hernia& appendictomy basics of rehabilitation and physical therapy principles

1. Hernia & Appendectomy
Supervised by : DR. MOSTAFA AHMED
LECTURER AT FACULTY OF PHYSICAL
THERAPY

2. INGUINAL HERNIA
• A hernia is a lump that occurs when part of the small bowel. or other abdominal
tissue protrudes through an area of weakness the wall of the abdomen.When
this occurs in the groin. It is described as an "inguinal" hernia.

3. cause of inguinal hernias:
They may be present at birth or develop later in life, when training, heavy
lifting, coughing or obesity increases the pressure within the abdomen,
applying strain on the muscles in the groin area.

4. Hernia repair:
The operation is routinely performed as
"open" surgery, involving an incision to the
lower abdomen.This may be aTension-free"
technique that uses a mesh of inert, sterile
material to cover the affected area. Less
commonly, it might be a traditional "darn"
repair, where surgical stitches are used to
repair the area of weakness in the abdominal
wall. Alternatively, the operation may be
performed as "keyhole" surgery
(laparoscopic), through small incisions in the
skin using special instruments.

5. Side-effects:
Side-effects are the unwanted but usually mild and temporary effects of
successful procedure. Common side effects of hernia repair include:
1. Discomfort, bruising or minor swelling at the site of the operation.
2. Feeling sick as a result of the anesthetic or painkillers
3. In men, the scrotum may swell for a few days.These symptoms will clear up
over a week or so, without the need for specific treatment.
4.There will be small scars from the keyhole incisions and a longer scar is open
surgery is performed.

6. Complication:
1. Unexpected reaction to the anesthetic.
2. Or developing a blood clot, usually in a
vein in the leg (deep vein thrombosis).To
help prevent this most people are given
compression stockings to wear during the
operation. Complications may require
further treatment such as returning to
theatre to stop bleeding. Or antibiotics to
deal with an infection.

7. Other complication can occur after hernia
operation:
1.There's a small chance of continuing pain in the groin area caused by the
handling of a nerve during surgery. Or by the pressure on the nerves by scar
tissue that forms during healing.
2. In men, painful swelling of the scrotum or testicles occasionally occurs.This
may require further surgery
3. Inguinal hernias recur in 1-4% of cases treated.
4. A small percentage of people have an inherited tendency to scars that are
unusually red and raised.

8. • The chance of problems depends on the exact type of operation and other
factors such as general health.The surgeon will be able to explain how the
risks apply to each person.

9. Patient's problems:
[1] Pain:
Pain is a common compliant with a point prevalence from 10% to 18% and
lifetime prevalence from 30% to 50%.
Common treatment consists of drugs, massage other manual treatments,
physiotherapy and exercise, local and epidural injections, and patient
education. Current treatment increasingly includes complementary methods
of which acupuncture and laser are the most common.

10. Decrease in muscle strength:
-After inguinal Herniorrhaphy, there will be decrease in the strength of abdominal
obliques muscles and hip flexors.
-Several studies are made to identify what are the muscles affected after surgery and
to how much and what is the recommended
-protocol to regain strength after surgery.These studies aimed to assess lower limb
and abdominal muscle strength, function, and pain level of patients with PAWD
(PAWS is a set of impairments that happen immediately after you experience
withdrawal from alcohol or other substances. It's caused by an imbalance of
neurotransmitters in the brain. As it tries to reach equilibrium, it causes brain
chemicals to fluctuate until they're stable.) before surgery compared with matched
controls, and then to compare these. Findings with the changes in muscle strength,
pain and function after surgery and six weeks of rehabilitation.

11. The assessment include:
a-questionnaire to establish pain levels, dominant side, functional ability and the
mechanism of injury.
b- An is okinetic measurement for hamstring and quadriceps strength.
c- An isometric measurement for hip flexor, abductors and adductors strength.
d- Pressure biofeedback assessment of the stabilizing abdominals was performed to
assess deficits in transverse abdominals and oblique function and recruitment.

12. The following protocol was made after surgery:
1st "week: Isometric abdominals and hip exercises, walk increased by 5 min day, stairs.
2nd week: active exercises for hips, transverse and oblique abdominal
3rd week: Flexibility work,TheraBand hip exs, transverse and oblique abdominal, jogging,
swimming.
4th week: running forward, progressing to upper abdominal work, low body weights,
5th week: sprinting, running in all direction, light ball skills, kicking, abdominal and gradual return
to training.

13. The results revealed that there is no decrease in the strength of quadriceps
and hamstring ms.
There is decrease in strength of hip flexors and abdominal muscles.
Both limbs had increased in strength after surgery and rehabilitation.
Therefore, surgery and rehabilitation program were considered successful.
The oblique abdominal showed the greatest deficit before surgery and the
greatest improvement after.

14. 3- Returning to work after:
Herniorrhaphy is a problem:
This is because patients are being advised to limit their physical activity for
six to eight weeks postoperatively to prevent recurrence.
Although no scientific backing exists for such advice, this common and costly
practice persists.
1.The integrity of a repair of a hernia depends on good surgical technique.
2. Strong sutures.
3. Strong hernial margins.
4.The correct application of prosthetic mesh support. After standard open
herniorrhaphy.

15. • The strength of the wound is 70% of that of intact tissue and strong enough
to withstand full physical activity. Open prosthetic mesh repair, correctly
done can withstand any degree of stress
• Patients' motivation is the driving factor in the decision to return to work
and that depends on their confidence in their repair.This in turn depends
largely on what they have been told the attending surgeon physician.
Repeated emphasis that or hat they do physically will not affect the
strength of their repair Pressures patients wthat early return to work is safe
and justified.

16. • Should be given to the patient for early return to work the allowing
advice: take it easy after operation.... Do no heavy lifting for four weeks
and resume full activity by eight weeks. Depending upon your occupation,
you can expect a recovery period lasting from one to six weeks.

17. APPENDICECTOMY

18. Definition
• It means removal of the vermiform appendix.

19. Indications
1- Acute appendicitis (urgent or interval appendicectomy).
2- Recurrent attacks of subacute appendicitis.
3- Carcinoid tumor of the appendix.

20. Contraindications:
1- Appendicular mass.
2- Appendicular abscess.

21. • Anesthesia:
General or spinal.
• Position:
Supine

22. • Incisions:
The most common incision used in this country is the gridiron (McBurney) or
muscle splitting incision. Other incisions are right lower paramedian incision
and lanz incision.

23. 1. Gridiron incision:
The incision is an oblique one and runs in a downward and inward direction in
the line of the external oblique muscle. It is about 5 cm in length, with its
center at the junction of the middle and lateral thirds of a line drawn from the
umbilicus to the right anterior superior iliac spine.

24. Muscles cut during this incision:
1- External oblique muscle.
2- Internal oblique muscle.
3-Transverse abdominal muscle.

25. Advantages of gridiron incision:
1- Direct exposure of the appendix.
2- Can be extended.
3- Heals rapidly.

26. Disadvantages of gridiron incision:
1. Not exploratory.
2. Its extension causes muscle damage.
3. May be followed by inguinal hernia.

27. 2. Right lower paramedian incision:
• Vertical incision that is situated 1.2-2.5 cm from the midline and below the
umbilicus.

28. Advantages:
Exploratory.
Disadvantages:
1- Doubtful diagnosis.
2- Appendicitis with generalized peritonitis.

29. Muscle cut during this incision:
Rectus abdominis muscle.
3- Lanz incision (transverse lower abdominal skin crease incision):
Done in the inter spinous crease, so cosmetically better as it passes with
langer’s line.

30. Exercise and the suture line:
Gridiron incision:
Because the muscles have been split in the direction of their fibers abdominal
exercises will not tend separate the sutured muscle edges/Nevertheless,
reasonable care should be shown in the choice and performance of trunk
exercises throughout the postoperative phase of treatment.

31. • Lanz incision and right lower paramedian incision: Both types of incision
entail cutting of the anterior and posterior sheaths of the rectus muscle.
Active trunk rotation movements. will therefore tend to pull more strongly
on the suture line than any other form of trunk exercise, when trunk rotation
movements are performed they should be of the slow controlled type, and
quick jerky movements must be avoided.

32. • Although it is quite possible, and safe for the average patient to perform
simple abdominal exercises of all types on the 1st and 2nd postoperative
days, it has been found more convenient in practice to leave these exercises
until the 3rd day.

33. Physical therapy treatment for appendicectomy:
• The patient is usually allowed to sit out in a chair for 30-45 minutes during
the morning or afternoon and to walk in the ward for a short distance. While
in the bed he is encouraged to spend much of his time lying on his back and
on the left and right sides. He remains in each position for about an hour at a
time.This alteration of posture assists in the ventilation of the lungs and
helps to break any flatulence which may present.

34. Post operative suspected complications:
1- Pain.
2- Delayed healing of incision.
3- Respiratory complications.
4- Circulatory complications.
5- Muscle weakness.

35. Primary aims:
1-To decrease the postoperative pain.
2-To encourage and accelerate the healing process.
3-To prevent postoperative respiratory complications.
4-To prevent postoperative circulatory complications.
5-To maintain and improve the abdominal muscles, particularly the oblique
and transversus groups.

36. Secondary aims:
6-To maintain and improve the power of other trunk muscles.

37. Modalities of treatment:
1-TENS:
- Electrode placement: Para incisional.
-Pulse duration: 80 us
-Pulse rate: 40 Hz
-Amplitude: comfort (submotor).
-Duration and frequency of ttt: 60 min/4hour

38. 2. Laser:
-Purpose of application: wound healing.
- Dosage: 90 sec/cm2.
- Distance from skin: 2-3 mm.
- Mode: continuous mode.
- Power: 1 mW.

39. 3. Pulmonary physical therapy: Incentive
spirometry training:
* Methods of application:
1. First method:
The patient should be instructed to exhale normally and then insert the
mouthpiece and take slow, deep inspiration. Occasionally, a nose clip may be
necessary if the patient has difficulty with proper inhalation technique.

40. 2- Second method:
Is the inhalation hold method.The patient takes a maximal inhalation and
momentarily holds the inspiration for a count of 3 to 5 sec.This technique
helps to ventilate airways that are collapsed distal to an obstruction such as a
mucous plug. Frequency: 10 consecutive breaths /hour.

41. Benefits:
1. Prevention of atelectasis.
2. Improve coughing mechanism due to improved inspiratory capacity.
3. Strengthening of the diaphragm.
4- Foot and leg exercise (circulatory exercise): Various factors have been
recorded as being responsible for the production of thrombosis and embolism.Three
main factors are now recognized as being the possible causes.
(a) increased tendency for the blood to clot
(b) injury to the intima of the vein at operation
(c) slowing of the venous circulation.The last is probably the most important... the
slowing starts in the second postoperative day and is present until the patient
becomes ambulant.

42. • Simple foot, ankle and leg exercises are used during the early
postoperative days to accelerate the venous circulation through the
lower limbs and pelvis.They are especially important in the period
before regular walking is allowed.

43. • In addition to forming part of regular treatment sessions organized by the
therapist, some of the more important exercises should be carried out by
the patient throughout the day in "little and often lines' this is especially
important in the period before regular walking is allowed.

44. It includes the following exercises:
It includes the following exercises:
1- Lying: alternate ankle bending and stretching.
2- Lying: alternate foot turning inwards and outwards.
3- Lying: single foot circling.
4- Lying: single slight knee raising and lowering, followed by firm leg down pressing.
5- Lying: single and double quadriceps contractions.
6- Lying: combined quadriceps and gluteal contractions.
7- Sitting over edge of bed: alternate ankle bending and
stretching.
8- Sitting over edge of bed: alternate leg swinging.
9- Sitting over edge of bed: alternate knee stretching.

45. 5- Abdominal muscle exercise:
-Duration of exercise: 20 Min.
-Type of exercise: active exercise.
-Procedure:
1- Stride lying; trunk turning with single arm carrying across the chest.
2- Crock lying; pelvis raising.

46. Definition of Abdominal Lipectomy:
• This surgical procedure is performed to remove excess skin and fatty
tissue from the abdomen and leaves transverse lower abdominal scar.
Excess fat and skin can be removed from other areas such thighs and
buttocks.

47. Problems of Lipectomy:
1- Post operative (Surgical) problems.
2.Wound problems.
3. Obesity problems.

48. Management of Lipectomy:
1- Preoperative program:
a) Preoperative Evaluation:
-Postural evaluation.
-ROM of shoulder and hip regions.
-Vital capacity measurement.
-Muscular evaluation of the trunk.
-Chest expansion measurement.

49. b) Preoperative Orientation:
Details of the surgery.
Explanation of treatment rationale.

50. c) PreoperativeTreatment:
1. Coughing training.
2. Costal and diaphragmatic breathing exercises.
3. Postural and trunk exercises.
4. Bed transferring and positioning.
5. Stool exercises.

51. The MainTherapeutic Objectives of Postoperative
PhysicalTherapy:
1-To minimize incisional pain.
2-To maintain and improve pulmonary capacity and prevent postoperative
atelectasis by:
a) Improving diaphragmatic muscular strength and endurance
b) Improving chest mobility (Chest expansion)
3-To maintain and increase full normal range or shoulder and trunk regions.
4-To maintain good body posture and prevent postoperative problems.

52. PostoperativeTreatment:
1. Life Saving Modulation:
a) Breathing Exercise: (From long sitting)
-Diaphragmatic breathing.
-Self respiratory exercises
*By using belt.
*By using patient's hands.
-Respiratory exercises associated with extremities exercises.
-Breathing exercises with incentive spirometer exercises.
-Resisted breathing exercises.

54. Bilateral pattern
5 x 3-3Times
7 x 3--3Times
10×3--3Times
↓
Dose of exercises

55. 2. Postoperative pain control modalities:
1.TENS Application:
Ten minutes ofTENS could be applied Para incisional using high frequency and
low amplitude and it could be combined with breathing exercises.

57. 4. Postoperative Recovery Modalities
a) Stool Exercises (4th postoperative)
Unilateral arm swing.
Bilateral arm swing.
Unilateral shoulder rotation.
Internal and external rotation with elbow at side (elbow extension and or
elbow 90° flexion)
Head and neck exercises.

58. • b) Walking training exercises.
• Bed exercises.
• Walking to toilet (2 times daily)
• Walking forward (10 m distance)
• Walking back word (10 m distance)
• Cross walking.
• Circular walking.
• Walking up and down stairs (4 steps up + steps down).
• Walking exercises underwater

59. 5- Solving problems of obesity modalities.
1. Dieting protocols: (Very Low-Calorie diets) =VLCDs,VLCD is considered as
including reduction of composition by reduce alternation of the composition
by reduce fat and increase fiber.
2. Exercises approaches (Aerobic exercises)
Some researchers suggested that exercises alone walking or jogging for 30
min 5 days per week lead to lost more fat weight and more lean body mass
and index for obesity control.
3. Acupuncture therapy:
It is one of the most effective methods for treatment obesity.