Surgery

1. UPPER GIT SURGERIES

2.  General objective
 At the end of the class the students will be able to get
through knowledge about clinical and physiotherapy
aspect of upper GIT surgeries
 Specific objective
 To know meaning of different surgeries
 To know incision sites
 To know complication of surgeries
 To know post operative PT management

6.  Upper Gastrointestinal surgeries include the
surgical management of patients with disorders
of the oesophagus, stomach, duodenum, small
bowel, pancreas, liver and biliary tree.
 Medical Conditions
 Peptic ulcer disease
 Gastro-oesophageal reflux
 Tumours, benign and malignant of the upper
gastrointestinal tract
 Strictures of the upper GI tract
 Foreign bodies in the GI tract
 Bleeding of the upper GI tract
 Liver disease

7.  Surgical procedures
 Endoscopy
 Endoscopic ultrasonography
 Small bowel enteroscopy
 Capsule endoscopy
 Laparoscopic surgery of the upper GI tract
 Open surgery of the upper GI tract
 Gastrectomy
 Oesophagectomy
 Pancreaticoduodenectomy (Whipple procedure)
 Hepatectomy
 Biliary surgery
 Cholecystectomy

8. ENDOSCOPY
 Endoscopy is a nonsurgical procedure used to
examine a person's digestive tract. Using an
endoscope, a flexible tube with a light and camera
attached to it pictures of digestive tract can be seen
on a color TV monitor.
 Endoscopes can be passed into the large intestine
(colon) through the rectum to examine this area of the
intestine. This procedure is called sigmoidoscopy or
colonoscopy depending on how far up the colon is
examined.
 ENDOSCOPIC ULTRASOUND or EUS combines
upper endoscopy and ultrasound examination to
obtain images and information about various parts of
the digestive tract

9.  Indications
 Stomach pain
 Ulcers, gastritis, or difficulty swallowing
 Digestive tract bleeding
 Changes in bowel habits (chronic constipation or diarrhea)
 Polyps or growths in the colon
 In addition, endoscope is also used to take a biopsy to
look for the presence of disease.
 Endoscopy may also be used to treat a digestive tract
problem. For example, the endoscope might not only
detect active bleeding from an ulcer, but devices can
be passed through the endoscope that can stop the
bleeding.

10. SMALL BOWEL ENTEROSCOPY
 A small bowel enteroscopy is used to view the entire
small bowel from either an oral or rectal approach, to
perform both diagnostic and therapeutic techniques
within the small bowel without the need of an open
surgical procedure.
 A special endoscope that, when inflated with air, can
expand sections of the small intestine to enable the
camera to get a closer view.
 Indications
 Small intestinal bleeding
 Obscure gastrointestinal bleeding
 Iron deficiency anemia
 Failed GI endoscopies.
 Crohn’s diseases

11. LAPROSCOPIC SURGERIES OF UPPER GIT
 Laparoscopic surgery, also called minimally invasive surgery,
bandaid surgery, or keyhole surgery, is a modern surgical technique
in which operations in the abdomen are performed through
small incisions (usually 0.5–1.5 cm) as opposed to the larger
incisions needed in laparotomy
 Keyhole surgery makes use of images displayed on TV monitors to
magnify the surgical elements.
 The key element in laparoscopic surgery is the use of a laparoscope.
There are two types:
(1) a telescopic rod lens system, that is usually connected to a video
camera
(2) a digital laparoscope where the charge-coupled device is placed at
the end of the laparoscope, eliminating the rod lens system, inserted
through a 5 mm or 10 mm cannula or trocar to view the operative
field.
 The abdomen is usually insufflated, or essentially blown up like a
balloon, with carbon dioxide gas. This elevates the abdominal wall
above the internal organs like a dome to create a working and
viewing space. CO2 is used because it is common to the human body
and can be absorbed by tissue and removed by the respiratory
system. It is also non-flammable, which is important because
electrosurgical devices are commonly used in laparoscopic
procedures

12.  Laparoscopic cholecystectomy (removal of gall
bladder) is the most common laparoscopic
procedure performed
 Advantages
 Reduced hemorrhaging
 Smaller incision
 Less pain
 shortens recovery time
 less post-operative scarring.
 less pain medication needed.
 Short hospital stay
 Reduced exposure of internal organs
 Reduced risk of acquiring infections.

13. ESOPHAGECTOMY
 An esophagectomy is surgery to remove part or
all of the esophagus, the tube that moves food
from your throat to your stomach. After it is
removed, the esophagus is rebuilt from part of
your stomach or part of your large intestine.
 Most of the time, esophagectomy is done to
treat cancer of the esophagus.

14.  Types
 Transhiatal esophagectomy is
performed on
the neck and abdomen simultaneously
 Transthoracic esophagectomy involves
opening the thorax

15. GASTRECTOMY
 Gastrectomy is surgery to remove part
or all of the stomach.
 If only part of the stomach is removed, it
is called partial gastrectomy
 If the whole stomach is removed, it is
called total gastrectomy
 Depending on what part of the stomach
is removed, the intestine may need to be
re-connected to the remaining stomach
(partial gastrectomy) or to the
esophagus (total gastrectomy)
 Indications
 Bleeding
 Inflammation
 Non-cancerous (benign) tumors
 Polyps

16. PANCREATIC DUODENECTOMY
 Pancreaticoduodenectomy is also called
Whipple procedure. It is done to remove
a tumor from the pancreas or bile duct. A
pancreatic or bile duct tumor forms when
cells become cancer.
 During the Whipple procedure, the
gallbladder, duodenum, bile duct, and
head of the pancreas may be removed.
 Sometimes, the pylorus and lymph nodes
may also be taken out. Enough of the
pancreas is left to produce digestive
juices and insulin.
 The small intestine will be attached to
the stomach and to the remaining bile
duct and pancreas.
 Incision used is upper midline and upper
bilateral costal margins.

17. HEPATECTOMY
 Hepatectomy consist of the
surgical resection of the liver.
 Indications
 Hepatic neoplasms, both benign or
malignant.
 Intrahepatic gallstones or parasitic
cysts of the liver
 Partial Hepatectomies are also
performed to remove a portion of a
liver from a live donor for
transplantation.

18. PT MANAGEMENT
PRE-OPRATIVE MANAGEMENT:
 Pre op notes should be read carefully, relevant
facts noted.
 Patient education
 Assess respiratory expansion and teach
diaphragmatic and lateral costal breathing.
 Proper coughing technique should be taught
 Foot and leg exercises should be taught and told
why they are important

19. POST OPERATIVE MANAGEMENT
Assessment
 Surgical notes must be read with nursing record
of patients condition
 Position of drainage tubes, iv lines, catheter and
type of dressing should be noted
 Therapist should arrange that analgesic are
given before PT treatment.
 Site and type of incision should be noted.
 Trachea must be kept patent to avoid obstruction
until the patient is unconscious
 Respiratory condition should be assessed.

20. Treatment
 Prevention of chest complications
 Prevention of thrombosis
 Prevention of pressure sores
 Pain management ( Incisional pain )
 Prevention of muscle wasting and joint
immobility

21. Post op day1
 Patient will be more alert & have good pain
control, ask the patient to sit out of bed for
shorter period of time.
 Early mobilization should be started to reduces
chances of respiratory complication.
 Planter/dorsi flexion every 15 min.
 Deep breathing exercises
 Coughing with splinting

22. Post op day2
 Make the patient ambulate for short distances
with assistance
 Continue day one exe.
 Commence pelvic rocking
 Incentive spirometry will be useful to encourage
patient to continue breathing exercise between
treatments.

23. Post op day3
 All drains may be removed, so patient’s level of
activity can be increased.
 Longer periods of sitting & walking can be
encouraged.
 Abdominal drawing in may be commenced as
sutures are removed.
 Continue day one exercises
 If incisional pain is there - Application of
TENS can be given.

24. At home
Week1-2
 Start walking for 5-10 mins to build up stamina
 Start up and down stairs
Week 2-3
 Start doing ADLs
 Increase walking time and distance each week

25. RESPIRATORY PHYSIOTHERAPY TO PREVENT
PULMONARY COMPLICATIONS AFTER ABDOMINAL
SURGERY* : A SYSTEMATIC REVIEW
P- Post operative Pulmonary complication
I- Respiratory Physiotherapy
C- No physiotherapy
O- Incidence of pulmonary complications

26. CHEST 2006;130;1887-1899
Patrick
Pasquina,
Martin R.
Tramèr,
Jean-Max
Granier and
Bernhard
Walder
High level
of evidence
– systemic
review,
searched
different
data bases
Respirator
y
Physiothe
rapy To
Prevent
Pulmonar
y
Complicati
ons After
Abdominal
Surgery* :
A
Systematic
Review
They searched
in databases
and
bibliographies
for articles in
all languages
through
November 2005.
Randomized
trials were
included if they
investigated
prophylactic
respiratory
physiotherapy
and pulmonary
outcomes, and if
the follow-up
was at least 2
days.
Thirty-five
trials tested
respiratory
physiotherapy
treatments. Of
13 trials with a
“no
intervention”
control group, 9
studies did not
report on
significant
differences, and
4
studies did.
in 1 study, the
incidence of
pneumonia was
decreased.
in 1 study, the
incidence of
atelectasis was
decreased.
in 1 study, the
incidence of
unspecified
pulmonary
complications was
decreased
There are few
trials that
support the
usefulness of
prophylactic
respiratory
physiotherapy.

27. PREVENTION OF RESPIRATORY COMPLICATIONS
AFTER ABDOMINAL SURGERY
RCT THORAX
P- A patient with abdominal surgery
I – Prophylactic respiratory physiotherapy
C- Different techniques of respiratory
physiotherapy or no therapy
O- Prevention of respiratory complication

28. THORAX 1997;52(SUPPL 3):S35–S40
Jonathan
Richardson,
Sabaratnam
Sabanathan
Prevention of
respiratory
complications
after
abdominal
surgery
Stratified
randomised
trial.
456 patients
undergoing
abdominal
surgery.
Patients less
than 60 years
of age low
risk. They
recorded the
time that
staff devoted
to
prophylactic
respiratory
therapy
The
incidence of
respiratory
complicatio
ns was 15%
for patients
in the
incentive
spirometry
group and
12% for
patients in
the mixed
therapy
group
The most
efficient
regimen of
prophylaxis
against
respiratory
complications
after
abdominal
surgery is deep
breathing
exercises for
low risk
patients and
incentive
spirometry for
high risk
patients.