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Similar to Abdominal surgery.pptx
Abdominal surgery.pptx
- 1. Physiotherapy management in Abdominal surgeries Presentedby- Dr. DIVYAGUNJAN SAHU (PT)
- 2. Basic Anatomy Surface landmarks: STRUCTURELANDMARK Xiphoid process T9 Pubic symphysis coccyx Highest point of Iliac crest L4 Inguinal ligament ASIS to pubic tubercle Umblicus L3-L4
- 3. SURFACE LANDMARKS: Supero-lateralmargins of the anterior abdominal wall are formed by right and left 7,8,9,10 costal cartilages. Posteriorly and laterally the abdominal wall is much less as it is replaced by thoracic cage in upper part and gluteal region in lower part. The anterior abdominal wall is divided into right and left halves by linea alba. Lateral to linea alba there is linea semilunaris which corresponds to lateral margin of rectus abdominis. SKIN : capable of undergoing enormous stretching as seen in pregnancy, ascites or obesity.
- 4. UMBLICUS: Normal scarin the anterior abdominal wall. Lymph and venous blood which flow upward above the plane of the umbilicus and downwards below this plane. In portal hypertension, dilated vein radiating from the umbilicus is seen called caput medusa.
- 5. SUPERFICIAL FASCIA: Dividedinto superficial fatty (fascia of Camper) and deep (fascia of Scarpa) CUTANEOUS NERVE: T7- T11, ilio-inguinal and ilio-hypogastric (T12-L1) enter the abdominal wall through inter-coastal spaces supplies front of abdomen. LYMPH NODES: Above the watershed lines lymphatic run upward to drain into axillary lymph nodes and below the level of umbilicus drain into inguinal lymph nodes. MUSCLES: Abdominal muscle provide a firm but elastic support for the viscera against gravity. It helps in all expulsive and expiratory acts.
- 6. MUSCLE ORIGIN INSERTIONACTION External Oblique Shafts of lower eight ribs Xiphoid, Linea alba, pubis Forceful expiration Internal Oblique Inguinal ligament, iliac crest 7-10 ribs, xiphoid, linea alba, pubis Ipsilateral trunk rotation Transversus Abdominis Inguinal ligament, iliac crest, thoracolumbar fascia Xiphoid, Linea alba, pubis Corset like effect- compress abdominal structures Rectus Abdominis Pubic crest and ligament Tendinous insertion to xiphoid Flexion of trunk Quadratus Lumborum Iliac crest 12th rib Stabilize pelvis, lateral flexion, accessory muscle to expiration
- 8. Quadrants And RegionsOf Abdomen Abdomen is divided into four quadrants to allow the localization of pain and tenderness, scars or lumps. Nine regions can be marked using two horizontal (subcoastal and intertubercular line) and two vertical dividing lines (midclavicular) QUADRANTS STRUCTURE Left upper Stomach, spleen, pancrease, left kidney, colon Left lower Descending colon, left ovary, left ureter Right upper Right kidney, liver, gall bladder, duodenum Right lower Right ovary, right ureter, appendix, ascending colon
- 9. QUADRANTS OF ABDOMENREGIONS OF ABDOMEN
- 10. Abdominal Incision: Awisely chosen incision and correct method of making and closing the wound is really important. Care is taken to avoid tram line incision and acute angle incision as it could lead to devascularisation of tissue causing delayed healing and incisional hernia. Physiotherapist has to juggle intra-abdominal and intra thoracic pressure to maintain maximum air entry and clearance of secretion without creating a rupture of the suture.
- 11.
- 12. Transverse Incision: Pfannestial incision Maryland incisionOblique muscle cutting incision
- 13. Kocher’s incision Transverse muscle dividingincision McBurney’s incision
- 14. INCISION ADVANTAGES DISADVANTADESMUSCLE CUT MUSCLE SPARED MARKINGS MIDLINE Bloodless, good accessibility, can be extended,no nerve injury Slow healing, Incisional hernia none all Follows linea alba PARAMEDIAN Good access to lateral structures, more secure Muscle atrophy, more bleeding, difficult to extend Rectus 2-5cm lateral to umblicus KOCHER’S Lesser post-op pain, early recovery Poor exposure Rectus, internal oblique, transversus abdominis External oblique 2-5cm below xiphoid which extends outward and downwards to costal margin
- 15. INCISION ADVANTAGES DISADVANTAGESMUSCLE CUT MUSCLE SPARED MARKINGS McBURNEY’S Good healing and cosmesis Accidental injury to iliohypogastric and ilio-inguinal nerve External oblique Rectus, internal oblique Medial 2/3rd and lateral 1/3rd of a line running from umbilicus to ASIS Transverse muscle cutting incision (Maryland incision) Reduced rate of incisional hernia, cosmetic appeal Painful, not offer sufficient exposure to Rectus and all the muscle are incised 5-8cm above pubic symphysis Pfannestial incision Heals faster, best cosmetic results More hemorrhagic Rectus muscle is not cut 12cm long and 2cm above the pubic symphysis.
- 16. History And Examination Commoncomplaints: Pain, dyspepsia, anorexia, weight loss, jaundice, altered bowel habit, blood loss and fatigue. History: Medical history- for e.g. person with β-blocking drug will not have tachycardia proportionate to internal hemorrhage. Surgical history- previous abdominal surgeries and it’s complication. Family history- evident particularly in cancer, inflammatory bowel disease, endocrine disease. Personal history- smoking, drinking or nicotine.
- 17. Type of injury- Closed Abdominal Injury- Closed injuries are due to waves of shock or direct compression of a viscera against a bony prominence. If a large segment of the abdomen or abdomino-thoracic wall is compressed it may burst or split organs like liver and spleen. A similar force may split the diaphragm if the breath is held and the diaphragm is tense. Open Abdominal Injury- With a severe open abdominal injury, abdominal organs sometimes protrude through the wound.
- 18. General Examination: Vitals:Tachycardia and tachypnea are noticed in internal hemorrhage. Subnormal temperature and low blood pressure are features of shock. Fever Weight loss Dehydration Anemia Jaundice or pale skin should be ascertain at sclera, skin, nail bed, under surface of the tongue, soft palate. Vomiting or constipation Loss of appetite is an early feature of carcinoma affecting any part of the gastro-intestinal tract. Ankle odema if bilateral suggests gallstones.
- 19. Pain: Abdominal painmay be due to inflammatory, infection or obstructive pathology. Pain from the viscera is principally due to ischaemia, muscle spasm or stretching of the visceral peritoneum. Unlike somatic pain, autonomic pain is deep and poorly localized. Pathology involving diaphragm or phrenic nerve (C4) pain arising in this region is referred to the tip of the shoulder. Pancreatitis often has an abrupt onset of severe epigastric pain radiating to the back.
- 20. Biliary colicwill classically results pain in the right upper quadrant of the abdomen which radiates to the angle of the scapula. Murphy’s sign- It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid- clavicular line. If the patient stops breathing in as the gallbladder is tender and winces with a "catch" in breath, the test is considered positive
- 21. Review Of System: GastrointestinalSystem: In gastric ulcer intake of food brings pain, whereas in duodenal ulcer food relieves pain. belching and heart-burn occurs in patients with oesophageal hiatus hernia. Hematemesis- vomiting of blood Black tarry (melena) — which indicates hemorrhage in the upper G.I. tract or ingestion of large doses of iron or bismuth whitish or clay colored indicates biliary obstruction. large, fatty and offensive stool suggests chronic pancreatitis.
- 22. Inspection Examiner shouldkneels by the patient’s bed so that the his eye is at the level of the patient’s anterior abdominal wall to examine for abdominal masses, scars, mobility on respiration, visible peristalsis, dilated veins, or swelling. Generalized distension of the abdomen occurs in internal hemorrhage. Localized distension may be due to localized internal hemorrhage or peritonitis. Abdominal distention may cause impairment of excursion of the diaphragm, may also inhibit the patient from coughing and deep breathing and thus, contribute to respiratory failure. An enlarged liver may be found when chronic right-sided heart failure has occurred as a consequence of chronic respiratory disease. There will be absence of abdominal movements in respiration due to peritonitis.
- 23. Bruise withhematoma affecting lumbar region which should arouse suspicion of renal injury and bruising with hematoma affecting lower ribs indicates liver or splenic injury. Grey Turner’s sign – skin discoloration of the flanks due to retroperitoneal haemorrhage in severe acute pancreatitis and leaking abdominal aortic aneurysm Cullen’s sign – discoloration around the umbilicus – may indicate severe acute pancreatitis, ruptured ectopic pregnancy or trauma to the liver.
- 24. Scar- linearscar indicates healing by first intention and broad or irregular scar suggestive of wound infection. Ask the patient to lift his or her legs with the knees extended, or perform Valsalva’s maneuvre for laterally placed swellings. Lumps superficial to the abdominal wall muscles will become more obvious and those arising within the muscle layer will become fixed and remain unchanged in size. An intra-peritoneal mass in contact with the diaphragm will move on respiration.
- 25. Palpation: Patient shouldlie flat on his back with knee flexed (to relax abdominal muscle) taking deep breaths. Palpation should start in the region furthest away from the site of pain. Under no circumstances he should be hurt. Otherwise abdominal muscles will go into spasm and important findings may be missed. Muscle Guarding represents contraction of the abdominal wall muscles over the area of pain due to peritonitis or presence of internal bleeding. Liver, spleen, gall bladder and kidneys are best palpated during inspiration.
- 26. Liver- Normally,the liver spans approximately 10 cm at the right midclavicular line. If the liver extends more than 10 cm, it is considered enlarged. To palpate for an enlarged liver one should place the hand on the right iliac fossa with the fingers pointing towards the left axilla (that means parallel to the right costal margin) Spleen- Normally 7-14 cm but when enlarged it extends from the left costal margin to the right iliac fossa. It moves freely with respiration. Spleen is palpation with the tips of the fingers pointing upwards and pressed inwards Left supraclavicular lymph nodes- indicates carcinoma of the stomach and other abdominal organs.
- 27. Percussion: Percussion helpsto distinguish whether distension is due to bowel gas from solid masses or free fluid in the abdomen. If the patient winces with pain on abdominal percussion it denotes underlying peritonitis The liver extends from the 6th rib to the costal margin on the right mid- axillary line. The spleen extends from the 9th to the 11th rib on the left mid-axillary line. When there is free fluid in the abdomen shifting dullness can be obtained.
- 28. Auscultation: The bellof the stethoscope is placed below and to the left of the xiphi- sternum. The point at which the sound changes is the boundary line of the stomach. Normal bowel sound almost excludes any serious injury to the abdominal viscera. Auscultation of the chest may indicate presence of bowel sound in case of rupture of the diaphragm.
- 29. Investigation: Blood- ESR Urine-haemteuria X-ray chest and abdomen Endoscpoy Sonography Peritoneocentesis Cystoscopy is of high value in diagnosis of urinary bladder injury.
- 30. Complications: Hematoma Stitchabscess Wound dehiscence Burst abdomen Fistula formation Pain Incisional hernia Adhesion and its complication
- 31. Physiotherapy Complications: Hemorrahage: palor,restlessness, thirst and anxiety. Pulmonary complication: Retention of secretions which may lead to pneumonia. secretions greater in volume due to irritation by the anaesthesia and sedatives, plus decreased depth of pulmonary ventilation. Secretions become more sticky and tenacious due to dehydration post operatively. The lying position creates low lung volume. Therefore airway early closure occurs early and atelectasis may occur.
- 32. Cough reflexsuppressed due to anesthesia, sedation and inhibiting effect of pain. Rarely there may be inhalation of foreign matter. Breathing during anesthesia, or under anesthesia is very even with no periodic sighs, this leads to low lung volumes and reduced surfactants and atelectasis. Vital Capacities can be reduced by >50% Atelectasis: Threatened collapse due to low lung volumes. Decreased rib cage movement Decreased breath sound,late inspiratory crackles occurs in first 24-48 hours
- 33. Complete obstruction dueto thick secretions: collapse of an area of lung seen on x-ray Fever.37.7 Increased pulse rate Decreased movement of the rib cage over involved area Dyspnea if extensive Absent breath sounds Occurs in first 24-48 hours Retention of secretions often in the large airway which may lead to broncho- pneumonia and bubbling sound may felt on palpation and auscultation during expiration
- 34. High risk factors: High incision causing splinting and reflex inhibition of lower rib cage and hemi- diaphragm on the same side. Elderly (over 50) due to normal effects of aging on the lungs Smokers Tendency to have mild bronchitis cough with cold Previous COPD and Bronchiectasis History of repeated attacks of pneumonia Obesity
- 35. The ability ofprehabilitation to influence post-operatively outcome after an intra-abdominal operation(2016) moran2016.pdf Post-op complications are more than mortality with a rate of about 35% after an abdominal operation. Prehab given are inspiratory muscle training, musculoskeletal and aerobic exercise. Results showed significant decreased in PPCs.
- 36. Physiotherapeutic approaches andthe effects on inspiratory muscle force in patients with chronic obstructive pulmonary disease in the pre-operative preparation for abdominal surgical procedures complication2019.pdf The modern and traditional bronchial clearance techniques associated with inspiratory muscle training were equally effective in gaining inspiratory muscle strength with increased Pmax.
- 37. Complication involving peripheralvascular system: Phlebitis- inflammation of vein Thrombosis- formation of clot in the blood vessel Phlebothrombosis- thrombosis without much inflammation Thrombophlebitis - usually accompanied by a certain degree of clot formation due to walls becoming rough as a result of inflammation. Thrombosis of leg veins which may lead to pulmonary embolism Physiotherapy is contra-indicated until danger of emboli is over. Immediate- elevation, supportive bandage, cradle, heparin and later calmodulin is given. Later- Elevation, mild heat infra-red, exercise should be gentle at first
- 38. Unhealed hernia: Healingis slowed down by several factors and when it occurs it leads to greater scar formation Causes: Infection Excessive strain Abdominal distention Presence of malignancies Diabetic patients Weak abdominals pre-op Hernia weakens anterior support of lumbar vertebre leading to increased lordosis and possible back problems. Weakness may lead to visceroptosis {abdominal organ fall to the lower part of abdomen} Pelvic floor weakness may lead to stress incontinence
- 39. Infections: Wound istender and increased temperature Hyperpyrexia Redness and swelling around the wound If infection occurs through the full thickness of the wall then rupture of the wound leads to Dehiscence Muscle atrophy: Muscles which are cut.
- 40. ICEAGE (Incidence ofComplications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery 13017_2018_Article_189.pdf PPC diagnostic criteria ICEAGE exercise protocol reps and repitition
- 41. Chest physiotherapy duringimmediate postoperative period among patients undergoing upper abdominal surgery: Randomized clinical trial manzanoSPMJ2008.pdf Immediate post-op period following upper abdominal surgery was effective for improving oxygen saturation that last longer.
- 42. Aims Of PhysiotherapyManagement: PRE- OP: Familiarize the patients with the post-op routine and explain the reason for all procedure To teach how to move in bed To teach correct breathing patterns To teach easy and effective coughing Increase vital capacity and breathing control.
- 43. Post-op: EARLY- To ensure full inflationof the basal lobes. To aid expectoration of mucus To maintain adequate speed of blood flow in lower extremities. LONG TERM- To ensure strength to the muscle cut. To reduce gastric distress or gas pains
- 44. Post Operative ExaminationAnd Evaluation: Pain Using VAS Muscle performance (functional strength) In anticipation of activities like ambulation with assistive device, transfer and ADL’s Integrity of skin Scar and it’s mobility Posture Identify the patient’s preferred posture (lean towards the painful side) Gait analysis Type of supportive device, degree of weight bearing, antalgic gait
- 45. Maximum protection phase(2-5 days): Protection is paramount due to tissue inflammation and pain. Exercise in patient’s tolerable range Educate about positioning Safe positioning and limb movements Decrease post operative pain muscle guarding Relaxation exercise, use of TENS, cold, heat Prevent wound infection Proper wound care Minimize post-operatively swelling Elevation, active muscle pumping of distal joints, gentle distal to proximal massage. Prevent respiratory complications Deep breathes, forced expiratory techniques Minimize muscle atrophy Muscle-setting exercises Maintain ROM of uninvolved side, joint above and below Active and resistive exercises
- 46. Moderate protection phase:(2-6weeks) Absence of pain at rest and inflammation is subsided. Educate the patient Monitor the effects of exercise program if swelling and pain increases Gradually restore soft tissue and joint mobility Active assistive and AROM ex. Joint mobilization Mobilise scar Massage across and around a mobilizing scar Strengthing of involved muscle and improve joint mobility Multiple angle muscle setting exercise, dynamic resistances ex against light resistance in open and chain position
- 47. Minimum protection phase(6-12weeks): Restoring functional strength and participating in ADL’s. Continue patient education Emphasis gradual progression Prevent re-injury and post operatively complications Reinforce self-monitoring Restore full joint mobilization Joint stretching and self-stretching. Maximize muscle peformance Progressive strengthening exercise using higher loads and speeds and integrate movements into exercise that stimulate functional activity.
- 48. Patient counselling: Moving inbed post abdominal surgery: Changing from side lying to crook lying Stretch and pull on any incision in the abdominal muscles can be minimized by flattening the lumbar spine and flexing the hip therefore, it is essential to use crook lying as a starting position in any post operatively patient. Slide heel upto the bed on the non operated side first Slide heel upto the bed on the operated side Reverse the sequence to return to lying
- 49. Log rolling: Logroll to crook lying to side crook lying Therapist assist the patient by supporting head and the shoulder girdle by one arm and the thighs with the other Patient should roll towards the therapist. Patient instructed to roll in one whole piece onto the sides. The shoulder, hip and knees should move together as one.
- 51. To sit upon the side of bed: Straighten the knees out so that the lower legs are resting parallel to close to the edge of the bed. Push trunk upwards with both hands in steps. Once the patient is sitting stay close to the patient. To assist patient upto long sitting from side lying in order to cough: If there is time, roll the head end of the bed up Place one hand under the patients head, brace the other hand and arm on the bed besides the patient upper thigh to protect your back Instruct the patient to keep the neck and upper back rigid Lift the patient up by using transference of your body weight To return the patient to lying hand position as above instruct the patient to push back very strongly against the resistance of the therapist. The back and hip extensors work very strongly and abdominals remain relaxed due to reciprocal innervation.
- 52. Respiratory exercises: Breathing exercise: Time visit with analgesics, nebulization. Focus on both lateral costal and diaphragmatic breathing pattern. Half lying to enhance lateral costal expansion. Crook lying to enhance diaphragmatic expansion. Side lying to lateral costal excursion in upper lung and diaphragmatic excursion in lower lung Slow sustained inspiratory breathing to increase Vital Capacity. Clearance of secreation: vibration, percussion and suctioning. Mobilization: Alter angle of head end of bed Moving around in bed Bending knees Turning onto sides
- 53. Ambulation: Getting outof bed by getting up from crook lying position using arms. Encourage ambulation Resisted foot exercises. Effective coughing : With knees well bent up in half lying or side lying except for pelvic surgeries legs adducted in lying and knees extended. Support incision-manually or using towel and pillow. Abdominal exercises: Should start with static contraction and pelvic tilt Progression should be gentle and should not produce pain Work on the upper and lower abdominals in all phases of their actions in rotation, forward flexion and side flexion. Donot breath hold its important to breathe normally while contracting.
- 54. Principle of exerciseafter abdominal surgeries: Recruit core muscle so that the trunk and pelvis has much better support which helps to counteract the shearing forces during activities such as lifting, coughing straining at stool. Two important muscles to be recruited is Transeversus abdominis and Mutifidus Core strengthening programme is an exercise program that improves trunk stability and support the spine.
- 55. Progression of abdominalexercise: Contract deep muscles Increase the endurance capacity of core muscle by contracting them in different positions and as long as they can Begin arm and leg movements while contracting core muscle.
- 56. Moving thepelvis and legs are mostly concentric in middle range therefore, suitable for strengthening exercise. Movement of head, arms and legs in the supine position automatically will involve static work for the abdominals even no actual trunk movement as occurred. Resistance to these movements will increase the strength of the isometric contraction of the abdominals. Concentric work of the abdominal muscle is only obtained when pelvis and or the ribs move towards one another.
- 57. ANDOMINAL TUCK-INS USING HANDSAND LEG(PROGRESSION)
- 58. ABDOMINAL EXECISES IN QUADRAPOD RESISTEDEXERCISE OF ARMS RECRUITING CORE
- 59.
- 60. Functions: To supportabdominal viscera To act as a synergic muscle for the diaphragm To fixate the thorax during head and arm movements. To fixate pelvis during leg movements Prevents loss of lumbar lordosis Assists in expulsive acts coughing defecation, childbirth To reduce gas pain: Abdominal contraction followed by bulging the stomach Alternate hip and knee flexion Knee to chest
- 61. POST-OP DAY EXERCISES 1Check wound, upright sitting, isometric abdominal exercise, knee to chest, knee roll 2-5 Previous exercise three times a day with increased reps, start walking(cardiovascular training) Alternate hip and knee flexion 6 Initiate core exercise (1*6), static cycling, core exercise 7-8 Increase sets (2*8), start aqua jogging wearing buoyancy belt if wound is closed and stitches are removed 9-12 Increased sets (3*10), continue cardiovascular exercises 13-15 Initiate walking on treadmill 16-18 Add squats, dynamic core strengthening 19-21 Increase speed in treadmill, progress to slow paced running, increased sets (4*10), gym ball exercises
- 62. CRUNCHES AND IT’SPROGRESSION
- 65. GYM BALL EXERCISES(MODERATE TO MINIMUM PROTECTION PHASE)
- 69. PLANKS (AT MINIMUMPROTECTION PHASE)
- 71. Wound management: Antiseptics forinfected wound but discontinue when wound is clean as damages fibroblast and endothelial cells. Povidone-idodine (betadine), Sodium hypochlorite solution, Hydrogen peroxide Anti-bacterials Neosporin, gentamycin, silver sulphadiazine, sulfamylon Analgesics {monitor vasoconstriction in nearby area} Tropical lidocaine Exogenous growth factors {only if natural healing has been stopped} Becaplermin gel Scar management {if contracted} Application of elastomer putty or silicon gel during maturation phase.
- 72. Mechanical Modalities: Ultrasound Increase cell activity, use hydrogel sheet for open wound Ultaviolet radiations Bactericidal effects, enhance granulation tissue. Hyperbaric oxygen therapy Increases oxygen available for cell metabolism, improving oxygen to hypoxic tissue. Negative Pressure wound therapy A suction tube is connected from the foam to a portable pump usually till 48 hours, it removes excess wound fluid and bacteria from wound bed. Cold laser therapy Low energy level infrared lasers, reduce pain by releasing nitric oxide into micro circulation.