Physiotherapy Management After Exploratory Laparotomy (10 Marks) - PT CVTS

Introduction

Goals of Physiotherapy

1. Prevention of PPCs (atelectasis, pneumonia, hypoxemia)
2. Airway clearance and secretion removal
3. Restoration of lung volumes and function
4. Early mobilization and prevention of DVT / deconditioning
5. Pain management to enable participation in rehabilitation
6. Wound support and splinting education
7. Restoration of full functional activity

Phases of Physiotherapy Management

Phase 1 - Pre-operative (Prehabilitation)

• Patient education: Explain breathing exercises, coughing techniques, and early mobilization
• Chest assessment: Baseline respiratory function, breathing pattern
• Breathing exercises: Teach diaphragmatic breathing and deep breathing (DB&C) BEFORE surgery so the patient can perform them effectively post-op
• Incentive spirometry instruction: Patient taught correct technique
• DVT prophylaxis education: Ankle pumps, heel-toe raises

Phase 2 - Immediate Postoperative (ICU / HDU) - Day 0 to Day 2

• Vital signs (HR, RR, SpO2, BP, temperature)
• Pain level (VAS scale)
• Breath sounds, chest X-ray findings
• Sputum: character and quantity

• Early upright positioning in bed: Semi-recumbent (30-45°) or high side-lying
• Upright sitting in bed as soon as hemodynamically stable
• Regular position changes every 2 hours to prevent dependent atelectasis

• Diaphragmatic / Deep breathing exercises (DB&C): Patient seated upright, posterior pelvic tilt position; instructed to breathe in slowly and deeply through the nose, expanding the lower chest and abdomen, then exhale gently. 5-10 deep breaths every 1-2 hours.
• Thoracic expansion exercises: Expansion with lateral costal breathing
• Sustained maximal inspiration (SMI): Hold breath at peak inspiration for 2-3 seconds (air stacking)
• Incentive spirometry (IS): Flow or volume-based - reinforces deep breathing effort; 10 repetitions, 3-5x/day

• Supported / splinted coughing: Patient holds a pillow firmly over the incision with both hands while coughing - reduces pain and protects the wound
• Huffing (forced expiration technique - FET): Effective, less painful alternative to coughing; huff 1-2 times after a medium breath, then deep breath and repeat
• Active Cycle of Breathing Technique (ACBT): Breathing control → thoracic expansion exercises → forced expiration technique (FET); repeated in cycles until secretions clear
• Positive Expiratory Pressure (PEP) therapy: PEP mask/device to stent open airways and mobilize secretions
• Manual chest techniques (percussion, vibrations) if indicated for retained secretions

• Wound support / splinting: Teach patient to support incision during coughing, movement
• TENS (transcutaneous electrical nerve stimulation) for pain relief
• Cold therapy to wound area where appropriate
• Coordinate physiotherapy sessions with peak analgesia times (e.g., 30-60 mins after IV analgesia)

• Ankle pumps (dorsiflexion-plantarflexion), 10-20 reps/hour while in bed
• Heel-toe raises
• Knee bends in supine
• These should begin on Day 0 or Day 1

Phase 3 - Early Mobilization - Day 1 to Day 3

1. Dangling at edge of bed (sitting on edge)
2. Standing at bedside with support
3. Transfer to chair: Sit out of bed for increasing periods
4. Ambulation in the ward: Short distances initially (5-10 metres), progressing daily
5. Stair climbing before discharge (if home environment requires)

• HR should not exceed HRmax × 60% (RPE ≤ 13 on Borg scale)
• SpO2 should remain ≥ 90%
• Watch for symptoms: dizziness, chest pain, shortness of breath, cold sweating - stop immediately if these occur
• Re-assess vital signs after each mobilization session

• Improves functional residual capacity (FRC)
• Reduces atelectasis by improving ventilation-perfusion (V/Q) matching
• Reduces DVT risk
• Prevents muscle wasting and deconditioning
• Shortens hospital stay

Phase 4 - Progressive Rehabilitation - Day 3 onwards

• Progressive walking program: increase distance and pace each day
• Light limb exercises, trunk strengthening (avoiding heavy abdominal loading)
• Shoulder range of motion exercises (restricted by posture post-surgery)
• Postural correction (tendency towards forward flexion to guard wound)
• Continue breathing exercises until full lung expansion is confirmed
• Education on activity restrictions (no heavy lifting for 6 weeks)

Phase 5 - Discharge Planning and Home Program

• Written home exercise program: breathing, walking schedule, graduated activity
• Warn against heavy lifting (>2 kg) for 6 weeks post-surgery
• Advise return to work: typically 6-8 weeks for desk work; 12 weeks for heavy manual work
• Advise driving: 4-6 weeks post-surgery
• Red flags to report: increased breathlessness, fever, wound breakdown, calf pain/swelling (DVT)
• Outpatient physiotherapy referral if needed

Summary Table

Key Points to Remember (Exam Focus)

• Splinted coughing is the most important technique to teach post-laparotomy patients
• ACBT is the gold-standard airway clearance technique
• Early mobilization from Day 1 is evidence-based and reduces PPCs and hospital stay
• Diaphragm function is directly inhibited by pain post-laparotomy - managing pain allows better breathing
• Incentive spirometry does not replace deep breathing instruction but reinforces patient effort
• Physiotherapy sessions should be timed to coincide with peak analgesia
• The NZ Physiotherapy Abdominal Surgery guidelines and evidence from PMC confirm DB&C exercises improve respiratory function, and early mobility reduces hospital stay