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Common Operations & Physiotherapy
Dr. Dibyendunarayan Bid [PT]Senior LecturerMPT, PGDSPTThe Sarvajanik College of Physiotherapy, Surat- 395003E-mail: [email protected]
2.1 Introduction
2.2 Cholecystectomy
2.3 Colostomy
2.4 Gastrectomy
2.5 Hernias
2.6 Mastectomy
2.7 Nephrectomy
2.8 Prostatectomy
2.1 Introduction
It is not proposed to deal at length with any specific operations but to give a
brief resume of operations commonly encountered by the physiotherapist,
together with particular points that should be noted. The basic principles of
preoperative and postoperative physiotherapy care should be applied to
patients undergoing surgical procedures not mentioned here if the patient is
at risk of developing pulmonary or circulatory complications. If the patient
is elderly he may require further physiotherapy in order to gain optimum
independence following surgery.
2.2 Cholecystectomy
This operation may be performed following the development of stones in the
gall-bladder and cystic duct (cholelithiasis). The stones cause attacks of colic
and jaundice and may obstruct the bile duct. If there is an acute attack of
cholecystitis the surgeon may treat the condition conservatively until the
inflammation has subsided and then operate. The pain experienced by the
patient may be very acute and cause considerable distress.
The surgeon may use a Kocher’s incision, a right paramedian or midline
incision. Following the removal of the gall-bladder a T-tube is inserted and
left for approximately 48 hours, or longer if necessary, to allow drainage of
any bile or blood into a bag. The amount of bile is measured to ascertain
whether any leakage is occurring. Provided that there are no postoperative
complications the patient usually makes a good recovery. Removal of the
gall-bladder does not require any special diet once the patient has recovered
from the operation. Complications that may occur after this operation are:
pulmonary, Haemorrhage, or leakage of bile.
Physiotherapy
The problem that is most likely to concern the physiotherapist is the risk of
pulmonary complications. Provided that the patient is not admitted for
emergency surgery it should be possible to assess the patient and decide on
the treatment required. The patient may be taught breathing exercises and
how to cough effectively. A careful explanation must be given to the patient
about the reasons for treatment and what will be expected of him after
surgery.
There are a number of factors that increase the likelihood of chest problems
after surgery. The actual surgical procedure is very close to the diaphragm,
and the irritation may cause the production of increased mucus secretions in
the lung. Postoperatively, deep breathing will be painful because of the
position of the incision and the presence of a drainage tube. Initially the
patient will have a Ryle’s tube which will make coughing difficult.
Atelectasis is most likely to occur in the lower lobe of the right lung because
of the position of the gall-bladder on the right side of the upper part of the
abdominal cavity. Analgesics given to relieve pain before treatment will
enable the physiotherapist to be more effective, although care must be
exercised in the amount of analgesic given as too much can depress the
cough reflex. Emphasis must be placed on gaining good expansion of the
right lung and getting rid of any secretions. As stressed in the last chapter,
the first 48 hours postoperatively are important in trying to prevent
pulmonary complications.
The physiotherapist should give the patient leg exercises and advice about
the amount of activity to try to prevent any circulatory problems. There is a
tendency for these patients to be overweight and if so they may not have
been very active before the operation which further increases the risk of
pulmonary and circulatory complications.
2.3 Colostomy
This is an artificial opening in the large bowel to divert the faeces to the
exterior where they are collected in a disposable, adhesive plastic bag.
Usually this procedure is carried out because of obstruction or disease of the
large intestine caused by diverticulitis, Crohn’s disease or carcinoma. The
colostomy may be temporary or permanent. A temporary colostomy is often
placed in relation to the transverse colon whereas a permanent one is usually
placed as far distally as possible.
There are a number of problems for a patient with a permanent colostomy.
Firstly, there is the worry about the success of the operation if it has been
carried out to remove a malignant tumor. Secondly, the patient will probably
be concerned about his ability to manage a colostomy, particularly if he is
elderly. Thirdly, the patient will be concerned about whether he can lead a
normal life, and once out of hospital may tend to shun social activities. The
patient must be helped to overcome these problems by all the members of
the team. In some hospitals there are nurses who have had special training in
dealing with colostomies, and they are known as stoma nurses or therapists.
Physiotherapy
As this operation Involves the lower part of the abdominal cavity and pelvis
there is an increased risk of a deep vein thrombosis developing
postoperative. The physiotherapist must teach the patient leg exercises
preoperatively and they should be continued for a couple of weeks
postoperatively. It may be considered that the patient is active enough when
he is up and walking but this activity may be minimal and it is wise to
encourage the patient to do a series of leg exercises before getting out of bed
and at regular intervals when sitting in a chair. It may be necessary to give
breathing exercises pre- and postoperatively if the physiotherapist has
assessed that the patient is at risk because of a chest condition, or because he
smokes, or because he is elderly and relatively inactive. Before the patient
leaves hospital he should be taught how to lift correctly and avoid excessive
strain on the abdominal muscles. The physiotherapist must help the patient
to appreciate that he will be able to undertake normal activities, both
physically and socially after he has recovered.
Ileostomy
This is similar to a colostomy except that the opening is in the right side of
the lower abdominal cavity. Usually it follows a more extensive resection of
the colon than a colostomy.
2.4 Gastrectomy
A partial gastrectomy for the treatment of gastric ulceration is a common
operation if healing does not occur following medical treatment. The
formation of ulcers usually occurs along the lesser curvature of the stomach
and if they do not heal they may undergo malignant changes. There are a
number of operations that may be used although the most common are the
Billroth and the Polya type. If there is a carcinoma of the stomach this may
be treated by a total gastrectomy, and sometimes splenectorry, provided the
disease is localized.
Duodenal ulcers are usually treated by a vagotomy, but if there is duodenal
and gastric ulceration the surgeon may perform a partial gastrectomy and
vagotomy.
Complications - Immediate postoperative complications may be a gastric or
duodenal fistula, gastric retention, haemorrhage or pulmonary problems.
Physiotherapy
As the operation is closely related to the diaphragm there is likely to be
irritation of adjacent tissues which could cause increased production of
mucus, particularly in the lower lobe of the left lung. The patient will be
reluctant to breathe deeply because
of pain. Similarly, coughing will be inhibited by pain and the presence of a
Ryle’s tube. So it is very important that the physiotherapist pays special
attention to the chest. Generally the patient may be treated preoperatively
with emphasis on deep breathing, particularly lower costal, and taught how
to cough effectively. Postoperatively the patient must be encouraged to do
the deep breathing with emphasis on the left lower costal area. Before
attempting to cough the patient should be helped to sit up in bed and lean
slightly forward as this makes it easier for him to cough. The patient places
his hands over the incision while the physiotherapist supports him in sitting
and places one hand over the patient’s hands and the other round his back to
give pressure, on the left lower costal area. Treatment to the chest should be
intensive, particularly if there is the slightest indication of a problem. The
patient is likely to tire quickly and so the treatment should be given for a
short duration and frequently. The nurses can remind the patient to do the
deep breathing after carrying out nursing procedures, and the patient must be
taught to practice on his own. The patient should do leg exercises to reduce
the risk of developing circulatory problems.
If the patient has been ill for some time before the operation the
physiotherapist may need to give general mobilizing and strengthening
exercises.
2.5 Hernias
A hernia is a protrusion of a viscus or part of a viscus through an abnormal
opening in the wall of the containing cavity.
Hiatal hernia
In this condition there is a weakness in the oesophageal opening of the
diaphragm and part of the stomach may pass upward into the thoracic cavity.
Treatment may be conservative but if this fails, surgery may be required.
The surgeon may use a thoracic or abdominal route, although the latter is
preferable as it may be necessary to investigate for other causes of
dyspepsia. There are various surgical procedures that can be used but the
main aim is to repair the hiatus.
Physiotherapy
This is similar to the treatment described for a gastrectomy as there is a risk
of pulmonary complications with operations in the- upper abdominal cavity.
Inguinal hernia
This may be indirect or direct and is a protrusion of a sac of peritoneum
containing omentum and possibly intestine through the inguinal canal. The
indirect hernia is usually congenital and passes through the length of the
canal whereas the direct hernia is medial and projects through a weakness in
the posterior wall of the canal. The latter usually occurs in middle-aged to
elderly men and often is associated with stress on the abdominal wall caused
by a chronic cough or strain on lifting. In infants with a congenital
abnormality a herniotomy with removal of the sac may be adequate.
However, in the adult more extensive surgery is preferable, unless the risk of
operation is too great because there are pulmonary or circulatory problems.
The operation performed is a herniorraphy which reduces the herniation and
repairs the weakness of the posterior wall.
Femoral hernia
These are more common in women and are a protrusion of the peritoneal sac
through the femoral ring. The increase of intra-abdominal pressure that
occurs in pregnancy may be a precipitating cause. Surgery is usually the
treatment of choice because of the risk of strangulation.
Strangulated hernia
This may require emergency surgery with resection of the gangrenous
section of the bowel.
Physiotherapy
For patients undergoing surgery for an inguinal hernia, pulmonary
complications may be a risk when there is a chronic chest condition, in
which case pre- and postoperative breathing exercises are important. The
surgeon may sometimes request physiotherapy to improve the condition of
the chest before he will operate.
A deep vein thrombosis is a possible complication after herniorraphy and so
exercises for the legs should be given before and after surgery.
These patients are likely to have weak abdominal muscles which should be
strengthened after surgery. A progressive scheme of exercises starting with
static contractions in the middle to inner range and following with free
active exercises should be implemented. Care should be taken not to go
beyond the ability of the individual patient and exercises in the outer range
of the abdominal muscles should be avoided. Patients should be instructed in
correct lifting techniques especially when the history indicates that lifting
might have been a precipitating cause in producing a rupture.
Patients undergoing surgery for a femoral hernia should have similar
physiotherapy. The risk of pulmonary complications is smaller but there
may be a greater risk of developing a deep vein thrombosis. Correct lifting
techniques should be taught so that the intra-abdominal pressure is not
abnormally high during lifting.
Umbilical hernias
These are more common in children although they can occur in older, obese
patients with weak abdominal muscles and possible weakness of tissues in
the umbilical region.
Incisional hernias
These may occur through previous operation scars, usually because of
infection at the site of operation, or poor healing which weakens the
incisional area. Surgery may be necessary if the hernia cannot be controlled
with a pad and abdominal belt as there may be a risk of strangulation.
2.6 Mastectomy
This entails removal of part or the whole of one breast for a malignant, or
sometimes benign, growth. This is the commonest site of carcinoma in
women, and if treatment is to be successful it is important to have early
diagnosis. Thus health education should aim to teach women to report any
lump in the breast to their doctor. Tests can then be carried out and if
treatment is required there is a greater chance of success before the disease
has spread. Some benign growths can be removed without removing the
whole breast and may not cause any disfiguration. Malignant tumours will
require more extensive surgery to remove the diseased tissue and there are a
number of operations that can be carried out. A simple mastectomy removes
the breast and if necessary may remove the axillary lymph nodes, whereas a
radical mastectomy removes breast, lymph nodes and pectoral muscles. The
latter is performed less often now as it did not give a greater success rate
than the less radical procedures and there was the problem of the patient
developing an edematous arm and stiff shoulder. Radiotherapy or
chemotherapy may be given after surgery.
Woman with radical mastectomy.
A pink highlighted area indicates tissue removed at mastectomy
B axillary lymph nodes: levels I
C axillary lymph nodes: levels II
D axillary lymph nodes: levels III
E supraclavicular lymph nodes
F internal mammary lymph nodes
This operation may cause severe emotional upset and the patient may be
very concerned about the disfigurement. All members of the surgical team
must be aware of these problems and try to help the patient through a
difficult time with understanding and advice. Good prosthetic devices are
available, and arrangements must be made for patients to be fitted with
suitable prostheses for their individual needs.
Physiotherapy
General pre- and postoperative care should be given to patients who are at
risk of developing complications. As the chest will be painful after surgery
the patient may be reluctant to breathe deeply or cough and if there is a
history of a chest problem or if the patient smokes she may require
treatment.
There is a danger of a stiff shoulder developing particularly with the more
extensive surgical procedures. The physiotherapist will discuss the
management with the surgeon as some surgeons prefer the arm not to be
abducted for the first few days because of the risk of developing a
haematoma. Hand and wrist movements should be carried out from the
beginning with shoulder shrugging and static contractions of deltoid. If a
radical mastectomy has been performed the physiotherapist may be
concerned with trying to prevent or treating oedema and mobilizing the
shoulder.
2.7 Nephrectomy
The kidney may be removed because of a malignant tumour or infection,
provided the remaining kidney is normal. The kidney lies in close proximity
to the diaphragm and so pulmonary complications following surgery are a
risk.
Physiotherapy
The emphasis should be on posterior basal and lower costal breathing,
concentrating on the side of the nephrectomy.
2.8 Prostatectomy
This is usually carried out for benign growths of the prostate which
commonly occur in elderly men. It is less commonly performed for
carcinoma because early diagnosis is difficult and the growth may have
spread too far. However, surgery may be required to relieve urinary
obstruction.
Physiotherapy
Pulmonary complications may occur because these patients are elderly and
may be relatively inactive. Also a number are likely to suffer from chronic
chest disease and so are at risk. In view of this, these patients should be
carefully assessed and treated if necessary. They are generally up within a
day or two after surgery but it is important to see they are sufficiently active
otherwise there is the risk of developing pulmonary complications.
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