Establishing the need for a surgical intervention Confirmation of relevant physical findings and review of the clinical history and laboratory investigations that support the need of surgical intervention Type of approach- Benefits & Risks of surgical procedure The incision site- ease of surgery as well as cosmetic considerations Type of anesthesia

1. General Surgery
Principles of Physiotherapy Management
Dr.Nidhi Ahya (Assistant Professor)
Cardio-Vascular And Respiratory
PT
DVVPF College Of Physiotherapy,
Ahmednagar 414111

2. Contents
• General Surgical Principles
• Type of Anesthesia and effect on
Cardio-pulmonary system
• Ideal incision
• Types of incision
• Common Post-operative
Complications
• Role of Physiotherapy
• Pre and Post-operative Assessment
& PT Management

3. Principles of General Surgery
Establishing the need for a surgical
intervention
• Confirmation of relevant physical findings and
review of the clinical history and laboratory
investigations that support the need of surgical
intervention
Type of approach- Benefits & Risks of
surgical procedure
• The incision site- ease of surgery as well as
cosmetic considerations
• Type of anesthesia

4. Pre-operative Work-up
• Consent for surgery, Pre-anesthetic Check-up
Peri-operative Considerations
• Length of the surgical procedure, volume of blood
lost during surgery, monitoring of vitals, risk
assessment and management uptill 72 hrs post-
surgery
Post-operative Management
• From 72 hrs post-opoeratively to uptill 30 days
• Incisional care and healing , management of risk
factors, evaluation for success of surgical
intervention for primary problem ,risk management

5. Types of Anesthesia
General Anesthesia
• Refers to the suppression of activity in
the central nervous system by inhalation
of anesthetic agent causing lack of
movement (paralysis), unconsciousness,
and blunting of the stress response
Regional Anesthesia
• Types- Infiltrative, Intravenous,
peripheral nerve blockade, topical,local
anesthesia,central nerve blockade
(spinal,epidural,caudal)

6. Ideal Incision
 The ideal incision characteristics:
• Easy to open
• Minimise damage to tissues
– Avoid cutting nerves
– Split rather than transect muscles
– Limit damage to fascia
• Easy to close
• Allow sufficiently strong closure
• Allow sufficient access
• Extendable if necessary
• Target organ
• Body habitus
• Previous operations

7. Classification of incisions
Vertical incision
Midline incisions
Paramedian incisions
Transverse and oblique incisions
Kocher's subcostal Incision
Mc Burney’s grid iron or muscle
splitting incision.
Pfannenstiel incision
Maylard Transverse Muscle cutting
Incision
Oblique Muscle cutting incision
Thoracoabdominal incisions.

8. Midline incision
Upper Midline Incision
 From xiphoid to above umbilicus.
 Skin  superficial and deep fascia 
linea alba  extraperitoneal fat 
peritonium.
 Division of the peritoneum is best
performed at the lower end of the
incision, just above the umbilicus so
that falciform ligament can be seen
and avoided.

9. . Lower Midline Incision
From the umbilicus superiorly to
the pubic symphysis inferiorly.
Allow access to pelvic organs.
The peritoneum should be
opened in the uppermost area
to avoid possible injury to the
bladder.
Full Midline Incision
From xiphoid to pubic
symphysis inferiorly.
Great exposure is needed.

10. Paramedian incision
 2 to 5 cm lateral to the midline.
 Over the medial aspect of the
rectus muscle.
skin  fascia  anterior rectus
sheath  The anterior rectus
muscle is freed from the anterior
sheath and retracted laterally
 The posterior rectus sheath
or transversalis fascia 
extraperitoneal fat ,peritoneum
excised allowing entry to the
abdominal cavity.

11. Kocher’s incision
Incision parallel to the right costal
margin
Starts at the midline, 2 to 5 cm
below the xiphoid and extends
downwards, outwards and
parallel to and about 2.5 cm
below the costal margin
It shows excellent exposure to
the gallbladder, biliary tract and
can be made on the left side to
show access to the spleen..

12. Chevron (Roof Top) Modification
The incision may be continued across the
midline into a double Kocher incision or roof
top approach which provide excellent access
to the upper abdomen
Used for:
 Total Gastrectomy.
 Total oesophagectomy.
 Extensive hepatic resections
 Bilateral adrenalectomy
.

13. The Mercedes Benz Modification
 Consists of bilateral low
Kocher’s incision with an
upper midline incision up
to the xiphisternum.
 Excellent access to the
upper abdominal
viscera. (mainly the
diaphragmatic hiatuses)
.

14. McBurney Grid -Iron Incision
First described in 1894 by Charles
McBurney
Is the incision of choice For most
Appendectomies.
 It is a muscle splitting incision
Made at the junction of the middle
third and outer thirds of a line
running from the umbilicus to the
anterior superior iliac spine
.

15. P - fannenstiel incision
 Used frequently by gynecologists
and urologists for access to the
pelvic organs, bladder, prostate
and for caesarean section.
 Usually 12 cm long and made in
a skin fold approximately 5 cm
above symphysis pubis.
 skin  fascia  anterior rectus
sheath  rectus muscle 
transversalis fascia 
extraperitoneal fat  perineum.
.

16. Maylard’s Incision
 It is a transverse muscle
cutting incision
 It is placed above but
parallel to the traditional
placement of
Pfannenstiel incision.
 Gives excellent exposure
of the pelvic organs.
.

17. Thoracoabdominal Incision
Converts the pleural and
peritoneal cavities into one
common cavity  excellent
exposure.
Left incision  Resection of the
lower end of the esophagus and
proximal portion of the stomach.
Right incision  elective and
emergency hepatic resections.
.

18. Post-Operative Complications
Vascular Complications
 Respiratory Complications
Haemorrhage
Muscle Atrophy and Imbalance
Poor Healing/gaping of incision
 Incisional Hernia

19. Vascular Complications
• Thrombosis or embolism
• Can occur at any time between the 3rd to
the 21st post-operative day
• Thrombosis are mainly of toe types
 Thrombo-phlebitis
 Phlebothrombosis
• Phlebothrombosis is by far the most
serious complication of operations on the
pelvis

20. Thrombo-Phelbitis
• Damage to the vein wall
caused by insertion of an
interavenous drip
• Vein becomes irritant,inflamed
and blood clots becomes
adherent to vein wall
• If inflammation spreads to the
surrounding tissue it may lead
to cellulitis.
• Condition is self limiting, and
resolves if irritant is removed

21. Phlebo-Thrombosis
• Formation of blood clot in the
depper viens
• It is non-inflamatory, so rarely
produces symptoms
• Lifethreating condition
• Common causes-
 slow blood flow
 in no.of platelets and their
cohesiveness
 more fibrinogen
 reduced movement

22. Embolism
• A thrombus formed in a vessel
wall,is attached to it only at the
point of origin
• Fragments from this thrombus
can become disloged, travel
within the circulation and block
the blood supply to vital organs
• Common sites- cerebral,
pulmonary

23. Chest Complications
• Reduced Ventilation
• Poor Lung Expansion
• Reduced Vital Capacity
• Accumulation of secretions
• Poor ability to clear secreations
• Lung Collapse

24. Haemorrhage
• It can be Internal or External
• What to look out for?
 Soakage of dressing
 Low blood Pressure
 Feeble Pulse
 Incresed RR
 Restlessness
 Fainting

25. Muscle Atrophy and Imbalance
• Muscles are retracted,cut,split
during surgery.
• Incision of the muscle reduces it
bulk as well as power
• Damage to the nerve supply of the
muscle can occur during surgery
• Reflex inhibition due to pain
• Protective inactivity of a muscle
lead to atrophy
• Addhesion formation can restrict
range of motion

26. Incisional Hernia
• Incision weakens the
abdominal wall
• Inadequately placed
sutures, poor apposition
of the tissues during
closure, excessive strain
from coughing, lifting
heavy weight can put
strain on the weakened
wall.

27. Delayed Healing
• Infection
 Surgical site
 Away from the site
• Sepsis
• Systemic Illness
• Poor post-surgical care

28. Physiotherapy
Assessment & Management
Pre-operative
Post-operative

29. Need for Pre-operative Assessment
• Acquaintance with the patient and patient’s
family
• To list out pre-operative complains and a
brief history of presenting illness
• Known systemic illness and its impact on
post-operative management
• To assess the risk of post-operative
complications and take steps to limit the
same
• To explain the post-operative physiotherapy
regime
• To assure the patient of total support during
post-operative period

30. Pre-Operative Management
• Teach the patient Ankle toe pumps and
general mobility exercises
• Appropriate airway clearance
techniques
• Incision Splinting, Huff-cuff
• Breathing Exercises
• Incentive Spirometry
• Bed Mobility
• Explain the benefits of early ambulation

31. Post-Operative Assessment
• Review of patients file- Anesthesia and
Surgical notes
 Type of surgery
 Incision- area, muscles cut, split or retracted,
length of incision, drain sites, closure (staples,
clips, sutures),dressing type
 Duration of surgery
 Complications during surgery
 Post-operative recovery till day of reference
• Review of Nursing Care Chart Monitored
vitals over time, Input-Output charting,
Medications
• Investigations- Chest X-ray, ABG

32. • Palpation
 Peripheral Pulses
 Chest Expansion
 Tactile fremitus
 Homan’s Sign
 Pedal edema
• Percussion
 Posterior Chest wall
• Auscultation
 Air entry B/l equal
 Presence of abnormal breath sounds

34. Post-operative Treatment
• DAY 1
 Ankle toe Pumps 10 reps per hour
 Active/assisted Mobility exercises
 Supported long sitting in bed
 Breathing Exercises
 Airway clearance techniques
 Splinting Incision and huff-cuffs
 Incentive Spirometry
* *Note: Only Inspiratory

35. • DAY 2
 Ankle toe Pumps 10 reps per hour
 Active Mobility exercises
 Sitting on edge of bed
 Breathing Exercises
 Airway clearance techniques
 Splinting Incision and huff-cuffs
 Supported Ambulation 20 meters
 Progression of Spirometry
* *Note: Only Inspiratory

36. • DAY 3
 Ankle toe Pumps 10x 2 times daily
 Active Mobility exercises in sitting
 Breathing Exercises
 Airway clearance techniques
 Splinting Incision and huff-cuffs
 Ambulation upto 30 meters
3-4 times in a day
 Incentive Spirometry
* *Note: Only Inspiratory

37. • DAY 4 to 7
 Independent bed mobility
 Active Mobility exercises in sitting
 Breathing Exercises
 Airway clearance techniques
 Splinting Incision in daily activities
 Independent Ambulation
3-4 times in a day, increase distance
gradually
 Incentive Spirometry
* *Note: Only Inspiratory

38. • Home Exercise Program
 Independent Ambulation
 Active Mobility exercises
 Breathing Exercises
 Incentive Spirometry
Inspiratory+ Expiratory beyond 4
weeks
• Precautions: DON’T DO
 Forward bending
 Lifting heavy weight
 Vigorous coughing
 Side-lying on operated side

39. Summary
• General Surgical Principles
• Type of Anesthesia
• Ideal incision
• Types of incision
• Post-operative Complications
• Role of Physiotherapy

40. QUESTIONS
1. WRITE THE GENERAL
SURGICAL PRINCIPALS.
5MARKS
2. WRITE ABOUT THE POST
OPRATIVE
COMPLICATIONS.7MARKS
3. WRITE THE ROLE OF
PHYSIOTHERAPIST. 7MARKS

41. Thank You…