 GENERAL SURGERY - PT

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
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
• The incision site- ease of surgery as well as
cosmetic considerations
• Type of anesthesia
 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
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)
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
Indications
 Trauma
 Infections
 Obstruction
 Benign Tumour
 Malignancy
 Stones
 Perforation
 Diagnosis
Investigations
 Blood Test
 Urine Test
 X-Rays
 Ultrasonography
 CT Scan
 Special Investigations like IVP
Pre op preparation
 Consent
 Nil by mouth
 Bath and shaving
 Enema
 Antibiotics
 Keep Blood ready
Anaesthesia
 General Anaesthesia
 Spinal Anaeshesia
 Epidural Anaesthesia
Anatomy
Anatomy
Anatomy
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.
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.
. 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.
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
abdo.minal cavity
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.
 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
.
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)

.
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

.
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.

.
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.

.
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.

.
 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 Kocher’s 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 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.
 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, 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.
 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 Ryle’s 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 patient’s 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.
Post-Operative Complications
 Vascular Complications
 Respiratory Complications
 Haemorrhage
 Muscle Atrophy and Imbalance
 Poor Healing/gaping of incision
 Incisional Hernia
Vascular
Complications
• Thrombosis or embolism
• Can occur at any time between the 3rd to
the 21st 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
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
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
Embolis
m
• 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
 Chest Complications
• Reduced Ventilation
• Poor Lung Expansion
• Reduced Vital Capacity
• Accumulation of secretions
• Poor ability to clear secreations
• Lung Collapse
Haemorrhag
e
• It can be Internal or External
• What to look out for?
 Soakage of dressing
 Low blood Pressure
 Feeble Pulse
 Incresed RR
 Restlessness
 Fainting
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
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.
Delayed
Healing
• Infection
 Surgical site
 Away from the site
• Sepsis
• Systemic Illness
• Poor post-surgical care
 Physiotherapy
 Assessment & Management
Pre-operative
 Post-operative
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
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
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
• 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
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
• 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
• 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
• 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
• 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
 Summary
• General Surgical Principles
• Type of Anesthesia
• Ideal incision
• Types of incision
• Post-operative Complications
• Role of Physiotherapy
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