Pphysiotherapy management in abdominal surgery.pptx

Physiotherapy

1. Thank you

2. Anatomy of the
Abdomen

Br

t AÑO

3. Surface anatomy of abdomen

1. Umbilicus

2. Xiphoid process

3. Lina emilunaris

4. Lina alba

5. Anterior superior iliac
spine (ASIS)

6. Inguinal ligament

7. Pubic symphysis

4. Quadrants of the abdomen

ㆍ Abdomen is divided either as four quadrants pattern or six

5. Planes used to estimate abdominal structures

ㆍ 1) midline plane

ㆍ 2)transumbilical plane 3 pa:
between the Intervertebral disk. (
IVD ) between L3-L4 vertebrae

・ 3)Subcostal plane : at the costal
cartilage of X rib .. And pass
through the body of L3 vertebrae

・ 4) transpyloric plane : at midline
between the jagular notch & pupi
symphysis .. Cross the costal margin
at rib IX...

・ 5) intertubercular plane : pass
through the tubercles of iliac crest,
it pass also through L4 vertebra ..

ㆍ 6)midclavicular plane E pass
through mid clavicle above and
between in the mid-point between
anterior superior iliac spine and
pupic symphysis

6. Abdominal quadrants

>Midline and transabdominal ・ Subcostal, intertubercular and 2
plane divided the abdomen into midclavicular planes divide the
4 quadrants ... abdomen into 9 quadrants

‘Subcoatal plane Midelevieuiar planes

| TEST |
> Transpÿioric paine may pe used

instead of subcostal plane !!

7. Nine-quadrants of abdomen

1. right & left hypochondrium (2)
2. epigastric (1)

3. right & left flank (2)

4. umbilicus (1)

5. right and left groin (2)

6. pubic (1)

8. Abdominal wall

Skin
Superficial fascia ( subcutaneous )
Muscles & associated deep fascia
Extraperitoneal fascia

Parietal peritoneum

Skin

‘Superficial fascia— ーー External oblique muscie
fatty layer
(Campers fascia) ita ya
¡Superficial tascia—
membranous la)

Transversus
(Scarpa's fascia)

abdominis muscie
Transversalls fascia

9. Superficial fascia of abdominal wall

On single layer above the umbilicus

and becomes 2 layers below it.

The two layers of superficial fascia

below umbilicus are :

1) camper's fascia :
hish date anne cial

igh over the inguinal
with fascia of perineum

nd contain
¡Cial Tascia of

igament and

In men, this fascia continue over the
enis, fuse with the deeper layer &
loss its fat and from a specialized

fascia contains a smooth muscles

called dartosa fascia

In women, this fascia is a
component of the labia majora

Campers
fascia

datrosa
fascia

10. Superficial fascia of abdominal wall
ㆍ 2) scrape's fascia :

- deep layer which is membranous
contains NO fat.

- Continous with thigh below inguinal
ligament and fuse with fascia lata (

- de SB thigh 62) superficial fascia (
camper's fascia ) on scrotum and penis

- oe3aWy in men penis, it will form
fundiform ligament of penis.

- In women, it is continuous with labia fascia
majora and perineum

11. Muscles of abdominal wall

・ Flat muscles muscles

・ Vertical muscles
*Enclosed by tendinous
aponeurosis formed by
the flat muscles

>
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External oblige
Internal oblique
Transverse abdominis

Rectus abdominus
Pyramidalis

12. Muscles of abdominal wal

Origin
External oblique Muscutar slips from the outer

surfaces of the lower eight
ribs (ribs V to X#)

internaloblique Thoracolumbar fascia; ilisc
est between origins of
external and transversus;
lateral two-thirds of inguinal

ligament
Transversus Thoracolumbar fascia; medial
abdominis lip of diac crest; lateral

‘one-third of inguinal
ligament; costal cartilages
lower six ribs (ribs Vil to Xu)

Rectus abdominis Pubic rest, pubic tubercle,
and pubic symphysis

Pyramidalis Front of pubis and pubic
symphysis

Insertion

Lateral Hp of iliac crest:
aponeurosis ending in
midline raphe (linea alba)

Inferior border of the
lower three or four ribs;
aponeurosis ending in
linea alba; pubic crest and
pectineal Ine
Aponeurosis ending in
linea alba; pubic crest and
pectineal ine

Costal cartilages of ribs V
to Vil; xiphoid process

Into linea alba

Innervation

Anterior rami of lower six
thoracic spinal nerves
(1710112

Anterior rami of lower six
thoracic spinal nerves
(17 to TI2)andLı

Anterior rami of lower six
thoracic spinal nerves
(17 10 T12 and Lt

Anterior rami of lower
seven thoracic spinal
nerves (T7 to T12)

Anterior ramus of T12

Function

Compress abdominal
contents: both muscles flex
trunk; each muscle bends
trunk to same side, tuning
anterior part of abdomen to
opposite side

‘Compress abdominal
contents; both muscles flex
trunk: each muscle bends
trunk and turns anterior part
of abdomen to same side

Compress abdominal
contents

Compress abdominal
contents; flex vertebral
column; tense abdominal wall

Tenses the linea alba

13. Muscles of abdominal wall

External Internal Transverse
oblique oblique abdominis

14. Abdominal wall muscles

・ 1) external oblique

- The most superficial one

- Immediately deep to superficial
fascia

- Fibers pass anterio-medially

- Large aponeurotic component
covers the anterior abdominal
wall (AAW)

15. Abdominal wall muscles

ㆍ 2) internal oblique
- Fibers pass superior-medial

- Aponeurotic part will bend with
linea alba as in external oblique.

ㆍ 3) transverse abdominis
- Taking its name from its fibers

- Aponeurotic part will blend with
linea alba

16. Transversalis fascia

* The very well developed deep
fascia, that lie underline the
transverse abdominis muscle.

・ It has a continuity with other
regions fascia like the perineum-
, PAW-, and diaphragm- related
fascia.

・ it has attachment to crest of hip
bone, then blend with fascia of

upper pelvic bone muscles and
pelvic cavity muscle.

17. Ligaments associated with the flat muscles of abdominal wall

ㆍ 1- Inguinal ligament
- Formed by the lower border of EO

- Pass between the ASIS and pubic
tubercle

- It folds on itself forming a trough
which will have an important role in
formation of inguinal canal

ㆍ 2- Lacunar ligament
- At the medial end of inguinal
ligament

- Pass backward to attached to pectin
ubis on superior ramus of pubic
one

ㆍ 3- Pectineal ligament ( of cooper's )

- fibers extend from the lacunar
pement along the pecten pubis of
the pelvic brim

18. Vertical muscles of abdominal wall

ㆍ 1) rectus abdominis

- 1 muscle on each side,
separated in midline by linea
alba

- 3 tendinous-intersections
divides the muscle transversely
…… SIX PACKS !!!

ㆍ 2) pyramidalis
- Traingular muscle

- Above RA
- Base on pubis while it is
attachemd medially and

superiorly to the linea alba
- Could be absent

19. Rectus sheath
+ The paired rectus abdominis muscles originate from the anterior
bony pubic bones toward the midline and run cephalad to insert
onto the xiphisternum and costal cartilages of ribs 5-7.

< They derive their blood supply from the superior and inferior
epigastric arteries from the internal thoracic and external iliac
arteries respectively, and their innervation from the anterior rami
of spinal nerve roots T7-T12.

Linea alba Rectus abdominis

~~ Panotal peritoneum

Transversus abdominis

External oblique

External oblique

intemal oblique

20. Rectus sheath

NO rectus sheath covers the posterior surface of the lower % of the
muscle. ( last end called the arcuate line )

Part of rectus sheath anterior to the muscle formed by aponeurosis
of both EO & IO , while the that posterior to the muscle is formed by
aponeurosis of both IO & TA.

In lower abdomen, when there is no rectus sheath posterior to the
muscle, al the aponeurosis will pass anteriorly.

Cross section of
rectus sheath

21. Important of the abdominal wall muscles

・ By their positioning, they form a firm, but flexible, wall that keeps
the abdominal viscera within the abdominal cavity, protects the
viscera from injury, and helps maintain the position of the viscera in
the erect posture against the action of gravity.

・ In addition, contraction of these muscles assists in both quiet and
forced expiration by pushing the viscera upward (which helps push
the relaxed diaphragm further into the thoracic cavity) and in
coughing and vomiting.

・ All these muscles are also involved in any action that increases
intraabdominal pressure, including parturition (childbirth) ,
micturition (urination), and defecation ( expulsion of feces from the
rectum) .

22. Peritoneum

ㆍ Serous membrane lined the
abdominal cavity

Superficial fascia

Fatty layer Membranous layer
(Campers) (Scarpa's)

・ Reflects on some organ
providing either complete or
partial covering

・ SO, there is :-

1. Parietal peritoneum

2. Visceral peritoneum

+ This membrane form a cavity
which is closed in men, but have
to openings in women (
semiclosed ) !!

23. Innervation of abdominal wall

・ The skin, muscles, and parietal
peritoneum of the anterolateral
abdominal wall are supplied by
T7 to T 12 and L1 spinal nerves.

・ Intercostal nerves T7-T12 pass
along the inferior margins of
respective ribs, between 10 & TA
muscles then pass deep to RA
muscle and pierce rectus sheath
at midline to supply skin

* subcostal nerve > T12

24. Innervation of abdominal wall

L1 branches also contribute to
supply of AAW including the ilio-
hypogastric & ilioinguinal nerves.

Nerves T7 to T9 supply the skin
from the xiphoid process to just
above the umbilicus.

T10 supplies the skin around the
umbilicus.

711,T12 , and L1 supply the skin
from just below the umbilicus to,
and including, the pubic region

Additionally, the ilio-inguinal nerve
la branch of L1 ) supplies the
anterior surface of the scrotum or
labia majora, and sends a small
cutaneous branch to the thigh.

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25. Arterial supply of abdominal wall
O At SUPERFICIAL level = で
1- musclophrenic artery

- Terminal branch of internal
thoracic artery ( branch of
subclavian a. )

2- superficial epigastric artery
- Branch of femoral a.

3- superficial circumflex iliac
artery
- Branch of femoral a.

26. Arterial supply of abdominal wall

O At DEEP level

1- superior epigastric artery

- Terminal branch of internal thoracic
artery ( from subclavian a. )

- Enter rectus sheath and pass below
TA

2- 10th, 11th, and subcostal arteries
3- inferior epigastric artery

- Branch of external iliac artery
- Enter rectus sheath and pass below

4- deep circumflex iliac artery
- Branch of external iliac artery

27. venous & lymphatic drainage of abdominal wall

> Venous drainage
・ Venous drainage is follow the
arteries

> lymphatic drainage
1) Superficial
a. Above umbilicus > axillary LN

b. Below umbilicus > superficial
inguinal LN

2) Deep / follow main arteries
a. Parasternal LN

b. Lumbar LN

c. External iliac LN

28. ABDOMINAL SURGERY

Abdominal surgery involves a surgical repair resection and
reconstruction of organ inside the abdominal cavity.It may
involve surgery of gall bladdar,small
intestine,largeintestine,liver,pancreas,spleen,oesophagus,and
appendix.
Abdominal surgeries can be performed by

1. open approach

2.keyhole approach
OPEN APPROACH - traditionally the surgeons operate through
an incision given over the abdominal wall or laparotomy which
is subsequently closed with sutures

KEYHOLE APPROACH — in recent advancements most surgeons
prefer to use the minimally invasive keyhole approach known as
laproscopy . During laproscopy several small incisions are made
to access with the help of laproscope

29. ABDOMINAL INCISIONS

A well planned surgical incision is one of the most crutial step in any
surgical procedure . It is always essential to determine the proper
location of the incision for optimum visualisation and to always keep in
mind anatomy, blood supply that may suffer compromise . Exact
placement and size of the incision utilised are also crutial for aesthetical
reason.In doing so ‚three essentials should be achieved :

1. Accessibility

2.Extensibility

3.Security
Ideally the incision is made in the direction of the line of clevage in the
skin i.e langer’s lines these lines are parallel to natural orientation of
the collagen fibres in the dermis as well as the underlying muscle fibres .
If the incision is made in the direction of langer lines they tends to heal
better and produce less scarring than those cross them.

30. ANTERIOR POSTERIOR

31. CHOICE OF INCISION
The choice of incision depends on :
1. the type of surgery
2.the organ to be exposed
3.build of the patient
4.The presence of previous abdominal incision
5.The experience and preference of surgeon

TYPES OF INCISION
1.Vertical incision
2.Thoracoabdominal incision
3.Transverse incision

32. VERTICAL INCISION

1. Midline incision
2. Paramedian incision
1.MIDLINE INCISION
It is the most common incision
INDICATIONS:
1. laprotomy
2. vagotomy
3.operation of pancreas, stomach,gall bladdar
4.peptic ulcer

33. OPENING : skin followed by subcutaneous fat linea
alba and than peritoneum

CLOSURE: peritoneum than linea alba fat layer and
than skin

TYPES OF MIDLINE INCISION

1. Supra umbilical : also known as upper midline
incision

It is the incision from the xiphoid to above umblicus
Rectus muscle is not usually encountered

It is used in case of dealing with organs such as
stomach liver pancreas duodenum gall bladdar spleen

34. 2.INFRA UMBILICAL : it is the incision from the umblicus
superiorly to pubic symphysis inferiorly

Incision divide rectus sheath and linea alba and peritoneum
should be opened in upper area to avoid injury to bladdar

It allows access to pelvic organs ,colon ,small intestine

3.FULL MIDLINE INCISION : it is the incision from xiphoid to
pubis .it is used when great exposure is needed

ADVANTAGES
equal exposure on both sides of abdomen
Less amount of blood loss due to avascularity of linea alba
No muscle fibre are divided
No nerve are injured
It is very quick to open as well as to close
It can be extended up and down
Easy to deal with pathology on both sides

NO) Ge SRE

35. DISADVANTAGES
1.More painful
2.Ugly scar
3.Post operative incisional hernia because linea alba is
avascular so is the weakest area of abdomen and as
no rectus sheath and muscle for support of abdominal
viscera
4.Lateral organs cannot be approached
5.Poor healing

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37. 2.PARAMEDIAN INCISION

It is the incision 2-5 cm lateral to the midline
OPENING : skin>fascia ant rectus sheath the ant rectus
muscle is freed from the anterior sheath and retracted
laterally to save vessels and nerves> the post rectus sheath or
transversalis fascia> extraperitoneal fat and peritoneum are
excised to allow entry into abdominal cavity
TYPES:
1.Right upper paramedian

indications-operation of gall bladdar and common bile duct
,in gastrectomy and enterectomy , operation of head of
pancreas
2.Right lower paramedian

indications —terminal ileum operation;proximal colon
3.Left upper paramedian

indications —splenectomy ,gastrectomy
4left lower paramedian

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39. ADVANTAGES
1. provides access to lateral structures such as spleen or
kidney
2. Less chance of incisional hernia because rectus
muscle acts as support

3. Better exposure
DISADVANTAGES
1.takes longer time to close and open

2.lt tends to weak and strip off the muscles from its
lateral vasculature and nerve supply resulting in
atrophy of muscle medial to incision

3.Possibility of extending the incision superiorly are
limited by costal margins

4.Does’nt give access to contralateral structure
5.Risk of epigastric vessel injury is there

40. THORACOABDOMIINAL INCISION

elt is the unique incision that connects the pleural
cavity and peritoneal cavity so excellent exposure is
there.It is used to expose thorax and abdominal
structure.

«Upper midline,upperparamidline,or upper oblique
incision is easily extended into either left or right
chest for better exposure (along the line of 8th
intercostal space)

*Right incision is used in hepatic resection and right
kidney

-Left incision is used in resection of lower oesophagus
and proximal portion of stomach

41. PROCEDURE

1.The patient is placed in corkscrew position i.e abdomen
tilted 45degree and thorax twisted into lateral position.
2.Vertical incision through abdomen is made which is
extended into the 8 中 intercostal space for abdominal and
pleural exposure

3.The incision will disrupt the rectus abdominis and
oblique muscles if places lateral and transversus
abdominis in abdomen and lattismus dorsi ,serratus
anterior and external oblique and intercostal muscle
resection exposes the pleural cavity

4. Once the thoracic cavity is enterd the lung is deflated
the two incision should meet at a sharp angle for clean
exposure

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44. TRANSVERSE AND OBLIQUE INCISIONS
ADVANTAGES :

offer excellent exposure to the upper Abdominal organs .
Cosmetically better .

Stronger than vertical incision .

Less painful .

More advantageous in children because of transverse length of
abdomen .

DISADVANTAGES :

provide limited exposure to the organs .

Accompanied by more blood loss.

More time consuming (Average : 13 min.) .

45. Transverse and oblique incisions are divided as:
1. Kocher subcostal incision |
2. Chevron incision
3. Mercedes Benz incision
4. Gridiron incision (right iliac
fossa muscle Split incision /
Mcburney incision )
. Lanz incision(Rockey Davis)

5
6. Rutherford-Marrison incision Domo And,
7. Pfannenstiel incision tee Oe

" Clique imcisions
9

. Maylard incision
. Transverse muscle dividing incision

46. KOCHER SUBCOSTAL INCISION :

Is a subcostal incision performed on the right side to the upper
abdomen.

INCISION LINE : started at midline ,2 to 5 cm below the xiphoid
process and extends downwards ,outwards and parallel to or about
25cm below the costal margin .

LAYERS OPENED :
Skin -> Subcutaneous fat -> anterior rectus
sheath (divided along the line of incision) ->
rectus abdominis muscle divided -> lateral ローー
abdominal muscles are split in an outward Division of rectus sheath
direction -> posterior rectus sheath divided and medial portion of the
-> peritoneum . lateral muscles

47. Use:

a) for open exposure of the
gall bladder and biliary tree .

b) for elective spleenectomy.

c) to give major exposure to
the upper abdomen.

There are two modification of kocher subcostal incision:
a) chevron incision
b) Mercedes - Benz modification

48. GRID IRON INCISION/ McBURNEY INCISION/ RIGHT

HAC FOSSA MUSCLE SPLIT INCISION
incision in which there is no postoperative weakness of abdominal
muscles because no muscles are cut across .

+ Skin incision is centered at Mcburney’s point , 2/3 of the distance
along a line which joins the umbilicus to the ASIS and is place at
right angles to this line.

+ Layers opened : Skin ->

Subcutaneous fat -> external
oblique ->Internal oblique->
transverseabdominis muscle ->^

Peritoneum .

49. + The muscles are held apart with retractors .

・ The retracted muscles slip back into place at the end of the
operation .

・ Use:
a) for appendicectomy .

1; Gridiron incision for appendicitis, at right angles to a line
joining the anterior superior iliac spine and umbilicus,
centred on McBurney's point. 网

50. LANZ INCISION/ ROCKEY DAVIS INCISION

*・ is similar to grid iron incision .

・ made at Mcburney point with the same anatomical layers but
the incision is a horizontal incision while grid iron is an
oblique incision .

・ Use: for open appendectomies.

1
\

51. RUTHERFORD-MARRISON INCISION

・ 15 an extension of Mcburney incision by division of oblique fossa.

・ lsan oblique muscle cutting incision.

・ Use: for right and left sided colonic resection caecostomy or
sigmoid colostomy .

Rutherford- 、 Mine
Morrison ~ — 때때

— Maytard
SS Ptannenstiel

52. PFANNENSTIEL INCISION

・ Aninfra umbilical transverse incision in the lower abdomen .

+ The incision is placed in the curving interspinous skin crease,
immediately inferior to the public hairline in the female .

+ Is usually 12 cm long and is approximately 5 cm above the public

symphysis. 1 |
。 Disadvantages: ee,

a) it is easy to damage the bladder . "us

b) limited exposure. EA

・ Advantages:
a) it leaves an almost imperceptible scar because it lies in a skin

crease and is abscured by pubic hairs.

53. ・ Layers opened: skin -> superficial fascia (superficial fatty layer
[ camper’s fascia ] and deeper fibrous layer [ scarpa’s fascia ] ) ->
anterior rectus sheath-> rectus muscle retracted laterally ->
Peritoneum.

1 Transverse division ofthe anterior rectus sheath, which isthen € The tech are retracted and the pertoneum opened, starting
Srded Wee of the adherent muscie, bug à

54. + Use:
a) elective open gynaecological surgeries .
b) elective caesarean section.
c) the retropubic approach to the prostate and the bladder neck.

55. MAYLARD INCISION / MACKENRODT INCISION

» Side of incision is above and parallel to the traditional
pfannenstiel incision .

・ The rectus fascia and rectus sheath are cut transversely and the
incision is extended as far as needed .
・ Use:
a) provide wider access to
the pelvic cavity .

b) for gynaecological surgeries.

56. TRANSVERSE MUSCLE DIVIDING INCISION
・ Done at the level above the umbilicus.
・ Layers opened : Skin -> Subcutaneous tissue -> oblique Muscles
( internal and external oblique muscles ) are partly cut and partly
split -> Transversus abdominis muscle is sit along the direction of
fibres -> rectus abdominis muscle
fibres are cut perpendicular to their
Direction -> peritoneum.
+ Uses:
a) preffered in newborns and
Infants because more abdominal
exposure will be gained .

57. LAPAROSCOPY

Surgery Performed Through Several tiny
"Keyhole Incisions". A fiber - optic
instrument is inserted through one of
the incisions to view the inside of the

Abdomen.Surgical Instruments are
Inserted through other incisions.

58. INDICATIONS

1.Cause of Chronic Abdominal Pain.
2.Cause of Female infertility.
3.Taking Biopsy Sample of
abdominal tissue.

4.Removal of Appendix and gall
Bladder or gallbladder stones.

5.In ectopic pregnancy removal of
the fetus from within the fallopian
tube.

59. 6.Removal if tumors/custs from ovary.
7.Taking Biopsy Sample of Abdominal
Tissue.

8.Surgery of The Urinary Bladder as
management of incontinence.

9.Removal of Parts of liver, spleen and
Adrenal Glands.

10.Complete Removal of Whole uterus
or ovary. (Hysterectomy/
Salpingectomy).

60. Preoperative Protocol

-Physical Exam
-Review Of medications

-Blood tests such as blood sugar.
Including pregnancy test, hemogram,
liver function test, electrolyte status.
-Urinalysis to rule out urinary tract
infection or diabetes.

-USG, CT or MRI of Abdomen

61. Description of Procedure

The surgeon cuts a small opening in the
abdomen. The location of this incision
varies depending on the procedure either
near the navel or in the lower abdomen for
pelvic conditions. A needle is inserted and
used to inject CO2 gas into the abdomen to
make abdominal cavity expand and makes
it easier to see the internal structures. The
surgeon then insert a long, thin tubular
instrunment(laproscope) thats light,
magnifies and projects image of the
internal organs onto a video screen.

62. If necessary, several other incisions may
be made in the abdomen through which
to insert instrunments that can take
Biopsies or perform various types of
surgery(such as repair or removal of
organ). After the laproscope and any
other tools are removed, the incisions
closed with stitches or clips and
covered with dressing.

63. Possible Complications

-Infection
-Gas embolism

-Excessive bleeding due to damage
to blood vessels sometimes require

Immediate open surgery for repair.
-Anaesthesia related problems.

64. Post Operative Care

The Patient Must:-
1.Avoid Heavy Lifting.

2.Do not drink carbonated beverages
for Two days.

3.Avoid Constipation.

65. Instructions Before Surgery

1.Inform surgeon immediately about any
Changes in patient health condition such as
fever or cold within 24 hours before the
scheduled surgery.

2.No food or drink allowed after midnight the
day before surgery.

3.No smoking or drinking 24 hours before the
surgery.

4.Patient must take only the medications
advised by the surgeon.

66. ctomy

SUBMITTED TO- DR. N.K MULTANI 2 Appendicectomy

SUBMITTED BY- GEETANJALI SAROYA 3. Hartmann's Procedure
ROLL NO.- 17341016 4. Anterior resection
B. P. T 4th YEAR 5, Whipple

6. Cesarean surgery
7. Splenectomy

8. Exp. Laprotomy
9. Cholecystectomy

67. Esophagus will be
connected directly to
your small intestine.

SLEEVE
GASTRECTOMY

Is the removal of up
to three-quarters of
stomach.

Usually left side of
the stomach is
removed.

Performed as a part
of weight loss surgery.

71. E GASTRECTOM Y
WEIGHT LOSS SURGERY

72. ・ Also k/a Apendicectomy.

+ Is a surgical procedure to remove Vermiform appendix.

・ Urgent and emergency procedure to treat complicated acute
appendicitis.

= May be perform laproscopically or as an open operation.

73. dd

74. Transverse

Colon 』
HARTMANN*S PROCEDURE 도 d 4
Ascending (Re Descending
Colon fi Y a Colon

Rectal stump |

remains in place Y

75. ANTERIOR RESECTION

Resection of the Rectum with Anastomosis

Cancer Cancer ang
ーー Tune Coton ana
poeta ds anus jones

76. After surgery

WHIPPLE | ed

to small intestine

PROCEDURE- \ met Gena /

~ 7
umor し
NR y à
Te... sa
> ancreas K …
\ SY 7 | | \
ㅣ | \
D | Remaining pancreas
【 0 r 1 1 a 0 smal
aa stomach atta intestine

| to small intestine

Small intestine

77. » Also k/a C-Section

ㆍ It is the surgical delivery of a baby by an incision through the
abdomen and uterus.

・ Is often id when a vaginal delivery would put the baby and
바이 at risk.

78. |

SPLENECTOMY
Aa

N
7 = | + Spleen

」

pA Laproscope |
—

79. abdomen with a large incision in order to visualise the

done to find the cause of problems( such as belly pain,
testing could not diagnose.

when an abdominal injury needs emergency medical care.

80. CHOLECYSTECTOMY A N

81. Laparoscopic Open lial Gallbladder Stone Removal
cholecystectomy cholecystectomy

82. Pre-operative Physiotherapy

83. Surgical prehabilitation

+ Surgical prehabilitation- The process of enhancing patients’ functional
capacity in anticipation of the physiological stress imposed by surgery.

Goals of pre-operative Physiotherapy

* Decrease postoperative complications

* Reduce healthcare utilization (e.g. hospital length of stay)
* Accelerate recovery (return to normal activities)

・ Motivate patients to adopt healthier lifestyles for good.

84. Pre-op Physiotherapy assessment

* Acquaintance with patient and patient’s family

To list out pre-operative complications and history of present illness
* Any systemic illness and its impact on the Post OP management

* Assess risk of Post OP complications

* To explain post operative physiotherapy regime

* To gain patient compliance

85. (a) Clinical notes reading

* Get detailed history of the patient.
* Obtain information about co-morbid conditions like asthma,
hypertension, obesity, etc.

+ Any other notes by physician/surgeon.

86. (b) Respiratory assessment

Barrel Chest* oliosis*

* Chest deformities- Kyphosis,
Kyphoscoliosis, pectus
excavatum, pectus carinatum,
Ps OMO ï ©

+ Breathing pattern- Normal rate
then measure inspiration and Se Pa y

expiration ratio.
* Abnormal breathing pattern-
> Pursed lip breathing @ | & $ D

> Tachypnoea, Bradypnoea

と Chyne-stokes breathing Physical Examination and Health Assessment, Table 18-3 Jarvis 2008
> Ataxic breathing

> Apneustic breathing

87. * Chest movements- New York Heart Association (NYHA)
> Symmetry of chest

movement ‘Symptoms
> Depth of respiration Vise eae
FA ee | Noliitaon on physical activi. Ordinary physical actly does not cause
undue fatigue, ion and dyspnea.
* Chest expansion- Both 1 eee jee ical acviy, Comfortable alrest Ordinary physical
observation and cabanas, pabitaion and dyspnea.
palpation IH Marked imiafon of physical activity Comfortable at rest Less than
* Orthopnoea- ordinary activity causes fatigue, palpitalion or dyspnea.
Breathlessness while IN Unable to carry on any physical activity without discomfort,
lying down Symptoms of heart fare at rest IH any physical actviy is undertaken,
* Dyspnoea- did ia

Breathlessness, graded
accordingly tn accecc the

88. EVENT. MERISINE RESPIRATORY PATTERNS & CAUSES

regent, Sisonganies with persan of apne "MMM Abnence of breatmng = - ーー =

89. (c) Circulatory assessment

+ Homan's sign- Used to test for DVT.
と In performing this test the patient will need to actively extend his
knee.
> Once the knee is extended the examiner raises the patient's straight
leg to 10 degrees, then passively and abruptly dorsiflexes the foot
and squeezes the calf with the other hand.

> Deep calf pain and tenderness may indicate presence of DVT.
> Care should be taken while performing this test.

* Peripheral oedema- Could indicate a problem in venous circulatory
system, lymphatic system or in the kidneys.

91. Pre-operative Physiotherapy management

(a) Patient education
+ Explain general plan of treatment
* Explain the importance of early ambulation after surgery

(b) Breathing exercise
* Diaphragmatic breathing
* Local expansion exercises

(c) Cough
* Teach coughing and huffing techniques for airway

92. 1. Stand, sit or lie down
comfortably in a quiet
place.

€

A Breathe in slowly through your
pose for Ihe seconds, Feel yout
stomach expand, Your chert should
remain sl

Jose your eyes and loosen any
tmwe maiciet Make sure to relax
your shoulders.

>

5. Breathe out slowly through
your rout for ove con fee!
you stomach move back

N

3 Place one hand on your upper
chest and another on your belly
beten

6 Repeat sep Land $
Cy mcreane the bme you
tale to breathe in and out

Four seconds in and four
second cut five second in and
five seconds out

93. (d) Arm exercises
* Short lever exercises
+ Long lever exercises

(e) Leg exercises
+ Ankle/toe movements
+ Ankle pump exercises
+ Static quadriceps and gluteus medie averriese

(f) Posture correction =2
・Advices
* Ergonomic advantages

94. Post operative physiotherapy

* Challenge
ㆍ Goalss
* Assessment
* Complications

95. Challenges

* Respiratory complications
* Reduced lung expansion

* Reduced ventilation

* Poor ability to clear secretions
* Accumulation of secretions
・ Lung collapse

* Vascular complications

* Thrombosis

* Thrombo-Phlebitis

* Phlebothrombosis

* Embolism

96. * Haemorrhage

+ Internal

+ External

* Reduced muscle strength

* Atrophy

+ Imbalance

* Incisonal hernia

* due to strain or inadequate suturing

97. Goals

. To prevent respiratory complications
. To improve circulatory component
‚To improve or maintain ROM

. To improve muscles strength

. Early mobilization

„Prevention of pressure sores

98. Assessment

* Surgery note reading

o Types of incision

o Type of anesthesia

o Any immediate complication/unwanted event

* Monitor vital signs

* Investigations: Chest X-Ray, ABG etc.
+ Understand the attachments/ lines
* Conscious/ orientation level

99. Physiotherapy Assessment

* Physiotherapy assessment occurs in the context of the patient condition, the
nature and type

* of the surgery, the ongoing medical plan, the patient's premorbid status and any
comorbidities

* impacting upon post-operative rehabilitation, Level of alertness, ability to follow
instructions

* and haemodynamic and respiratory stability will be carefully assessed before any
therapeutic

* intervention is considered, Consensus guidelines for physiotherapy assessment
and treatment

100. Respiratory assessment

* Breathing pattern

* Difficulty in coughing...??
* Auscultation

* Circulatory Assessment

* Homan's sign

* Oedema

* Peripheral pulse

101. * Posture and Mobility
* Kypho-scoliosis
* Bed mobility

* Pain Assessment
+ VAS / NPRS/ MPQ

102. Complications

Possible complications—

* Infection

* Gas embolism

* Excessive bleeding due to accidental damage to blood vessel

* Pain: the patient may experience soreness for a couple of days. A unique
postoperative

* pain may be experienced in the right shoulder related to pressure
entrapped from CO2.

* This pain may be relieved by lying down on the left side with right knee &
thigh drawn

* upto chest. Walking may also help by increasing the reabsorption of gas.

103. Post Operative Management

Goals:-

To prevent respiratory complications
To improve circulatory component
To improve or maintain ROM

To improve muscles strength

Early mobilization

Prevention of pressure sores

104. Post Operative PT management

Day 1
・ Ankle foot Pumps (10 Reps. Per hour)
ㆍ Active/ Assisted limb mobility exercises
・ Breathing exercises (in upright sitting/ long sitting in
bed)
o Diaphragmatic breathing
o Segmental expansion
+ Airway clearance Techniques
ㆍ Huffing/ coughing with incisional support (hand
support/ pillow support/ binder)
+ Incentive spirometry

105. Day 1

106. Day 2

Continue with Day 1 regime

Pelvic tilting

Knee rolling

Edge of bed sitting

Supported ambulation (according to patient tolerance/upto 20
meters)

Progression of incentive spirometry

Day 3

ㆍ

Continue with Day 2 regime

chair sitting

Supported ambulation (progression according to patient tolerance)
Increase frequency of ambulation (3-4 times a day)

Progression of incentive spirometry

107. Knee Rolling

108. Day 4 to 7

Continue with Day 3 regime

Gradually increase the frequency & distance
of ambulation Patients usually discharge from
the hospital after two weeks of surgery, once
the stitches have been removed. Some patient
takes longer times for recovery.

109. Electrotherapy in Pain management

Electrotherapy devices that help control both chronic and acute pain fall
into three categories: Interferential therapy, Microcurrents,
Transcutaneous Electric Nerve Stimulation.

Interferential Therapy: It works on the spinal gate of pain. In IFT two
different frequencies work together to stimulate large impulse nerve
fibers and interfere the transmission of pain message at spinal cord level
and block their transmission to brain. It also stimulates the
parasympathetic nerve fibers for increased blood flow.

Microcurrent Therapy: it thought to mimic the body’s own electrical
system.it uses subtle current to build upon naturally occurring impulses to
decrease pain.

Transcutaneous Electric Nerve Stimulation (TENS): it is most effective pain
modality. It works on two approaches: first, it target sensory nerves,
stimulating them to block pain signals and preventing their transmission
to brain. Second, it promotes production of endorphins. It's also a very
effective replacement for narcotic analgesics. In post operative conditions,
TENS may be applied continuously at the operative site, through surface
electrode on either side of suture line.

110. Electrotherapy in Fluid management

Excessive fluid known as oedema, is
detrimental to any healing process. It causing
swelling around the injured area and hinders
the circulation as well as resist the removal of
waste products. Electrotherapy uses IFT,
faradism under pressure to move the excess
fluid from the injured area back to the
circulation.

111. HOME EXERCISES PROGRAM

To improve the stamina
and strength of muscles.
It includes

+ core stability exercises

+ Strengthening exercises

112. + REGULAR SHORT WALK OF 5-10 ・AVOID HEAVY LIFTING
MINS.

+ REST DURING THE DAY "ABDOMINAL EXERCISES

113. ABDOMINAL EXERCISES
|. PELVIC TILTING

-Help to prevent back pain

OAs you breathe out, gently tighten your abdominal muscles in
oGently tilt the pelvic and flattened the back into the bed

oHold for 3sec and gently release

oRepeat for 5 times

114. 2. KNEE ROLLING

TECHNIQUE
Keep knees together

Gently move knees down towards each side as far as comfortable
Repeat 5 times each day

115. WEEK 2 -5

"WALKING : INCREASE DISTANCE AS ABLE AND AS FEELS COMFORTABLE
“STILL NO HEAVY LIFTING

*CONTINUE WITH EXERCISES OF WEEK 1

"AND ADD “ABDOMINAL HOLLOWING IN 4POINT KEELING”

TECHNIQUE

oKneel on all 4 keeping your back straight
cGently tighten the muscles in the lower

part of your tummy without arching your back
hold for 5 sec and relax

¡Repeat for 10 times,3 times a day

116. WEEK 6

LOW IMPACT AEROBIC EXERCISES

“CYCLING

-ABDOMINAL EXERCISES

117. ABDOMINAL EXERCISES

1. ABDOMINAL CURL UPS
TECHNIQUE
Lie on back with knees bent and both feet on the floor
Place hand on each thigh

Lift your head and shoulder off the floor by sliding your hands along your thighs
towards knees

Slowly low your head and shoulders back to the floor.

e”.

118. 2. ABDOMINAL OBLIQUE CURL UPS

TECHNIQUE:

Lie on your back with your knees bent and both feet on the floor.

Place your right hand on the left thigh

Lift your head and right shoulder off the floor by sliding your right hand along
your left thigh.

Slowly lower your head and shoulder back to the floor.

Repeat this exercise on the other side by sliding left hand towards the right
knee

119. 3.BRIDGING

TECHNIQUE
Lie on your back with your knees bent and both feet on the floor.
Keeping knees together and arms by side , lift your bottom off the floor as
high as you can
Hold for few seconds and then lower yourself onto the floor.

120. WEEK 12

Normal activities.

Continue all of the above exercises until you feel
back to normal

This may take atleast 12 weeks

A

121. HOME ADVICE WITH DOs and DO'NTs
> DOs
+ Independent ambulation

+ Active mobility exercises (walking, cycling)
+ Breathing exercises

+ Incentive spirometry

122. »DOs.....

+ GOOD POSTURE
+ GETTING INTO AND OUT OF THE BED USING
‘LOG ROLLING TECHNIQUE’.

Stooped Correct
posture posture

123. > DO’NTS...

+ AVOID FORWARD BENDING.
+ SIDE LYING ON OPERATIVE SIDE.

+ LIFTING HEAVY WEIGHT:
+ Reduce lifting weight in first 6 weeks following surgery.
- When you do lift , do it correctly.

~ —

124. Thank you