Abdominal surgery: pre- and post-operative care

1Definition

Abdominal surgery includes operations on the stomach, intestines, liver, gallbladder, pancreas, spleen, kidneys and abdominal wall, done open (laparotomy) or by keyhole surgery (laparoscopy). Post-operative pulmonary complications (PPCs) are lung problems after surgery, such as atelectasis and pneumonia, that delay recovery.

2Classification: incisions (3 marks in S16 and W16)

3Risk factors for lung complications

• Surgery: upper abdominal or thoracic site, open rather than laparoscopic, long operation, emergency surgery, nasogastric tube.
• Patient: older age, smoking, COPD or asthma, obesity, poor fitness, poor nutrition, heart failure, sleep apnoea, poor general health.

4Pathophysiology to impairments

1. General anaesthesia relaxes the diaphragm and reduces functional residual capacity; small airways at the lung bases close.
2. After surgery, wound pain stops deep breaths and coughing; the diaphragm works poorly for days after upper abdominal surgery.
3. Opioid painkillers and lying flat reduce breathing further; secretions are retained.
4. Result: atelectasis, low oxygen, and later pneumonia.
5. Bed rest adds DVT risk, weakness and loss of fitness; abdominal muscles cut in the incision weaken trunk support.

5Clinical features after surgery

• Wound pain, shallow fast breathing, weak cough, reduced breath sounds at the bases, low SpO₂ if atelectasis.
• Drains, catheter, nasogastric tube, drips; nausea; bowel not working for a few days (ileus).
• Fatigue and weakness, especially after major cancer surgery.

6Investigations

• Pre-op: lung function in high-risk patients, fitness tests, haemoglobin, albumin.
• Post-op: chest X-ray (basal atelectasis, raised diaphragm, effusion), ABG or SpO₂, blood counts, inflammatory markers.

7Medical and surgical management

• Good pain control: epidural, wound catheters, regular analgesia.
• Enhanced recovery after surgery (ERAS): pre-op education, short fasting, minimal drains, early eating, early mobilisation on the day of surgery or day 1, early removal of tubes.
• DVT prophylaxis, antibiotics, nutrition.
• Gastrectomy (S16): removal of part or all of the stomach (often for cancer) through an upper midline or rooftop incision: high risk of lung complications; small frequent meals afterwards.

8Complications and prevention (7 marks in S22)

9PT assessment

• Pre-op: type and site of surgery, risk factors (smoking, lung disease, obesity, fitness), breathing pattern, cough, baseline mobility.
• Post-op: chart (operation, incision, drains, analgesia), pain on coughing, breathing rate, SpO₂, chest expansion, auscultation, sputum, bed mobility, sitting and walking ability.
• Outcome measures: incidence of chest complications, SpO₂ on air, walking distance, time to independent mobility, length of stay.

10PT diagnosis by ICF

Practice case built from past questions (not a single paper): a 58-year-old smoker, day 1 after open partial gastrectomy for cancer through an upper midline incision.

• Impairments: incisional pain, shallow breathing and reduced lung bases (atelectasis risk), weak cough with sputum, fatigue, weakness, DVT risk.
• Activity limitations: bed mobility, sitting up, walking, self-care.
• Participation: work and family roles suspended during recovery and any chemotherapy.
• Environmental factors: drains and tubes (barrier), ERAS ward routine and family support (facilitators).
• Personal factors: smoking, age, anxiety about cancer.

11Problem list and goals

• Short-term (days): no chest complications; effective supported cough; sitting out on day 1; walking in the ward on day 1–2.
• Long-term (weeks): walking independently outdoors; back to daily activities; no hernia; return to work as advised.

12PT management

Pre-operative physiotherapy (7 marks in W16 and W20)

• Assessment to find high-risk patients.
• Education: what will happen after surgery, why breathing and early walking matter, pain relief.
• Teach and practise: deep breathing with a 3–5 second hold, ACBT, supported cough (hands or pillow over the wound), log-roll bed mobility, ankle pumps, getting up from bed.
• Prehabilitation for high-risk patients: aerobic and strength training, and inspiratory muscle training, for a few weeks before surgery.
• Stop smoking as early as possible.

Rationale of pre-operative goals (3 marks in W21)

Post-operative physiotherapy

Principles of physiotherapy after abdominal surgery (7 marks in W25)

1. Control pain first: treat when analgesia is working; support the wound with a pillow or hands for breathing, coughing and moving.
2. Restore lung volume: upright positions, deep breathing with a hold, early walking.
3. Clear secretions: ACBT and supported huff and cough when sputum is present.
4. Mobilise early: sit out of bed on the day of surgery or the next day, then walk several times a day (the basis of enhanced recovery programmes).
5. Prevent circulatory problems: ankle pumps and walking against DVT; check for calf pain and swelling.
6. Protect the wound: log-roll to get up; no heavy lifting or sit-ups for about 6 weeks, or as the surgeon advises.
7. Restore posture and trunk movement: patients bend forward to protect the wound, so correct posture and add gentle trunk and core exercise, progressed after about 6 weeks.
8. Watch for complications: fever, low SpO₂, breathlessness, wound leakage, abdominal swelling; report them.
9. Educate and plan discharge: home walking programme, safe lifting, return to work.

Exploratory laparotomy (7 marks in W21 and S23)

A long vertical midline incision, often an emergency for peritonitis (perforation), obstruction, trauma or abdominal bleeding. These patients are often sicker than planned-surgery patients: sepsis, ICU stay, nasogastric tube, several drains, urinary catheter, sometimes a stoma, and a swollen abdomen (ileus) that pushes the diaphragm up. The lung complication risk is high.

• If in ICU or ventilated: positioning, airway clearance, suction and early mobilisation as on the ICU physiotherapy card.
• On the ward: sit upright; deep breathing with a hold, 5–10 every hour while awake; ACBT and huffing with a pillow pressed over the wound; ankle pumps; log-roll to sit; sit out and walk from day 1 if stable, managing tubes and drains.
• Wound protection: the long midline wound has a real risk of opening (dehiscence) and of a later incisional hernia: support it when coughing, no straining or heavy lifting, abdominal binder if the surgeon uses one.
• With a stoma: support the stoma with a hand or pillow when coughing; gentle core work later, to lower the risk of a hernia around the stoma.
• Later: graded walking and endurance, posture, gradual core strengthening, return to work.

Day 2 after cholecystectomy: rationale and procedure (7 marks in S24)

13Precautions

• Always support the wound during coughing and moving.
• Check drains, catheter and lines before moving; keep bags below the wound.
• Epidural: check leg strength and BP before standing.
• Watch for postural hypotension, bleeding, sudden breathlessness (PE).
• No heavy lifting or strong abdominal exercises for about 6 weeks.
• No percussion near fresh abdominal wounds and drains.

14Education and home programme

• Keep walking every day; increase gradually.
• Support the wound with a pillow when coughing or laughing.
• Get out of bed by rolling onto your side first.
• Avoid lifting heavy objects (such as water buckets or gas cylinders) for about 6 weeks.
• Stop smoking; eat well for wound healing.
• Report fever, wound discharge, calf pain or sudden breathlessness.

15Prognosis

Most patients recover well with good pain control and early mobilisation. Lung complications lengthen hospital stay and can be largely prevented by pre-operative teaching and early activity.

16Exam corner

• 7-mark questionsPhysiotherapy after gastrectomy (S16). Importance of pre-operative chest physiotherapy in major abdominal surgery (W16, W20). Complications of abdominal surgery, and physiotherapy of DVT (S22). Physiotherapy after exploratory laparotomy (W21, S23). Rationale and procedure of physiotherapy on day 2 after cholecystectomy (S24). Principles of physiotherapy after abdominal surgery (W25).
• 3-mark questionsThree incisions in abdominal surgery (S16, W16, S26). Rationale of any three goals of pre-operative physiotherapy (W21).

Technique cards for this topic: breathing exercises, ACBT and autogenic drainage, bed rest, ICU physiotherapy.

Keywords to underline

upper abdominal incision post-operative pulmonary complications pre-operative education supported cough early mobilisation ERAS log-roll no heavy lifting 6 weeks

Draw these

• An abdomen outline with the incisions marked (midline, Kocher's, McBurney's, Pfannenstiel)