This article presents a comparative analysis of the characteristics of methods of rehabilitation treatment in patients after gynecological laparotomy and laparoscopic surgery, in both the early and late postoperative periods of reconstructive treatment.

Currently, surgical treatment is regarded as a safe and effective therapeutic procedure, which ensures the rapid development of operative gynecology and increases the total number of operations [1,6]. But the problem of restorative treatment and rehabilitation in gynecology, especially after surgical treatment, is still urgent. It is connected with the fact that modern unfavorable ecological, economic, social, psychological situation is characteristic for gynecological patients due to various extragenital pathologies, decrease of adaptive possibilities of an organism, emotional lability, unbalanced nutrition, hypodynamia [1,2,4,5]. 

In recent years, in gynecological practice, for the prevention of postoperative complications and medical rehabilitation, rather effective drug therapy is used. In addition, non-pharmacological methods of rehabilitation are increasingly being used - a variety of natural factors, widely used physical therapy methods, various means of physical rehabilitation: physical therapy, massage, physiotherapy, api - and phytotherapy [1,4,5].

A large number of gynecological surgeries performed in recent years in Ukraine requires the development of new, adapted complexes of recovery after their conduct [1,2,4]. The introduction of new laparoscopic surgical techniques into surgical practice has changed the tactics and scope of rehabilitation measures, both in the early and late postoperative periods in gynecological patients [1,2,6].

When writing this article, the author used the method of literary analysis of thematic articles and methodological guidelines and recommendations, on the issue under study.

The purpose of this article is to present a number of methods and means of rehabilitation and restorative treatment, in the early and late postoperative periods, after gynecological operations performed by both laparotomy and laparoscopy.

Modern operative gynecology is a good anesthesia support, perfect surgical technique, new technologies (microsurgery, surgical laparoscopy). However, in modern unfavorable ecological and socio-psychological environment, the presence of negative pre-morbid background of many women can have a negative influence on the postoperative period. For the complete recovery of the patient a special restorative treatment aimed at the prevention of postoperative complications, relapse prevention and elimination of functional disorders caused by the underlying pathological process is necessary [1,2,4].  

Rehabilitation of women after surgical gynecological treatment is a rather complicated process in gynecological practice. The postoperative period in gynecology, besides the direct technique of the surgery and the character of the healing processes, is particularly affected by the psycho-emotional stress suffered by the patient both before and during the surgery. This plays an important role later on, having a direct impact on the normal functioning of hormonal and, consequently, reproductive functions of the female body [1,2,4,5].

According to a number of researchers in the field of physical rehabilitation in gynecology, it is shown that in the pre- and postoperative periods it is necessary to actively use physical therapy and therapeutic exercises and massage, as well as various complexes of special exercises to prevent and eliminate postoperative complications, relapse prevention, elimination of functional disorders caused by the main pathological process and the existing concomitant pathology [1,2,4].

I would like to touch on another important aspect. There is, in my opinion, a misconception among a number of physical rehabilitation specialists that only physical rehabilitation means can achieve full recovery of patients after their illnesses. This is by no means true! Rehabilitation of a patient should be comprehensive, and include both medical rehabilitation in the first place, and the methods and means offered by physical rehabilitation. In addition, it is important that the full course of rehabilitation of operated patients, including the process of medical and social rehabilitation. In the case of rehabilitation of patients after gynecological operations, especially removal of reproductive organs, it is difficult to talk about complete restoration of their reproductive function without using HRT (hormone replacement therapy), restoring (to an acceptable extent) the sexual function of women, restoring her social status as a wife and mother, as well as her professional rehabilitation and ability to work as an active member of society [1,4,5].

It is difficult to talk about a complete rehabilitation of a patient of reproductive age after a high-level laparoscopic surgery, if the patient has a negative psychological attitude, she is desperate to lose her ovaries, uterus, and therefore will not be able to have children anymore! Yes, she was spared the pathology that threatened her life and health. But no amount of surgery or physical rehabilitation, either together or separately, no matter how well they are used, can solve all of the patient's rehabilitation and socialization issues [4,5]. 

Does this mean that the role of methods and means of restorative treatment and rehabilitation, in the postoperative period, is not significant enough? Of course not! In my opinion, the use of the arsenal of physical exercises and various physical activity methods is impossible without interaction between physical rehabilitation and the methods and means of medical and psychological rehabilitation. A specialist in rehabilitation treatment and rehabilitation needs medical knowledge and skills, knowledge of modern methods of diagnosis, treatment and prevention of diseases. He must be a good psychologist and work in collaboration with specialists in this field. Without these "three whales" of rehabilitation treatment - medical, physical and psychological rehabilitation, it is difficult to talk about the effectiveness of our patients' full recovery [4,5].

This problem directly relates to the issue of rehabilitation, in the postoperative period after gynecological surgery, and the timing of its implementation, both in the early and in the late postoperative period. The understanding of peculiarities of modern gynecological surgery techniques, using different types of endoscopic methods, laparoscopic techniques, the use of unconventional approaches in performing the surgery itself (vaginal access in hysterectomy, uterine artery embolization in uterine myoma) put the physical rehabilitation specialists before the question about an individual, differential approach to forming complex methods of rehabilitation treatment in the patients after gynecological surgery, both in the early and late postoperative periods. [1,4,6].

Modern surgical technologies have been widely implemented in Ukraine for many years. Nowadays, laparoscopic props and gynecological surgeries performed with their use are not a novelty in many city and district hospitals [6].

Nevertheless, abdominal (laparotomy) surgical interventions are still used in gynecological practice in our country for various reasons. And their percentage is rather high in Ukraine. According to various sources, they account for 65-70 % of all gynecological surgeries [6]. And if the methods and means of reconstructive treatment and rehabilitation after abdominal operations in surgery and gynecology are devoted a lot of studies, the available information on the application of reconstructive treatment and rehabilitation after endoscopic methods in gynecology in domestic and foreign literature is clearly insufficient [1,2,5].

Taking into account the technique of modern gynecological surgeries (laparoscopy, vaginal access), it becomes clear that their active introduction clearly changes the methodological approach to the creation of rehabilitation programs in female patients. First, these surgeries are less traumatic, they do not disturb the anatomy and topography of the small pelvis organs, they preserve most of the structures and organs in the small pelvis, and they are virtually bloodless. Methods and means of reconstructive treatment, active reconstructive treatment and active means of rehabilitation, can be applied already, in the early postoperative period.

Secondly, and very importantly, these operations, in comparison with laparotomy, practically do not affect abdominal and perineal muscles, vessels and nerve endings, other organs and tissues that are damaged and grossly disturbed during perineal resection. [6,7].

Thirdly, the length of stay of operated patients in gynecological hospitals is significantly reduced and the period of their rehabilitation, both in the early and in the late postoperative period, is significantly reduced.

Fourthly, after these operations there are practically no scars, scars and other damages on the skin, which is of aesthetic and cosmetologically importance for women. This is a weighty psychological argument for almost all operated patients [6,7].

Finally, a maximum percentage of women, in the shortest time possible, return to normal sexual life, work and their daily duties. [1,5,7]. This has a huge positive social and economic effect for the country! 

What do these benefits bring to the practice of physical rehabilitation after gynecological surgery, starting from the early postoperative period? In the first place, the moments of significant preoperative preparation come to the fore. If we exclude emergency gynecological surgeries performed by different techniques, then in case of elective surgical interventions, the rehabilitation specialist has enough time and opportunities to work with the patients. But in order to do this, a professional and collegial contact between treating physicians and rehabilitation specialists must be established at a sufficient level in the system of modern practical healthcare [1,4,7].

Before the surgery, both the patient and the rehabilitologist have plenty of time to get acquainted, to find common ground on how they can work together to restore health and its functions after the surgery. The rehabilitologist has a significant advantage, as he is equipped with important information after contact with the attending physician about the patient's condition, her premorbid background, the presence of contraindications to surgery, the proposed plan and technique of surgical intervention, type of anesthesia, possible risks and complications during the operation and in the postoperative period.

All this gives the rehabilitologist an opportunity to make the patient feel positive about the treatment process, to teach her elementary behavioral skills and a set of exercises, which she will do under his guidance both in the early and in the late postoperative period.

After the preliminary agreement with the attending physician, the rehabilitation therapist can work to create a positive psychological backdrop and positive attitude toward the operation and the entire subsequent rehabilitation period as part of the psychological preparation for the surgery. To do this he must pay attention to improving his medical knowledge and skills, consider the preliminary plan and scope of the future physical rehabilitation of the patient, taking into account her individual peculiarities.

If time allows and there is an opportunity, in the preoperative period the patient should be taught the basic techniques of breathing exercises, exercises for the upper and lower extremities, to demonstrate how to perform these physical exercises, to rehearse them with her. [1,2,7].

Such trainings have a positive psychological effect on the patient and distract her from her distressing thoughts about the future surgery and its possible consequences. Interaction with the nursing staff of the department in teaching the patient hygiene skills and postoperative care before surgery will contribute to the patient's early recovery and help significantly reduce both the possible postoperative complications and the patient's stay in the gynecological hospital [1,4,7].

A rehabilitologist, being aware of the method and technique of surgery, can plan in advance the terms and volume of the rehabilitation program at the hospital stage of the patient's recovery after surgery, in the early postoperative period. Thus, on average, the length of stay in the gynecological hospital after laparoscopic surgery and surgery performed vaginoscopically or vaginoscopically assisted can be from 2 to 4 days [1, 6, 7]. At the same time, after laparotomy-assisted gynecological surgery, provided there are no postoperative complications, the patient's stay in the gynecological hospital can be from 5-7 to 10 days [2,5,6].

All this dictates the peculiarities of compiling an individual, differentiated rehabilitation program for each operated patient, to whom this program will be offered [1,2,4,7].

What arsenal of methods and means of physical rehabilitation after gynecological surgeries does a specialist rehabilitator have today? Firstly, these are the means of physical rehabilitation, in the application of which the operated (by any method) woman herself takes an active part, being a direct performer of physical exercises. This includes various types and modifications of TPE (therapeutic physical education) and TG (therapeutic gymnastics).

In the postoperative period in gynecological patients special complexes of TPE and LG according to the method of D.N. At abekov and K.N. Pribilov, modified by F.A. Yunusov (1985) [1,4,5], a complex of exercises in isotonic and isometric mode according to Epifanov V.A. method (1989) [2,5], a complex of special exercises for muscles of the stomach and pelvic floor, by Vasilyeva V.E. method. E. Vasilieva [1,4], Kegel's special exercises [1,3,7], VUM-building exercises by the method of Muranivsky V.L. [2,5], fitness ball, aqua aerobics, aqua yoga, various yoga practices, fitness, Chinese breathing gymnastics [1,2,4].

 Secondly, these are physical methods in which the patient remains relatively passive, perceiving the therapeutic effects of numerous types of physical therapy, including balneotherapy and hydrotherapy, the effects of various currents, magnetic and inductive therapy, light therapy, the effects of numerous types of massage, including gynecological massage in its various modifications, various methods of reflex therapy [2,4,5].

Thirdly, these are numerous natural factors, which are especially actively used at the sanatorium treatment stage. These include mud therapy, ozokerit- and paraffin therapy, thalassotherapy, phyto- and aromatherapy, apitherapy, helio- and climatotherapist. [2,5,7].

And, of course, the stage of postoperative rehabilitation in many gynecological patients, especially in cases of removal of the uterus and/or ovary/ovary, becomes impossible without monitoring by a gynecologist, endocrinologist, with the prescription of HRT (hormone replacement therapy), antibacterial, anti-inflammatory and other types of medical and supportive treatment, considered as an important part of medical rehabilitation, which should have invaluable support, in using physical rehabilitation to preserve [2,4,7].

1. Patients undergoing surgical treatment of their gynecological pathology require the use of individual, differentiated physical rehabilitation programs, both in the preoperative and in the early and late postoperative periods of rehabilitation.
2. Patients after gynecological surgeries, especially when such important reproductive organs as the uterus and ovaries are removed, need comprehensive rehabilitation that includes both elements of medical rehabilitation and the use of a variety of comprehensive individual physical rehabilitation techniques.
3. Physical rehabilitation in operated patients should be staged and at least four stages, including work on the rehabilitation of the patient in the preoperative period, in the early and late postoperative periods (inpatient and outpatient stage) and, necessarily, the sanatorium stage of rehabilitation. 
4. Operated patients, in the period from 6 months to 1 year after the gynecological surgeries, must necessarily continue their rehabilitation process at the stage of sanatorium-resort treatment.
5. The methodology of using methods and means of physical rehabilitation after gynecological surgical interventions requires, at the present stage, revision of the available methods of rehabilitation, taking into account the techniques and methods of such operations.

The author is preparing other articles devoted to rehabilitation treatment and rehabilitation after gynecological surgical interventions for such pathologies as ectopic pregnancy, ovarian apoplexy, uterine myoma and hysterectomy.

The author of the article notes the absence of any kind of conflicts related to this article.