PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
CONTENTS OF ABDOMEN
• Stomach
• Small intestine (jejunum and ileum)
• Large intestine (colon)
• Liver
• Spleen
• Gallbladder
• Pancreas
• Uterus, fallopian tubes, and ovaries (in women)
• Kidneys, ureters, and bladder
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CONDITIONS
LESSON 4: General Surgery
ABDOMINAL CONTENTS
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CONDITIONS
LESSON 4: General Surgery
QUADRANTS OF ABDOMEN
1.
2.
3.
4.
5.
6.
7.
8.
9.
EPIGASTRIC REGION
UMBLICAL REGION
HYPOGASTRIC REGION
RIGHT HYPOCHONDRIAC REGION
LEFT HYPOCHONDRIAC REGION
RIGHT LUMBAR REGION
LEFT LUMBAR REGION
RIGHT INGUINAL REGION
LEFT INGUINAL REGION
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CONDITIONS
LESSON 4: General Surgery
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CONDITIONS
LESSON 4: General Surgery
INDICATIONS
1. Inflammation of the appendix (acute appendicitis)
2. Inflammation of the pancreas (acute or chronic pancreatitis)
3. Pockets of infection (retroperitoneal abscess, abdominal abscess,
pelvic abscess)
4. Presence of uterine tissue (endometrium) in the abdomen
(endometriosis)
5. Inflammation of the fallopian tubes (salpangitis)
6. Scar tissue in the abdomen (adhesions)
7. Cancer (of the ovary, colon, pancreas, liver)
8. Inflammation of an intestinal pocket (diverticulitis)
9. Hole in the intestine (intestinal perforation)
10. Pregnancy outside of the uterus (ectopic pregnancy)
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CONDITIONS
LESSON 4: General Surgery
TYPES OF ABDOMINAL SURGERY
1. Exploratory Laporatomy
2. Appendectomy
3. Laparoscopy
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CONDITIONS
LESSON 4: General Surgery
Exploratory Laporatomy
 Abdominal exploration is a type of surgery where the abdomen is opened
(laparotomy) and explored (exploratory laparotomy) for examination and
treatment of problems.
 This refers to the opening of the abdominal cavity for direct examination of its
contents , for example, to locate a source of bleeding or trauma.
 It may or may not be followed by repair or removal of the primary problem.
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CONDITIONS
LESSON 4: General Surgery
Appendectomy
 Surgical opening of the abdominal cavity and removal of the
appendix.
 Typically performed as definitive treatment for appendicitis, although
sometimes the appendix is prophylactically removed incidental to
another abdominal procedure.
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CONDITIONS
LESSON 4: General Surgery
Laparoscopy
1.A minimally invasive approach to abdominal surgery where rigid
tubes are inserted through small incisions into the abdominal cavity.
2. The tubes allow introduction of a small camera, surgical
instruments, and gases into the cavity for direct or indirect
visualization and treatment of the abdomen.
3. The abdomen is inflated with carbon dioxide gas to facilitate
visualization and, often, a small video camera is used to
show the procedure on a monitor in the operating room.
5. The laparoscopic method speeds recovery time and reduces
blood loss and infection as compared to the traditional "open"
cholecystectomy.
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
TYPES OF INCISIONS
• Upper midline incision
• Lower midline incision (prostactectomy)
• Right upper paramedian incision ( laparotomy)
• Left lower paramedian incision
• Transverse incision
• Right groin incision(hernia)
• Lateral groin incision (nephrectomy)
• Kuchers incision / right subcostal incision (cholecystectomy)
• Gridiron incision (appendicectomy)
• Oblique iliac incision (colostomy)
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CONDITIONS
LESSON 4: General Surgery
TYPES OF INCISIONS
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CONDITIONS
LESSON 4: General Surgery
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CONDITIONS
LESSON 4: General Surgery
MIDLINE INCISION
Use: Virtually all abdominal procedures may be performed
through this incision.
Location: In the midline of the abdomen, and can extend from
the xiphoid process to just above the umbilicus.
It can be continued to below the umbilicus by curving the
incision around the umbilicus.
Layers of the abdominal wall:
Skin, fascia , linea alba, transversalis fascia, extraperitoneal fat
and peritoneum.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
ADVANTAGES
Adequate exposure of most of the abdominal viscera
Minimal blood loss as the incision is through the linea alba.
Minimal nerve injury.
Minimal muscle injury.
Can be quickly made, such as in an emergency and quickly closed
with a mass closure technique.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
DISADVANTAGES.
• Care needs to be taken just above the umbilicus.
• Midline scar
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
PARAMEDIAN INCISION.
Use:
Provides laterality to the midline incision, allowing lateral
structures such as the kidney, adrenals and spleen to be
accessed.
Location:
About 2- 5cm to the left or right of the midline incision.
Incision is over the medial aspect of the transverse convexity of
the rectus.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Layers of the abdominal wall
•Skin, fascia and the anterior rectus sheath are incised.
•The anterior rectus muscle is freed from the anterior
sheath and retracted laterally.
•The posterior rectus sheath or transversalis fascia ,
extraperitoneal fat
•and peritoneum are then excised allowing entry to the
abdominal cavity.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Advantages.
• Provides access to lateral structures.
• Rectus muscle is not divided.
• Can be extended by a curvilinear incision towards the xiphoid
process if required
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
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LESSON 4: General Surgery
Disadvantages:
• Takes longer to make and close.
• Incision needs to be closed in layers.
• Difficult extension superiorly as limited by the costal margin.
• Tends to strip the muscles of their blood and nerve supply
resulting in atrophy of the muscle medial to the incision
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LESSON 4: General Surgery
Transverse incision.
Use:
Right or left colon, duodenum, pancreas, sub-hepatic space
Location:
This incision is made just above the umbilicus, dividing one or
both of the rectus muscles.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Layers of the abdomen:
Skin, fascia, Anterior rectus sheath, Rectus muscle , internal
oblique, Transversus abdominus, Transversalis fascia,
Extraperitoneal fat and peritoneum.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Advantages.
•
•
•
•
•
Less pain than a midline incision.
Good access to midline upper GI structures.
Transverse incisions cause the least amount of damage.
Muscular segments can be rejoined.
Commonly used in children and the obese as greater
abdominal exposure is gained in comparison with the vertical
midline.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Disadvantages.
•Limited lateral access in comparison with midline incisions
that can then be extended.
•More wound infections compared to midline thought to be
due to greater difficulty in controlling bleeding and
hematoma formation.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Subcostal incision.
Use:
• Gallbladder and biliary tract, spleen.
• It is also known as the Kocher subcostal incision, after the
person who discovered it.
• With the roof top or Chevron modification, access to
oesophagus, stomach, kidney and adrenals and liver is also
possible.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Location:
•Starts in the midline, 2-5 cm below the xiphoid, extending in
parallel with the costal margin at about 2.5 cm below the
costal margin.
•A rooftop of Chevron incision is a double Kocher incision.
•The mercedes incision involves a vertical incision from the
rooftop incision, like a mercedes sign.
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Layers of the abdominal wall:
Skin,Rectus sheath, Rectus muscle, Internal oblique,
Trasnversus abdominus, Transversalis fascia, Extraperitoneal fat
and Peritoneum.
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CONDITIONS
LESSON 4: General Surgery
Advantages.
Greater lateral exposure.
Less painful to midline incision.
Less post-operative complications.
Heals well.
Disadvantages
Longer operation time as the incision is closed in 2-3 layers
PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Pre- operative care
• Assess the risk of developing circulatory and respiratory
complications.
• Assess the associated medical problems.
• Patient with respiratory problems may admitted few days
before surgery in order to clear the chest and ensure a optimal
lung function.
.
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LESSON 4: General Surgery
Pre operative treatment
• Explain the importance of post operative exercises
• Teach deep breathing exercise, lower costal and posterior
basal expansion exercise.
• Effective cough with splinting.
• Leg exercises
• Postural correction specific to surgery
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CONDITIONS
LESSON 4: General Surgery
COMPLICATIONS
• Bleeding
• Wound infection
• post-surgical adhesions
• Paralytic Ileus (short-term paralysis of the bowel)
• Chest infections
• Intra-abdominal infection
• Blood Clots
• Urinary difficulties
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CONDITIONS
Co-morbid
conditions:
LESSON 4: General Surgery
•
•
•
•
•
•
•
•
•
Cardiovascular diseases
Respiratory diseases
DM
Renal diseases
Metabolic factors
Infections
Wound healing
Peripheral vascular diseases
Drug therapy (Concurrent drugs used)
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LESSON 4: General Surgery
Complications of surgery may broadly be classified as those:
I. Due to Anesthesia
II. Due to Surgery
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
DUE TO ANAESTHESIA:
The anesthetic complications depend upon the mode (General,
Regional & Local) and types of anesthetic (the anesthetic agent
toxicity).
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
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LESSON 4: General Surgery
COMMON COMPLICATIONS OF ANAESTHESIA
LOCAL ANAESTHESIA
• Injection site:
Pain, haematoma, Nerve trauma, infection
• Vasoconstrictors:
Ischemic necrosis
• Systemic effects of LA agent: Allergic reactions,
toxicity
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
SPINAL, EPIDURAL & CAUDAL ANESTHESIA:
• Technical failure
• Headache due to loss of CSF
• Intrathecal bleeding
• Permanent N. or spinal cord damage
• Paraspinal infection
• Systemic complications (Severe hypotension)
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
GENERAL ANESTESIA:
• Direct trauma to mouth or pharynx.
• Slow recovery from anesthesia due to drug
interactions OR in-appropriate choice of
drugs or dosage.
• Hypothermia due to long operations with
extensive fluid replacement OR cold blood
transfusion.
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CONDITIONS
LESSON 4: General Surgery
Allergic reactions to the anesthetic agent:
 Minor effects
eg: Postoperative nausea & vomiting
 Major effects
eg: Cardiovascular collapse, respiratory depression)
Hemodynamic Problems:
 Vasodilation & shock
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Complications of Surgery
Specific (procedure related)
Postoperative complications which may be
considered under 2 headings:
I. Immediate OR early
II. Late
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Immediate or Early complications
Respiratory:
 Collapse, consolidation, aspiration etc.
Cardiovascular:
Hemorrhage (Primary, Reactionary,Secondary)
 Shock (Hypovolemic, septic,
neurogenic)
 Myocardial infarction
 Deep venous thrombosis
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cardiogenic,
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LESSON 4: General Surgery
Septic:
 Wound, abscess collections
Gastrointestinal:
 Intestinal obstruction
 Anastomotic leakage, intraabdominal abscess
formation, enterocutaneous fistulae
Wound complications:
 Infections, dehiscence, etc.
Renal:
 Oliguria, acute renal failure
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CONDITIONS
LESSON 4: General Surgery
• Hepatic:
 Jaundice, hepatocellular dysfunction/insufficiency
• Cerebral:
 Psychological, Neuropsychiatric complications
(delirium, etc.)
• Drug-related:
 Anesthetic, antibiotics, specific medical disease
treatment toxicity
• Nerve injuries:
 Compression, traction, cautery, severed, etc.
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LESSON 4: General Surgery
LATE POST OPERATIVE COMPLICATIONS
Wound:
 Hypertrophic scar, keloid, wound sinus,
implantation dermoids, incisional hernia
Adhesions:
 Intestinal obstruction, strangulation
Altered anatomy/Pathophysiology:
 Bacterial overgrowth, short gut syndrome,
postgastric surgery syndromes, etc.
Susceptibility to other diseases:
 Malabsorption, incidence of cancer, tuber-culosis, etc.
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CONDITIONS
LESSON 4: General Surgery
General Considerations:
•
•
Complications are made in the operating rooms.
Minimize the risk:
1.
2.
3.
•
Rigorous preoperative evaluations
Meticulous operative technique
Careful monitoring of patients preoperatively
Fever:
 1st postop day --> atelectasis/aspiration/UTI
 4th-5th postop --> wound infection /
anastomotic leak
•
Hypotension:
 Immediate --> continuous hemorrhage / depressive drugs
 Later ---> sepsis
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Atelectasis:
•
90% postoperative pulmonary complications
Etiology:
1.
Obstruction of the tracheobronchial airway
a)
b)
c)
2.
Pulmonary insufficiency (hypoventilation)
•
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Changes in bronchial secretions
Defects in expulsion mechanism
Reduction in bronchial caliber
Decrease surfactant
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LESSON 4: General Surgery
Postoperative Pulmonary Complications
Atelectasis:
Predisposing factors:
1.
2.
3.
Smoking
Pulmonary problem (bronchitis, asthma, etc)
Anesthesia:
•
•
4.
GA - duration and depth
Postop narcotics – depress cough reflex
Depress cough reflex
•
•
•
Chest pain
Immobilization
Splinting w/ bandages
Naso Gastric Tube – increased secretions and predisposed
aspiration
6. Congestion of the bronchial walls
5.
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CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Atelectasis:
Manifestations:
1st 24 hrs postop ----> fever, tachycardia, rales, decrease
breath sound ----> persist ----> pneumonia (increase
fever, dyspnea, tachycardia and cyanosis) ---> lung
abscess
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Atelectasis:
Treatment:
1. Preop prophylaxis:
a. No smoking (2 wks)
b. Treatment of pulmonary problem
2. Postop prophylaxis:
−
−
−
−
−
Minimal use of depressant drugs
Prevent pain
Early ambulation
Change body position
Deep breathing and coughing exercises
3. Drugs:
a. Expectorants
b. Mucolytic
c. bronchodilators
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CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Pulmonary Aspiration:
•
•
General anesthesia – patients are in supine position and absence of
normal protective reflexes.
Increased risk:
1.
2.
3.
4.
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Pregnant
Elderly
Obese
Patients with bowel obstruction
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Pulmonary Aspiration:
Prevention:
•
•
Fasting 6hrs prior to surgery
Emergency – NGT do gastric lavage and give antacid.
Treatment:
•
•
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Continuous mechanical ventilation
antibiotics
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Postoperative
Pulmonary Complications
LESSON 4: General Surgery
Pulmonary Edema:
Etiology:
1.
Circulatory overload (infusion of fluid during operation)
2.
Left ventricular failure (incomplete cardiac emptying)


3.
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Due to anesthetic, narcotic or hypnotic agents which decrease myocardial
contractility
Decrease peripheral perfusion -----> peripheral vasoconstriction ----> cause blood to
shift centrally ----> pulmonary edema
Negative pressure in airway.
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
CONDITIONS
LESSON 4: General Surgery
Postoperative Pulmonary Complications
Pulmonary Edema:
Treatment:
1.
2.
3.
4.
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Provide oxygen (increase inspired concentration)
Remove obstructing fluid (diuretics, head up or sitting position)
Correcting the circulatory overload
Increase airway pressure (PEEP)
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LESSON 4: General Surgery
Postoperative Pulmonary Complications
Respiratory Failure:
•
•
•
•
25% of postoperative deaths
PaO2 is low,PaCO2 is more
Usually seen in patients who underwent operations for major trauma
or who have multisystem disease.
Mechanism is unknown
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
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LESSON 4: General Surgery
Post operative assessment
• Summary of the surgery
• Vital signs
• alertness and consciousness
• Analgesics – dosage and time
• Pain assessment
• Posture assessment
• Frequent assessment –to alter and modify the treatment
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LESSON 4: General Surgery
PHYSIOTHERAPY
AIMS
1. PREVENTION OF RESPIRATORY COMPLICATIONS
2. PREVENTION OF POST OPERATIVE INFECTIONS
3. PREVENTION OF THROMBOSIS
4. PREVENTION OF PRESSURE SORES
5. PREVENTION OF MUSCLE WASTING AND JOINT
IMMOBILITY
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PHYSIOTHERAPY PRACTICE IN CARDIO-RESPIRATORY
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LESSON 4: General Surgery
PREVENTION OF RESPIRATORY COMPLICATIONS
Consider the effects of anesthesia on respiratory tract.
• Pain causes reflex inhibition of diaphragm and makes respiration
difficult.
• Incision of abdominal muscles – patient tends to avoid due to pain or
fear of pain which hampers respiratory movement.
• Too much analgesics may inhibit the cough reflex and lead to
accumulation of secretion.
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LESSON 4: General Surgery
PREVENTION OF RESPIRATORY COMPLICATIONS
• Breathing exercises with more emphasis on lower costal and
posterior basal areas.
• Breathing should be as deep as possible with emphasis on
expiration to promote secretion clearance and cough reflex.
• Avoid continuous deep breaths as this may result in fainting.
• Coughing and splinting.
• Knee flexion during cough relax the abdominal muscles and
reduces the stretch.
• If secretions are very thick – use airway clearance techniques.
• Chest complications are most likely too occur in 1st 48 hrs – so
treatment should be frequent during this period.
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LESSON 4: General Surgery
Prevention of thrombosis
• Leg exercises should be given until the patient is up and moving.
• Hip and knee exercises, quadriceps exercises.
• Early mobilisation
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LESSON 4: General Surgery
Prevention of pressure sores
• Can be prevented by early mobilization
• Elderly and prolonged immobilization patients are at risk.
• Positioning and early mobilization
Prevention of muscle wasting and joint movement
• Elderly and prolonged immobilization patients are at risk.
• Early mobilization and strengthening to regain independence
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LESSON 4: General Surgery
PROTOCOLS
• Day 1 
Deep breathing exercises
• Splinted Huffing and Coughing
• Circulatory exercises
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LESSON 4: General Surgery
Day 2
• Continue with Day 1 exercises +
• Isometric contraction of abdominal muscles.
• Alternate leg movements along with trunk rotation
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LESSON 4: General Surgery
Day 7-10 onwards
• Continue the exercise protocols and include
strengthening exercises for abdomen muscles. [Repeat
each of these exercises 6 times, 3 times each day.]
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LESSON 4: General Surgery
Home Program
Dont’s
• Exercises
• Avoid lifting heavy
weights
• Rest
• Walking (20min./day)
• Driving [ After 6 weeks]
• Don’t strain for 6 weeks
• Avoid fatty foods
• Work and Sports
(After 8 weeks)
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