Physiotherapy Management After Explorative Laparotomy

(For 10 Marks - PT CVTS)

Introduction

Why Physiotherapy is Needed - Patho-physiological Basis

1. Diaphragmatic dysfunction - Reflex inhibition of diaphragmatic contraction due to pain and surgical trauma reduces tidal volume.
2. Reduced FRC (Functional Residual Capacity) - FRC falls by 20-30% immediately post-op, leading to basilar atelectasis.
3. Mucociliary clearance impairment - General anesthesia suppresses ciliary activity, causing secretion retention.
4. Pain splinting - Patient avoids deep breathing due to incisional pain, worsening atelectasis.
5. Restricted mobility - Bed rest promotes DVT and further respiratory compromise.

Physiotherapy Goals

• Prevent and treat atelectasis
• Improve ventilation and oxygenation
• Facilitate secretion clearance
• Prevent DVT and pulmonary embolism
• Restore functional mobility
• Prevent wound complications (adhesions, reduced trunk mobility)

Physiotherapy Management - Phase Wise

A. Pre-operative Physiotherapy (Prehabilitation)

1. Patient education - Teach deep breathing exercises, supported coughing, use of incentive spirometry, importance of early mobilization
2. Inspiratory muscle training (IMT) - Reduces PPCs by up to 50% with NNT of 7 (using inspiratory threshold device for 1-2 weeks pre-op)
3. Smoking cessation counseling - Cessation ideally 4-8 weeks pre-op
4. Oral hygiene instruction - Reduces post-op pneumonia (tooth brushing + antigingivitis rinse)
5. Breathing exercises - Diaphragmatic and segmental breathing taught pre-operatively

B. Immediate Post-operative Phase (Day 0-2: ICU/HDU)

1. Positioning

• Semi-recumbent (30-45 degree head elevation) - Reduces aspiration risk, improves diaphragmatic excursion
• Frequent side-to-side turning every 2 hours to prevent gravitational atelectasis
• Avoid prolonged supine position

2. Breathing Exercises

• Diaphragmatic breathing - Patient places hands on abdomen; slow deep inspiration through nose, active exhalation
• Segmental breathing - Manual contact over hypoventilated zones to direct air flow
• Sustained maximal inspiration (SMI) - Patient takes maximal breath and holds for 2-3 seconds

3. Incentive Spirometry (IS)

• Patient inhales slowly through the device to raise the ball/piston to a target level
• 10 repetitions per session, 4-6 sessions/day
• Evidence: Deep breathing exercises and IS are equally effective in preventing atelectasis and pneumonia
• IS is incorporated into the I COUGH protocol (Murray & Nadel's, p. 827)

4. Supported / Assisted Coughing (Huffing)

• Essential for secretion clearance
• Wound support (splinting): Patient clasps hands or uses pillow firmly over incision during cough to reduce pain
• Huff coughing technique: Open-glottis forced exhalation - less traumatic to wound, equally effective in mobilizing secretions
• Manual assisted cough: Therapist applies firm upward pressure over upper abdomen during expiratory phase

5. Airway Clearance Techniques

• Active cycle of breathing technique (ACBT): Breathing control - thoracic expansion exercises - forced expiration technique (FET)
• Postural drainage: Modified positions (avoid head-down in acute abdominal surgery) to drain specific lung segments
• Percussion and vibration: Gentle chest wall percussion over involved segments to loosen secretions
• PEP (Positive Expiratory Pressure) therapy: Helps stent open airways, mobilize secretions

6. Non-invasive Ventilation Support

• CPAP (Continuous Positive Airway Pressure): Applied immediately post-extubation for high-risk patients; OR 0.37 for PPC reduction after major abdominal surgery
• IPPB (Intermittent Positive Pressure Breathing): Reserved for high-risk patients unable to cooperate with IS or deep breathing exercises
• BiPAP: For patients with pre-existing COPD or acute respiratory failure

C. Sub-acute Phase (Day 3-7: General Ward)

1. Progressive Mobilization (I COUGH Protocol)

• Sitting over the edge of bed (Day 1-2)
• Standing at bedside (Day 2-3)
• Ambulation in room and corridor (Day 3 onwards)
• Progressive increase in distance walked each day

2. Trunk Mobility and Core Stability Exercises

• Gentle trunk rotation and side bending to prevent adhesions
• Core muscle re-education (transversus abdominis activation)
• Scar tissue mobilization after wound healing

3. DVT Prophylaxis Exercises

• Ankle pumps - Dorsiflexion/plantarflexion (10 reps hourly while in bed)
• Knee extension and hip flexion - Maintain venous return
• Early ambulation is the single most effective DVT preventive measure
• TED stockings / compression devices - Applied by nursing, maintained during physio

4. Pain Management (Adjunct to Physio)

• Coordinate breathing and exercise sessions with analgesic peak (e.g., 30 minutes after IV opioid or after epidural top-up)
• Epidural analgesia allows deeper breathing and better cooperation with physiotherapy
• TENS (Transcutaneous Electrical Nerve Stimulation): May reduce incisional pain, improving participation in exercises

D. Recovery Phase (Week 2 onwards)

1. Progressive aerobic exercise - Walking program with gradual increase in distance and speed
2. Respiratory muscle strengthening - Continued IMT
3. Abdominal strengthening - Begin when wound is stable (6-8 weeks post-op: sit-ups, leg raises cautiously)
4. Postural correction - Patients tend to adopt a flexed posture to guard the incision; correct thoracic kyphosis
5. Functional activity retraining - Stair climbing, ADL retraining
6. Patient education - Return to work, activity restrictions, lifting limitations

Complications Physiotherapy Aims to Prevent

Enhanced Recovery After Surgery (ERAS) Protocol

• Pre-op prehabilitation and education
• Early extubation and mobilization
• Multimodal opioid-sparing analgesia enabling better physio participation
• Reduced PPCs, shorter hospital stay, faster return to function

Summary Points for 10-Mark Answer

1. Pre-op prehabilitation (IMT, education, smoking cessation)
2. Positioning (semi-recumbent, regular turns)
3. Breathing exercises (diaphragmatic, segmental, SMI)
4. Incentive spirometry (10 reps, 4-6x/day)
5. Supported coughing / huff coughing / manual assisted cough
6. ACBT, chest percussion, PEP therapy
7. CPAP/IPPB for high-risk patients
8. Early mobilization (I COUGH protocol)
9. DVT prophylaxis exercises
10. ERAS integration and phase-wise progression

Sources: Murray & Nadel's Textbook of Respiratory Medicine (p. 826-827); Fishman's Pulmonary Diseases and Disorders (p. 1825-1826); Miller's Anesthesia 10e (p. 1683)