Structure
2.1 Introduction
2.2 Cholecystectomy
2.3 Colostomy
2.4 Gastrectomy
2.5 Hernias
2.6 Mastectomy
2.7 Nephrectomy
2.8 Prostatectomy
2.1 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 not mentioned here 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.
2.2 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 pain experienced by the patient may be very acute and cause considerable distress.
The surgeon may use a Kocher’s incision, a right paramedian or midline incision. Following the removal of the 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 a bag. The amount of bile is measured to ascertain whether any leakage is occurring. Provided that there are no postoperative complications the patient usually makes a good recovery. Removal of the gall-bladder does not require any special diet once the patient has recovered from the operation. 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.
There are a number of factors that increase the likelihood of chest problems 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. Analgesics given to relieve pain before treatment will enable the physiotherapist to be more effective, although care must be exercised in the amount of analgesic 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. As stressed in the last chapter, the 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.
2.3 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.
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 tumour. 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. The patient must be helped to overcome these problems by all the members of the team. In some hospitals there are nurses who have had special training in dealing with colostomies, and they are known as stoma nurses or therapists.
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 postoper-
ative. 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.
2.4 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 splenectorry, provided the disease is localized.
Duodenal ulcers are usually treated by a vagotomy, but if there is duodenal and gastric ulceration the surgeon may perform a partial gastrectomy and vagotomy.
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. Similarly, coughing will be inhibited by pain and the presence of a Ryle’s tube. So 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 tc 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. Treatment to the chest should be intensive, particularly if there is the slightest indication of a problem. The patient is likely to tire quickly and so the treatment should be given for a short duration and frequently. The nurses can remind the patient to do the deep breathing after carrying out nursing procedures, and the patient must be taught to practise on his own. 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.
2.5 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. There are various surgical procedures that can be used but the main aim is to repair the hiatus.
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. However, 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.
2.6 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. 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 oedematous arm and stiff shoulder. Radiotherapy or chemotherapy may be given after surgery.
This operation may cause severe emotional upset and the patient may be very concerned about the disment. 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.
2.7 Nephrectomy
The kidney may be removed because of a malignant tumour 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.
Physiotherapy
The emphasis should be on posterior basal and lower costal breathing, concentrating on the side of the nephrectomy.
2.8 Prostatectomy
This is usually carried out for benign growths of the prostate which commonly occur in elderly men. It is less commonly performed for carcinoma because early diagnosis is difficult and the growth may have spread too far. However, surgery may be required to relieve urinary obstruction.
Physiotherapy
Pulmonary complications may occur because these patients are elderly and may be relatively inactive. Also a number are likely to suffer from chronic chest disease and so are at risk. In view of this, these patients should be carefully assessed and treated if necessary. They are generally up within a day or two after surgery but it is important to see they are sufficiently active otherwise there is the risk of developing pulmonary complications.
