Common Operations &

Physiotherapy

BY:- DR. GAGAN GUPTA (PT)

CONTENT

Introduction
Cholecystectomy
Colostomy
Gastrectomy
Hernias
Mastectomy
Nephrectomy
Prostatectomy

 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 ,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.

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 surgeon may use a Kochers incision, a right

paramedian or midline incision.

Provided that there are no postoperative
complications the patient usually makes a good
recovery.
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.
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 Ryles 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 gallbladder on the right side of the upper part of the
abdominal cavity.

 Emphasis must be placed on gaining good

expansion of the right lung and getting rid of any

secretions.
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.

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, Crohns 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.

COMPLICATIONS
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.

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.

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

splenectomy, provided the disease is localized.

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.
coughing will be inhibited by pain and the presence
of a Ryles tube.
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 patients hands and the
other round his back to give pressure, on the left
lower costal area.
The patient is likely to tire quickly and so the
treatment should be given for a short duration and
frequently.
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.

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.

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.

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.

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.

Types
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.

Nephrectomy
The kidney may be removed because of a malignant tumor

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.
There are various indications for this procedure, such as

renal cell carcinoma, a non-functioning kidney (which may

cause high blood pressure) and a congenitally small kidney
(in which the kidney is swelling, causing it to press on
nerves which can cause pain in unrelated areas such as the
back).

The surgery is performed with the patient under general

anesthesia. The surgeon makes an incision in the side of

the abdomen to reach the kidney. Depending on
circumstances, the incision can also be made midline. The
ureter and blood vessels are disconnected, and the kidney
is then removed. The surgery can be done as open surgery
, with one incision, or as a laparoscopic procedure, with
three or four small cuts in the abdominal and flank area.
Recently, this procedure is performed through a single
incision in the patient's belly-button. This advanced
technique is called as single port laparoscopy.

Complications
During the operation the lung cavity may be entered

and this is repaired during the procedure, but this

may create lung complications.
DVT or pulmonary embolism .
Wound infection.
Poor wound healing or weakness in the wound site
Urine infection: which is more likely if a catheter is
present.

Physiotherapy
To avoid respiratory complications, educate the

patient by giving pre operative breathing exercises,

thoracic mobility ex. And techniques of Huff and
Coughs followed by post op. ex.
Active ankle toe movement and limb elevation.
Wound care with use of massage, UVR, etc.
Bladder training for weak bladder.
Gentle active exercises for general conditioning.

Home advice
Recovery time after this operation varies but generally you
should feel improvements 2 -3 weeks after your operation.
During the first 2 -3 weeks you should not drive.
Avoid heavy lifting for 2-3 weeks
Exercise should be increased gradually. Start with short
walks and gentle exercise.
Getting back to work will depend on the type of job that you
do. Usually 2- 3 weeks off work are needed.
Drink plenty of fluids and pass urine regularly; this will help
to keep your remaining kidney healthy.
Sexual activity can resume 3 -4 weeks after your operation.