Common Operations & Physiotherapy

Dr. Dibyendunarayan Bid [PT]Senior LecturerMPT, PGDSPTThe Sarvajanik College of Physiotherapy, Surat- 395003E-mail: dnbid@yahoo.com

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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