Types of abdominal surgeries and their PT management

1. ABDOMINAL SURGERY
types & their PT
management

2. Common abdominal surgeries
1. Gastrectomy
2. Cholecystectomy
3. Appendectomy
4. Herniotomy
5. Nephrectomy
6. Spleenectomy

3. 1.GASTRECTOMY
Gastrectomy is surgery to remove part or all of the stomach.
There are 4 main types of gastrectomy:-
1. Partial gastrectomy
– the lower part of the stomach is removed
2. Total gastrectomy
– the whole stomach is removed
3. Sleeve gastrectomy
– the left side of the stomach is removed
4. Esophagogastrectomy
– the top part of the stomach and part of the esophagus

5. Indications for gastrectomy
› Benign,or non cancerous tumors
› Bleeding
› Perforations in the stomach wall
› Polyps,or growth inside your stomach
› Severe peptic or duodenal ulcers
› To treat obesity

6. Type of incisions in gastrectomy
I. A right upper paramedian incision is commonly used .
II. Sometimes a left upper paramedian incision is used.
III. The incision is vertical in direction and is situated 1·2-2'5 cm
from the midline.

7. Stages of incision
› Incision of skin and subcutaneous tissues, down to the
anterior sheath of the rectus muscle.
› Incision of the anterior sheath of the rectus muscle in the line
of the skin incision.
› Retraction of the rectus muscle laterally, so that no large
nerves or vessels are damaged.
› Now incision of the posterior rectus sheath.

8. EXERCISE AND THE SUTURE LINE
› Active trunk rotation will therefore tend to pull more strongly
on the suture line
› Slow controlled trunk movement
› Simple abdominal exercises of all types on the 1st and 2nd
postoperative days,
› Breathing exercises and movements for the lower limbs are
essential during the first 2 postoperative days.

9. 2.CHOLECYSTECTOMY
› Surgical removal of the gallbladder.
› Location & function of gallbladder:-
• Located in the right hypochondrium region.
• Collects and stores bile.
› Cholecystectomy is common in symptomatic gallstones and
other gallbladder conditions.
› Can be performed either laproscopically or open surgery.

11. TYPE OF INCISION
› Common incision used in cholecystectomy is right upper para-
median incision.
› In certain cases where good exposure is required kocher’s
subcostal incision is used.
1.Right upper paramedian incision
› Vertical incision situated 1.2-2.5cm from the midline.
› Extends from the coastal margins to a point one side of the
umbilicus.

12. 2.kocher’s incision
› Right subcostal incision begins just below the xiphiod process
and extends downwards and outwards to the tip of 9th costal
cartilage.
› 2.5 cm below and parallel to costal margin
› The 9th intercostal nerve is severed causing flaccid paralysis of
certain fibers resulting in incisional hernia.
Stage of the incision
- same as gastrectomy -

13. Drainage
› In simple cholecystectomy some form of drainage is employed
for 48-72 hrs to drain the bile secretions.
› When common bile duct is incised a T-tube is used to drain
the duct into a bag.

14. 3.APPENDECTOMY
› Surgery to remove the appendix when it is infected (appendicitis)
› Appendix is a thin pouch attached to large intestine located above
right ASIS (rt.groin)
› Appendectomy is performed in the treatment of acute, sub-acute
and chronic inflammation of vermiform appendix.
Types of incision
› Most common incision used is gridiron(MC Burney) or
muscle splitting incision
› Other incisions are battle’s and the rt. Lower paramedian
incision

15. 1.Gridiron incision
› Oblique incision runs in downwards and inwards direction parallel
to the fibers of external oblique.
› About 5cm in length and lies in middle and lateral 3rd in a line
drawn from umbilicus to the rt.ASIS
2.Battle’s pararectal incision
› Gives better view but is prone to hernia.
› Vertical incision about 5cm in length sub-umbilical in position.

16. 3.Right lower paramedian incision.
› The incision is used when the diagnosis is uncertain,or when
exploration of the lower abdomen is desired.
Stage of incision
- same as gastrectomy -

17. Exercise and the suture line
1.Gridiron incision
› Because the muscles have been split in the directions of their fibers
abdominal exercise will not tend to separate the suture edges.
› But a proper care and performance of the trunk exercise should be
focused throughout the post-operative phase.
2.Battel’s incision & rt.lower Paramedian incision.
› Both of these incisions, transect the anterior and posterior sheath
of the rectus muscles through the aponeurosis of the transverse
and oblique muscles.
› So active trunk rotation will tend to pull the suture edges.

19. 4.spleenectomy
› Surgical removal of the spleen.
› Spleen is an organ that sits underneath the ribs on the left
side (left hypochondrium region)
› Functions of spleen are:-
– Filtering out germs that can cause serious infections.
– Removing blood cells that are damaged or old.
– Creating some of the WBCs that fight infections.
– Storing extra blood when it isn’t needed.

20. Indications for spleenectomy
› Performed to treat wide variety of conditions
– Ruptured spleen
– Enlarged spleen
– Blood disorder (idiopathic thrombocytopenic
purpura, polycythemia vera, thalassemia)
– Cancer
– Infection
– Cyst or tumor

21. › The incision depends on the size of the spleen, the reason for
splenectomy, and the preference of the surgeon.
› Generally, in emergency or trauma situations, an upper
midline incision is preferable.
› splenectomy for a hematologic disorder, a left subcostal
incision is employed, beginning to the right of the midline and
proceeding obliquely to the left approximately two
fingerbreadths below the costal margin.

22. 5.Nephrectomy
› Surgical removal of kidney
› Fist sized organ.
› Located at the back of the upper abdomen, just below the
diaphragm, behind the liver on the right, and the spleen on
the left.
› Depending on the condition all or some part of the kidney is
removed:-
– Partial nephrectomy
– Simple nephrectomy
– Radical nephrectomy
– Bilateral nephrectomy

24. Functions of kidney
› Filters wastes & excess fluid & electrolytes from your blood.
› Produces urine
› Maintain proper levels of minerals in your bloodstream.
› Produces hormone that help to regulate your blood pressure
& that influence the number of circulating RBCs
Indications for nephrectomy
› Cancer of kidney
› Chronic kidney stones
› Transplant

25. TYPE OF INCISION

26. 6.Herniotomy
1.Incisional hernia
› Due to weak musculature after surgery ,occurs around the
incisional site
2.Inguinal hernia
› Occurs near the groin area, due to weakness in right or left
inguinal canal at the base of the abdomen.

27. Mechanism of inguinal hernia
› Fail in defence mechanism of inguinal canal
› The inguinal canal constitutes a weak area in the abdominal
wall.
› During a temporary increase in intra-abdominal pressure, such
as occurs, for example, in coughing and defaecation, there is a
tendency for the abdominal viscera to be forced into the
canal.
› The canal possesses an efficient defence mechanism against
this occurrence:

28. › Shutter mechanism
› Valvular mechanism

29. Post-operative care immediately after surgery
› Depending on the severity of the surgery, the patient may be
sent to a regular surgical room or may be sent to the surgical
ICU to be more closely monitored.
› Fluids are given by vein i.v.
› Antibiotics are usually given I.V. for 24hrs
› Oxygen may be given by nasal catheter
› Gradually the diet is increased from liquids to soft food and
then more solid foods.
› The wound is kept clean to prevent infection. Lotions should
not be applied to the wound.

30. Principles of physiotherapy in abdominal surgery
› To prevent chest (respiratory) complications
› To prevent circulatory complications
› To maintain muscle power & joint ROM
› To prevent pressure sores
› To maintain good posture
› To improve & enhance bed mobility
› To gain co-operation and confidence

31. Pre-operative assessment
1. Read the notes/details about condition
2. Assess the respiratory function
3. Check for circulatory problems
4. Detailed history of the patient

32. 1.Clinical notes reading
› Co-morbid condition
› Cause for surgery
› Any other note by the surgeon
2.Respiratory assessment
› Symmetry
› Rate
› Depth
› Chest expansion
› Dysnoea
› Assessory muscle involvement
› Measurements

33. 3.Circulatory assessment
› Homan’s test
› Oedema
4.History taking
› Medical history
› Subjective history

34. Pre-operative training
› Breathing exercises
– Diaphragmatic and local expansion exercises
– Cough
– Teach the real mechanism of cough
› Arm exercises
– Short lever & long lever exercises
› Leg exercises
– Ankle & toe movements
– Static quads & glutei
› Posture correction
– Advices
– Ergonomic advantages

35. Post-operative assessment
Surgery notes reading
›Type of incision
›Type of anaesthia
›Duration of surgery
›Immediate complications/unwanted
events/management

36. Vital signs checking
› Tidal volume-2ml/kg body weight
› Minute volume- 100ml /kg body wt.
› FVC – 70ml /kg
› FEV1- 70-90% of FVC
› Pao2 – not less than 70mm/hg
› Paco2 – not more than 50mm/hg
› RR – 12-16/min
› ABG analysis

37. › Pulse oxymetry
› PR
› ECG
› Heart sounds
› Systemic arterial blood pressure
› CVP
› TPR chart
› Ventilator support

38. Understanding the attachments
› IV lines
› Nasogastric tube
› Catheter
› PCA
› Drains

39. Orientation assessment
– Communication ability
– Alertness
– Perceptual ability to follow instructions
Objective assessment
– Respiratory
– Circulatory
– ROM/muscle power
– Mobility/functional

40. Respiratory assessment
– Painful breathing
– Difficulty in coughing
– Impaired respiration
– Accumulation of secretions
– Palpation
– Auscultations
› Circulatory assessment
- do -

41. Posture & mobility
– Kypho scoliosis
– Bed mobility
› Pain assessment
– VAS
– MPQ

43. Recommended rehabilitation plan

47. Pt management
Initial 1st week
IV therapy & one limb is immobilized
Use of ryle’s tube
Application of postural drainage.
Sitting out of bed
If no respiratory complications then allow sitting for 10-20 min
Remedial aims
To prevent post-op respiratory & circulatory complications

48. Primary exercise
› Breathing, ankle/foot & leg exercise
› Diaphragmatic breathing should be instituted
› Kinesio-taping
› Chest raising
› Bridging , slow contraction and relaxation of abdomen by placing the hand
› Maintain abdominal muscles & trunk muscles activity strength
› Lying & hip drawing up, 1 leg raise
› Crook lying (hand on abdomen ;abs contractions)
› Stride lying; moving arm across the chest
› Head bending side ways
› Leg raise and hold

49. Management continued……
› Flexion-by dangling the legs over the side of the bed
› Half lying in bed. And ankle movement
› Static bed cycle
› Sitting @ the edge of bed (balancing)
› Sitting in chair with arm support.
› Stride sitting & trunk bending side ways and forward & backward.
› Preparing for wt.bearing
› Coming in assisted standing & encouraging the pts to hold standing on his own for time
till he is comfortable.
› Short periods of walking around bed with& without support
› Leg raise
› Walking practice.

50. › Redevelop the muscles that are responsible in walking i.e.longitudinal
arch muscles , calves , thigh muscles.
› Re-educate neuromuscular co-ordination.
› Balance exercises
› When patient is stable after few weeks of surgery
› Sitting on ball & shaking
› Swiss ball exercise for abs and trunk
› Quadraped on ball
› Bridging on ball, lying supine on ball and shaking
› Side lying & leg raise
› Cross leg thera-band exercise

51. Electro-therapy post abdominal surgery
› Abdominal binder
› TENS
› Hot pack
› Muscle stimulator
› Ultrasound to heal deep fibers