post op physio

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Physiotherapy in General Surgical Conditions

There are certain cases in the general surgical surgical conditions that require the attention of the physiotherapist. Let’s have a look over the general surgical conditions.

Reasons for Surgery

Surgery is undertaken for the following reasons:

1- To remove a disease tissue- In case of an organ or the gland, the operation is referred to by the suffix –ectomy. For example, haemoroidectomy is the removal of haemorroids, a pneumonectomy is the removal of the lung, and a mastectomy is the removal of the mammary gland. The removal may be complete or it may be partial, as with a partial gastrectomy. The removal of the limb is known as amputation.
2- For Purposes of repair- In these cases the suffix –orraphy is applied, and so the repair of hernia is a herniorraphy, the repair of the lacerated perineum is colporrhaphy. Some time the repair has suffix –plasty; for example reshaping a joint may be called an arthoplasty.
3- To produce an artificial opening- In such cases a suffix –otomy or –ostomy is applied. An opening made in the stomach for the purpose of feeding or evacuating the stomach is a gastrostomy or gastrotomy. An opening made in the transverse or sigmoid colon for the evacuation of the contents is called a colostomy, and an opening made in the trachea to assist breathing is termed a tracheostomy.
4- For Inspection- If a speculum or some type of viewing apparatus is passed the suffix –oscopy is applied. A cystoscopy is the inspection of the bladder, gastroscopy the inspection of the stomach; sigmoidoscopy is the inspection of the sigmoid colon. If an area is opened for inspection, the term –otomy is again used; for example a laparotomy is performed to inspect the abdominal contents.

Preoperative Treatment

Ideally the patient is admitted to the hospital 24 hours or more before operation. This allows the patient to settle in and to meet those who will be responsible for the treatment. Any necessary checks on the condition of the patient will be carried out, the operation site can be prepared, premedications given and sedatives administered as necessary.
If any specialized treatment, tests or investigations are considered necessary, the patient will be admitted several days or even weeks before the operation.

Types of Anaesthetic

Many of the former operative risks and complications arose from the methods of anaesthetic used. Following methods are commonly used:
1- General anaesthetic- This used for most major operations when it is necessary to render the patient unconscious. The anaesthetic may be administered by inhalation or intravenously. Unlike chloroform or ether which were used in the past, modern drugs, such as Pentothal, are easily broken down and excreted from the body. This avoids much of the nausea and vomiting, common in former days, together with many post operative risks.
2- This is often used for minor surgery and has the advantage of reducing the post operative risks of chest complications which can follow inhalation anaesthesia.
3- The anaesthetic is injected into the subarachnoid space surrounding the cauda equine. Anaesthetic of the perineal region and the legs can be achieved and this may be used for the certain surgical procedures to the pelvis and legs.
4- Regional anaesthesia- Anaesthesia of the limb may be achieved by injecting an anaesthetic into the nerve plexus. This method may be used if the patient is not fit enough to tolerate to tolerate general anaesthesia.

Types of Incisions

These may be mastectomy incision, right sub costal (cholecystectomy), left sub costal incision (splenectomy), upper midline incision, lower midline incision, paramedian incision (laparotomy), inguinal incision (herniorraphy), oblique left iliac incision (colostomy), and appendectomy incision.

Clips, ligatures and sutures

Materials used to hold the edges of a surgical incision in close apposition vary according to the operation and which method of closure of a particular surgeon wishes.

Clips may be used when it is important to gain a good cosmetic effect. Clips are usually removed after 4-5 days and then subcutaneous stitches protect the wound from any stretching.

Dressings are used to protect the incision from infection, make the patient more comfortable and to absorb any exudation. It is important to keep wound as dry as possible. Gauze and adhesive strapping have been used to cover the incision but more recently some surgeons prefer to use an adherent seal.

Post Operative Treatment

The patient may be moved to recovery room where staff is specially trained to deal with immediate post operative complications and there is apparatus to deal with resuscitation, or he may be returned to surgical ward depending upon the particular circumstances.
Post operatively, the trachea must be kept patent and free from obstruction until the patient regains consciousness, and for this purpose an air tube is used.

The patient is nursed flat in the bed in the side lying position until he regains consciousness.

If the patient is in shock he may have a saline drip.
Sedatives may be given to relieve pain but care must be taken in the type and amounts used as they can depress respiratory activity and increase the risk of pulmonary complications.

Normal micturation must be established as soon as possible, a catheter being passed if necessary to prevent retention and the possibility of bladder infection.

After certain abdominal operations, it will be necessary to rest the stomach and gastrointestinal tract. The diet will be a fluid one administered intravenously, and the contents of stomach will be evacuated by means of suction apparatus. The suction apparatus will have been inserted in the operation theatre, as will any drainage apparatus that may be required. In cases other than abdominal operation it is better to reestablish bowel action as soon as possible, and even if a fluid diet is required it will be given for as short a time as required. It is essential to keep a careful watch on the patient’s chart as any alteration in temperature, pulse rate or respiration may herald post operative collapse, hemorrhage, infection or embolism.

Post Operative Complications

Respiratory

Despite modern advances in anaesthesia, certain complications do still arise which can in part be attributed to anaesthesia. One of its effects is to dry and thicken the mucous secretions in the respiratory tract. The mucous then become difficult to dislodge and tends to remain in the air passages. Plugs of mucous may form, and the bronchi or bronchioles are in danger of becoming blocked. Normally the cough reflex would be stimulated but this could be depressed by the administration of analgesics or patient may try to stop coughing because it is painful.

Several chest conditions may arise:

1- Post Operative Atelectasis- This is due to the blockage of bronchus or bronchioles causing absorption collapse of a segment of lobe of the lung. The basal lobes are most commonly affected as the patient is nursed in the half lying position once he has regained consciousness. If the main bronchus is occluded, the whole lung collapses but this is a rare occurrence. High abdominal, thoracic and mediastinal operations carry a higher risk of atelectasis than do lower abdominal and pelvic operations than do lower abdominal and pelvic operations because of the proximity of lung tissues to these regions. Atelectasis occurs between the first and third day after operation.

2- Pneumonia or bronchopneumonia- If the mucous secretions are not removed, there is danger of infection with the development of one of these conditions, particularly in the elderly. Aspiration pneumonia may occur due to the inhalation of vomit although this is much less frequent with modern anaesthesia.

To prevent or reduce the risk of the above complications it is essential to clear the secretions and to maintain full ventilation postoperatively.

Deep Venous Thrombosis

There are number of factors that predispose to the development of deep venous thrombosis. There may be slowing of blood due to the pressure of calf during surgery and postoperatively if the patient is lying in the bed, and also if the patient is inactive during the early stage after operation. There is rise in the number of platelets and concentration of fibrinogen after surgery which will predispose to coagulation. The risk is higher in lower abdominal and pelvic operations when there may be handling of abdominal and pelvic viscera. The patient may have another condition, such as varicose veins, which could increase the risk of a thrombus following surgery.

Pulmonary Embolus

The great danger following the deep venous thrombosis lies in the fact that a small fragment (embolus) may break off the clot and travel in the blood stream until it lodges in a smaller vessel. The most likely destination is the pulmonary circulation as the blood passes back to the right atrium and then from the right ventricle into the pulmonary circulation. The point at which embolus lodges depends upon its size. If it occludes a large artery, then there may be rapid collapse and the patient will die, whereas if it occludes a small vessel, there may be pain and dyspnoea and there may be time to treat the patient.

Postoperatively the patient must be active as soon as possible to reduce the risk of deep venous thrombosis and the further danger of a pulmonary embolism.

General Muscle Weakness and loss of mobility

Early mobilization after surgery has decreased the incidence of muscle weakness and loss of mobility. However, elderly patients may already be weak either because they have been confined to bed waiting for surgery or because of other conditions such as osteoarthritis of the hips and knees. Some younger patients may be week if their illness has prevented them moving about freely for a period of time before surgery.

Pressure Sores

Pressure sores should be prevented but they can occur very quickly in any one who is very ill and immobile for any length of time, and again the elderly are particularly at risk

Wound Infection

Wound infection is always a risk although the modern theatres and surgical techniques along with improved post operative care in the wards have reduced this risk.

Haemorrhage

Haemorrhage can be a postoperative complication although the risk is greater with some surgical procedures than the others.

<span style="text-decoration:underline">Physiotherapy Manage</span>

Being a part of medical team physiotherapist should be aware of any medical problem that patient if suffering, history must be checked. Any respiratory or circulatory problems and risk factors should be noted. Having proper assessment of the patient general condition, the physiotherapist explains the importance of post operative physiotherapy management plan to the patient.

Principles of Physiotherapy

1- To prevent chest complications by maintaining the lung function and aiding the clearance of secretions.

2- To prevent thrombus of legs by encouraging active leg movements or if necessary by passive exercises.

3- Prevention of pressure sores

4- Prevention of muscle wasting and joint immobility

5- To be aware of danger signals

6- To be aware of specific Clinical features indicating any abnormality.

Prevention of Chest Complications

The physiotherapist must take other factors into considerations besides the effects of anaesthetics on secretions in the respiratory tract. One is that pain causes reflex inhibition of diaphragm and therefore breathing is difficult. Another is that in any operation affecting the abdominal muscles the patient tends to avoid using them because of pain and fear of pain and this again hampers the respiratory movements. Administration of too many analgesics may inhibit the cough reflex and lead to accumulation of secretions.

Breathing exercises should be given to all parts of the chest but particularly the lower costal and posterior basal areas. Breathing should be as deep as possible with emphasis on expiratory movements as this help to loosen the secretions and stimulate the cough reflex. It is important to make the patient too many breaths at one time as this may make the patient feel faint.

The patient must be encouraged to cough and try to clear any secretions. It is important to give as much support as possible when the patient attempt to cough. It is easier to cough as the patient sits forward and the physiotherapist support him in this position. It helps if the patient places his hands over or around the wound.as the pressure helps to prevent stretching of the wound as the patient coughs. In abdominal surgery, it may help if the patient can bend his knees up as this relaxes the abdominal wall and decreases the stretch on it as the patient coughs. If the secretions are very sticky the patient may need an inhalation to loosen them.
If the secretions can not be removed, it may necessary to use other techniques such as postural drainage and vibrations. These may have to be modified depending upon the condition of the patient and the particular surgical procedure.

The frequency and length of treatment will depend upon the individual case. Chest complications are most likely to occur in the first 48 hours after surgery and so treatment should be given frequently during this time and the patient should be encouraged to do them on his own if he can. The physiotherapist can stop treatment when there appears to be no further risk and the patient has good respiratory movement and no secretions. If a complication does occur, then treatment must be frequent and intensive until the problem is resolved.

Prevention of thrombosis

Adequate movement postoperatively is essential. While the patient is in the bed, he must be encouraged to move about and be as independent as he can. Leg exercises should be given until the patient is up and moving around the ward. It is particularly to give full range dorsi and plantar flexion as this improves venous return from the lower limbs by the use of muscle pump. Hip and knee exercises and quadriceps pump should also be included. The exercises may have to be modified if the patient has an intravenous drip in the leg or if there is any form of pelvic drainage. Once the patient is up, the physiotherapist should see that he is moving around as it is not sufficient for the patient just to sit in a chair.
It is important that these exercises are done properly. Initially the physiotherapist should supervise them but the patient must practice them on his own.

Prevention of pressure Sores

These should not occur in patients who have early mobilization after surgery. Care must be taken in positioning the patient and must be encouraged to move around in the bed.

Prevention of muscle wasting and joint immobility

Muscle weakness and joint stiffness are particularly likely to occur in the elderly if they remain in the bed for any length of time before and after surgery. The physiotherapist may need to give general mobilization and strengthening exercises to enable the patient to regain the independence.

Danger signals

A very careful watch must always be kept on the patient chart. The physiotherapist must know what he is looking for. A rise of temperature may presage any of the post operative complications. A swinging temperature usually indicates sepsis.
Alteration in the pulse rate and or respiratory rate and depth may indicate respiratory or circulatory complications, shock or hemorrhage.

Specific Clinical Features

Physiotherapist should be aware of any significant abnormalities and should report immediately.

Post-operative atelectasis-The chart will indicate the rise in temperature, pulse rate and respiratory rate. In addition the patient is flushed and feverish and may complain of feeling of tightness and discomfort on the affected side. There is poor chest expansion on the affected side. The percussion sounds are flat and there are adventitious sounds. An X-ray reveals the collapse.

Thrombosis- If there is deep thrombosis, the chart may reveal a rise in temperature and the calf may swollen and tender. Passive dorsiflexion may cause pain in the calf muscles-Homan’s sign. If the thrombus is superficial, the site is painful and swollen; the skin is red and shiny.

Pulmonary Embolism- In serious cases the chart reveals a rapid rise in temperature, pulse and respiration. The patient color is poor and he complains of severe pain in the chest. Death may ensue in the minutes. If he survives, he will be very ill for some time. In less severe cases, the chart reveals a rise in temperature, pulse and respiration. The patient complains of a short stabbing pain in the side of chest. To all intents and purposes he has pleurisy. In 2-3 days the sputum becomes blood stained and the condition begins to subside.

Common Operations

The details of common operations and their physiotherapy management are as under:

Cholecystectomy

This operation may be performed following the development of the 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 some acute attack of cholecystitis, the surgeon may treat the condition conservatively until the inflammation has subsided and then operate. The pain experienced by the patient may be very acute and cause considerable distress.
The surgeon may use the Kocher’s incision, a right paramedian or midline incision. Following the removal of gall bladder a T tube is inserted and left for approximately 48 hours or longer if necessary to allow drainage of any bile or blood into bag. The amount of blood is measured to ascertain whether any leakage is occurring. Provided that there is no post operative complications, the patient usually make a good recovery. Removal of the gall bladder does not require any special special diet once the patient has recovered from operation. Complications that may occur after this operation are pulmonary, haemorrhage, or leakage of bile.

The problem that is most likely to concern the physiotherapist is the risk of pulmonary complications. Provided that 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 the breathing exercises and how to cough effectively. A careful explanation may be given to the patient about the reason for treatment. And what will be expected of him after surgery.

There are number of factors that increase the likelihood of chest problems after surgery. The actual surgical procedure is very close to the diaphragm, and irritation may cause the production of increased mucous secretions in the lung post operatively. Post operatively deep breathing will be painful because of the position of incision and position of the drainage tube. Initially patient will have the Ryle’s tube which will make coughing difficult. Atelectasis is most likely to occur in the lower lobe of right lung because of the position of the gall bladder on the right side of the upper part of the abdominal cavity. Analgesics given before to relieve pain before treatment will enable the physiotherapist to be more effective, although care must be exercised in the amount of analgesics given as too much can depress the cough reflex. Emphasis must be placed on gaining good expansion of the right lung and getting rid of any secretions. First 48 hours are important in trying to prevent pulmonary complications. The physiotherapist should give the patient exercises and advice about the amount of activity to try to prevent any circulatory problems.

Colostomy

This is an artificial opening in the large bowel to divert the faeces to the exterior where they are collected in the disposable adhesive plastic bag. Usually this disease is carried out because of the obstruction and disease of 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.

As this problem involves the lower part of abdominal cavity and pelvis, there is an increased risk of deep venous thrombosis developing post operatively. The physiotherapist must teach the patients post operatively and they should be continued for a couple of week post operatively. 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 necessary to give breathing exercises postoperatively if the physiotherapist has assessed that the patient is at risk because of chest conditions. Patient must also be taught how to lift correctly and to avoid the excessive strain on the abdominal muscles.

Ileostomy

This is similar to a colostomy except that the opening is in the right side of 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 the medical treatment. The formation of ulcer usually occurs usually occurs along the lesser curvature of the stomach and if they do not heal they may under go malignant changes. There are a number of operations that may be used although the most common are the Billroth 1 and polya type. If there is a carcinoma of the stomach, this may be treated by the total gastrectomy, and some times splenectomy provided the disease is localized.

Duodenal ulcers are usually treated by a vagotomy, but if there is duodenal and gastric ulcers, but if there is duodenal or gastric ulceration, the surgeon may perform a partial gastrectomy and vagotomy.
Immediate post operative complications may be a gastric or duodenal fistuala, gastric retention, haemorrhage or pulmonary problems.

As the operation is close to the diaphragm, there likely to be the irritation of adjacent tissues which could cause increased production of mucous particularly in the lower lobe of the left lung. The patient will be reluctant to breath deeply because of pain. Similarly coughing will be inhibited by pain and the presence of the Ryle’s tube. So it is very important that physiotherapist pay particular attention to the chest. Generally the patient may be treated pre operatively with emphasis on deep breathing particularly low costal and taught how to cough effectively. Post operatively, the patient must be encouraged to do deep breathing with the emphasis on the lower costal area. Before attempting to cough, the patient should be helped to sit up in bed and lean forward as this make it easier 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 hand and the other round his back to give pressure over the lower costal area. Treatment to the chest should be intensive, particularly if there is slightest problem to the chest. Patient should be taught deep breathing exercises. Patient should do the 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 mobilization exercises 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. Surgeon may use a thoracic or abdominal route although the latter is preferable as it may be necessary to investigate other causes of dyspepsia. There are various surgical procedures that can be used but the main aim is to repair the hiatus.

As the operation is close to the diaphragm, there likely to be the irritation of adjacent tissues which could cause increased production of mucous particularly in the lower lobe of the left lung. So it is very important that physiotherapist pay particular attention to the chest. Generally the patient may be treated pre operatively with emphasis on deep breathing particularly low costal and taught how to cough effectively. Post operatively, the patient must be encouraged to do deep breathing with the emphasis on the lower costal area. . Patient should be taught deep breathing exercises. Patient should do the leg exercises to reduce the risk of developing circulatory problems.

Inguinal hernia

This may be indirect or direct and is a protrusion of the sac of peritomium containing omentum and possibly intestine through the inguinal canal. The indirect cause is usually congenital and passes through the length of 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 the weakness in the posterior wall of the canal. The operation performed is herniorraphy which reduces the herniation and repair 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 intraabdominal pressure that occurs in pregnancy may be a precipitating cause. Surgery is usually a treatment of choice because of the risk of risk of strangulation.

Strangulated Hernia

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

For patient undergoing surgery for an inguinal hernia, pulmonary complications may be a risk when there is chronic chest condition in which case pre and post operative exercises are important
A deep venous thrombosis is a possible complication after hernirraphy and so exercises for legs may be given before and after surgery.
The 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 exercises should be implemented. Care should be given not to go beyond the ability of the individual patient and exercise in the outer range of the abdominal muscles should be avoided. Patients should be instructed in the good lifting techniques especially when the history indicates that lifting might have been the precipitating cause in producing a rupture.
Patients undergoing femoral hernia have smaller risk of pulmonary complications but a greater risk of developing DVT. Correct lifting techniques are taught so that intra abdominal pressure is not abnormally high during lifting.

Umbilicus Hernia

These are more common in children although the can occur in olders obese patients with weak abdominal muscles and possible weakness of tissues in the abdominal wall.

Incisional Hernia

This may occur through the previous incision scars. Usually because of infection at the site of operation or poor healing, this weakens the incisional scar. Surgery may be necessary if the hernia can not be controlled with a pad and abdominal belt as there may be risk of strangulation.

Mastectomy

This entails removal of part or whole of one of breast for malignant or benign growth. This is the commonest type of carcinoma in the women. An if treatment is to be successful. Thus the health education should be to teach the women to report any lump in the breast to their doctor. Some benign tumours can be removed without removing the whole breast may not cause any disfigurement. Malignant tumours require extensive surgery to remove the disease tissue and there are a number of operations that can be carried out. 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. There is problem of developing oedematous arm and stiff shoulder.

General Pre& post operative care should be given to the patients who are at risk of developing complications. As chest may be painful after surgery, the patient is reluctant to breathe deeply or cough and if there is a history of chest problems or if the patient smokes he may require treatment. There is a danger of a stiff shoulder developing particularly with more extensive surgical procedures. Hand and wrist movements should be carried out from the beginning with shoulder shrugging and static contraction of deltoid. If radical mastectomy is performed, the physiotherapist may be concerned with trying to prevent and treat oedema& mobilize shoulder.

Nephrectomy

The kidney may be removed because of tumour and infection, provided the remaining kidney is normal. The kidneys lies in close proximity to diaphragm and so pulmonary complication following surgery are at risk.

Emphasis must be on posterior basal and lower costal breathing concentrating on the side of nephrectomy.

Prostectomy

This carried out in the benign growth of prostate which commonly occur in the elderly man. It is less commonly performed for carcinoma because early diagnosis is difficult and growth may have spread too far. However surgery may be required to relieve urinary obstruction.

Pulmonary complication may occur because these patients are elderly and may be relatively inactive. So the breathing exercises and routine physiotherapy should be carried out.