BY: - DR. GAGAN GUPTA (PT)

Common Operations & Physiotherapy

CONTENT

  Introduction

Cholecystectomy Colostomy Gastrectomy Hernias Mastectomy Nephrectomy Prostatectomy

Introduction

It is not proposed to deal at length with any specific operations but to give a brief resume of operations commonly encountered by the physiotherapist, together with particular points that should be noted. The basic principles of preoperative and postoperative physiotherapy care should be applied to patients undergoing surgical procedures ,if the patient is at risk of developing pulmonary or circulatory complications. If the patient is elderly he may require further physiotherapy in order to gain optimum independence following surgery.

Cholecystectomy

This operation may be performed following the development of stones in the gall-bladder and cystic duct (cholelithiasis).

The stones cause attacks of colic and jaundice and may obstruct the bile duct. If there is an acute attack of cholecystitis the surgeon may treat the condition conservatively until the inflammation has subsided and then operate

The surgeon may use a Kocher’s incision, a right paramedian or midline incision.

Provided that there are no postoperative complications the patient usually makes a good recovery.

Complications that may occur after this operation are: pulmonary, Haemorrhage, or leakage of bile.

Physiotherapy

The problem that is most likely to concern the physiotherapist is the risk of pulmonary complications. Provided that the patient is not admitted for emergency surgery it should be possible to assess the patient and decide on the treatment required.

The patient may be taught breathing exercises and how to cough effectively.

A careful explanation must be given to the patient about the reasons for treatment and what will be expected of him after surgery.

The actual surgical procedure is very close to the diaphragm, and the irritation may cause the production of increased mucus secretions in the lung.

Postoperatively, deep breathing will be painful because of the position of the incision and the presence of a drainage tube.

Initially the patient will have a Ryle’s tube which will make coughing difficult.

Atelectasis is most likely to occur in the lower lobe of the right lung because of the position of the gall-bladder on the right side of the upper part of the abdominal cavity.

Emphasis must be placed on gaining good expansion of the right lung and getting rid of any secretions.

first 48 hours postoperatively are important in trying to prevent pulmonary complications.The physiotherapist should give the patient leg exercises and advice about the amount of activity to try to prevent any circulatory problems.

There is a tendency for these patients to be overweight and if so they may not have been very active before the operation which further increases the risk of pulmonary and circulatory complications.

Colostomy

This is an artificial opening in the large bowel to divert the faeces to the exterior where they are collected in a disposable, adhesive plastic bag.

Usually this procedure is carried out because of obstruction or disease of the large intestine caused by diverticulitis, Crohn’s disease or carcinoma.

The colostomy may be temporary or permanent.

A temporary colostomy is often placed in relation to the transverse colon whereas a permanent one is usually placed as far distally as possible.

COMPLICATIONS

There are a number of problems for a patient with a permanent colostomy.

Firstly, there is the worry about the success of the operation if it has been carried out to remove a malignant tumor.

Secondly, the patient will probably be concerned about his ability to manage a colostomy, particularly if he is elderly.

Thirdly, the patient will be concerned about whether he can lead a normal life, and once out of hospital may tend to shun social activities.

Physiotherapy

As this operation Involves the lower part of the abdominal cavity and pelvis there is an increased risk of a deep vein thrombosis developing postoperative.

The physiotherapist must teach the patient leg exercises preoperatively and they should be continued for a couple of weeks postoperatively.

It may be considered that the patient is active enough when he is up and walking but this activity may be minimal and it is wise to encourage the patient to do a series of leg exercises before getting out of bed and at regular intervals when sitting in a chair.

It may be necessary to give breathing exercises pre- and postoperatively if the physiotherapist has assessed that the patient is at risk because of a chest condition, or because he smokes, or because he is elderly and relatively inactive.

Before the patient leaves hospital he should be taught how to lift correctly and avoid excessive strain on the abdominal muscles.

The physiotherapist must help the patient to appreciate that he will be able to undertake normal activities, both physically and socially after he has recovered.

Ileostomy

This is similar to a colostomy except that the opening is in the right side of the lower abdominal cavity. Usually it follows a more extensive resection of the colon than a colostomy.

Gastrectomy

A partial gastrectomy for the treatment of gastric ulceration is a common operation if healing does not occur following medical treatment.

The formation of ulcers usually occurs along the lesser curvature of the stomach and if they do not heal they may undergo malignant changes.

There are a number of operations that may be used although the most common are the Billroth and the Polya type

If there is a carcinoma of the stomach this may be treated by a total gastrectomy, and sometimes splenectomy, provided the disease is localized.

Complications

Immediate postoperative complications may be a gastric or duodenal fistula, gastric retention, haemorrhage or pulmonary problems.

Physiotherapy

As the operation is closely related to the diaphragm there is likely to be irritation of adjacent tissues which could cause increased production of mucus, particularly in the lower lobe of the left lung.

The patient will be reluctant to breathe deeply because of pain.

coughing will be inhibited by pain and the presence of a Ryle’s tube.

it is very important that the physiotherapist pays special attention to the chest

Generally the patient may be treated preoperatively with emphasis on deep breathing, particularly lower costal, and taught how to cough effectively.

Postoperatively the patient must be encouraged to do the deep breathing with emphasis on the left lower costal area.

Before attempting to cough the patient should be helped to sit up in bed and lean slightly forward as this makes it easier for him to cough.

The patient places his hands over the incision while the physiotherapist supports him in sitting and places one hand over the patient’s hands and the other round his back to give pressure, on the left lower costal area.

The patient is likely to tire quickly and so the treatment should be given for a short duration and frequently.

The patient should do leg exercises to reduce the risk of developing circulatory problems.

If the patient has been ill for some time before the operation the physiotherapist may need to give general mobilizing and strengthening exercises.

Hernias

A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the wall of the containing cavity.

Hiatal hernia

In this condition there is a weakness in the oesophageal opening of the diaphragm and part of the stomach may pass upward into the thoracic cavity

Treatment may be conservative but if this fails, surgery may be required.

The surgeon may use a thoracic or abdominal route, although the latter is preferable as it may be necessary to investigate for other causes of dyspepsia.

Physiotherapy

This is similar to the treatment described for a gastrectomy as there is a risk of pulmonary complications with operations in the- upper abdominal cavity.

Inguinal hernia

This may be indirect or direct and is a protrusion of a sac of peritoneum containing omentum and possibly intestine through the inguinal canal.

The indirect hernia is usually congenital and passes through the length of the canal whereas the direct hernia is medial and projects through a weakness in the posterior wall of the canal.

The latter usually occurs in middle-aged to elderly men and often is associated with stress on the abdominal wall caused by a chronic cough or strain on lifting.

In infants with a congenital abnormality a herniotomy with removal of the sac may be adequate.

in the adult more extensive surgery is preferable, unless the risk of operation is too great because there are pulmonary or circulatory problems.

The operation performed is a herniorraphy which reduces the herniation and repairs the weakness of the posterior wall.

Femoral hernia

These are more common in women and are a protrusion of the peritoneal sac through the femoral ring.

The increase of intra-abdominal pressure that occurs in pregnancy may be a precipitating cause.

Surgery is usually the treatment of choice because of the risk of strangulation.

Strangulated hernia

This may require emergency surgery with resection of the gangrenous section of the bowel.

Physiotherapy

For patients undergoing surgery for an inguinal hernia, pulmonary complications may be a risk when there is a chronic chest condition, in which case pre- and postoperative breathing exercises are important.

The surgeon may sometimes request physiotherapy to improve the condition of the chest before he will operate.

A deep vein thrombosis is a possible complication after herniorraphy and so exercises for the legs should be given before and after surgery.

These patients are likely to have weak abdominal muscles which should be strengthened after surgery.

A progressive scheme of exercises starting with static contractions in the middle to inner range and following with free active exercises should be implemented.

Care should be taken not to go beyond the ability of the individual patient and exercises in the outer range of the abdominal muscles should be avoided.

Patients should be instructed in correct lifting techniques especially when the history indicates that lifting might have been a precipitating cause in producing a rupture.

Patients undergoing surgery for a femoral hernia should have similar physiotherapy. The risk of pulmonary complications is smaller but there may be a greater risk of developing a deep vein thrombosis. Correct lifting techniques should be taught so that the intra-abdominal pressure is not abnormally high during lifting.

Umbilical hernias

These are more common in children although they can occur in older, obese patients with weak abdominal muscles and possible weakness of tissues in the umbilical region.

Incisional hernias

These may occur through previous operation scars, usually because of infection at the site of operation, or poor healing which weakens the incisional area. Surgery may be necessary if the hernia cannot be controlled with a pad and abdominal belt as there may be a risk of strangulation.

Mastectomy

This entails removal of part or the whole of one breast for a malignant, or sometimes benign, growth.

This is the commonest site of carcinoma in women, and if treatment is to be successful it is important to have early diagnosis.

Thus health education should aim to teach women to report any lump in the breast to their doctor.

Tests can then be carried out and if treatment is required there is a greater chance of success before the disease has spread.

Some benign growths can be removed without removing the whole breast and may not cause any disfiguration.

Malignant tumours will require more extensive surgery to remove the diseased tissue and there are a number of operations that can be carried out.

Types

A simple mastectomy removes the breast and if necessary may remove the axillary lymph nodes.

Whereas a radical mastectomy removes breast, lymph nodes and pectoral muscles.

The latter is performed less often now as it did not give a greater success rate than the less radical procedures and there was the problem of the patient developing an edematous arm and stiff shoulder.

Radiotherapy or chemotherapy may be given after surgery.

Woman with radical mastectomy.A pink highlighted area indicates tissue

removed at mastectomyB axillary lymph nodes: levels IC axillary lymph nodes: levels IID axillary lymph nodes: levels IIIE supraclavicular lymph nodesF internal mammary lymph nodes

This operation may cause severe emotional upset and the patient may be very concerned about the disfigurement.

All members of the surgical team must be aware of these problems and try to help the patient through a difficult time with understanding and advice.

Good prosthetic devices are available, and arrangements must be made for patients to be fitted with suitable prostheses for their individual needs.

Physiotherapy

General pre- and postoperative care should be given to patients who are at risk of developing complications.

As the chest will be painful after surgery the patient may be reluctant to breathe deeply or cough and if there is a history of a chest problem or if the patient smokes she may require treatment.

There is a danger of a stiff shoulder developing particularly with the more extensive surgical procedures

The physiotherapist will discuss the management with the surgeon as some surgeons prefer the arm not to be abducted for the first few days because of the risk of developing a haematoma.

Hand and wrist movements should be carried out from the beginning with shoulder shrugging and static contractions of deltoid.

If a radical mastectomy has been performed the physiotherapist may be concerned with trying to prevent or treating oedema and mobilizing the shoulder.

Nephrectomy

The kidney may be removed because of a malignant tumor or infection, provided the remaining kidney is normal. The kidney lies in close proximity to the diaphragm and so pulmonary complications following surgery are a risk.

There are various indications for this procedure, such as renal cell carcinoma, a non-functioning kidney (which may cause high blood pressure) and a congenitally small kidney (in which the kidney is swelling, causing it to press on nerves which can cause pain in unrelated areas such as the back).

The surgery is performed with the patient under general anesthesia. The surgeon makes an incision in the side of the abdomen to reach the kidney. Depending on circumstances, the incision can also be made midline. The ureter and blood vessels are disconnected, and the kidney is then removed. The surgery can be done as open surgery, with one incision, or as a laparoscopic procedure, with three or four small cuts in the abdominal and flank area. Recently, this procedure is performed through a single incision in the patient's belly-button. This advanced technique is called as single port laparoscopy.

Complications

During the operation the lung cavity may be entered and this is repaired during the procedure, but this may create lung complications.

DVT or pulmonary embolism .Wound infection.Poor wound healing or weakness in the

wound site Urine infection: which is more likely if a

catheter is present.

Physiotherapy

To avoid respiratory complications, educate the patient by giving pre operative breathing exercises, thoracic mobility ex. And techniques of Huff and Coughs followed by post op. ex.

Active ankle toe movement and limb elevation.

Wound care with use of massage, UVR, etc.Bladder training for weak bladder.Gentle active exercises for general

conditioning.

Home advice

Recovery time after this operation varies but generally you should feel improvements 2 -3 weeks after your operation.

• During the first 2 -3 weeks you should not drive. • Avoid heavy lifting for 2-3 weeks • Exercise should be increased gradually. Start with short

walks and gentle exercise. • Getting back to work will depend on the type of job that

you do. Usually 2- 3 weeks off work are needed. • Drink plenty of fluids and pass urine regularly; this will

help to keep your remaining kidney healthy. • Sexual activity can resume 3 -4 weeks after your

operation.