Abdominal surgery

Establishing the need for a surgical intervention
Confirmation of relevant physical findings and review of the clinical history and laboratory investigations that support the need of surgical intervention

Type of approach- Benefits & Risks of surgical procedure
The incision site- ease of surgery as well as cosmetic considerations
Type of anesthesia

1. General Surgery Principles of Physiotherapy Management Dr.Nidhi Ahya (Assistant Professor) Cardio-Vascular And Respiratory PT DVVPF College Of Physiotherapy, Ahmednagar 414111

2. Contents General Surgical Principles Type of Anesthesia and effect on Cardio-pulmonary system Ideal incision Types of incision Common Post-operative Complications Role of Physiotherapy Pre and Post-operative Assessment & PT Management

3. Principles of General Surgery Establishing the need for a surgical intervention Confirmation of relevant physical findings and review of the clinical history and laboratory investigations that support the need of surgical intervention Type of approach- Benefits & Risks of surgical procedure T he incision site- ease of surgery as well as cosmetic considerations Type of anesthesia

4. Pre-operative Work-up Consent for surgery, Pre-anesthetic Check-up Peri -operative Considerations Length of the surgical procedure, volume of blood lost during surgery, monitoring of vitals, risk assessment and management uptill 72 hrs post-surgery Post-operative Management From 72 hrs post- opoeratively to uptill 30 days Incisional care and healing , management of risk factors, evaluation for success of surgical intervention for primary problem ,risk management

5. Types of Anesthesia General Anesthesia Refers to the suppression of activity in the central nervous system by inhalation of anesthetic agent causing lack of movement (paralysis), unconsciousness, and blunting of the stress response Regional Anesthesia Types- Infiltrative, Intravenous, peripheral nerve blockade, topical,local anesthesia,central nerve blockade ( spinal,epidural,caudal )

6. Ideal Incision The ideal incision characteristics: Easy to open Minimise damage to tissues Avoid cutting nerves Split rather than transect muscles Limit damage to fascia Easy to close Allow sufficiently strong closure Allow sufficient access Extendable if necessary Target organ Body habitus Previous operations

7. Classification of incisions Vertical incision Midline incisions Paramedian incisions Transverse and oblique incisions Kocher's subcostal Incision Mc Burney’s grid iron or muscle splitting incision. Pfannenstiel incision Maylard Transverse Muscle cutting Incision Oblique Muscle cutting incision Thoracoabdominal incisions.

8. Midline incision Upper Midline Incision From xiphoid to above umbilicus. Skin  superficial and deep fascia  linea alba  extraperitoneal fat  peritonium . Division of the peritoneum is best performed at the lower end of the incision, just above the umbilicus so that falciform ligament can be seen and avoided.

9. . Lower Midline Incision From the umbilicus superiorly to the pubic symphysis inferiorly. Allow access to pelvic organs. The peritoneum should be opened in the uppermost area to avoid possible injury to the bladder. Full Midline Incision From xiphoid to pubic symphysis inferiorly. Great exposure is needed .

10. Paramedian incision 2 to 5 cm lateral to the midline. Over the medial aspect of the rectus muscle. skin  fascia  anterior rectus sheath  The anterior rectus muscle is freed from the anterior sheath and retracted laterally    The posterior rectus sheath or transversalis fascia  extraperitoneal fat ,peritoneum excised allowing entry to the abdominal cavity .

11. Kocher’s incision Incision parallel to the right costal margin Starts at the midline, 2 to 5 cm below the xiphoid and extends downwards, outwards and parallel to and about 2.5 cm below the costal margin It shows excellent exposure to the gallbladder, biliary tract and can be made on the left side to show access to the spleen. .

12. Chevron (Roof Top) Modification The incision may be continued across the midline into a double Kocher incision or roof top approach which provide excellent access to the upper abdomen Used for: Total Gastrectomy. Total oesophagectomy. Extensive hepatic resections Bilateral adrenalectomy .

13. The Mercedes Benz Modification Consists of bilateral low Kocher’s incision with an upper midline incision up to the xiphisternum . Excellent access to the upper abdominal viscera. (mainly the diaphragmatic hiatuses) .

14. McBurney Grid -Iron Incision First described in 1894 by Charles McBurney Is the incision of choice For most Appendectomies. It is a muscle splitting incision Made at the junction of the middle third and outer thirds of a line running from the umbilicus to the anterior superior iliac spine .

15. P - fannenstiel incision Used frequently by gynecologists and urologists for access to the pelvic organs, bladder, prostate and for caesarean section. Usually 12 cm long and made in a skin fold approximately 5 cm above symphysis pubis. skin  fascia  anterior rectus sheath  rectus muscle  transversalis fascia  extraperitoneal fat  perineum. .

16. Maylard’s Incision It is a transverse muscle cutting incision It is placed above but parallel to the traditional placement of Pfannenstiel incision. Gives excellent exposure of the pelvic organs. .

17. Thoracoabdominal Incision Converts the pleural and peritoneal cavities into one common cavity  excellent exposure. Left incision  Resection of the lower end of the esophagus and proximal portion of the stomach. Right incision  elective and emergency hepatic resections. .

18. Post-Operative Complications Vascular Complications Respiratory Complications Haemorrhage Muscle Atrophy and Imbalance Poor Healing/gaping of incision Incisional Hernia

19. Vascular Complications Thrombosis or embolism Can occur at any time between the 3 rd to the 21 st post-operative day Thrombosis are mainly of toe types Thrombo -phlebitis Phlebothrombosis Phlebothrombosis is by far the most serious complication of operations on the pelvis

20. Thrombo-Phelbitis Damage to the vein wall caused by insertion of an interavenous drip Vein becomes irritant,inflamed and blood clots becomes adherent to vein wall If inflammation spreads to the surrounding tissue it may lead to cellulitis . Condition is self limiting, and resolves if irritant is removed

21. Phlebo -Thrombosis Formation of blood clot in the depper viens It is non- inflamatory , so rarely produces symptoms Lifethreating condition Common causes- slow blood flow in no.of platelets and their cohesiveness more fibrinogen reduced movement

22. Embolism A thrombus formed in a vessel wall,is attached to it only at the point of origin Fragments from this thrombus can become disloged , travel within the circulation and block the blood supply to vital organs Common sites- cerebral, pulmonary

23. Chest Complications Reduced Ventilation Poor Lung Expansion Reduced Vital Capacity Accumulation of secretions Poor ability to clear secreations Lung Collapse

24. Haemorrhage It can be Internal or External What to look out for? Soakage of dressing Low blood Pressure Feeble Pulse Incresed RR Restlessness Fainting

25. Muscle Atrophy and Imbalance Muscles are retracted,cut,split during surgery. Incision of the muscle reduces it bulk as well as power Damage to the nerve supply of the muscle can occur during surgery Reflex inhibition due to pain Protective inactivity of a muscle lead to atrophy Addhesion formation can restrict range of motion

26. Incisional Hernia Incision weakens the abdominal wall Inadequately placed sutures, poor apposition of the tissues during closure, excessive strain from coughing, lifting heavy weight can put strain on the weakened wall.

27. Delayed Healing Infection Surgical site Away from the site Sepsis Systemic Illness Poor post-surgical care

28. Physiotherapy Assessment & Management Pre-operative Post-operative

29. Need for Pre-operative Assessment Acquaintance with the patient and patient’s family To list out pre-operative complains and a brief history of presenting illness Known systemic illness and its impact on post-operative management To assess the risk of post-operative complications and take steps to limit the same To explain the post-operative physiotherapy regime To assure the patient of total support during post-operative period

30. Pre-Operative Management Teach the patient Ankle toe pumps and general mobility exercises Appropriate airway clearance techniques Incision Splinting, Huff-cuff Breathing Exercises Incentive Spirometry Bed Mobility Explain the benefits of early ambulation

31. Post-Operative Assessment Review of patients file- Anesthesia and Surgical notes Type of surgery Incision- area, muscles cut, split or retracted, length of incision, drain sites, closure (staples, clips, sutures),dressing type Duration of surgery Complications during surgery Post-operative recovery till day of reference Review of Nursing Care Chart Monitored vitals over time, Input-Output charting, Medications Investigations- Chest X-ray, ABG

32. Palpation Peripheral Pulses Chest Expansion Tactile fremitus Homan’s Sign Pedal edema Percussion Posterior Chest wall Auscultation Air entry B/l equal Presence of abnormal breath sounds

33. Post-operative Treatment DAY 1 Ankle toe Pumps 10 reps per hour Active/assisted Mobility exercises Supported long sitting in bed Breathing Exercises Airway clearance techniques Splinting Incision and huff-cuffs Incentive Spirometry * *Note: Only Inspiratory

34. DAY 2 Ankle toe Pumps 10 reps per hour Active Mobility exercises Sitting on edge of bed Breathing Exercises Airway clearance techniques Splinting Incision and huff-cuffs Supported Ambulation 20 meters Progression of Spirometry * *Note: Only Inspiratory

35. DAY 3 Ankle toe Pumps 10x 2 times daily Active Mobility exercises in sitting Breathing Exercises Airway clearance techniques Splinting Incision and huff-cuffs \ Ambulation upto 30 meters 3-4 times in a day Incentive Spirometry * *Note: Only Inspiratory

36. DAY 4 to 7 Independent bed mobility Active Mobility exercises in sitting Breathing Exercises Airway clearance techniques Splinting Incision in daily activities Independent Ambulation 3-4 times in a day, increase distance gradually Incentive Spirometry * *Note: Only Inspiratory

37. Home Exercise Program Independent Ambulation Active Mobility exercises Breathing Exercises Incentive Spirometry Inspiratory + Expiratory beyond 4 weeks Precautions: DON’T DO Forward bending Lifting heavy weight Vigorous coughing Side-lying on operated side

38. Summary General Surgical Principles Type of Anesthesia Ideal incision Types of incision Post-operative Complications Role of Physiotherapy

39. QUESTIONS WRITE THE GENERAL SURGICAL PRINCIPALS. 5MARKS WRITE ABOUT THE POST OPRATIVE COMPLICATIONS.7MARKS WRITE THE ROLE OF PHYSIOTHERAPIST. 7MARKS

40. Thank You…