bożena
Sadowska) and volunteers Barbara Zwoździak and Iwona
Gołębiewska, I organized the necessary humanitarian aid. We
120
managed to purchase the needed medical materials necessary on
the war front. These were first aid measures for the treatment of
injuries and wounds, dressing materials as well as antibiotics. I
organized medical assistance in many parts of the world. You
have to respond to the needs of your surroundings. Nobody
would have thought before that in the 21st century the needy
would be so close. Every day, come mainly to Poland, people
who are even more devastated by the war, in an increasingly
difficult condition and who have finally managed to get out of
Ukraine, who require more and more comprehensive assistance.
121
Role Of ICS Indonesia Section In The Post
COVID-19 Era: An Opportunity And
Solutions For Achieving Health, Welfare, And
Economic Development To Build Back Better
Prof. Paul L. Tahalele, MD, PhD, FICS1; Fransiscus Arifin,
MD2
1
Cardiothoracic Surgeon. President of ICS Indonesia Section.
2
Digestive Surgeon. Ph.D. Program Student of Airlangga
University
COVID-19 in Indonesia
President Jokowi in September 2021 give instruction to
the people “to learn to live with COVID-19” for future, because
COVID-19 is virus infection, it is self-limiting disease.
(Detik.com, September 10th, 2021). Indonesian Ministry of
Health's tagline “5M” against Covid 19:
1. Wear a mask (wear a mask when leaving the house)
2. Hand washing (washing hands with soap for 40 seconds)
3. Keep a distance (keep a distance of at least 2 meters)
4. Avoiding the crowd
5. Reduce mobility
Campaign by our president Jokowi was spread over

7230 sub-districts in 514 cities in 34 provinces:
“Take care of yourself, Take care of your family, Take care of
the environment
LET’S GO…! Unite against covid!!!
The environment is maintained, the nation state is strong, the
people are healthy”
122
Figure 32
Figure 33
123
Figure 34
Figure 35
Figure 36
124
ICS Indonesia Section Activity Report During Covid-
19 Pandemic
Introduction
The covid 19 pandemic restrict meetings and travels. It
also claims multiple lives, including physicians. More than 100
doctors, including surgeons become volunteer, including our
fellow colleagues, one of the ICS Indonesia bearer Prof.
Hendrian, ophthalmologist. However, it is crucial to still follow
up the ICS missions and to contribute to the pandemic solution.
ICS Indonesia Section Activities in Pandemic Era (2020 –

2022)
1. Continuous international webinar meetings on surgical

forum and other medical topics (ICS Surgical Forum 4 th up
to 26th , held each month), previously held offline
2. Assistance to Surabaya government, in collaboration with
ICS Global and ICS Taiwan section for covid treatment
3. ICS Indonesia Section Humanitarian Aid from ICS Taiwan
Section. Symbolic Online Meeting - Handover of Donation
from ICS Taiwan Section which is part of ICS Global,
Kaoshiung Medical University Hospital and Taiwan
Government to ICS Indonesia Section to help COVID-19
patients in August 2021, because Indonesia had Delta
Variant peak on July 2021, with very high death rate and lack
of hospital facilities to help COVID-19 patients.
125
Figure 37
4. President ICS Indonesia section has received donation on

August 2021 with total amount around Rp 1.730.019.000
(USD 110.000), which donate to:
• Indonesia Medical Association (medical doctors
impacted by covid 19), 30 Volunteer doctors, Rp.
8.000.000 (around USD 500) each, for the total of Rp.
240.000.000
126
Figure 38
• Surabaya City Government, 20 hospitals, received by

Head of Surabaya District Health Office, Febri
Rachmanita,MD consist of:
a. High Flow Nasal Canula (HFNC), 20 units, Rp
40.000.000 each, total of Rp.800.000.000
b. Syringe pump, 15 units, Rp. 23.000.000 each, total
of Rp.345.000.000
Figure 39
5. Symbolic Handover to the Mayor of Surabaya City consist

of 20 Units of High Flow Nasal Canules and 15 units of
Syringe Pumps, and groceries coordinated by The Major of
Surabaya City.
127
Figure 40
6. Gotong Royong WM Teaching Hospital, received by Marda,

MD as Hospital Director consist of:
a. 2 units ICU monitors, Rp 57.600.000 total of Rp
115.200.000
b. 1 unit Defibrillator, Rp 161.700.000
Figure 41
7. Online instruction from Mayor of Surabaya City to distribute

groceries to low-income society such as becak driver,
laborer, cleaning service, etc. affected by Covid-19
pandemic in 31 districts.
8. Distribution of Groceries by Paul L Tahalele as president of
ICS Indonesia section to low income society affected by
128
Covid-19 pandemic in Benowo Traditional Market Pakal
District in West Surabaya City among total 31 districts in
Surabaya
Figure 42
9. Award from Major of Surabaya City Mr. Eri Cahyadi on 10 th

November, 2021 at Surabaya Town Hall, to President of ICS
Indonesia Section for distributing the donation from ICS
Taiwan Section, Kaoshiung Medical University Hospital and
Taiwan Government.
Figure 43
129
Figure 44
Figure 45
Conclusion
• We cannot predict the end of COVID-19 pandemic.
• After 2 years, we are still in Pandemic situation that
changes our behavior and now entering Economic
Recovery Era (New Normal)
130
• As member of ICS Global, we need to collaborate, hand
in hand to help the people in Developing country with
lack of health facilities.
• Indonesia's success to handle the Covid-19 pandemic is
due to:
– Mass Vaccine program from the government
– Strict Health Protocol (5M)
– “Gotong royong” culture (Cooperation between
communities)
131
Functional Endoscopic Sinus Surgery In
Patients With Chronic Rhinosinusitis
Sari Wulan Dwi Sutanegara, MD, PhD, FICS
Otorhinolaryngologist. Faculty of Medicine, Udayana
University.
Background
Rhinosinusitis is an inflammation in nasal and paranasal
sinus mucosa with symptoms of nasal obstruction, facial pain,
and thick or purulent nasal discharge. Based on its onset and
duration of symptoms, rhinosinusitis can be classified into acute
and chronic rhinosinusitis. Chronic rhinosinusitis (CRS) is
considered one of the most frequent infections of the nose. Data
taken from the Ministry of Health of the Republic of Indonesia
(Departemen Kesehatan Republik Indonesia) in 2003 stated that
in Indonesia, nose and sinus disease was ranked 25th out of 50
major disease patterns or about 102,817 hospital outpatients.
Research conducted at Sanglah Hospital from January to
December 2014 found that 106 patients with rhinosinusitis
(32.1%) are of productive age, which will affect the socio-
economic conditions of the patients. 1,2
The recommended treatment of CRS according to EPOS
2012 is with steroid 3,4,5 nasal spray, nasal irrigation using normal
saline, short term oral antibiotics (less than 4 weeks), allergens
avoidance for patients with a history of allergies, and long-term
oral antibiotics for more than 12 weeks for patients with normal
serum
IgE levels. If medical therapy is unsuccessful, or if there
are complications of disease or abnormality in the ostiomeatal
complex (OMC), a minimally invasive surgery method such as
Functional Endoscopic Sinus Surgery (FESS) can be considered.
6,7
132
Anatomy
Figure 46 Paranasal sinus anatomy8
Figure 47 Nasal and paranasal sinus anatomy8
The nasal mucociliary system is an important defense

system in the upper respiratory tract. The mucociliary activity is
a combined work of mucus and cilia, and both can affect
133
mucociliary transport systems. Mucociliary transport is
necessary for the health of the nose and sinuses. Inspiredair can
contain bacterias or foreign particles, and the nasal mucosa will
try to eliminate them. When the bacteria and foreign particles
enters the nasal cavity, it will be covered by mucus and pushed
by cilia to be transported and discharged into the throat
(nasopharynx) and then swallowed or coughed up. In patients
with CRS, the function of nasal mucociliary clearance is
decreased significantly.10 The ostiomeatal complex is the
combination all the ostia that empties into the middle meatus and
is anatomically the narrowest area that tends to get blocked.
Additionally, the functional diameter of OMC is small,
averaging only 2-4 mm for the maxillary sinus ostium and even
smaller with the ethmoid sinus ostium. The ostiomeatal complex
plays an important role in normal sinus function and sinus health.
In the OMC, there is a connection between the middle meatus
and the group sinus group, especially the anterior ethmoid sinus.
If there is an anatomical deformity such as bullous medial concha
or if there is a disease process that causes two mucosal surfaces
to be in direct contact, it will cause nasal obstruction, local ciliary
stasis and subsequently infection of the sinus cavity. 8,11,12,13
Pathogenesis
The pathogenesis of rhinosinusitis can be compared to a
closed circle, starting with inflammation of the nasal mucosa
which will thencause swelling or edema
and the exudation process. Edema that occurs on the
entire surface of the nasal mucosa and the paranasal sinus ostium
in the OMC will result in obstruction of the sinus ostium.13
Sinus ostium obstruction will cause ventilation and
drainage problems. Obstacle of sinus drainage will cause the
normal mucociliary transport system to be disrupted, which will
provide an ideal condition for bacterial growth and
134
multiplication. Oxygen in the sinus cavity will be reabsorbed by
the mucosa, causing hypoxia. The resulting hypoxia is a
condition with decreased oxygen and pH levels, along with
negative pressure in the sinus cavity. This condition will further
cause an increase in the capillary permeability and glandular
secretion resulting in transudation. Increased serous exudate and
decreased ciliary function will result in retention of secretions in
paranasal sinuscavities.14,15
Figure 48 A. Sinus cycle with open ostium, B. Sinus cycle with

closed ostium15
Functional Endoscopic Sinus Surgery (FESS)

The Functional Endoscopic Sinus Surgery of FESS is a
minimally invasive surgical procedure of the nose and paranasal
sinuses by utilizing endoscopy and specialized instruments. One
of the most common indications of FESS is chronic rhinosinusitis
that does not respond to maximal medical therapy.
FESS requires good visualization as one of the important
factors for successful operation. Controlled hypotension
technique is one of the methods used to reduce bleeding during
surgery in order to obtain a good surgical field of view.
135
Indications for surgery
Generally indicated for cases of CRS unresponsive to
therapy (such as nasal steroid and nasal saline irrigation) and in
patients with CRS complications and morbidity.16
1. Refractory CRS (with or without nasal polyps)
2. Dentogenic sinusitis
3. Antrochoanal polyps
4. Epistaxis management
5. Sinonasal tumor
6. Skull base surgery
Surgical objectives
In addition to clear the source of infection and
inflammation, FESS is performed with the aim of restoring
airway patency without excessive manipulation, so as to maintain
and restore the natural function of the mucociliary system. FESS
also aims to increase absorption of topical drugs, improved
delivery of nasal washes, and improve exposure to olfactory
stimuli. A clear surgical objectives will help as a guide during the
operation. However, the surgical objective should not be too
excessive, such as over reduction of the inferior turbinate to
increase airway patency may cause empty nose syndrome
characterized by crusting, dry nose, nasal obstruction, and
sometimes pain.16
Presurgical evaluations
Before doing FESS, we have to do presurgical
evaluations that can act as guide in the operating table. Paranasal
sinus CT-scan is essential before surgery. Ideally the CT-scan
should be in thin slices and can be viewed from 3 different axes.
With the CT-scan images, we can obtain essential datas to ensure
a safe and effective dissection.17
136
It is important to know the patient's anatomical
landmarks and variations, such as concha bullosa, Onodi cells
and Haller cells. In addition, the surrounding structures and
dangerous structures must also be identified before the
operation.17 Acute infection or inflammatory disease should be
treated before surgery. Blood-thinning medications such as
warfarin should be discontinued 5 days before surgery, and
aspirin and clopidogrel for 7 days before surgery. If the patient
has other comorbidities, then it is appropriate to refer the patient
to relevant specialistic department.17
The things that must be considered when doing FESS is
how to prevent complications. The most important thing to
remember is the anatomical landmarks and markers to identify
where we are when doing the FESS. When dissecting or
removing certain structures, it is important to know the exact
tissue that we are removing. Beside understanding where we are
anatomically, it is also important to identify important nearby
structures such as the lamina papyracea, optic nerve andcarotid
artery. Cauterization should be avoided unless there is severe
arterial bleeding. Thus, a complete surgery that is safe and
maintains nasal mucosa functions can be achieved.16,17
Complications during surgery such as bleeding should be
controlled by identifying the source of bleeding and cauterization
with bipolar can be performed. Less severe bleeding can first try
to be controleld with tampons and topical agents.16,17
In addition to extensive knowledge and surgical
techniques, it is equally important for us as doctors to provide
clear information to patients before surgery. This informations
should include the indications for surgery, surgical risks, steps of
surgery, possible surgical outcome, and postoperative care.16
137
Conclusions
Chronic rhinosinusitis is one of the most frequent
infections of the nose. Rhinosinusitis occurs due to inflammation
of the nasal mucosa that causes edema of the nasal mucosa.
Edema that occurs along the nasal mucosa and ostiomeatal
complex will cause obstruction of the sinus ostium, thereby
interfering with sinus drainage and causing sinusitis. If maximal
medical therapy is unsuccessful or there are complications of
disease, then Functional Endoscopic Sinus Surgery (FESS) may
be considered. The presurgical evaluations include knowing the
anatomy, indications, goals, and preparation of the surgery.
During surgery, there are several things that need to be
considered for a successful operation to run safely, smoothly and
maintain the integrity of the mucociliary system of the nasal
mucosa.
Reference
1. Abuzaid W, Thaler ER. Etiology and impact of
rhinosinusitis. In: Thaler ER, Kennedy DW, eds.
Rhinosinusitis – A guide for diagnosis andmanagement. New
York: Springer 2008; 1-15.
2. Culig J, Leppee M, Vceva A, Djanic D. Efficiency of
hypertonic and isotonic seawater solutions in chronic
rhinosinusitis. 2010; 7(1):116-123.
3. Sharp HJ, Denman D, Puumala S, Leopold DA. Treatment
of acute and chronic rhinosinusitis in the united state, 1999-
2002. Arch Otolaryngol Head and Neck Surg 2010.
4. Roos K. The pathogenesis of infective rhinosinusitis. In:
Lund V, Corey J, eds. Rhinosinusitis : current issue in
diagnosis and management. London:The Royal Society of
Medicine Press Limited 2009; 3-9.
5. Kristyono I, Maharyati R. Data Poli Rawat Jalan Sub Bagian
Umum, Bagian THT-KL RSUD Dr. Soetomo, Surabaya
2007-2009.
138
6. Helms S, Miller AL. Natural treatment of chronic
rhinosinusitis. Alternative Medicine Review 2016; 11:196-
206.
7. Papsin B, McTavish A. Saline nasal irrigation – Its role as an
adjunct treatment. Can Fam Physician 2013; 49:168-73.
8. Ballenger JJ. Clinical anatomy and physiology of the nose
and paranasal sinus. In: Ballenger JJ. Otorhinolaryngology
head and neck surgery. 18th ed. USA: People’s Medical
Publishing House, 2016;37:1670-1699.
9. Boek WM, Graamans K, Natzijl H, Van Rijk PP, Huizing
EH. Nasal mucociliary transport : new evidence for a key
role of ciliary beat frequency. Laryngoscope 2012; 112:570-
3.
10. Baroody FM. Mucociliary transport in chronic rhinosinusitis.
Clin Allergy Immunol 2007; 20:103-19.
11. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I,
Baroody F, dkk. European position paper on rhinosinusitis
and nasal polyps. Rhinology 2012; 23:1-298.
12. Stierna PL. Physiology, mucociliary clearance, and neural
control. In: Kennedy DW, Bolger WE, Zinreich SJ, eds.
Disease the sinuses diagnosis and management. London:
Hamilton, 2011; 35-55.
13. Pinheiro AD, Facer GW, Kern EB. Rhinosinusitis: current
concepts and management. In: Bailey BJ, Calhoun KH,
Healy GB, Johnson JT, Jackler RK, Pillsbury HC, dkk. Head
and neck surgery – otolaryngology. 5th ed. London:
Lippincott Williams and Wilkins, 2013; 345-8.
14. Clerico DM. Medical treatment of chronic sinus disease. In:
Kennedy DW, Bolger WE, Zinreich SJ, eds. Disease the
sinuses diagnosis and management. London: Hamilton,
2011; 35-9.
15. Lane AP, Kennedy DW. Sinusitis and polyposis. In:
Ballenger JJ. Otorhinolaryngology head and neck surgery.
18th ed. USA: People’s Medical Publishing House, 2016;
37:1670-1699.
16. Barnes M, Surda P, Douglas R, Shao A. Functional
endoscopic sinus surgery (FESS) part 1. ENT and audiology
news 2016; 25(3):104-107
139
17. Barnes M, Surda P, Douglas R, Shao A. Functional
endoscopic sinus surgery (FESS) part 2. ENT and audiology
news 2016; 25(5):104-108
140
Cisternostomy, An Emerging Surgical
Technique For Traumatic Brain Injury: An
Experience Of Two Cases
Nyoman Golden, MD, PhD
Neurosurgical Division, Faculty of Medicine, Udayana
University
Abstract
Background: The main goal of treating traumatic brain injury
(TBI) is to avoid or reduce secondary brain injury.
Decompressive craniectomy has been used as a surgical
procedure to reduce intracranial pressure (ICP). However, it
provides space for the brain to expand only without reducing
intraparenchymal pressure. Cisternostomy (CS) is an emerging
microsurgical procedure in the management of brain edema.
Many studies showed the effectiveness of CS in reducing
cerebral edema, hence it provides better clinical outcomes. We
report our preliminary experience of using CS in the management
of TBI
Method: This is a retrospective report of two patients with severe
TBI that underwent CS in addition to standard protocol.
Results: Two patients with severe TBI were included in this
report. A 13-year-old male presented with GCS E1V2M3 after
falling from a motorcycle. He was intubated and put under
ventilator support. CT scan showed multiple contusions with
severe brain swelling. CS was performed. The patient had
pneumonia postoperatively, however it was well treated. Four
months after the procedure, the patient can go back to school. A
26-year-old male was presented with GCS E1V2M4 and left
hemiparesis. The mode of injury was not clear. CT scan showed
acute subdural hematoma and brain swelling. Clot evacuation
141
and CS were performed. Seven months after surgery, he can walk
with slight hemiparesis and minimal cognitive impairment.
Conclusion: These two cases showed the effectiveness of CS as
an armamentarium in managing TBI. However, to support this
preliminary experience, a randomized clinical trial with big
sample size and involving many trauma centers should be
conducted.
Keywords: case report, cisternostomy, traumatic brain injury
Introduction
The goal of treatment for traumatic brain injury (TBI) was
mainly focused on reducing secondary brain injury.1 This can be
achieved by controlling intracranial pressure (ICP).
Decompressive craniectomy (DC) has been used as a surgical
procedure for reducing ICP by providing a space for brain tissue
to expand.1 DC has been shown to reduce ICP but in reality, it
only reduces the ICP without reducing brain edema. DC was
associated with many complications such as brain herniation to
the created space, axonal stretching, and the need for
cranioplasty. The glymphatic system has proven that
cerebrospinal fluid (CSF) from the cisterns (and not from the
ventricles) communicates with the parenchyma through Virchow
Robin spaces. 2,3,4,5
Briefly, cisternostomy (CS) is a new armamentarium using
knowledge of skull base and microsurgery. It has been proposed
that in TBI, the CSF is shifted from cistern to brain tissue through
Virchow-Robin (VR) space leading to severe brain swelling. CS
is a surgical technique that opens the brain cistern to atmospheric
pressure.3,4 CS has been shown to reduce ICP and parenchymal
pressure due to the reverse of CSF shift from parenchymal brain
tissue to the cistern through VR space.1,3,4,5,6 In this report, I
present two cases with severe TBI who underwent CS.
142
Cases presentation
Case 1
A 13-year-old male was presented to the emergency unit
with severe TBI (GCS E1V2M3) after falling from a motorcycle.
In the emergency ward, the patient was intubated and put under
ventilator support by an anaesthesiologist on duty. There was no
significant injury on the other part of his body. CS was performed
immediately with the drain was kept for 5 days (Figure 32). The
patient had acquired pneumonia and fortunately, it was well
treated. Four months after TBI, the patient was normal and can
go back to school (Figure 33).
Figure 49 A: Intraoperative nuances of case 1 showing

exposure of Liliequist membrane; B: Postoperative Non
contrast head CT scan of case 1 on first day after CS.
143
Figure 50 Photograph of case 1 taken 4 months after injury .
Case 2
A 26-year-old male was presented to the emergency ward
with severe TBI (GCS E1V2M4) and left hemiparesis. A head
CT scan showed an acute subdural with brain swelling and small
hematoma in the right putamen (Fig 34A). The mode of injury
was not clear. The patient was intubated and supported by a
ventilator machine. The patient did not have other significant
injuries. The patient underwent CS (Figure 34B).
Postoperatively, the patient was still put under ventilator support
for 3 days. Fortunately, the patient did not has pneumonia during
his stay in the hospital. Seven months after the injury, the patient
can walk with slight paresis and minimal cognitive impairment
(Figure 35).
144
Figure 51 A: Preoperative head CT scan of case 2; B:
Intraoperative nuances of case 2. The Liliequist membrane had
been sharply dissected.
Figure 52 Photograph of case 2 taken 7 months after injury.
Discussion
Severe traumatic brain injury is a life-threatening
condition, which needs evolving management to reduce
mortality and improve morbidity.6 An uncontrolled ICP has been
associated with poor outcomes. The goal of the management of
TBI is to reduce damage caused by secondary brain injury, which
is mostly caused by increased ICP. DC has been used to reduce
ICP. However, its effectiveness in improving outcomes remains
debated.
145
The pressure in the cistern rapidly increases after TBI. This
increasing pressure shifts the CSF to parenchymal brain tissue. It
is supported by the disappearance of the cistern system and
compressed ventricle. Many studies have reported the
effectiveness of CS in reducing ICP and parenchymal brain tissue
pressure.3,4,5 Grasso and Cherian in their study of CS for TBI
showed decreasing brain swelling, mortality, and morbidity.1
Chandra et al. in their clinical trial comparing CS and DC in the
management of TBI showed CS is effective in reducing ICP,
better GOS, and low complications in the postoperative period. 2
Giammattei et al. retrospectively compared DC and DC plus CS
as adjuvant treatments in TBI. Their report showed that DC
combined with CS significantly improved the GOS than those
treated with DC only.7 Agrawal et al. in their meta-analysis of
CS in TBI showed CS is a promising surgical technique leading
to better survival benefits and clinical outcomes.8 These
promising results need further confirmation by a bigger clinical
trial with big-size samples involving multi centres.
CS in two cases in our preliminary report showed good GOS.
However, of course, we cannot make any conclusion showing
that CS really replaces DC. CS is a novel surgical technique that
incorporates skull base and microsurgery. Therefore, the
universal implementation of CS at trauma centres will be
problematic. Implementing CS will be easier in the centre that
performs skull base surgery and clipping aneurysm regularly.
Conclusion
Our preliminary implementation of CS in two cases with
severe TBI showed a promising result. Many other studies
showed the effectiveness of CS in TBI compared to DC. This
promising result should be supported by a larger clinical trial
involving multi-center. The implementation of this technique
146
needs training because it is a combination of skull base and
microsurgery.
References:
1. Grasso G, Cherian I. Cisternostomy for traumatic brain
injury: A new era begins. Bull Emerg Trauma. 2016; 4:119
– 120.
2. Ramesh Chandra VV, Chandra Mowliswara PB, Banavath
HN, Reddy Kalakoti CS. Cisternostomy VS decompressive
craniectomy for the management of traumatic brain injury.
A randomized control trial. World Neurosurg 2022; 162:
e58 – e64.
3. Munakomi S, Yi G, Cherian I. Cisternostomy: Replacing the
age old decompressive hemicraniectomy? Asian J
Neurosurg. 2013; 8: 132 – 8.
4. Cherian I, Grasso G, Bernardo A, Munakomi S. Anatomy
and physiology of cisternostomy. Chin J Traumatol. 2016;
19(1): 7 – 10.
5. Cherian I, Burhan H, Dashevskiy G, Hinojosa Motta SJ,
Parthiban J, Wang J, et al. Cisternostomy: A timely
intervention in moderate to severe to severe traumatic brain
injuries: Rationale, indication and prospects. World
Neurosurg. 2019; 131: 385 – 90.
6. Campos Paiva AL, Vitorino, Araujo JL, Lovato RM.
Microsurgical cisternostomy for treating critical patients
with traumatic brain injury-an alternative therapeutic
approach. Arq Bras Neurocir 2020; 39(3): 155 – 160
7. Giammattei L, Starnoni D, Maduri R, Bernini A, Abed-
Maillard S, Roca A et al. Implementation of cisternostomy
as adjuvant to decompressive craniectomy for the
management of severe brain trauma. Acta Neurochir 2020;
162(3): 469 – 479.
8. Agrawal M, Mishra K, Babal R, Purohit D. Cisternostomy
in traumatic brain injury for a novel approach to treatment:
Review of current status. Indian J Neurotrauma. 2021.
147
Neuroendoscopic Surgery For Hemorrhagic
Stroke
Dewa Putu Wisnu Wardhana1, Made Bhuwana Putra1,
Dede Frisky Wianjana1, Rohadi Muhammad Rosyidi2,
1
Dept of Neurosurgery, Medical Faculty Udayana University
2
Dept of Neurosurgery, Medical Faculty Mataram University
Abstract
Background: Intracerebral hemorrhage comprises of 10% of all
stroke cases, causing high social economic burden. Evacuation
of spontaneous ICH has been conventionally done with open
surgical technique. Surgical evacuation of ICH can be done
through several method. Endoscopic method of ICH evacuation
is a technique developed to reduce the invasiveness of
conventional open technique. This method was associated with
lesser blood loss, operative time, better post operative scar
formation and length of stay with possibly better outcome.
Case Series Description: Eleven ICH cases were done through
neuroendoscopic method. Outcome was evaluated with Glasgow
outcome scale, along with surgical time and rate of evacuation.
Conclusion: ICH Evacuation through endoscopic method offers
a better clot evacuation, surgical duration and less complication
with similar outcome to conventional method.
Keywords: Intracerebral Hemorrhage, Neuroendoscopic,
Introduction
Intracerebral hemorrhage comprises 10% of stroke
cases. The incidence of ICH is up to 24.6 per 100.000-person
year.1 ICH is one of most common cause of morbidity and
mortality with mortality rate up to 44-50% in 30 days.1,2,310 –
15% of hemorrhagic stroke cases are on young adult age group
148
which causes social and economic burden. 4,5 One of the major
predictors that could determine the outcome of patient with ICH
is the combination of initial Glasgow coma scale (GCS) and ICH
volume. ICH volume of more than 60 cm3 and GCS score less
than 8 have 91% mortality rate with 96% and 98% sensitivity and
specificity rate accordingly.5
Hypothetically, surgical removal of the clot may give
potential benefit in improving neurological outcome due to
reduction of intracerebral pressure and mitigating nerve damage
due to harmful blood byproduct that may further cause tissue
injury. Despite the theoretical potential benefit, the efficacy of
surgery in management of ICH still remained to be debated.2,3,6
ICH evacuation through endoscopic method first
reported on 1985.7 Since then endoscopic technique has been
widely practiced and potentially reduce invasiveness and
improve outcome. Endoscopic ICH evacuation is associated with
lower rebleeding rate compared to conventional technique.
Endoscopic technique also related with lower mortality rate,
which may be due to lesser operative blood loss and tissue
destruction.7
Case Series
Patient 1
A fifty-year-old female with no past medical history
presented with a decreased consciousness 6 hours before
admission. On arrival, she had a Glasgow Coma Scale (GCS)
score of E2V2M5, left-sided hemiparesis, and blood pressure of
150/90 mmHg. Sririraj score revealed a score of 2, Glasgow
Outcome Scale (GOS) of 4, National Institutes of Health Stroke
Scale (NIHSS) of 19, and Modified Rankin Scale (mRS) of 2. A
CT head examination demonstrated ICH requiring surgery.
Endoscopic Assisted Surgery was performed within 24 hours of
149
arrival. Duration of surgery was 140 minutes. The patient was
discharged after 11 days of admission with sequelae.
Patient 2
A nineteen-year-old male with a previously healthy
condition presented with a decreased consciousness 2 hours
before admission. Physical examination revealed a GCS score of
E3V5M6, left-sided hemiparesis, and blood pressure of 130/90
mmHg. CT examination demonstrated right thalamic ICH with a
volume of 24 cc and 5 mm midline shift. Sririraj score revealed
a score of -0.5, GOS of 5, NIHSS of 7, mRS of 1, and CT-ICH
score of 0. Endoscopic Assisted Surgery was performed for about
100 minutes, and the patient was admitted for 22 days. Upon
postoperative CT-Scan, we found 1.2 cc of remaining ICH with
no midline shit. The evacuation rate of the ICH was 95%.
Patient 3
A fifty-seven-year-old male with a history of
hypertension, diabetes mellitus, and stage V of chronic kidney
disease came to the ER with a complaint of a decrease in
consciousness. She had a GCS score of E2V2M4, right-sided
hemiparesis, and blood pressure of 170/110 mmHg. A 66 cc of
left basal ganglia ICH and 5 mm midline shift was revealed on
the CT-Scan. Sririraj score indicated a score of 1, GOS of 1,
NIHSS of 19, mRS of 6, and CT-ICH Score of 2. Endoscopic
Assisted Surgery was performed after more than 24 hours of
arrival. Duration of surgery was 130 minutes. The patient was
discharged after 14 days of admission with sequelae.
Postoperative CT-Scan revealed a 75.76% evacuation rate with
16 cc of ICH and 8 mm of midline shift.
150
Patient 4
An eleven-year-old boy with an otherwise healthy
condition showed a decreased consciousness 24 hours before
admission. She had a GCS score of E3V5M6, left-sided
hemiparesis, and blood pressure of 130/80 mmHg. Sririraj score
revealed a score of 2, GOS of 4, NIHSS of 19, mRS of 2, and
CT-ICH of 1. A CT head examination demonstrated ICH
requiring surgery. Endoscopic Assisted Surgery was performed
within 24 hours of arrival, with duration about 90 minutes. The
patient was discharged after 11 days of admission with sequelae.
A complete evacuation rate (100%) with no remaining ICH was
found on the postoperative CT-Scan.
Patient 5
A sixty-two-year-old male with a history of hypertension
was admitted to the hospital due to a decreased consciousness 2
hours before admission. Upon physical examination, blood
pressure of 170/100 mmHg, GCS Score of E2V2M4, and right-
sided hemiparesis. Sririraj score revealed a score of 0, Glasgow
Outcome Scale (GOS) of 1, National Institutes of Health Stroke
Scale (NIHSS) of 19, and Modified Rankin Scale (mRS) of 6. A
CT head examination demonstrated ICH requiring surgery.
Endoscopic Assisted Surgery was performed for about 160
minutes, and the patient was discharged after 14 days of
admission.
Patient 6
A fifty-one-year-old male with controlled hypertension
presented with a decreased consciousness and headache 30
minutes before admission. Physical examination revealed a GCS
score of E3V5M6, left-sided hemiparesis, and blood pressure of
130/90 mmHg. CT examination demonstrated right thalamic
ICH with a volume of 24 cc and 5 mm midline shift. Sririraj score
151
revealed a score of -0.5, GOS of 5, NIHSS of 7, mRS of 1, and
CT-ICH score of 0. Endoscopic Assisted Surgery was performed
less than 24 hours after the arrival, duration of surgery was 150
minutes. A postoperative CT scan showed a 65% evacuation rate
with 16 cc remaining ICH. The patient was discharged after 7
days of admission.
Patient 7
A sixty-four-year-old female with a history of
hypertension was admitted with a decrease in consciousness 3o
minutes before admission. She had a GCS score of E3V2M5,
left-sided hemiparesis, and blood pressure of 160/100 mmHg. A
12.82 cc of right external capsule ICH was revealed on the CT-
Scan. Sririraj score revealed a score of 0.5, GOS of 4, NIHSS of
14, mRS of 3, and CT-ICH Score of 1. Endoscopic Assisted
Surgery was performed within 24 hours of arrival. The patient
was discharged after 10 days of admission with sequelae.
Patient 8
A twenty-nine-year-old female with uncontrolled
hypertension and chronic kidney disease presented with a
decreased consciousness, headache, and seizure 1 day before
arrival. She had a GCS score of E3V5M6, left-sided hemiparesis,
and a blood pressure of 190/120 mmHg. A 31.6 cc of right
external capsule ICH and 3 mm midline shift was revealed on the
CT-Scan. Sririraj score revealed a score of 4.5, GOS of 3, NIHSS
of 12, mRS of 4, and CT-ICH Score of 1. Endoscopic Assisted
Surgery was performed for about 100 minutes. The patient was
discharged within 7 days of admission.
Patient 9
A forty-seven-year-old male with uncontrolled
hypertension and hypertensive heart disease showed a decrease
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in consciousness 1 hour before admission. On arrival, she had a
Glasgow Coma Scale (GCS) score of E3V2M4, left-sided
hemiparesis, and blood pressure of 150/90 mmHg. Sririraj score
revealed a score of 2, NIHSS of 18, mRS of 6, and CT-ICH score
of 2. A CT head examination demonstrated a 54 cc of right
thalamic ICH with an 8 mm midline shift. Endoscopic Assisted
Surgery was performed for about 120 minutes with a
postoperative CT-Scan showing a 91.7% evacuation rate (4.44 cc
of remaining ICH with 5.6 mm midline shift). The patient was
discharged after 7 days of admission.
Patient 10
A forty-eight-year-old female with a decrease in
consciousness since 24 hours before admission. When the patient
came with a Glasgow Coma Scale (GCS) score of E2V2M4. CT
Scan showed ICH with a volume of 80 cc not well demarcated
on the left basal ganglia. After 170 minutes of endoscopic
surgery, on 2 days of treatment, patient experienced re-bleeding
of ICH. Then we performed open evacuation of ICH with
duramater and bony decompression. Patient died on nine days
postoperative. Patient had severe comorbidity of uncontrolled
Diabetes Mellitus and obesity.
Patient 11
A forty-four-year-old female came on referral to our
hospital after a decrease of consciousness 18 hours before being
admitted to the hospital. The patient came with a Glasgow Coma
Scale (GCS) score of E3V2M4. CT Scan showed ICH with a
volume of 60 cc on the right basal ganglia. After 130 minutes of
endoscopic surgery, the Glasgow Coma Scale (GCS) score was
E4V5M6. Significant motoric improvement from 1 to 3. The
length of stay was 10 days, patient had a history of post covid
lung infection before.
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Discussion
In general, the treatment of ICH can be divided into
preparation for treatment or surgery. Management of cases of
spontaneous ICH is concerned with mitigating the effects of
primary and secondary brain damage8. Primary brain damage
occurs due to mechanical suppression and expansion of the
hematoma that compresses the brain parenchyma and causes
ischemia in the surrounding brain tissue, while secondary brain
damage can occur due to various inflammatory responses,
damage to the blood brain barrier to the neurotoxic effects of
hematomas8
Most cases of ICH may not require surgery, but there are
several hypotheses about the benefits of clot evacuation. 9 This
advantage is based on the assumption that removing clots can
help restore brain structure, eliminate mass effects, and reduce
brain pressure so as to improve brain perfusion. Eliminating clots
can also help reduce the neurotoxic effects of hemoglobin,
thereby reducing the occurrence of secondary brain damage. 9
Several surgical approaches are used to treat ICH cases,
including the insertion of External Ventricular Drainage (EVD),
craniotomy and clot evacuation, decompressive craniectomy
with or without clot evacuation, to minimally invasive
procedures with endoscopy and ICH evacuations with
stereotactic aspiration.9
Endoscopic technique is better than other techniques in
ICH with hematoma volume > 60cc and is associated with lower
rebleeding rates than standard craniotomy techniques.10 In one
study that also included spontaneous ICH patients with a volume
size of 99 – 130cc, it was found that endoscopic ICH evacuation
reduced mortality11. This can be caused by the amount of
bleeding and brain tissue damage that was more minimal. There
are differences of opinion regarding the endoscope entry point in
154
ICH evacuation surgery. Some authors suggest entering at points
that correspond to the ventriculostomy point such as the Kocher,
Keen or Frazier points12,13 while others suggest performing a
corticotomy at the point closest to the clot, or parallel to the axis.
longest of the hematomas14,15
The endoscope canal as a container for inserting the
endoscope can use an endoport or an assembled transparent
canal16,17. There are several ways to minimize trauma when
creating an endoscope entrance, one of which is by using a
balloon catheter that can be easily assembled 13. Hemostasis is
one of the challenges in endoscopic surgery. The limitation of
instrumentation that can be used is one of the factors that makes
hemostasis management more difficult in this procedure, even
though multifunctional instruments have been developed13. Care
must be taken to adjust the suction force when evacuating the
clot. In one case series, thin clots adhering to the brain
parenchyma can be left behind and seeping bleeding can be
managed by placing hemostats13. The risk of rebleeding after
ICH evacuation surgery per endoscopy can be predicted by
looking at the pre-operative CT scan18. The presence of a blend
sign which is a two-density picture with a Hounsfield Unit
difference of more than 18 is associated with a higher risk of
postoperative rebleeding. Other signs such as the blackhole sign
and island sign were not associated with the risk of rebleeding
after ICH surgery18.
The use of endoscopes in ICH evacuation is associated
with better ICH evacuation rates. This can be associated with the
ability to visualize when evacuating a group 19. In addition,
secondary brain tissue damage was less severe when compared
to standard ICH evacuation craniotomy12,14,20,21. The endoscopic
technique is considered safer and more effective in evacuating
ICH, especially in patients with a bleeding volume of more than
60 cc or a GCS score of 4-820. Placement and distribution of
155
hemostats such as surgicel on the entire surface of the post-
evacuation cavity is quite difficult to do with the endoscopic
technique, but with this technique it is very easy to directly see
small clots and sources of bleeding which are generally difficult
to evaluate with standard craniotomy techniques12.
The duration of surgery using an endoscope was
significantly shorter than that of a standard craniotomy (229 +/-
50 minutes for craniotomy and 158 +/- 47 minutes for endoscopic
technique)14. This is consistent with other researchers have
found21,22,23. There is significantly less bleeding in endoscopic
surgery compared to craniotomy surgery14,22,23. This can be
attributed to the smaller incision compared to the craniotomy
surgical technique.
Cho et al, in their study revealed that there was no
significant difference in the length of stay in the ICU and the
length of stay in hospital and the cost of treatment in the two
treatment groups, although the endoscopic technique of these
three factors was found to be lower14. This is in contrast to other
researchers who found that the postoperative length of treatment
was significantly shorter in cases treated with endoscopic
techniques23.
Endoscopic ICH surgery is associated with better
functional outcome14. Although there was no significant
difference between the two surgical techniques in terms of
mortality21,22,23, craniotomy was associated with higher
postoperative complications such as pneumonia22. The risk of
postoperative rebleeding was found not to be significantly
different between the two surgical techniques21. One of the
investigators found a higher incidence of perihematoma edema
on the 7th postoperative day in the craniotomy surgical
technique22. This is associated with more severe tissue damage in
the surgical technique when compared to the endoscopic
technique. Perihematoma edema is associated with decreased or
156
decreased neurologic deficits during the treatment period and
increased mortality and morbidity rates at 90 days. This can also
be associated with a shorter intensive care period and a lower risk
of postoperative complications22. Ye et al in their meta-analysis
found that the outcome of craniotomy was worse when compared
to endoscopic procedures, this was assessed from mortality,
modified Rankin score (mRS), Glasgow Outcome Scale (GOS),
and Barthel Index19.
Conclusion
Neuroendoscopic method for stroke hemorrhagic is safe,
also offers a better results clot evacuation, surgical duration and
less complication.
Reference
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7. Ziai, W., Nyquist, P. and Hanley, D. F. 2016. Surgical
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9. Manoel, D. O. 2020 Surgery for spontaneous intracerebral
hemorrhage. Critical Care. 24:45
10. Luzzi, S. et al. 2019. Indication, Timing, and Surgical
Treatment of Spontaneous Intracerebral Hemorrhage:
Systematic Review and Proposal of a Management
Algorithm. World Neurosurgery.
11. Yamashiro, S. Y. et al. 2015. Effectiveness of Endoscopic
Surgery for Comatose Patients with Large Supratentorial
Intracerebral Hemorrhages. Neurol Med Chir. pp. 819–823.
12. Eroglu C. The interplay between neurons and glia in synapse
development and plasticity. Current opinion in neurobiology.
2017;42:1-8.
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hematoma evacuation in patients with spontaneous
supratentorial intracerebral hemorrhage’, Journal of the
Chinese Medical Association. 78(2), pp. 101–107.
14. Cho, D. et al. 2006. Endoscopic surgery for spontaneous
basal ganglia hemorrhage : comparing endoscopic surgery ,
stereotactic aspiration , and craniotomy in noncomatose
patients. Surgical Neurology. 65:547-56
15. Yao, Z. et al. 2018. Effect and Feasibility of Endoscopic
Surgery in the Spontaneous Intracerebral Hemorrhage: A
Systemati Review and Meta-Analysis. World Neurosurgery.
16. Nishihara, T. et al. 2000. A transparent sheath for endoscopic
surgery and its application in surgical evacuation of
spontaneous intracerebral hematomas. J Neurosurg. 92, pp.
1053–1055.
17. Chen, C. et al. 2017. Alcohol use and risk of intracerebral
hemorrhage. Neurology. 88, pp. 1–10.
18. Yagi, K., Tao, Y., Hara, K., Hirai, S., Takai, H., & Kinoshita,
K. et al. (2019). Does Noncontrast Computed Tomography
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Neurosurgery, 127, e965-e971.
19. Ye, Z. et al. 2017. Comparison of neuroendoscopic surgery
and craniotomy for supratentorial hypertensive intracerebral
hemorrhage.
20. Li, Z. 2017. Minimal invasive puncture and drainage versus
endoscopic surgery for spontaneous intracerebral
hemorrhage in basal ganglia. Neuropsychiatric Disease and
Treatment. pp. 213–219.
21. Nagasaka, T. et al. 2011. Early Recovery and Better
Evacuation Rate in Neuroendoscopic Surgery for
Spontaneous Intracerebral Hemorrhage Using a
Multifunctional Cannula : Preliminary Study in Comparison
With Craniotomy. Journal of Stroke and Cerebrovascular
Diseases. 20(3), pp. 208–213.
22. Fu, C. et al. 2018. Surgical Management of Moderate Basal
Ganglia Intracerebral Hemorrhage: Comparison of Safety
and Efficacy of Endoscopic Surgery, Minimally Invasive
Puncture and Drainage, and Craniotomy. World
Neurosurgery. IC, pp. 1–7
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comparison with craniotomy. pp. 1–7.
159
Acupuncture Role in ICS Humanitarian
Health Services and Treatment of Post-Surgery
Pain and Residual Complication
Choo Aun Neoh, MD, PhD, FICS
Anesthesiologist. ICS Executive Council Member.
Abstract
International surgery humanitarian efforts provide essential
services to patients who would not otherwise have access to
specific surgery health care services. However, such mission
programs present to us with many practical challenges. Such as:
1. Many a time we went to a remote area or country but we cannot
carry out our humanitarian surgery services due to the local
government medical law or requirement. 2. Some time we do not
have the necessary equipment to proceed with the necessary
surgery. 3. But we are already there, so at least we can do
acupuncture treatment for those patients to relief their suffering.
4. We all know that sometime after our surgery there are many
postoperative complications and sequelae that cause suffering to
our patients. 5. Acupuncture especially the Neoh Acupuncture
system that combined East and West needling methods can help
to solve these problems and return our patient normal function.6.
During our humanitarian surgical services, we can also solve
their previous surgical postoperative complications and sequelae.
There were intra- and postoperative complications: direct large
vessel and neurological injuries (cord, roots, nerves), late
thrombophlebitis, various thoracic cavity problems, esophagus
and ureter injuries, peritoneum perforation, ileus, wound
infections, stabilization failure, increase of deformity and late
adjacent joint and bone problems. thrombophlebitis and
sympathetic lysis, symptoms and signs in the lower limbs were
the most common complications related with anterior lumbar and
160
lumbosacral surgeries. There is always pain follow operation
even after morphine, nerve block. There are also lots of
discomfort beside pain, like dizziness, vertigo, abdominal
fullness, weakness, numbness, neck stiffness, headache, blurred
vision, frozen shoulder etc. Some time there are complications
after operation. These most can be relief with East-West
Integrated Acupuncture Needling. Pain usually persisted, may be
a little subside after morphine, NSAIDS. Other discomfort even
cannot subside with western medication alone. Usually, the
patient will complain or think that for example headache,
dizziness, vertigo, blurred vision is due to craniotomy or its
complication but actually are due to stress, posture and cold
environment of operating room that activated the patient
myofascial pain syndrome. With the help of trigger point
needling and traditional acupuncture, scalp acupuncture we can
help surgeon and patient to solve these problems and improve
their quality of life after operation. Acupuncture is not only using
traditional acupuncture points. In Neoh acupuncture system, we
use both traditional acupuncture and dry needling of trigger point
needling and superficial needling. Below is an explanation of
trigger points dry needling with acupuncture needle for treatment
of post operative pain and other severe pain and discomfort that
may seem need a surgical operation. In the comprehensive trigger
point manual by Travell and Simons, MTrPs are subclassified
into different types, e.g., active and latent amongst others. An
active MTrP produces a constant pain complaint while a latent
only produces pain during manual palpation. It was hypothesized
that a sustained muscle contraction in MTrPs promotes hypoxia
and ischemia with a following increase in concentrations of
substances such as calcitonin gene-related peptide (CGRP) and
substance P (SP). A myofascial trigger point is defined as a
hyperirritable spot in skeletal muscle that is associated with a
hypersensitive palpable nodule in a taut band. It has been
161
suggested that myofascial trigger points take part in chronic pain
conditions including various disorders. Active trigger points can
spontaneously trigger local or referred pain. Therefore, both
active and latent trigger points cause allodynia at the trigger point
site and hyperalgesia away from the trigger point following
applied pressure. The important is to let surgeon know that these
all can be solved easily with East West Integrated Acupuncture
Needling. The Myofascial Pain and Dysfunction text book and
other acupuncture text book will be of good help to ICS surgeon
and anesthesiologist.
162
CHAPTER 2
ABSTRACTS FROM PARTICIPANTS
163
Burn Patients in Regional Public Hospital:
Profile and Treatments Options in Regional
Public Hospital Dr. Djasamen Saragih,
Pematang Siantar From Period 2017-2019
Vincent Anggriant1, Rajin Saragih2, Sersanta Pinem2
1 General Practioner, Regional Public Hospital dr. Djasamen Saragih,
Pematang Siantar, North Sumatera, Indonesia
2 General Surgeon, Regional Public Hospital dr. Djasamen Saragih,
Pematang Siantar, North Sumatera, Indonesia
Abstract
Background: Burns are one of the types of trauma which high
morbidity and mortality. Burns cause damage of skin tissue
caused by various causes such as flame, scald or hot water,
electric, chemicals, and radiation, that still often occurs today.
Burns are a common health problem in developing and poor
countries. Epidemiology of burns that occurs in Indonesia is still
quite rarely reported.
Purpose: This study is to report burns at regional public hospital
dr. Djasamen Saragih, a type B regional hospital in North
Sumatra, Indonesia.
Method: This is a descriptive analysis with cross-sectional by
using medical records of burn patients treated from January 2017
to December 2019. The data are presented in tabular and graphic
form.
Results: There were 68 samples in this study. The highest
incidence of burns was found in the adult age group as many as
46 cases (67,6%) and dominated by men 45 persons (66,2%),
with the most cases being caused by burns due to scald injury 39
cases (57,4%). The majority of incidents in this study suffered
from second degree burns, recorded 61 cases (89,7%). Excisional
164
debridement is the most commonly surgical performed therapy
as much as 42 cases (62%) in this study.
Conclusions: From this study, it was shown that the high-risk
groups in cases of burns were adult and men. The number of
events that cause high morbidity and mortality can be prevented
by increasing knowledge of burns, implementing preventive
measures, especially in low socio-economic communities.
Keywords: Burns., age., sex., etiology., degree., treatment
165
Case Report: A 55th Year Old Man With Long
Total Occlusion Of Left Axillary Artery Due
Chronic Use Of Crutch At The Left Armpit
Dananto C, Revianto O,
Department of Thoracic, Cardiac, & Vascular Surgery
Faculty of Medicine Airlangga University
Abstract
Background: Long-term use of axillary crutch may precipitate
upper limb arterial disorders such as thromboembolism,
aneurysm and stenosis. This disorder can be dangerous for the
upper extremity
Objective: To report a patient with long total occlusion of left
axillary artery due chronic use of crutch at the left armpit
Case Description: We report a case of long total occlusion of
left axillary artery due to chronic use of crutch at the left armpit
in a 55 years old man who use had left him with lower limb
paralysis the assistance of axillary crutches to help him walk all
of his life since poliomyelitis during childhood. The patient feels
paresthesia and ache at the left upper extremity. His examination
revealed pulseless at left brachial, left radial and left ulnar artery,
but the skin still warm. From CT-angiography examination we
confirmed the presence of 19,3 cm in length total occlusion from
left axillary artery to the left brachial artery.
We did bypass grafting from left the axillary to left brachial
artery with PTFE graft 0,6 mm. General
Anesthesia used during the surgery. In a supine position, we
abducted 90 degree and with the shoulder slightly elevated.
Infraclavicular incision used to expose the left axillary artery and
we expose the left brachial artery was exposed via bicipital sulcus
incision longitudinally. We evaluate the axillary artery there was
strong pulse and there is no plaque and thrombus. We evaluate
166
the brachialis artery, there was no pulse then we had arteriotomy
that showed no flow, and there is a thrombus and plaque. Then
we had an endarterectomy and thrombectomy at the site
anastomosis of brachial artery. We gave 5.000 iu intravenous
injection then we clamp the proximal axillary artery. After the
clamp we performed n end to side proximal anastomosis using 6-
0 polypropylene sutures, to the 0,6 mm PTFE graft. Then we
tunneled the graft to the brachial incision The distal end-to-side
anastomosis was performed using 6-0 polypropylene sutures.
After the surgery, the patient feel better. The symptom is
gradually ease.
Conclusion: A long total occlusion of left axillary artery is rare,
but can be dangerous for the upper limb. Surgical is the best
option for this patient.
Keywords: axillary artery, long occlusion, crutch
167
Perforator Flap For Giant Keloid On The
Deltoid Region: A Case Report
I Komang Botha Wikrama*, Nyoman Putu Riasa**
*General Surgery Departement. Faculty of Medicine, Udayana
University
** Plastic Surgeon. Faculty of Medicine, Udayana University
Abstract
Introduction: The reconstruction of extensive soft tissue defects
following complete keloid resection is challenging to surgeons.
Perforator flap concept plays an important role in reconstructive
surgery, because it allows less invasive and more complex
reconstruction by preserving major vessels and muscles with
intramuscular vessel dissection.
Case presentation: A 52-years-old female was admitted to
Plastic and Reconstructive surgery, with chief complaint
recurrent major keloid over her left arm area, which she had for
18 years. The physical examination showed 15 cm × 4 cm × 1.5
cm epidermal red firm rubbery mass was seen on left upper arm
area. A perforator flap of 6 cm × 10 cm skin dimension was
harvested on the lateral lower side of her upper arm. After 1
month the patient continued to heal well and the flap showed
stable circulation without limited necrosis or other conditions. At
her 2-month follow-up, she was asymptomatic and demonstrated
no sign of recurrent keloids.
Discussion: A perforator flap is a flap consisting island of skin
and/or subcutaneous fat based on one or more vascular tributaries
of a single source artery. Perforator flap concept plays an
important role in reconstructive surgery, because it allows less
invasive and more complex reconstruction by preserving major
vessels and muscles with intramuscular vessel dissection.
Conclusion: Therapy for large symptomatic recurrent keloids is
often plagued with complicated reconstruction manner and
168
recurrence. Perforator flap is considered as new promising
surgical technique because it’s clinical and cosmetic advantages
in large difficult keloid treatment.
169
Management of Accidental Foreign Body
(Headscarf Pin) Aspiration at The Brochial
Segment: A Case Report
Rahajeng Puspitasari1, Dhihintia Winarno2
1. Resident of Cardiothoracic and Vascular Surgery, Faculty of
Medicine, Universitas Airlangga
2. Cardiothoracic and Vascular Surgeon, Faculty of Medicine
Universitas Airlangga
Abstract
Background: Tracheobronchial foreign body aspiration is a life-
threatening problem which can be seen in all ages. Most of them
are seen in children under the age of 15 and the elderly. It leads
to various symptoms such as cough, dyspnea or complications
such as pneumonia, atelectasis, and recurrent pulmonary
infections. The diagnosis can be made by history and radiological
examinations. The main treatment is by using flexible or semi-
rigid bronchoscopy, but thoracotomy may be required if the
location is difficult or failed by using bronchoscopy.
Case Presentation: An 11-year-old female came to the
Emergency Unit of Dr. Soetomo Hospital with history of
headscarf pin aspiration. She had a brief choking episode at the
beginning while she fixed up her headscarf and remained
asymptomatic thereafter. Her vital signs were within normal with
no clinical signs of respiratory distress. The patient had a
bronchoscopy but failed. Thoracotomy was performed and the
pin can be removed.
Discussion: Headscarf pin aspiration is unique condition which
is seen in young girl who wear the hijab. The incidence occurred
by talking or laughing as the pin was placed between lips and
teeth. Once diagnosed by physical examination and chest X-ray
or chest CT scan, it should be removed immediately before any
complications happened. The main treatment is by using
170
bronchoscopy, but thoracotomy should be done if bronchoscopy
fails.
Conclusion: Headscarf pin aspiration can be life threatening, so
that immediate extraction should be done by bronchoscopy or by
thoracotomy if bronchoscopy fails.
Key Words: Foreign body, bronchoscopy, thoracotomy
171
Surgical Reconstructive Procedure For
Diabetic Patient With Grade IV Pressure Ulcer
at Peripheral Hospital: Case Series
Aditya Rahman*, Ruhaya Fitrina**, Heroe Soebroto***
* Resident of Thoracic-Cardiac-Vascular Surgery. Faculty of
Medicine, Airlangga University
** Neurologist. Moh. Hatta Bukittinggi Hospital
*** Thoracic-Cardiac-Vascular Surgeon. Faculty of Medicine,
Abstract
Background: Pressure ulcer commonly found in immobilized
patient. Grade III and IV pressure ulcer might become serious
condition for diabetic patient. Early debridement followed by
reconstructive procedure usually needed to get good outcome.1,2
Purpose and Objectives: The aim of this study was to present our
case series of diabetic patient with grade IV pressure ulcer that
performed surgical reconstructive procedure at peripheral
hospital.
Methods: Descriptive-prospective study was conducted in
diabetic patient with stage-IV pressure ulcer admitted at Moh
Hatta Bukittinggi Hospital from 2019 to 2021. Two-staged
surgery, debridement then reconstruction with pedicled flap, was
performed. We collected data for age, gender, risk factor, ulcer
location, and type of reconstructive procedure. Patient was
followed for 30 days to measure the outcomes.
Results: We had 6 cases that included in the criteria. The
averages ages were 64 + 5,5 years, male was dominant gender
(four cases), most of the ulcer located at sacral region (three
cases). Five cases were performed pedicled musculocutaneous
flap. No mortality (in hospital- and 30 days-mortality) and no
post-operative sepsis were found. But, one patient had
reoperation because of dehiscence.
172
Conclusion: Early debridement and reconstruction with pedicled
musculocutaneous flap for stage IV gangrenous pressure ulcer
were safe and improved outcome of the patient. By minimizing
infected tissue and raw surface, it could improve general
condition, earlier mobilization, nutritional status, and blood
glucose.
Keywords: Diabetic, pressure-ulcer, reconstructive-surgery
173
Characteristics of Elderly Medical Problems of
Social Services Program in Celuk Village, Bali
Saturti, T.I
College Student of Doctoral Program, Faculty of Medicine Udayana
University
Background: The life expectancy is increasing, hence the

number of elder populations is high. These conditions bring
challenges in medical aspects, including increasing numbers of
patients living with one or more chronic conditions,
polypharmacy, dementia, and increasing reliance on surrogate
decision-makers at the end of life1,2. Hearing and vision loss are
a part of normal aging. Cardiovascular disease, osteoporosis,
dementia, osteoarthritis, diabetes, and related mobility disability
are common and increasing in prevalence as the population ages.
These population is considered public health importance.
Clinician should consider life expectancy, lag time to benefit, and
patient goals2,3,4.
Purpose And Methods: To determine the characteristic of elder
population during social services program in Celuk Village, Bali.
Result: During the social services program, we found that 36
patients (32%) had vision disturbances, 19 patients (17,27%) had
hypertension and only 4 patients under treatment with anti-
hypertension, 14 patients (12,7%) with osteoarthritis, 9 patients
(8%) with low back pain, and 6 patients (5,4%) with dyspepsia.
All medical problems were related to ageing process and most of
them untreated for the complaints. The patients were treated and
referred to the health center to get further examination and
treatment.
Conclusion: The health problem in geriatric is relatively similar.
In some study, geriatric tend to be treated with polypharmacy,
otherwise in Celuk Village, the elder patients mostly
174
undiagnosed. To treat elder patients, need active screening and
social approached.
Keywords: elder, geriatric, medical problem, disease
References
1. Jaul E, Barron J. Age-Related Diseases and Clinical and
Public Health Implications for the 85 Years Old and
Over Population. Front Public Health. 2017;5:335.
Published 2017 Dec 11. doi:10.3389/fpubh.2017.00335
2. Herrmann FR. Geriatric epidemiology: practical
considerations when involving elderly subjects in
studies. Swiss Med Wkly. 2004 Mar 6;134(9-10):117-
25. PMID: 15106021.
3. Catic, A.G. (2017). Geriatric Epidemiology. In: Catic, A.
(eds) Ethical Considerations and Challenges in
Geriatrics. Springer, Cham. https://doi.org/10.1007/978-
3-319-44084-2_1
4. https://www.who.int/news-room/fact
sheets/detail/ageing-and-health
175
Pancreatolithiasis: A Case Report
Arland Chandra1, Tomy Lesmana2
1
Trainee of Digestive Surgery, Medical Faculty of Airlangga
University.
2
Digestive Surgeon, Dr. Soetomo General Hospital.
Abstract
Background: Pancreatolithiasis is a rare medical condition and
is often a sequalae of chronic pancreatitis. The most common
etiologies are alcoholism and smoking. While its pathogenesis
remains unclear, there are two hypotheses explaining that
inflammation and lithostatin deficiency are the main cause of
stone formation in the pancreatic duct. The most common
symptoms are epigastric pain that radiates to the back, worsened
by the consumption of fatty food. At long term, this symptom
could cause loss of appetite, weight loss, and poor quality of life.
The main goal of treatment is to remove the stone and relieve the
pain. Despite its pretty high recurrence rate, to this day, surgery
as one of pancreatolithiasis modality still provides good stone
free rate and pain relief.
Case Presentation: Male, 49 y.o., complained of epigastric pain
that radiated to his back along with nausea, vomiting, loss of
appetite, and weight loss more than 10 kg over the last 3 months.
Pain was felt constantly and brief relief was achieved with
analgesia. There was no comorbid in this patient. Diabetes,
alcoholism, and acute pancreatitis was denied. Physical
examination showed stable hemodynamic, no anemia nor
jaundice. There was a slight tenderness in the epigastric region
of the abdomen. Laboratory showed hemoglobin level 14,5 g/dL,
leucocyte 7.880/µL, platelet 408.000/µL, SGOT 38 U/L, SGPT
59 U/L, amylase 82 U/L, lipase 25 U/L, total bilirubin 0,32
mg/dL, direct bilirubin 0,17 mg/dL, blood sugar 135 mg/dL, AFP
63 U/L, CEA 1.17 ng/mL, ca 19-9 48.03 U/mL, normal
176
electrolyte level, and normal hemostatic function. Abdominal
sonography showed normal pancreas contour, dilated pancreatic
duct 17.8 mm with multiple stone at the pancreatic duct.
Abdominal MRI/MRCP showed hypointense multiple pancreatic
stone (size ± 8 mm) with dilatation of the pancreatic duct (1.5
cm) and distal part of the common bile duct (1.2 cm). Modified
Puestow procedure was performed. During surgery, incision was
made from the neck of the pancreas to the distal part of the
pancreas. There was dilatation of the pancreatic duct ± 1.5 cm.
Stone extraction was performed and there were 4 stones ± 1 cm.
Ductoscopy showed no remaining stone in the pancreatic duct.
Lateral pancreaticojejunostomy Roux en y was performed.
Discussion: Pancreatolithiasis is a challenging case which can
impair patient’s quality of life due to the pain it causes,
gastrointestinal symptoms, and high recurrence rate. Surgery
remains one of the treatments of pancretolithiasis. Despite its
invasive nature, surgery gives high stone free rate and significant
pain relief. Cahen et al states that pain relief is better achieved
through surgery than endoscopy (75% vs 32%, P = 0,007). RCT
by Dite et al also states that pain relief in surgery is better than
endoscopy. Sujo et al states that pain free rate post-surgery is as
high as 91% and there’s no acute exacerbation in 95% patient.
Regarding the type of surgery for pancreatolithiasis, modified
Puestow procedure (Partington-Rochelle procedure) was the
methods of choice in our hospital. Stone extraction is achieved
through longitudinal incision along the anterior side of the
pancreatic duct without the need of distal pancreatectomy,
splenectomy, or mobilization of the pancreas from its
retroperitoneal attachment.
Conclusion: Despite its invasive nature, surgery remain the
mainstay of treatment for pancreatolithiasis due to its high stone
free rate and good pain relief, especially in developing country,
where minimal invasive equipment are still limited.
177
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Sugiyama M, et al. Management of pancreatolithiasis: a
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al.High risk factors of pancreatic carcinoma. J Huazhong
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8. Zhang GW, Zhou J, Li CL, Huang YQ. Diagnosis and
treatment of pancreatolithiasis: Report of 16 cases.
Hepatobiliary Pancreat Dis Int. 2005;4:135–138
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Comparison of CT duodeno-cholangio-pancreatography to
ERCP for assessing biliary obstruction. J Comput Assist
Tomogr. 2005;29:596–601
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Idiopathic chronic pancreatitis in India: Phenotypic
characterisation and strong genetic susceptibility due to
SPINK1 and CFTR gene mutations. Gut. 2010;59:800–807.
11. Li JS, Zhang ZD, Tang Y, Jiang R. Retrospective analysis
of 88 patients with pancreatic duct stone. Hepatobiliary
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Sumiyoshi S, Kobayashi Y. Successful treatment of
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A. Intra- ductal ultrasonography for the assessment of
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15. Furukawa T, Tsukamoto Y, Naitoh Y, Hirooka Y,
Hayakawa T. Differ- ential diagnosis between benign and
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180
Lobectomy In A 3 Weeks Neonate With
Congenital Cystic Adenomatoid Malformation
(Ccam): A Rare Case
Siddiq Wiratama1; Dhihintia Jiwangga2; Mohamad Rizki2
1
Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of
2
Senior Surgeon in Department of Thoracic, Cardiac, and Vascular
Surgery, Faculty of Medicine, Airlangga University
Abstract
Background: We present a case of a Congenital Cystic
Adenomatoid Malformation (CCAM) in newborn. CCAM is a
rare case with incidence range from 1:25.000 thus providing
challenges in diagnosis and treatment, especially in developing
countries. Any delay in diagnosis and management could lead
into severe complication
Case Presentation: A baby with suspected CCAM diagnosed
during antenatal care from an ultrasonography examination. A
multidisciplinary discussion decided to do an Ex-Utero
Intrapartum Treatment with insertion of a 12 French chest tube.
Chest radiograph evaluation shown multiple loculated
hyperlucent lesion at right lung with mediastinal shifting to left
side. A Thorax CT-Scan show multiple cystic lesions at middle
lobe suggestive a CCAM Type I. Patient underwent a lateral
thoracotomy at the age of 3 weeks, intraoperative finding shown
a giant bulla at middle lobe filled with mucoid material, a right
middle lobectomy was then performed. The diagnosis was
confirmed with pathological study of a CCAM Type I.
Postoperative result were good in the first week, mediastinal
shifting was improved, patient able to wean from ventilator
although oxygen dependent with non-invasive ventilation.
Infection signs started to appear on day 6 postoperative and
patient died 14 days postoperatively from a sepsis
181
Discussion: Most CCAM patient present with acute respiratory
distress. Symptomatic lesion after birth should be resected with
lobectomy as standard procedure
Conclusion: Congenital cystic adenomatoid malformation is a
rare disease of lung and require early diagnosis and proper
treatment, with surgical resection giving a good result
Keyword: Congenital Cystic Adenomatoid Malformation,

Lobectomy
182
Manougian Aortic Root Enlargement
Procedure: Surabaya’s First Experience And
Success On Short-Term Follow Up
Adistya Triasiholan1; Oky Revianto2; Chikita Nur
Rachmi3
1
Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of
2
Surgery, Faculty of Medicine, Airlangga University
2
Surgery, RSAL Dr. Ramelan
Abstract
Background: Small Aortic Root (SAR) defined as the diameter
of the sinotubular junction compared to patient’s height is
<1,4cm/m in females, <1,5cm/m in males and having an aortic
annulus diameter <21,3mm. Prosthesis-Patient Mismatch (PPM)
happens when the Effective Orificum Area (EOA) of the
prosthetic valve is smaller compared to the Body Surface Area
(BSA). The value of this is called Effective Orificum Area Index
(EOAI). Severe PPM is when the EOAI is <0,65cm 2/m2. Surgical
management for SAR is the Aortic Root Enlargement (ARE)
procedure, consists of Manougian, Nicks, and Konno-Rastan.
Case Report: Patient is a 30year-old female with Severe Mitral
Stenosis, Moderate Mitral Regurgitation, Severe Aortic Stenosis,
Moderate Aortic Regurgitation, and Moderate Pulmonal
Hypertension planned for Double Valve Replacement in which
during the procedure it was discovered that the aortic diameter is
smaller than the smallest prosthetic valve size. Selected ARE
procedure was the Manougian technique, with a size 16 aortic
prosthetic valve and a size 25 mitral prosthetic valve for the
183
double valve replacement. The patient was discharged after 5
days uneventfully.
Discussion & Conclusion: Echocardiography to measure the
aortic annulus and BSA measurement in patients with possibility
of SAR before valve replacement is important for the strategy on
whether we need to prepare for an ARE procedure. Manougian
technique is the most frequent technique with minimal
complications. Anticipating SAR-related discoveries during
procedure, hospitals with cardiac surgery services needed to
provide the prosthetic materials. Lastly, echocardiography
examination after the procedure is important to evaluate the
effect of possible PPM.
Keywords: small aortic root, patient-prosthetic mismatch,

manougian, aorta
184
Management Of Mixed Neuroendocrine-Non-
Neuroendocrine Neoplasms Of The Digestive
System
Ida Bagus Ananta Wijaya1, Gede Eka Rusdi Antara2
1
Resident, Department of Surgery, Udayana University
2
Department of Surgery, Udayana University
Abstract
Introduction: The classification of mixed neuroendocrine-non-
neuroendocrine neoplasms (MiNEN) is evolving, and no clear
management guidelines are currently available. However, recent
studies provide insight into factors affecting outcomes and could
help develop treatment decisions for patients with these rare
malignancies. MiNENs are a specific subtype of mixed NE
neoplasms. Traditionally, mixed NE neoplasms include
composite tumor, collision tumors, amphicrine tumors and non-
NE neoplasms with focal neuroendocrine differentiation (NNE-
NEDs). Each neoplasm is derived from a separate precursor cell
which has independently undergone its own molecular
evolutionThe majority of MiNENs have a poorly differentiated
neuroendocrine carcinoma (NEC) component which is
associated with an aggressive clinical course and poor outcomes.
Diagnosis: MiNENs are 'neoplasms' instead of 'carcinomas'
because benign non-NE components such as adenomas or
papillomas can still be a part of MiNENs in sites outside of the
digestive system. Definitive diagnosis of a MiNEN usually
follows after surgical resection. The presurgical biopsy
diagnoses are roughly evenly split between 1/3 adenocarcinoma,
1/3 NEC, and 1/3 suspicious for MiNEN. The NE component
tends to lie deeper in the tumor which can influence the diagnosis
on biopsy depending on the depth of tumor sampled.
The majority of MiNENs do not contain NETs but rather contain
poorly differentiated NECs. Tumor cells in NECs show nuclear
185
crowding and pleomorphism. Nuclei are hyperchromatic with
increased nuclear membrane irregularity. Single cells are
common, and mitoses are obvious. Necrosis can be present, and
nuclei display smearing or crush artifact. NE markers remain
sensitive, however immunohistochemical markers for the
primary site of origin are lost. Aberrant expression of TTF-1 and
CDX-2 is common, making these markers unreliable and a
potential pitfall for mistaking the site of origin. The average Ki-
67 proliferative index of NECs in MiNENs is 70%.
There is currently no widely accepted system for grading
MiNENs. La Rosa et al[1] in which the term MiNEN was coined
also proposed a grading scheme in which MiNENs were divided
into low-grade, intermediate grade, and high grade categories.
Tumors with a NEC component, which constitute the vast
majority of MiNENs, would be designated high grade
neoplasms. Tumors in which the non-NE component was the
most aggressive, such as adenocarcinomas with a NET
component, would be intermediate grade. Indolent tumors in
which a NET was the most aggressive component would be low-
grade.
Management: In the digestive system in general, 82% of
MiNENs present with localized disease and 18% present with
distant metastases. Patients with localized disease generally
proceed to surgical resection. Select patients with advanced
disease may undergo palliative resection. No guidelines exist
currently for adjuvant or neoadjuvant chemotherapy. NEC driven
tumors are usually treated with etoposide and cisplatin-based
regimens. Adenocarcinoma driven cancers are commonly treated
with 5-FU based backbones, however treatment options vary
based on the site of the primary, with chemotherapies for
MiNENs arising from a particular organ mirroring the systemic
therapy for adenocarcinomas at that site. The oncologist may
attempt a tailored combination of therapy in which the agents
186
employed display efficacy against both components. Radiation
therapy has been suggested in tumors from the esophagus,
stomach, rectum, and anus. The genetic similarity of MiNENs to
adenocarcinomas and reports of KRAS, BRAF V600E, APC,
MMR, and HER-2 amplifications occurring in both components
of MiNENs invites the possibility of targeted therapies in these
tumors.
Prognosis: The median overall survival for localized MiNENs,
including regional lymph node metastases (Stages I-III), is 39
mo. For advanced disease with distant metastasis (Stage IV)
median overall survival is 11 months.
Conclusion: Surgical management is appropriate in early-stage
disease with a low threshold for addition of adjuvant
chemotherapy. Multimodality treatment with chemotherapy
offers a survival benefit in advanced disease or when surgical
resection is not possible without significant morbidity.
Chemotherapy should be directed at the more aggressive
component which is often the NEC component. In addition,
molecular testing should be employed to evaluate patients for
enrollment in clinical trials and other targeted treatments.
187
Cancer Clinicopathologic Characteristics
Patient in Udayana University Hospital
Ni Gusti Ayu Agung Manik Yuniawaty Wetan 1, Hendry
Irawan1, Putu Erika Paskarani2
1
Dept of Surgery, Faculty of Medicine Udayana University
2
Pathology Anatomy, Faculty of Medicine Udayana University
Abstract
Background: Cancer is a leading cause of death worldwide,
accounting for nearly 10 million deaths in 2020, and also in
Indonesia. Cancer is also the largest user of government health
insurance funds (BPJS). Udayana University (UNUD) Hospital
is a teaching hospital that has only been running for about 2 years,
after previously being used as a Covid referral hospital. UNUD
Hospital is a type C government hospital that also serves cancer
patients but limited.
Objective: to identify the clinicopathologic characteristics of
cancer patients in Udayana University Hospital.
Methods: We performed a retrospective review for patients
treated for cancers at the Udayana University hospital in
Jimbaran between 2018 and 2022. The patients’ characteristics
were analyzed using descriptive analysis.
Results: There was a total of 30 patients collected. The mean age
of the patients was 52.23 ± 14.03 years. There were 25 (83.3%)
female and 5 (16.7%) males. Most of the cancer were breast
cancer (33.3%), followed by papillary thyroid cancer (20%) and
other types of cancer like ovarian, prostate, squamous cell
carcinoma of skin cancer, nasopharynx, lymphoma, urogenital
cancer, and brain cancer. Most of the patients took less than 2
hours to reach the hospital from their home (93.1%).
Unfortunately, only 6 patients (20%) can be treated completely
and the other was referred for definitive therapy.
188
Conclusion: By knowing the characteristic of cancer patients,
we understand the patients better, and we can make an integrated
cancer service plan so we can provide better services to prevent
mortality and morbidity.
Keywords: Cancer, Characteristics, UNUD Hospital.
189
A Bayesian Network Meta-Analysis in
Comparing Biliary Stent Types’ Outcome and
Complications in Unresectable Malignant
Biliary Obstructions
Citra Aryanti1, I Made Mahayasa2, I Made Mulyawan2
1
2
Division of Digestive Surgery, Udayana University
Abstract
Background: Biliary stents placement had widely been used for
palliative care in unresectable malignant biliary obstruction
(MBO). However, no head-to-head trials that compared those
therapies in terms of the outcome and complications.
Objectives: To conduct a network meta-analysis (NMA) in
comparing biliary stents types’ performance and complications
in unresectable malignant biliary obstructions
Methods: Comprehensive searches were done in randomized
controlled trials that included subjects with unresectable MBO
using biliary stents either with full-covered metal (FMS),
partially-covered metal (PMS), uncovered metal (UMS), plastic
(PLS), Iodine-125 seeds strands (IRS), antireflux (ARS), or
paclitaxel-coated (PXS) stents. The outcome parameters were
clinical success, median patency duration, medial survival, and
early 30-day mortality. The complications included were stent
occlusion, stent migration, cholangitis, cholecystitis,
pancreatitis, hemorrhage, and hemobilia. NMA will be done in R
Studio (BUGSnet – Bayesian) and presented in Sucra plot, league
table, and forest plot.
Results: There were 37 studies included with 3678 total subjects.
ARS had the best clinical success rate and longest median
patency duration compared to others stents. However, it was
associated with higher rate of early 30-day mortality, stent
190
migration, cholecystitis, hemobilia, and cholangitis
complications. IRS had a good clinical success, long median
patency duration, and high significant survival rate (MD 69.89;
95%CI 22 to 117.57 than UMS). It was associated with lower
complications, only unsignificant but higher rate of cholecystitis,
hemobilia, and hemorrhage complications relative to others
stents.
Conclusion: Iodine-125 seeds strands had the best outcome with
tolerable complications compared to others and should be
considered as a standard.
Keywords: network meta-analysis, stent, malignant biliary
191
Case Report: Open Amputation And Negative
Pressure Wound Treatment In Severe
Necrotizing Fasciitis, Life Or Limb Saving?
Ramadani G, Revianto O,
Department of Thoracic, Cardiac, & Vascular Surgery
Faculty of Medicine Airlangga University
Abstract
Background: Necrotizing fasciitis, also known as the "flesh-
eating disease", is a rare and life-threatening infection with high
mortality rate.
Objective: To report a case of Necrotizing fasciitis treated with
open amputation and repeated surgical debridement. Negative
Pressure Wound therapy (NPWT) was applied repeatedly to the
surgical wound until it was closed.
Case Description: We report a case of 36 years old man
presented to the emergency department (ED) with fever, sepsis
and severe infection of the left lower extremity that getting worse
in 2 weeks. He denied any history of diabetes mellitus,
cardiopulmonary diseases, vascular diseases, recent surgeries, or
smoking. The wound was entirely on the left lower extremity
with exposed fascia, wide area of necrotic tissue, purulent
discharge and gas gangrene. Open amputation with guillotine
incision was done followed by NPWT. During operation, the
above knee tissue was not viable, filled with purulent pus on the
posterior and lateral sides. Femoral artery pulsation was present,
with sclerotic plaque and no thrombus. Negative Pressure Wound
therapy (NPWT) was applied and evaluation was performed
every 5 days. Microbiology cultures of tissue sample showed
Morganella morganii. The patient underwent repeated
debridement (5 times) until granulation tissue appeared and
purulent discharge was absent. Clinical and laboratory
192
parameters was gradually improved, and the patient was
discharged 22 days after admission (2 days following above knee
stump closure).
Conclusion: Necrotizing fasciitis is life-threatening infection.
Open Amputation with Negative Pressure Wound therapy
(NPWT) should be considered for life saving procedures.
Keywords: Necrotizing fasciitis, Open Amputation, Negative

Pressure Wound Therapy
193
Successful Surgical Management Of Gunshot
Wound To The Right Chest Causing
Traumatic Hematothorax, Lung Parenchymal
Laceration And Bullet Trapped Between The
Superior Vena Cava And Right Pulmonary
Artery : Case Report
Al Jufri, Agil1; Jiwangga, Dhihintia 2, Rizky, Mohamad2
1
Resident of Department of Thoracic, Cardiac and Vascular Surgery,
Airlangga University.
2
Senior Attendant of Department of Thoracic, Cardiac and Vascular
Surgery, Airlangga University.
Abstract
Background: Gunshot injuries are always challenging for a
surgeon. Thoracic penetrating trauma is serious problem,
knowledge of proper management is needed because it has high
morbidity and mortality. In this case, we present a case report of
gunshot wound causing progressive haematothorax, lung
laceration and a bullet lodged in the mediastinum.
Objective: To report surgical management of bullet evacuation
and complications that occur.
Case Report: A 27-year-old woman was gunshot wound in right
chest. The examined was found the bullet in mediastinum, and a
progressive right hematothorax. A CT-scan obtained metal
density, the impression was a bullet located between the right
atrium, right ventricle, and aortic root with pulmonary
hematoma, but a ct-scan could not show the details of the bullet
location, echocardiography result bullet was not found in
intracardiac.
Results: The patient underwent surgery with left lateral
thoracotomy approach, exploration with fluoroscopy but the
194
bullet difficult to reach. The operation was decided to convert
right lateral thoracotomy. Obtained Haematohorax 400cc. A
through and through laceration was found in the middle lobe.
With the fluoroscopy it was decided to open pericardium.
Obtained 50cc haematopericard. Exploration of mediastinum did
not lacerations of the heart and blood vessels. The bullet is caught
between the Superior Vena Cava and Right Pulmonary Artery.
Evacuation of the bullet, repair of lung lacerations. The patient
has been discharged from the hospital in good condition.
Conclusion: Surgical approach, good diagnostic are needed to
prevent morbidity and mortality.
Keywords: gunshot, bullet, lung laceration
195
Simultaneous Surgery of Pectus Excavatum
and Tetralogy of Fallot: A Case Report
Septiandi, Yohannes1; Hakim, Arief Rakhman2
1
Resident of Department of Thoracic, Cardiac and Vascular Surgery,
2
Senior Attendant of Department of Thoracic, Cardiac and Vascular
Surgery, Airlangga University
Abstract
Background: Simultaneous repair of pectus deformities and
heart defects has been avoided because of fear of technical
difficulties of intracardiac repair or other major complications
including bleeding. Major trauma usually complicated with
infection and metabolic complications like hypoalbuminemia.
Timing of definitive operation for reconstruction for chest wall
defect after trauma is important to avoid reconstruction failure
even wound complications.
Objective: To present management of pectus excavatum and
tetralogy of fallot with simultaneous procedures.
Method: A 7 years old boy was referred to a tertiary hospital in
Surabaya from a primary hospital in Kediri. Patients complain of
fatigue easily when playing with friends. The patient will always
take a crouching position while experiencing fatigue. The patient
underwent one stage of simultaneous elective surgery for chest
wall reconstruction and total correction.
Results: Postoperatively the patient was treated in the intensive

care room with intubated conditions. Extubation is done three
days after the patient is treated in the intensive care room. Three
days after extubation the patient went home. 14 days
postoperatively patient controls into the outpatient department of
cardiothoracic surgery.
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Conclusion: Surgical decision of pectus excavatum is not just
based on cosmetic deformity. When the deformity starts to
interfere with the function of the heart, the decision of surgery
must be taken.
Keywords: pectus excavatum, tetralogy of fallot
197
Geriatric’s Vision Disturbance In Social
Services Program At Celuk Village, Bali
Gede Eka Rusdi Antara
College Student of Doctoral Program, Faculty of Medicine Udayana
University
Abstract
Background: Vision loss among the elderly is a major health
care problem. Approximately one person in three has some form
of vision-reducing eye disease by the age of 65. The most
common causes of vision loss among the elderly are age-related
macular degeneration, glaucoma, cataract and diabetic
retinopathy. Vision impairment is associated with a decreased
ability to perform activities of daily living and an increased risk
for depression.
Purpose And Methods: To identify vision problem in elder
population during social services program at Celuk Village, Bali
Result: We found 81 patients, 45 female patients (55,5%), 36
male patients (44,5%) with vision disturbance during social
services program. Five patients with pseudophakia, 6 patients
with dry eyes, 61 patients with presbyopia, and 1 patient with
glaucoma. Patient with refractory problems were treated with
glasses and advised to consul to ophthalmologist.
Conclusion: Presbyopia is the commonest vision problem in
geriatric population with vary underlying primer disease from
macular degeneration, refractory problems, cataract and
glaucoma. Active screening from public health center is
necessary to get early treatment and improve geriatric’s quality
of life.
Keywords: elder, geriatric, vision, presbyopia
References
198
1. https://www.aafp.org/pubs/afp/issues/1999/0701/p99.html
2. Quillen DA. Common causes of vision loss in elderly
patients. Am Fam Physician. 1999 Jul;60(1):99-108.
PMID: 10414631.
3. Servat, Juan Javier. (2011). Visual Impairment in the
Elderly: Impact on Functional Ability and Quality of Life.
Clinical Geriatrics. 19.
4. Jin J. Screening for Impaired Visual Acuity in Older
Adults. JAMA. 2022;327(21):2158.
doi:10.1001/jama.2022.7534
199
Primary Breast Lymphoma: A Case Report
I Wayan Sudarsa, Ni Gusti Ayu Agung Manik Yuniawaty
Wetan, Hendry Irawan
Surgical Oncology Division, Department of Surgery, Faculty of
Medicine Udayana University
Abstract
Background: Primary breast lymphoma (PBL) is a rare disease,
approximately 0.04-0.5% of all malignant breast tumors, <1% of
all patients with non-Hodgkin’s lymphoma, and 1.7-2.2% of all
patients with extranodal lymphomas. Often found as a solitary
indolent mass, it is difficult to distinguish from breast cancer on
imaging and difficult to diagnosed for the first time based on
histological findings. Diffuse large B-cell lymphoma is the most
common histological subtype.
Objective: We report a rare case of PBL, successfully treated
with surgery, chemotherapy
Methods: We collect data from medical record of patient with
diagnosed PBL.
Case: A 56-year-old woman visited our hospital because of a
painless mass in the right breast. Breast ultrasonography showed
a solid lesion with 2 cm diameter and based on imaging findings
it was suspected breast cancer. A wide excision was performed
and the pathology result was non-Hodgkin lymphoma with a
differential diagnosis of invasive lobular carcinoma. Further
examination of immunohistochemical staining diagnosed diffuse
large B-cell lymphoma. The patient has been treated with CHOP
for 6 cycles and remains alive without recurrence in a year.
Conclusion: Although the high prevalence of breast cancer,
awareness of primary breast lymphoma is essential for accurate
and timely diagnosis and for avoiding unnecessary surgery.
Keywords: primary breast lymphoma, immunohistochemistry.
200
Laparoscopic Cholecystectomy During The
COVID-19 Pandemic In A Tertiary Care
Hospital In Germany
A.A.Ngurah Krisna Dwipayana1, Gede Eka Rusdi Antara1
Dept of Surgery. Faculty of Medicine, Udayana University
Abstract
Background: The COVID‐19 pandemic caused a global health
crisis in 2020. This pandemic also had a negative impact on
standard procedures in general surgery. A Milanese study
presented an overall success rate of 87.5% after percutaneous
cholecystostomy with a mean post-procedural hospitalization
length of nine days. Fifty percent of these patients underwent a
definitive laparoscopic cholecystectomy Surgeons were
challenged to find the best treatment plans for patients with acute
cholecystitis. The aim of this study is to investigate the impact of
the COVID‐19 pandemic on the outcomes of laparoscopic
cholecystectomies performed in a tertiary care hospital in
Germany.
Methods: We examined perioperative outcomes of patients who
underwent laparoscopic cholecystectomy during the pandemic
from March 22, 2020 (first national lockdown in Germany) to
December 31, 2020. We then compared these to perioperative
outcomes from the same time frame of the previous year.
Results: A total of 182 patients who underwent laparoscopic
cholecystectomy during the above‐mentioned periods were
enrolled. The pandemic group consisted of 100 and the control
group of 82 patients. Subgroup analysis of elderly patients (> 65
years old) revealed significantly higher rates of acute [5 (17.9%)
vs. 20 (58.8%); p = 0.001] and gangrenous cholecystitis [0
(0.0%) vs. 7 (20.6%); p = 0.013] in the “pandemic subgroup”.
Furthermore, significantly more early cholecystectomies were
201
performed in this subgroup [5 (17.9%) vs. 20 (58.8%); p =
0.001]. Table 2 illustrates intra- and postoperative outcomes. We
performed more early laparoscopic cholecystectomies in the
pandemic group than in the control group [19 (23.2% vs. 36
(36.0%)]. There were no significant differences between the
groups both in the overall and subgroup analysis regarding the
operation time, intraoperative blood loss, length of
hospitalization, morbidity and mortality.
Conclusion: Elderly patients showed particularly higher rates of
acute and gangrenous cholecystitis during the pandemic.
Laparoscopic cholecystectomy can be performed safely in the
COVID‐19 era without negative impact on perioperative results.
Therefore, we would assume that laparoscopic cholecystectomy
can be recommended for any patient with acute cholecystitis,
including the elderly.
Keywords: COVID‐19, Pandemic, Cholecystitis,

Cholecystectomy, Hepatobiliary surgery, Laparoscopic surgery
202
Recurrent Abdominal Liposarcoma infiltration
to Gallbladder: A Case Report
Giovani F Odo1, Gede Eka Rusdi Antara2
1 General Surgery Resident, Medical Faculty, Udayana University
2 Department of Digestive Surgery, Medical Faculty, Udayana
University
Abstract
Background: We report a case of a patient diagnosed with a
local recurrent retroperitoneal liposarcoma with infiltration to
Gallbladder after complete tumor resection 4 years ago.
Liposarcoma is the most common retroperitoneal sarcoma and
mesenchymal tumor in the abdomen. Patient usually presents
with vague symptoms due to its large size and slow growth at the
time of diagnosis. Liposarcoma is associated with a high local
recurrence rate according to its histology, size and growth rate
with heterogeneous clinical behavior. Patients with
retroperitoneal liposarcoma have obvious symptoms at a very
late stage, when the mass develops enough to press or invade the
neighboring organs. Surgical resection is effective treatment for
primary and recurrent abdominal liposarcoma.
Case: A 42 year old patient was complaining of significant
abdominal enlargement. The patient already had excision of
abdominal liposarcoma on 4 years ago.
On physical examination and ultrasonography, a 50-cm swelling
extending from epigastric region extend to suprapubic region
with infiltration to Gallbladder. An en bloc resection of the tumor
with Cholecystectomy was performed through a midline
abdominal incision.
Discussion: Giant recurrent liposarcomas over 20kg are
extremely rare. Dedifferentiated liposarcomas comprise about
50% of the total liposarcoma incurrences. The resection of a
retroperitoneal sarcoma of remarkable size is a challenge for the
203
surgeon owing to the anatomical site that makes it hard to obtain
safety margin and to the adherences with other organs. Histologic
subtypes and negative surgical margins are associated with poor
prognosis and recurrency. This explains the high rate of local
recurrence after surgical excision. Surgical resection of the
malignancy remains the treatment of choice for liposarcomas,
with clinically negative margins (R0) if feasible. Adjuvant
radiation treatment administration is highly effective in local
recurrence prevention. In this case, patient already had complete
excision of the tumor and cholecystectomy due to tumor
infiltration. Patient was discharged and referred to the Digestive
department for further management.
Conclusion: We here report a case of a recurrent giant
retroperitoneal liposarcoma in a 42 year old female who was
admitted with a complaint of an abdominal enlargement.
Ultrasonography showed a large retroperitoneal mass from the
epigastric area down to the pelvic cavity. After laparotomy, the
masses measured 50×32×18 cm. Postoperative pathological
report showed retroperitoneal liposarcoma. Liposarcoma has a
high rate of local recurrence but a low rate of distant metastasis.
Patient was advised to take adjuvant therapy. A long-term
follow-up examination is absolutely needed.
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Endoscopic Surgery Considerations During
Covid-19
Kristian Gerry Raymond Sinarta Bangun1, Gede Eka Rusdi
Antara2
1
Departement of Surgery, Faculty of Medicine, Udayana University
2
Department of Digestive Surgery, Medical Faculty, Udayana
University
Abstract
Introduction: Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2), referred to as COVID-19, has become a global
pandemic. Human-to-human transmission occurs through
respiratory secretions, aerosols, feces, and contaminated
environmental surfaces. The novel severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) has affected more than
4.5 million people in 213 countries, and has been declared a
pandemic by World Health Organization on March 11, 2020. The
transmission of SARS-CoV-2 has been reported to occur
primarily through direct contact or droplets. There have also been
reports that SARS-CoV-2 can be detected in biopsy and stool
specimens, and it has been postulated that there is potential for
fecal–oral transmission as well. Thus, can be concluded that
Covid-19 could be transmitted via endoscopic surgery through
the equipment as well as the surgery staff
Potential of transmission pre, during, and post Endoscopic
Procedure: The virus characteristics made it possible to transmit
via person-person, aerosols generated during surgery,
contaminated surroundings, and bodily fluid. Patient-
contaminated fluids often splatter when inserting or removing a
piece of equipment from the endoscope. Before the endoscopic
procedure is done, the patients must be selected carefully, if the
case is not urgent the procedure should be delayed to decrease
the risk of pre-hospitalization infections, if the case is urgent, the
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patients must be screened again for symptoms, and the
temperatures checked again, also the patients must get PCR
tested for Covid-19. Asian Pacific Society for Digestive
Endoscopy and ESGE Suggest that no caregivers or relatives
should be allowed to enter the endoscopy center.
During the endoscopy procedure, all members of the surgery
team must be tested for Covid-19 before entering the surgery
room, while during the surgery the members must wear complete
personal protection equipment (PPE), usually consisting of N95
or surgical mask, eye shield/ googles, face shield, water resistant
gown and gloves. Also, during the procedure, the members
required to use 2 sets of gloves in high-risk procedures. The
number of members that are allowed in the room is the only
essential one. After the procedure is done, all environments
contacted with the procedure must undergo extensive cleaning.
Endoscopes and endoscopic accessories are reprocessed with
standardized reprocessing procedures. Positive samples of covid-
19 were found on the shoes, and stethoscopes of the members
during the procedure, while the anteroom or corridor outside the
room is free of Covid-19.
Conclusions: The Covid-19 Pandemic made the medicine field
take enhanced measures to limit the spread of the disease, cause
of the characteristic of the virus that made it so contagious. The
patients must be selected carefully and got “Triaged” into urgent
or elective procedures, if the procedure is elective, the treatment
must be delayed until the number of Covid-19 cases go down,
meanwhile if the case is urgent, preemptive measures must be
taken to limit the chance of Covid-19 spread. The chance of the
virus to spread is relatively high if preemptive measures is not
taken. So, a standard operational procedure must be made for
every working endoscopic center during Covid-19 to limit the
spread, and to keep the patients and working members of the
healthy.
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Keywords: Endoscopy, Covid-19, Surgery
207
Ovarian Serous Cystadenoma Finding During
Laparoscopy Surgery
Bismantara Aditya Putra1, Gede Eka Rusdi Antara2
1
Dept of Surgery, Faculty of Medicine, Udayana University
2
Digestive Surgery Division, Faculty of Medicine, Udayana
University
Abstract
Background: Epithelial neoplasms of the ovary account for 60%
of all ovarian tumors and 40% of benign tumors. They classify
as benign, borderline, or malignant tumors. Ovarian
cystadenomas are common benign epithelial neoplasms which
carry an excellent prognosis. The two most frequent types of
cystadenomas are serous and mucinous cystadenomas1. In this
case we present a large serous cystadenoma that mimicking
intraabdominal tumor.
Case: A twenty-two-year-old female complaining abdominal
mass over the last 5 years ago companied by dull pain. There is
no digestion or defecation problem. History of weight loss were
positive. From the physical examination we found 20x20cm
mass that fixed, with clear border and tenderness. Patient
underwent abdominal ultrasound and revealed anechoic lesion
filled abdominal cavity and protrude solid organ to lateral side.
There is no intralesional vascularization, suggestive to a cyst.
Laparoscopic resection of tumor was carried but after camera
insertion we found the abdominal cavity fulfilled with cystic
mass. We convert to laparotomy and done complete mobilization
of the cyst. Continued by complete resection, we found the cyst
rising from right ovary. Consulted obsgyn division and done
frozen section, Histopathologic revealed serous cystadenoma.
Patient discharged at third day post operative with no
complication
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Conclusion: Ovarian cystadenomas are benign tumors which
carry an excellent prognosis2. The treatment is always complete
resection. This type of cyst rarely recurs after complete
resection3. They are ideally managed by an interprofessional
team that consists of digestive surgeon, gynecologist,
radiologists, and pathologists.
Keywords: Serous cystadenoma, laparoscopic, Ovarian tumor
209
D-Dimer Coagulation Activation On
Septicaemia
I Putu Mana Nitia 1, Gede Eka Rusdi Antara 2
Abstract
Introductions: The new recommendations define sepsis as life-
threatening organ dysfunction due to a dysregulated host
response to infection. Septic shock is defined as a subset of sepsis
in which particularly profound circulatory, cellular, and
metabolic abnormalities substantially increase mortality. The
World Health Organization (WHO) estimates that sepsis affects
over 30 million people each year, and is responsible for over 6
million deaths worldwide, including one million newborns.
Recently, for the first time, the Global Burden of Disease (GBD)
Study included sepsis estimates in its reporting of cause of death
data from over 100 million individual death records across 195
countries. In 2017, the estimated annual incidence of sepsis
around the world was 508 cases per 100,000 however, reported
incidence rates vary significantly by country. The inflammation
will increase the production of proinflammatory cytokines that
will activate coagulation and suppress fibrinolytic system,
measured by D-dimer. D-dimer (DD) is the most used fibrin-
related marker because DD assays are widely available, simple
and rapid and has been proposed, either alone or in combination
with other variables, as prognostic factor in patients with sepsis.
Discussions: Normal body responses to fight infections in sepsis
is by releasing a wide variety of proinflammatory mediators that
can stimulate activation of coagulation system in sepsis initially
stimulated by the tissue factor pathway (extrinsic pathway),
mediated by several pro-inflammatory cytokines. Extrinsic
pathway the dominant mechanism that activates the coagulation
system in sepsis will eventually increase production of thrombin.
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Contact factors in the intrinsic pathway are also activated due to
endothelial damage caused by bacteria and its substances that
increases fibrin formation. Fibrinolysis function decreases in
sepsis despite persisting coagulation activity, causing greatly
increased fibrin formation and eventually microvascular
thrombosis. Fibrinolysis activity can be assessed by D-dimer
measurement. DD is a fibrin breakdown product that arises from
three reactions: 1) fibrinogen to fibrin conversion by thrombin,
2) fibrin cross-linking by activated factor XIII and 3) fibrin
degradation by plasmin. This implies that the levels of circulating
DD depend on both coagulation and fibrinolysis activation.
Fibrinolysis activity assessed by examination of D-dimer levels,
increased with a median 1.15 μg/mL (0.1 to 4 μg/mL), it was
same as Kinasewitz’s study in 2004, who found a median of D-
dimer 4.2 ug/mL (2.2- 8.4 μg/mL). Mayrommatis et al. reported
40 of 82 patients with sepsis had positive D-dimer levels (>0.5
μg/mL). This study showed that D-dimer levels were positive in
30 sepsis patients (55.6%). Increased levels of D-dimer in sepsis
is a description of hemostasis function disorder due to the
occurrence of DIC and as a parameter for detecting sepsis
complications. This result was associated with the occurrence of
a hypercoagulable state due to activation of coagulation, caused
by proinflammatory cytokines that were increased in early sepsis.
Normal liver function a compensated situation leading to the
value of PT and aPTT shortened or normal in sepsis.
Conclusions: Based on many research it can be concluded that
coagulation activity in sepsis patients showed that D-dimer levels
were increased. There is a widespread agreement that
dysfunctions in coagulation develop during sepsis and lead to
inappropriate intravascular fibrin deposition. Any consensus
beyond that statement, however, remains frustratingly elusive. In
patients with severe sepsis and Disseminated Intravascular
Coagulation (DIC), the parameters should be determined for
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detecting complications sepsis such as fibrinogen levels in order
to diagnose DIC, and some of the proinflammatory cytokines that
increased in early sepsis.
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Ultra Low Anterior Resection Laparoscopy
Post Chemotherapy
Ida Bagus Putra Ambara 1, Gede Eka Rusdi Antara 2
Abstract
Introductions: Colorectal cancer is the third most common
cancer and the fourth most common cancer cause of death
globally. More than 1-2 million patients are diagnosed with
colorectal cancer every year and more than 600.000 die from the
disease. Incidence is higher in men than women and low at ages
younger than 50 years, but strongly increases with age.
Approximately 30% of colorectal cancer are diagnosed in the
rectum and around one third of rectal cancer (RC) are located on
its third distal part. Apart from age and male sex, the following
risk factors (which often co-occur and interact) have been
identified and established in epidemiological studies: family
history of colorectal cancer, inflammatory bowel disease,
smoking, excessive alcohol consumption, high consumption of
red and processed meat, obesity and diabetes.
The primary treatment for colorectal cancer is still surgery.
Surgery however, may be either preceded of followed by
chemotherapy and radiotherapy as and when needed. Ultra-low
anterior resection (ULAR) is defined as a procedure in which the
entire rectum is removed. This is usually for a low rectal cancer
and a coloanal anastomosis will therefore be performed. ULAR
can be performed via an open incision or laparoscopic approach.
The goals of surgery for rectal cancer are cure, maintenance of
function, and optimization of quality of life. For carefully
selected patients with low-lying rectal cancers, ultralow anterior
resection (ULAR) has become an alternative technique to
abdominal perineal resection as it provides a chance for organ
213
preservation. When coupled with coloanal anastomosis (CAA),
ULAR has been shown to allow normal continence and an
acceptable frequency of bowel movements one year after
surgery. Neoadjuvant radiotherapy and chemotherapy have
further increased the rate of sphincter preservation for patients
with low rectal cancers.
Discussion: For carefully selected patients with low-lying rectal
cancers, ultralow anterior resection (ULAR) can be an effective
alternative to abdominal perineal resection, and together with
neoadjuvant chemotherapy can provide the opportunity for
sphincter preservation. However, ULAR is not without potential
postoperative complications, particularly anastomotic
dehiscence which increases in likelihood after receiving
chemotherapy. While surveillance imaging is not indicated three
years beyond initial surgical resection, changes in chronic
symptoms refractory to conservative management may warrant
further investigation.
Preoperative chemoradiotherapy in the treatment of rectal
carcinomas can be beneficial among patients with a planned
resection for locally advanced disease. When used in conjunction
with total mesorectal excision, chemoradiotherapy has been
found to reduce local recurrence, increase sphincter sparing, and
reduce rates of positive margins. However, radiation-induced
damage to the anorectal area can lead to fibrosis, stenosis, and
eventual bowel dysfunction. It is estimated that 90% of patients
develop a permanent change in their bowel habits after pelvic
chemoradiotherapy and surgery, 50% of which have an
associated reduction in quality of life. Patients can present with
incontinence, rectal bleeding, mucoid discharge, tenesmus,
abdominal cramps, and increased stool frequency.
While surgical technique and neoadjuvant therapies play a role
in anastomotic breakdown, patient-related factors such as age
greater than 60 years, male gender, preoperative medical disease,
214
obesity, bowel obstruction, smoking, and alcohol abuse can
significantly influence the probability of leakage. Postoperative
management should be catered to the patient based on risk
assessment, and appropriate follow-up is essential regardless of
efforts to reduce complications. Cancer Care Ontario guidelines
recommend surveillance imaging annually for three years
following surgical resection for a colorectal malignancy. Beyond
this, it is unclear when to conduct follow-up imaging. For a
patient well beyond surgery, CT and MRI are not indicated when
patients are devoid of symptoms that would suggest recurrence.
Conclusions: Patients must be monitored for anastomotic
dehiscence as this can cause bothersome symptoms, reduced
anorectal function, abscess formation, and infection. Following
curative intent multimodal therapy for locally advanced rectal
cancers, patients typically enter a program of surveillance that
includes endoscopic evaluation and imaging. The goals of
surveillance are to identify foci of recurrence and to monitor for
and prevent complications. However, for patients having
undergone ULAR, careful attention must be paid to new
symptoms even many years following treatment, as late events
can still occur.
215
Virtual Reality-Based Rehabilitation For
Spinal Cord Injury: A Systematic Review
Dicky Teguh Prakoso1, Tjokorda Gde Bagus Mahadewa2
1
Neurosurgery Residency Program, Faculty of Medicine, Universitas
Udayana
2
Neurosurgery Division, Department of Surgery, Faculty of Medicine,
Universitas Udayana
Abstract
Background: Spinal cord injury (SCI) often causes limitations
to an individual's functional status which would reduce quality of
life. Therefore, an effective rehabilitation protocol should be
executed to mitigate these limitations. Virtual reality (VR)-based
rehabilitation has emerged as an alternative in
neurorehabilitation. The use of VR-based technology has
somewhat proven to be beneficial in neurological and
psychological outcomes. This study aimed to examine the effect
of VR-based rehabilitation in SCI patients.
Methods: A systematic review of English articles using PubMed
and the Cochrane CENTRAL without year restriction.
Additional studies were searched manually in Google scholar and
Google search engine. Search terms included “spinal cord
injury”, “paraplegia”, “tetraplegia”, “quadriplegia”, “virtual
reality” and “randomized controlled trial”. Only randomized
controlled trial studies were included in this study.
Results: Seven studies were included in this study. These studies
had evaluated 187 patients with SCI that follow a set of
rehabilitation protocols. These studies measured different
outcomes, including motoric, sitting balance, and neuropathic
pain. The authors observed a large amount of heterogeneity
regarding rehabilitation protocol and outcome measures used.
However, the trend of efficacy in VR-based rehabilitation can be
observed. Four studies (57.14%) reported better outcome in VR-
216
based rehabilitation. In addition, one study (14.29%) reported a
great outcome while combining VR-based rehabilitation with
another neurorehabilitation.
Conclusion: This study suggest that VR-based rehabilitation
produced a positive outcome in SCI patients, more as an
adjunctive neurorehabilitation protocol. Further high-quality
studies with larger sample are needed to draw a strong conclusion
of VR-based rehabilitation protocol in SCI patients.
217
Vertex Epidural Hematoma : Operative
Considerations
Kristian Gerry Raymond Sinarta Bangun1, Sri Maliawan2
1
Udayana
2
Universitas Udayana
Abstract
Vertex Epidural Hematoma (EDH) are rarely seen and form a
small percentage of all EDH. The cause of the hematoma is
usually caused by the tearing of the superior sagittal sinus or the
fracture from the parietal bone, usually from the diploe veins.
Usually, this type of EDH is followed by sudden death. In this
study we report a 10-year-old boy, sustained a head injury
followed by loss of consciousness for 10 minutes before he
regained his consciousness. After the incident the patients was
administered to Ngoerah General Hospital, we reevaluate the
patient GCS Score (E4V5M6), pupils size was normal, we did a
head CT-Scan that revealed a small EDH at Vertex region and
decide to do conservative treatment, after 12 hours observation
the patient headache is reported progressively increased, and the
patient looked sleepy all the time, after we reevaluate the patient,
we found the GCS score decrease slightly (E3V5M6). This time
we redid the Head CT-Scan that revealed the volume of the
hematoma had increased rapidly. The emergency surgery was
decided for the patient. Before the surgery was done, the patients
neurological status and Vital sign remained the same as before.
During the surgery we found a linear fracture of the parietal
bones, and after the bone was elevated we found the hematoma
clot with volume around 60cc, and the cause of the hematoma
was from the diploic vein of the bone. Post-surgery the patient
GCS slowly recovered and no neurological deficits were found.
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Keywords: Epidural Hematoma, Head Injury, Vertex
219
Severe Translational Atlantoaxial Dislocation
With Type Iii Odontoid Fracture Stabilization
Management: A Case Report
Eufrata Silvestris Junus1 , Steven Awyono1 , Tjokorda Gde
Bagus Mahadewa2
1
Udayana
2
Universitas Udayana
Abstract
Background: Atlantoaxial joint dislocation with an odontoid
fracture is a rare case that is estimated only less than 2% of upper
cervical injuries. Atlantoaxial dislocation is when there is a loss
of stability between C1-C2 that results in loss of normal
articulation. The cause of this loss of stability is traumatic,
inflammatory, idiopathic, or congenital abnormalities.
Case report: A male patient came to the emergency department
with tingling in the hands and feet 1 week ago after he was
massaged on the neck in a massage parlor. No abnormalities were
found in the primary survey, secondary survey, and neurological
status examination. The patient was diagnosed with type III
odontoid fracture, type III Atlantoaxial dislocation fielding,
Atlantooccipital dislocation, and SCI ASIA E then planned for
C3 occipital fusion stabilization surgery.
Conclusion: Atlantoaxial dislocation with type III odontoid
fracture is indicated for posterior stabilization with surgical
treatment. Occipitocervical fixation is used to treat instability
between the skull and cervical spines such as Atlantoaxial or
Atlantooccipital dislocation, odontoid fracture, and occipital
condyle fractures. An Occipital plate and screw with a rod are
used in Occipitocervical fixation. Upper cervical spine
220
instrumentation should be included if the patient’s anatomy is
appropriate.
Keywords: Atlantoaxial dislocation, Type III odontoid fracture,

Occipitocervical fixation
221
Spontaneous Resolution Of Traumatic Acute
Subdural Hematoma: A Case Report
I Gusti Ketut Agung Surya Kencana, Anak Agung Ngurah
Agung Harawikrama Adityawarma, Made Gemma
Daniswara Maliawan
Department of Neurosurgery Faculty of Medicine, Udayana
University
Abstract
Acute Subdural Hematome (ASDH) is one of the highest
leading causes of death in patient with traumatic brain injury, that
requiring emergency decompression surgery 1. Even after a
rigorous treatment and monitoring the prognosis for patient with
ASDH is relatively poor1,2. In this study we reporting a 7-month
male baby with traumatic ASDH that requiring immediate
surgical intervention from the first CT Scan. While waiting to be
referred to our hospital, the neurological condition is improved,
and we conduct second CT scan, and found majority of the
hematome is disappeared, we continue the treatment as
conservative and closed monitoring in intermediate ward, the
patient was discharged with great clinical condition. In this report
we also discuss the possible mechanism of the spontaneous
resolve ASDH that happen in our case and consideration in
choosing conservative treatment for patient with Acute Subdrual
Hematome.
Keywords: Acute Subdural Hematome, Spontaneous Resolve,

Conservative
222
Needlefish Bite Wound To The Left Pelvic
Region; A Case Report
Joestiantho Laurenz Kilmanun1, Gregorius Batara P. S.
Sutardi2
1Debut Primary Health Care, Southeast Maluku
2Departement of Orthopaedic and Traumatology, Karel Sadsuitubun
General Hospital
Abstract
Introduction: Needlefish are predatory schooling fish with long
slender jaws that have been known to leap out of the surface of
the water at high speeds. Needlefish (Family Belonidae) are
carnivorous fish that have long beaks that are studded with teeth,
elongated bodies measuring up to 2 m, and live in temperate
waters. Benefits of the emergency debridement and antibiotic
prophylaxis.
Case Illustration: A 30-year-old male, fisherman by profession,
presented 7 h after an odd accident while at sea. He gave a history
of being injured by the horn of a 2-ft-long needlefish, which rose
above the water and went through the right pelvic region. Clinical
examination revealed an entry wound of 3x5 cm based on bone.
The patient was hemodynamically unstable and in pain. The
routine biochemical parameters in his blood were normal. We did
the emergency resuscitation and debridement with local
anesthesia in primary health care. The patient was
hemodynamically stable 40 hours after debridement. We gave
antibiotics, pain management, and tetanus prophylaxis. The
patient was discharged home and 1 week after the accident there
was no complaint.
Conclusion: While rare, Needlefish related injuries can have
clinical significance in excess of their external appearance.
Injuries caused by Needlefish and other fish should be considered
when the patient’s injury history is consistent with a possible
223
injury by a Needlefish or similar organism. The diagnosis was
prompt, and even though the presentation to the casualty was
delayed, immediate resuscitative measures and surgery ensured
successful management of the patient.
Keywords: Needlefish, penetrating injury, pelvic
224
Giant Primary Adult Retroperitoneal
Teratoma: A Case Report
1
Yustina M., 2Lesmana T.
1
Trainee of Digestive Surgery, Airlangga University
2
Chairman of Digestive Surgery, Airlangga University
Abstract
Introduction: Teratomas are bizarre neoplasms derived from
embryonic tissues that are typically found only in the gonadal
and sacrococcygeal regions of adults1. Retroperitoneal teratomas
in adults are rare, representing only 1-11% of all primary tumors
in that anatomic region and demand challenging diagnosis and
management2,3.
Purpose: To review the clinical manifestations, diagnosis and
surgical treatment procedure of this case retrospectively
Case Presentation: A-51-year-old man admitted to hospital
complained of enlarged mass in his abdomen since 4 months ago.
He lost 20 kg in that time. No tenderness, nausea and vomiting,
defecation and urination also within normal limit. We performed
abdominal CT scan with contrast, the result showed solid mass
with cystic component, necrotic and calcification 11.4x20.7x20
cm in the right side suspected for teratoma dd sarcoma. We
performed complete resection and right nephrectomy by
laparotomy approach. The surgical specimen was a large tumor
mass measuring 28x23x15 cm in size and weighing 20 kg
covered with a smooth membrane. The external surface was
lobulated and ragged in areas, with cut sections revealing mostly
yellow fat with cystic areas filled with brown, cheesy material
and calcification area compatible with bone were also noted The
patient discharge on 4th day and at follow-up, the patient was
eventful.
Conclusion: Primary retroperitoneal teratoma is a rare entity in
adults. The diagnosis can be established pre operatively by its
225
characteristic appearance on computed tomography. The
definitive treatment is surgical resection.
Keywords: teratoma, abdominal mass, tumor, retroperitoneal
226
Gastric Sleeve Twisting Post Laparoscopy
Gastric Sleeve: A Case Report
Gede Eka Rusdi Antara
Consultant of Digestive Surgery, Faculty of Medicine Udayana
University
Abstract
Introduction: Twist of gastric remnant post sleeve gastrectomy
is a rare entity and difficult to diagnose pre-operatively. It is
serious complication of laparoscopy sleeve gastrectomy with
gastric obstruction symptoms. Gastric twist can be classified into
intraoperative diagnosis, early postoperative and delayed
postoperative diagnosis. It presents as an acute abdominal
emergency or a chronic condition. Diagnosis and management of
gastric sleeve twisting is challenging. Here we present delayed
gastric sleeve twisting
Purpose: This study aims to review the diagnosis, etiology, and
management options for axially twisted sleeve gastrectomy.
Case Presentation: A-27-year-old female admitted to the
hospital due to persistent non bilous vomit and dehydration. The
patient had laparoscopy sleeve gastrectomy 19 days prior to
admission. Intraoperatively during LSG, endoscopy evaluation
was performed, it showed good tube patency, no narrowing and
no leak or bleeding from the stapling line. The patient was
rehydrated and we performed endoscopy. During endoscopy, the
sleeve was obstructed, the gastroduodenoscope was unable to be
inserted further. We performed laparoscopy diagnostic and
found adhesion between the stapling line and surrounding
structure and twisted the gastric sleeve. Following release
adhesion, gastric by-pass was performed due to risk of recurring.
The patient was uneventful during follow up.
Discussion: Gastric sleeve twisting can be present as an acute
abdominal emergency or a chronic cause of abdominal pain,
227
diagnosed by Borchardt triad, which consists of epigastric pain,
unproductive retching and inability to pass a nasogastric tube. GT
may be chronic if the rotation is minimal and there is no vascular
compromise4. Twisting may occur due misalignment of the
staples on the anterior and posterior planes leading to
intraoperative diagnosis. Delayed adhesions in the gastric serosa,
indentation of the incisura within the gastric lumen which
produces a flap valve leading to delayed presentation 6. Delayed
presentation can be managed by endoscopic dilatation, surgery ,
and surgery after failure of endoscopic treatment. Endoscopic
dilatation can be attempted three times before surgical
management. In the surgical management approach options are
Roux-en-Y gastric.
Conclusion: Laparoscopy sleeve gastrectomy is an effective and
popular bariatric procedure which has specific risk and
complication. Gastric sleeve twisting is a rare complication but
should be considered in patient with symptom of gastric
obstruction post LSG. Upper GI endoscopy is a valuable
diagnostic tool. Gastric bypass is an option in certain condition.
Keywords: gastric twist, torsion, sleeve, bariatric, complication,

gastric stenosis
References
1. Subhas G, Gupta A, Sabir M, Mittal VK. Gastric remnant
twist in the immediate post-operative period following
laparoscopic sleeve gastrectomy. World J Gastrointest Surg.
2015;7(11):345-348. doi:10.4240/wjgs.v7.i11.345
2. Abd Ellatif ME, Abbas A, El Nakeeb A, Magdy A, Salama
AF, Bashah MM, Dawoud I, Gamal MA, Sargsyan D.
Management Options for Twisted Gastric Tube after
Laparoscopic Sleeve Gastrectomy. Obes Surg. 2017
Sep;27(9):2404-2409. doi: 10.1007/s11695-017-2649-y.
PMID: 28361494.
228
3. Abd ellatif, Mohamed & Abbas, Ashraf & El Nakeeb,
Ayman & Magdy, Alaa & Salama, Asaad & Bashah, Moataz
& Dawoud, Ibrahim & Gamal, Ali & Sargsyan, Davit.
(2017). Management Options for Twisted Gastric Tube after
Laparoscopic Sleeve Gastrectomy. Obesity surgery. 27.
10.1007/s11695-017-2649-y.
4. Gupta P, Khan S, Thusoo T, Kaushal A. Should Gastric
Sleeve be xed? Torsion of Gastric Sleeve after Laparoscopic
Sleeve Gastrectomy: A Case Report. Open Access J Surg.
2017; 2(3): 555588.
5. Landreneau, J.P.; Strong, A.T.; Rodriguez, J.H.; Aleassa,
E.M.; Aminian, A.; Brethauer, S.; Schauer, P.R.; Kroh, M.D.
Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric
Bypass. Obes. Surg. 2018, 28, 3843–3850. [CrossRef]
6. Burgos AM, Csendes A, Braghetto I (2013) Gastric Stenosis
After Laparoscopic Sleeve Gastrectomy in Morbidly Obese
Patients. Obes Surg 23(9): 1481- 1486.
229
Safe Endoscopy In Pandemic Covid 19 :
Literature Review
Ni Nyoman Amik Indrayani1, Gede Eka Rusdi Antara2
1 Department of Surgery, Faculty of Medicine Udayana Univeristy
2 Digestive Surgeon, Faculty of Medicine, Udayana University
Abstract
The coronavirus disease (COVID-19) pandemic has changed
endoscopic practice with the need for COVID-19 testing,
screening questionnaire, and use of personal protective
equipment with the hope for the “old normal” as a distant dream.
Although there are no data on whether endoscopy is an aerosol-
generating procedure, positive insufflation during endoscopic
procedures could pose a risk of generating aerosol and increase
the risk of SARS-CoV-2 transmission.
Viral shedding in stools is reported both symptomatic and
asymptomatic patients. Stool specimen positive rate was rate was
identified as high as 29%. Infections related to the
duodenoscopes and echoendoscopes are more frequent than
colonoscopesn and EGD scopes. While most of these infections
occur due to multidrug resistant organisms, the transmission of
other microbial organisms has also been reported.
After the Covid 19 pandemic, patients undergoing endoscopy
were screened by looking at the presence of fever, travel history,
occupation, cluster and contact. When the screening is positive,
a Covid test will be carried out. If positive or no Covid test is
available, endoscopy will be performed with enhanced PPE and
infection control and carried out in a negative pressure room. For
positive screening results and negative covid tests. As well as
negative and asymptomatic screening, endoscopy was performed
with standard PPE and infection control.
It can be concluded that the change in the endoscopy guideline
after covid spread, was carried out to prevent wider spread.
230
Keyword : Covid 19, Endoscopy, Screening
References
1. Balekuduru, A.B., Sahu, M.K., Bongu, S.S., Satyal, A.,
Devarasetty, S., Matta, R., Reddy, Y.P.D. Bidirectional
Endoscopy – A Trend for Future in Covid Era. Society of
Gastrointestinal Endoscopy of India. 2022; 13: 70-76
2. Chiu, P.W.Y., Ng, S.C., Inoue, H., Reddy, D.N., Hu, E.L.,
Cho, J.Y., et. al. Practice of Endoscopy during Covid 19
Pandemic: Position Statement of Asian Pasiefic Society for
Digestive Endoscopy (APSDE-COVID statesments). Gut
2020; 69: 991-996
3. Pribadi R.R. Utari, A.P., Muzzelina V.N., Nursyirwan, S. A.
Maulahela, H. Renaldi, K. Syam, A.F. Clinical Practice of
Gastrointestinal Endoscopy in Covid-19 Patients: An
Experience from Indonesia. Clin Endosc 2022; 55: 156-159.
4. Perisetti, A., Gajendran, M., Boregowda, U., Bansal P.,
Goyal H. Covid-19 and Gastrointestinal Endoscopies:
Current Insight and Emergent Strategies. Digestive
Endoscopy 2020; 32: 715-22
231
Ventricular Septal Rupture As A Result Of
Acute Myocardial Infarction : A Case Report
Lie, Zanella1 ; Sembiring, Yan Efrata2
1
Resident in Thorax, Cardiac and Vascular Department Faculty of
Medicine Airlangga University
2
Senior Surgeon in Thorax, Cardiac and Vascular Department Faculty
of Medicine Airlangga University
Abstract
Background: Ventricular Septal Rupture (VSR) is a rare but
lethal complication of acute myocardial infarction. VSR tends to
occur within the first week after the onset of the infarct itself.
This condition is a surgical emergency needing immediate
treatment especially in symptomatic patients. Timing of surgery
is still debatable, because of the fragility of heart tissue. Some
studies suggest surgical intervention between 7-21 days after
VSR is detected.
Purpose : to report our success in repairing VSR in day 8 after
the onset
Case : A 57 years old woman with typical chest pain as a chief
complaint came to our ER department. Transthoracic
echocardiography is performed, then VSR was found with 0.7 cm
in size and L to R Shunt is also detected. After multimodality
discussion, the patient underwent surgery for repairing VSR
using Dor procedure and coronary bypass using great saphenous
vein as conduit was performed. Intraoperatively, we found
multiple VSR with the biggest diameter being 2 cm.
Result : The operation went successful. Postoperatively, the
patient developed symptoms such as bluish toes in both lower
extremities. Patient eventually was diagnosed with acute limb
ischemia and underwent bilateral lower extremity amputation.
Conclusion : Surgical timing is still controversial in surgical
repair of VSR. Some studies suggest after day 14 was a
232
considerable approach. Nonetheless, the patient's condition
should be considered as a first priority to take action in surgical
management. Repair VSR as a definitive therapy is a must in
treating this case.
Keywords : Ventricular Septal Rupture, Acute Myocardial

Infarct, Repair VSR
233
Repair Ventricular Septal Defect (Vsd) With
Infective Endocarditis Post Pulmonary Artery
Banding Using Monocusp Implantation In
Pediatric Patient: A Case Report
Atiya Nurrahmah1 , Heroe Soebroto1 , Arief Rakhman
Hakim1 , Erdyanto Akbar1
1
Department of Thoracic, Cardiac, and Vascular Surgery,
Background. Pulmonary valve reconstruction has been

problematic until now, especially for pediatric patient. Implanted
prosthetic pulmonary valve must be re-open in the future because
of prosthetic mismatch during child development. But
pulmonary valve regurgitation after resection of the vegetation
may be prone to right ventricular dysfunction because of volume-
overload in the right ventricle. The aim of this study is to describe
the monocusp implantation as surgical repair for pediatric patient
with infective endocarditis pulmonary valves.
Case description. A-one-year-old boy was diagnosed with
infective endocarditis and peri membranous type ventricular
septal defect (VSD). He was performed pulmonary artery
banding eight months ago as a previous procedure because of
severe pulmonary hypertension. Transthoracic echocardiography
(TTE) showed a large peri membranous type of VSD with left-
to-right shunt and there were multiple vegetations in the
pulmonary valve. The first vegetation was 5x7 mm and the
second vegetation was 6x8 mm. There was a severe pulmonary
stenosis with pulmonary valve trans gradient 85 mmHg. From
the right arteriotomy we performed VSD closure using PTFE
patch and then we released pulmonary artery banding. Next, we
resected the vegetation from the transpulmonary approach. Then,
we performed monocups implantation using PTFE patch and
234
released the pulmonary stenosis with transannular patch using
pericardial patch. Transesophageal echocardiography (TEE) post
operative showed there was trivial pulmonary regurgitation and
there was no pulmonary stenosis. The monocusp was well
functioned. It showed no residual flow from the interventricular
septal patch. The patient was discharged from hospital after
seven days.
Discussion. Moderate or severe pulmonary stenosis caused by
infective endocarditis must be treated with a surgical
replacement, but in pediatric patient, repair is more acceptable
than replacement. It is because of the patient was growing up. A
0.1-mm-polytetrafluoroethylene (PTFE) monocusp valve has
proven to be a simple and reproducible technique, especially for
rural area. It showed excellent early postoperative function with
minimal pulmonary insufficiency.
Conclusion. For pediatric patient, Monocusp implantation has
proven to be a good choice for surgical repair of pulmonary
valves with infective endocarditis
235
Subaortic Stenosis With Ventricle Septal
Defect : A Case Report
Ni Kadek Sulistyaningsih1, Erdyanto Akbar2, Arief
Rakhman Hakim2
1
Cardiothoracic And Vascular Surgery Resident
2
Consultant Of Cardiothoracic And Vascular Surgery
Background: Subaortic stenosis manifests as left ventricular

outflow obstruction which may present as a part of other
congenital anomalies that accounts for approximately 3-6% of
congenital heart defects. The lesion typically progresses as one
age, implying that the patients might be asymptomatic early in
life but gradually develops symptoms. The timing of surgery is
still controversial; however, some studies advocate early surgery
to alleviate the progression of the disease.
Purpose: to report our success in treating sub-aortic stenosis
with large VSD.
Case: This report presents a case of a female child with signs of
failure to thrive, who was diagnosed with subaortic stenosis and
ventricular septal defect from echocardiography. The patient
already receives congestive heart medication to slow down the
progression of the heart failure. Intraoperatively, we found an
aortic band obstructing the LVOT and successfully excised it.
Result: The patient has already undergone VSD closure and
aortic band procedure with a satisfactory result from the
postoperative echocardiography. The patient was discharged 5
days later in good condition and was completely symptom-free
at follow-up 4 weeks later.
Conclusion: Subaortic stenosis is a rare congenital anomaly that
can cause congestive heart failure. Early diagnostic and
intervention were mandatory to prevent heart decompensation.
236
Keywords: congenital sub-aortic stenosis, aortic band excision
237
Cholangiocarcinoma : The Latest Advances In
CCA
I Gede Hendra Wijaya1, Gede Eka Rusdi Antara2
General Surgery Training Program, Medical Faculty of Udayana
University
Division of Digestive Surgery, Medical Faculty of Udayana
University
Introduction : Cholangiocarcinoma (CCA) is a malignant tumor

of the biliary system that came from the biliary epithelium in any
part of extrahepatic and intrahepatic biliary tree. Its incidence is
increasing currently accounting for 15% of all primary liver
cancers and 3% of gastrointestinal malignancies.
Discussion : The risk factor include duct cyst, infection,
hepatolithiasis, primary sclerosing cholangitis and toxin have
been contribute to the incidence of CCA. The asymptomatic
nature of these tumors combined with their highly aggressive and
chemotherapy refractory contribute to mortality rate which
represents 2% of all cancer-related deaths worldwide each year.
The staging of CCA depends on extend of prymary tumor, lymph
node involvement and presence of metastasis. Current diagnosis
of CCA with non-invasive approaches is less accurate,
histological confirmation is required in the diagnosis. The high
heterogeneity of CCA at the genomic, epigenetic, and molecular
levels strongly influences the response to available therapies. The
management of CCA should be multidisciplinary approach
including physical condition preparation, preoperative, staging,
aggressive surgical treatment, transplantation and adjuvant
therapy.
Conclusion : knowledge of CCA needs to be expanded, but
current information should be included in the future treatment
decisions. increased efforts have been made to understand the
238
complexity of these tumors and to develop new diagnostic and
therapeutic tools that can help improve patient outcomes.
Keywords : CCA, malignancies, transplantation
239
Management of Esophagogastric Junction
Adenocarcinoma: A Case Report
Elika Larasati1, I Made Mulyawan2
1
General Surgery Training Program, Medical Faculty of Udayana
University
2
Division of Digestive Surgery, Medical Faculty of Udayana
University
Background: Esophagogastric junction cancer (EGJ) is defined

as a malignant neoplasm located in the area 2 cm above to 2 cm
below the EGJ. Several risk factors, such as gastro-esophagal
reflux disease (GERD), obesity, smoking, and low Helicobacter
pylori (H.Pylori) infection rates, have been associated with an
increase in the prevalence of EGJ adenocarcinoma. According to
the National Comprehensive Cancer Network (NCCN)
Guidelines, distal esophagus and EGJ cancers are managed
distinctly from proximal gastric cancer. The Management of EGJ
adenocarcinoma is according to the stage of cancer.
Case Report: A 44 years old man with complaint of difficulty
swallowing since 3 months before being admitted to the hospital.
This complaint has been getting worse since 1 month ago.
Sometimes feels pain when swallowing. The patient can only eat
soft rice but sometimes vomits. The patients have history weight
loss of 7 kg in the last 3 months. Physical examination found the
abdomen was not distended, bowel sounds were within normal
limits and there was no palpable mass, only tenderness was found
in the epigastric region. The patients underwent esophagography
on January 12,2022 with the results of filling defect and mucosal
irregularity at the esophagogastric junction at the level of the left
Th12-L1 paravertebral with rat tail sign, which caused partial
stenosis at that level and proximal esophageal dilatation,
suspected pseudochalasia. The patient was then performed EGD
and biopsy with the results of secondary esophageal achalasia
240
with a distal esophageal tumor extending to the stomach, with
result small cell type lymphoma. The staging of the tumor is
T33N0M0. The patients underwent diagnostic laparoscopy
surgery and then converted laparotomy with distal
esophagectomy, total gastrectomy, bypass Roux en Y and
excision infiltrating tumor in peritoneal. The histopathologic
examination showed histomorphology was suitable for
adenocarcinoma esophageal junction.
Conclusion: The management of EGJ adenocarcinoma
according to the stage of cancer. Preoperative chemoradiation,
perioperative chemotherapy, or preoperative chemotherapy
followed by surgery is management of EGJ adenocarcinoma.
Surgery is recommended for early-stage disease, but in advanced
case where metastases have occurred, the treatment is to improve
quality of life.
Keywords: Esophagogastric junction, adenocarcinoma, EGJ
241
Nutritional Management In Patients With
Gastric Cancer After Gastrectomy Surgery: A
Case Report
David Rendra Mahardika, Tjahya Aryasa, Pontisomaya
Parami
Department of Anesthesiology and Intensive Care, Faculty of
Medicine, Udayana University
Introduction: Weight loss and malnutrition occurred in 15% and

80% patients diagnosed with gastroesophageal cancer which are
associated with morbidity and mortality.1
Aim: Managing perioperative malnutrition in cases of gastric
cancer is a critical thing to increase the success of treatment in
patients.
Case description: A 44-year-old male patient with a diagnosis
of a distal esophageal tumor extending to gaster with suspected
mucosa-associated lymphoid tissue had weight loss of ±30 kg in
the last 6 months with Nutrition Risk Index (NRI) score 89.5
(Moderate malnourishment). Preoperatively patient was fasted
on solid foods for 8 hours and clear water for hours before
surgery. Total gastrectomy, distal esophagectomy, and bypass
esophago-jejunostomy was performed under general anesthesia.
Postoperatively, the patient was fasted by surgeon for 5 days.
After surgery the patient admitted to ICU for 24 hours. Nutrition
was given parenterally using 500 ml of Bfluid® (210 calories)
and 500 ml of D5% (100 calories) for 24 hours. After 24 hours
the patient transferred to nursing ward and was given parenteral
nutrition by the nutritionist using 500 ml of Bfluid® (210
calories), 500 ml of D5% (100 calories), 500 ml of Amiparen®
every 24 hours (100 grams of protein) and SMOF Kabiven®
1206 ml (800 calories) every 3 days. On the sixth day, the patient
242
received oral intake. On the seventh day, the patient was allowed
outpatient treatment.
Discussion: In the guidelines of the European Society for
Parenteral and Enteral Nutrition (ESPEN), preoperative
nutritional support is recommended for gastric cancer patients
with insufficient dietary intake defined as an oral food intake
<500 Kcal/day or ≤ 75% of the requirement for more than 1-2
weeks. According to this patient case who experienced a weight
loss of ± 30 kg in the last 6 months, indicating that the patient’s
food intake was less than 75% of his caloric needs. This patient
should be given preoperative nutrition support performed
through nasogastric or a nasoenteric tube, but the patient was not
receiving it. Preoperative oral carbohydrate fluid loading using
800 ml of 12.5% carbohydrate drink the night before operation
and 400 ml of 12.5% carbohydrate drink in the morning of the
operation day 2-3 hours prior to the induction of anesthesia is
recommended to reduce insulin resistance induced by surgery
and to sustain normal bowel function. Oral carbohydrate loading
may shorten the length of hospital stay, compared with overnight
fasting, in gastric cancer patients receiving gastrectomy, but the
patient was not receiving it. Compared to total parenteral
nutrition, early enteral tube feeding may shorten hospital stay and
decrease medical cost in gastric cancer patients following
gastrectomy. After surgical treatment, small intestinal functions
resume between 6 and 12 hours after surgery, indicating that
enteral nutrition could be started at that time, but the patient was
fasted for 5 days and did not receive early enteral tube feeding.
Following gastrectomy for gastric cancer, patients receiving
early oral feeding (EOF) beginning on postoperative day 3
resulted shorter hospital stay without increasing complications
than those receiving parenteral nutrition regardless the extent of
the gastric resection and the type of surgery, but the patient was
fasted for 5 days, received oral intake on the 6th days and did not
243
receive EOF. EOF had a shorter postoperative hospital stay and
a higher oral energy intake on early phase, compared with those
with late oral feeding (LOF). The incidence of complications did
not show significant differences between patients receiving EOF
and LOF after gastrectomy.2 All guidance from the Taiwan
nutritional consensus was not performed on this patient and may
be the cause of prolong length of hospital stay. Patient
preoperative malnutrition status without preoperative nutrition
support also increase risk of complication, increase incidence of
surgical site infections and decrease overall survival rate.
Conclusion: Condition assessment and nutritional intervention
are very important to prevent nutritional deficiency in
perioperative gastric cancer patients. Preoperative nutritional
support, clear oral carbohydrate fluid loading, early enteral tube
feeding followed by early oral feeding will increase overall
survival rate and decrease complication risk and length of
hospital stay.
Reference:
1. Rosania R, Chiapponi C, Malfertheiner P, Venerito M.
Nutrition in Patients with Gastric Cancer: An Update.
Gastrointest Tumors. 2015;2(4):178-187.
doi:10.1159/000445188
2. Hsu PI, Chuah SK, Lin JT, et al. Taiwan nutritional
consensus on the nutrition management for gastric cancer
patients receiving gastrectomy. J Formos Med Assoc.
2021;120(1):25-33. doi:10.1016/j.jfma.2019.11.014
244
Infantile Hemangioma of The Unilateral Breast
Ketut Suparna1, Luh Putu Kavita Elra Veda2
Department of Surgery, Faculty of Medicine, Ganesha University
Abstract
Unilateral infantile hemangioma of the breast is a rare case with
very few reports. Symptoms that arise vary according to the
phase the patient is experiencing, such as changes in skin color,
and protrusion. Handling cases of infantile hemangioma can be
in the form of observation, pharmacological therapy to surgery.
In the case of infantile hemangioma of the breast. surgical
treatment is avoided as much as possible because it can interfere
with the growth and function of the breast.
Introduction: Unilateral infantile hemangioma of the breast is a
rare case. Progressive proliferation occurs in vascular endothelial
cells. Changes in color to the structure of the skin that occur vary
according to the phase experienced
Case: A 5-month-old baby girl patient came with a lump in her
left breast since she was 42 days old. The lump is located in the
nipple-areolar centre region with a soft consistency, movable, flat
surface, 10 cm in diameter and no discharge from the nipple. The
result from cytological examination with Fine Needle Aspiration
Biopsy showed left mammary hemangioma.
Discussion: The patient had an infantile hemangioma because
the first time lump was noticed in the patient's left breast when
the patient was 42 days old and none at birth. The lesion is
categorized as a superficial lesion based on the depth of location
and it is also categorized as a local lesion based on the anatomical
configuration of the lesion because there is only 1 lesion. In this
case, the hemangioma is in the proliferative phase with a visible
bulge on the left breast with red and bluish color. The patient did
not complain any of pain. Results of the FNAB examination
245
showed the microscopic picture only contained erythrocytes, so
it was concluded that the left mammary hemangioma.
Besides being rare, this case is risky because the location of the
hemangioma is on the left breast and the patient is female, so it
has the potential to inhibit the patient's breast growth in the
future. Based on this condition, the management given to the
current patient is observation until the patient is 5 years old with
regular follow-up. The prognosis from the patient in this case is
ad vitam bonam ad sanationam bonam ad functionam dubia. This
is based on the location and see the growth of this hemangioma.
If the growth of the hemangioma interferes with the growth of
the patient's breast, there can be a change in prognosis.
Conclusion: Unilateral infantile hemangioma of the breast is a
rare case and starting from a few days to week of age.
Hemangiomas can appear in the outer, inner, or mixed depth of
the skin and can appear in one or more locations. Clinical
symptoms are different in each phase. Management of
hemangioma is not always surgical, where most cases of
hemangioma do not need any intervention so inly observation is
done. Pharmacological and surgical management is still
recommended if there is and indication.
Keywords: Unilateral breast, hemangioma, baby girl
246
Bardach Two Flap Palatoplasty In Submucous
Cleft Palate Patient: A Case Report
Anak Agung Bagus Satria Brahmananta*, Agus Roy Rusly
Hariantana Hamid**, I Gusti Putu Hendra Sanjaya **I
Made Suka Adnyana**
Plastic Reconstructive and Aesthetic Surgery Division
Faculty of Medicine Udayana University
Resident*, Consultant**
Abstract
A submucous cleft palate consists of a notch in the posterior hard
palate, diastasis of soft palate musculature in the midline (zona
pellucida), and a bifid uvula. The estimated incidence of
submucous cleft palate is at 1:1,250 to 1:6,000, occurring as an
isolated anatomic deformity or as part of a syndrome. The
majority of patients with a submucous cleft palate are
asymptomatic, but some may experience velopharyngeal
insufficiency. Treatment of cleft palate has evolved and currently
aiming to successfully close of the cleft palate and improve
optimal speech without compromising maxillofacial growth.
This study reports a 1-year-old male patient with submucous
palatal cleft. Local physical examination on facial region did not
show cleft lip, intraoral regional did not show cleft alveolar and
hard palate, however bifid uvula and pellucid zone was seen.
Palatoplasty with Bardach Two Flap Palatoplasty technique was
planned in this patient. Despite being the oldest technique,
Bardach Two Flap Palatoplasty is still used until today and a
good option for wide and incomplete clefts because this
technique facilitates dissection. The Bardach Two Flap
Palatoplasty technique is useful in management of the
submucous cleft with one major addition. Studies have shown
that simple Bardach Two Flap Palatoplasty closure can give good
results in cases with a long soft palate. In several cases where soft
247
palate was in sufficient length, a modified Bardach Two Flap
Palatoplasty can be incorporated.
Keyword: submucous cleft palate, palatoplasty, Bardach Two

Flap Palatoplasty technique
248

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1

All praise and gratitude we say to the presence of

Prof. Sri Maliawan, MD, PhD, FICS

Good Morning Ladies and Gentlemen,

May we thank God for the making of this ICS Bali

Director : Komang Januartha Putra Pinatih, MD, PhD

Secretary and Treasurer

Licensing and Spiritual Division

Accessories and Consumption Division

CHAPTER 1: MANUSCRIPT FROM SPEAKER ................. 20

Gut Microbiota and Gastrointestinal Tract Surgery ................. 21

The Ethical Concern in Surgery .............................................. 34

Bariatric Strategies Post COVID-19 Pandemic ....................... 39

Overview Management Of Cerebrovascular Accidents In Bali41

Robotic And Minimally Invasive Cardiac Surgery ................. 52

Head and Neck Infection, The Sequalae and Its Reconstruction

Horse-Shoe Flap Reconstruction Technique in Breast Surgery:

The Challenges of Performing Surgeries During The New

Ksatria Airlangga Hospitalship,Voyage The Ocean To Save The

Add-On Benefits Through The Collaboration Among

Ageing Population In World And Singapore – New Directions

Humanitarian Medical Care 2022 ......................................... 120

Role Of ICS Indonesia Section In The Post COVID-19 Era: An

Cisternostomy, An Emerging Surgical Technique For

Neuroendoscopic Surgery For Hemorrhagic Stroke .............. 148

Acupuncture Role in ICS Humanitarian Health Services and

CHAPTER 2: ABSTRACTS FROM PARTICIPANTS ........ 163

Burn Patients in Regional Public Hospital: Profile and

Perforator Flap For Giant Keloid On The Deltoid Region: A

Management of Accidental Foreign Body (Headscarf Pin)

Characteristics of Elderly Medical Problems of Social Services

Pancreatolithiasis: A Case Report ......................................... 176

Lobectomy In A 3 Weeks Neonate With Congenital Cystic

Manougian Aortic Root Enlargement Procedure: Surabaya’s

Cancer Clinicopathologic Characteristics Patient in Udayana

A Bayesian Network Meta-Analysis in Comparing Biliary Stent

Case Report: Open Amputation And Negative Pressure Wound

Successful Surgical Management Of Gunshot Wound To The

Simultaneous Surgery of Pectus Excavatum and Tetralogy of

Primary Breast Lymphoma: A Case Report .......................... 200

Laparoscopic Cholecystectomy During The COVID-19

Recurrent Abdominal Liposarcoma infiltration to Gallbladder:

Endoscopic Surgery Considerations During Covid-19 .......... 205

Ovarian Serous Cystadenoma Finding During Laparoscopy

D-Dimer Coagulation Activation On Septicaemia ................ 210

Ultra Low Anterior Resection Laparoscopy Post Chemotherapy

Virtual Reality-Based Rehabilitation For Spinal Cord Injury: A

Vertex Epidural Hematoma : Operative Considerations ........ 218

Severe Translational Atlantoaxial Dislocation With Type Iii

Spontaneous Resolution Of Traumatic Acute Subdural

Giant Primary Adult Retroperitoneal Teratoma: A Case Report

Gastric Sleeve Twisting Post Laparoscopy Gastric Sleeve: A

Safe Endoscopy In Pandemic Covid 19 : Literature Review . 230

Ventricular Septal Rupture As A Result Of Acute Myocardial

Repair Ventricular Septal Defect (Vsd) With Infective

Subaortic Stenosis With Ventricle Septal Defect : A Case

Cholangiocarcinoma : The Latest Advances In CCA ............ 238

Management of Esophagogastric Junction Adenocarcinoma: A

Nutritional Management In Patients With Gastric Cancer After