Download posterior repair with perineoplasty

50119thStreet,TrusteeTowers FORTSANDERSWOMEN’SSPECIALISTS 1924PinnaclePointWay
Suite401,KnoxvilleTn37916 P#865-331-1122F#865-331-1976
Suite200,KnoxvilleTn37922
Dr.CurtisElam,M.D.,FACOG,AIMIS,Dr.DavidOwen,M.D.,FACOG,Dr.StevenPierceM.D.
Dr.DeanTurnerM.D.,FACOG,ASCCP,Dr.F.RobertMcKeownIII,M.D.,FACOG,AIMIS
Dr.BrookeFoulk,M.D.,FACOG,Dr.G.WaltonSmith,M.D.,FACOG,Dr.SusanRobertsonM.D.,FACOG
POSTERIORREPAIRWITHPERINEOPLASTY
Pleasereadandsignthefollowingconsentformwhenyoufeelthatyoucompletelyunderstandthesurgicalprocedurethatis
tobeperformedandafteryouhaveaskedallofyourquestions.Ifyouhaveanyfurtherquestionsorconcerns,pleasecontact
ourofficepriortoyourproceduresothatwemayclarifyanypertinentissues.
Definition:Posteriorrepairisasurgicalproceduretocorrectarectocele.Arectoceleoccurswhenthethinwalloftissue
that separates the rectum from the vagina weakens, allowing the rectum to bulge into the back wall of the vagina. A
posteriorrepairreturnstherectumbackintoitsnormalpositionandstrengthensthewallbetweentherectumandthe
vagina.Aperineoplastyisthereconstructionoftheopeningofthevagina(introitus)andtheareabetweentheanusand
the vagina (perineum). These procedures are performed completely through the vagina, no abdominal incisions are
made.
Procedure:Aftersedationfromgeneralanesthesiaisachieved;thesurgeonwillbeginbyplacingacatheterinthe
bladdertokeepitemptyduringtheprocedure.Anincisionisthenmadealongthebackwallofthevaginaanda
measuredportionoftheweakenedandstretchedvaginaltissue(thatcoverstherectum)isdissectedawayfromthe
rectalwall.Therectalbulgeisthenidentifiedandplacedbackintoitsnormalpositionandheldinplacewithdissolvable
sutures.Thestrongsupportivetissuesoneachsideofthepelvisarethenbroughtbacktothemidlineandsutured
together;thisrecreatesastrongmuscularwallbetweentherectumandthevagina.Lastly,aperineoplastyispreformed.
Theopeningofthevagina(introitus)andtheareabetweentheanusandthevagina(perineum)are
reconstructedbythesurgeon,muchlikeanepisiotomyrepairaftervaginalchildbirth.Thesurgeonmayremovesome
skinduringtheperineoplastytorestorethenormalstructureoftheexternalaspectofthevaginalopening.Sometimes
thesurgeonmayplaceagauzepackinthevaginatemporarilytoreducevaginalbleedingorbruising.
Diagnosis: The reason to have a posterior repair and perineoplasty is a Rectocele: the bulging of the rectum into the
back wall of the vagina, due to the weakening of the wall that separates the rectum and the vagina. Factors that
contributetothelossofnormalsupportbetweentherectumandthevaginaare:pregnancyandchildbirth,menopause,
chroniccoughing,obesity,chronicconstipation,yearsofstrenuousactivityorheavylifting,and/orothergynecological
orrectalsurgeries.Themostcommonsymptomsassociatedwitharectoceleare:constipation,difficultywithevacuation
during a bowel movement, the need to press against the vagina and/or space between the rectum and the vagina in
order to have a bowel movement, uncomfortable or painful sexual intercourse, and/or the sensation of pressure or
fullnessinthevagina.
ExpectationsofOutcome:APosteriorRepairandPerineoplastytypicallytakeapproximately60to90minutesto
complete.WhenyouawakefromsurgeryyoumayhaveanIV,bladdercatheter,andpossiblyavaginalpackinginplace.
Mostpatientswillgohomethesamedayassurgerywhileothersmayhaveadditionalsurgerieswiththeirposterior
repairandwillstayonenightinthehospital.Recoveryfromaposteriorrepairtypicallytakes4-6weeks;itisvery
importanttoabstainfromsexualintercourseandheavyliftinguntilreleasedbyyourdoctor.Followingtherecovery
fromaposteriorrepair,itisexpectedforpatientstohaveimprovementwithincompletebowelemptyingand/or
constipation.Itisalsoexpectedforpatientstohaverelieffromthevaginalpressure/fullnesssensationandintercourse
shouldbemorecomfortable.
PossibleComplicationsoftheProcedure:Allsurgicalprocedures,regardlessofcomplexityortime,canbeassociatedwith
unforeseenproblems.Theymaybeimmediateorevenquitedelayedinpresentation.Whilewehavediscussedtheseand
possiblyothersinyourconsultation,wewouldlikeyoutohavealistofsomespecificcomplicationssothatyoumayask
questionsifyouarestillconcerned.Asidefromanesthesiacomplications,alistofpossiblecomplications,wouldinclude,but
arenotlimitedto:
•OrganInjury:Duringanypartoftheprocedure,anyorganinthepelvis(intestine,bladder,uterus,ureter,rectum,
etc)canbeinadvertentlyinjured.ArectalorbowelInjuryismostlikelyinthistypeofsurgery.Itispossibletomakeaholein
thedeepertissueoftherectumorbowel.Inmostcasestheholecanberepairedandtherearenolong-termproblems.
However,ifasurgicalinjuryismajorortherepairiscomplicated,moreextensivesurgerymaybenecessary.Thismayprolong
thehospitalstayandrecoveryandmightalsonecessitateadditionalsurgicalproceduresinthefuture.
•Infections:AlthoughprophylacticantibioticsaregiventhroughyourIVpriortosurgery,postoperativeinfectionscan
stilloccur.Themostcommontypeofinfectionisabladderinfection(UTI).AUTIcancauseburningwithurination,increased
urinaryfrequency,bloodintheurine,pelvicorbackpain,feverandorchills.Aninfectioncanalsooccurintheincisionsinthe
vaginaand/orperineum.Ifaninfectionispresentthepatientmayhaveafevermorethan100degrees,increasingpaininthe
vagina/rectum,severeconstipation,andfoulsmellingorodorousvaginaldischarge.Theincisionalongtheperineummayalso
beredandwarmtotouchifaninfectionispresent.Pneumoniaisaninfectioninvolvingthelungs.Pneumoniamayoccurfrom
lackofdeepbreathingaftersurgeryduetopainfromtheincisionsites.Earlyambulationanddeepbreathinghelpstoreduce
theriskofpneumonia.Whilerare,sepsisisanotherinfectionthatcanoccur.Sepsisiswhentheinfectionentersthe
bloodstreamandcanmakeyouveryill.Sepsissymptomsusuallyinclude:fever,chills,weakness,nausea,vomitingandor
confusion.Ifanyoftheabovesymptomsofinfectionoccur,callouroffice.
•
•
RectalSpasm/pressure:TheLevatormusclesaretypicallypartoftheconnectivetissuethatissewnbacktogether
tostrengthenthewallbetweentherectumandthevagina.Themuscleshavecommonlybeenseparatedfor
sometimeandtheymayspasmduringtheweeksfollowingsurgeryastheygetusedtotheirnewposition.Your
painmedicationshouldhelp.Ifthespasmsaresevere,thencontacttheofficeduringregularhourstorequest
additionalmedicationstorelaxthemuscles.
Constipation:Itisveryimportanttoavoidbecomingconstipatedaftersurgery.Constipation,hardbowel
movements,orstrainingaftersurgerycoulddamagetherepair.Unfortunately;anesthesia,painmedications,
decreasedactivity,andpost-operativepaincanallcauseconstipation.Itisbesttostartfibersupplementspriorto
surgeryandmaintainthemaftersurgerytominimizetheriskofconstipation.Laxativesandstoolsoftenersare
alsooktotakeaftersurgery.
•VascularInjury:Anyofthevesselsinsidethepelvisareatpotentialriskforinjuryduringaposteriorrepair.
Inadvertentinjurytoabloodvesselcanoccurasinstrumentsareintroducedintothepelvis,duringtherepairofthevaginal
andrectaltissues,orfromelectricalinjurytothevesselwall.Anothertypeofvascularinjuryoccurswhenthesealedor
suturedvesselcomeslooseaftertheprocedurehasbeenfinished.Mostoftheseinjuriesarerecognizedandresolvedatthe
timeofsurgery.Majorvesselinjuryordelayedbleedingmayrequireadditionalsurgery,prolongedhospitalstayandrecovery,
readmissiontothehospital,andbloodtransfusion.
•BloodLoss/Transfusion:Thevaginalregionisvascular.Usuallythebloodlossinthisprocedureisminimal.Insome
casesbloodlosscanbesignificantenoughtonecessitateabloodtransfusion.Ifatransfusionisnecessary,thereisasmallrisk
ofbloodrelatedinfectionssuchasHepatitisorHIV.
•PainfulIntercourseandVaginalShortening:Afteraposteriorrepair,thedepthofthevaginamaybelessenedand
theanglechanged,causingsomewomentocomplainofpainordifficultywithintercourseaftersurgery.Thispainisusually
temporarybutmaybepermanent.Itispossiblefortheintroitus(openingofthevagina)tobecometootight,making
intercoursedifficultoruncomfortable.Vaginaldilatationorsurgerytoincreasethesizeoftheopeningmaybenecessary.Itis
extremelyimportanttonotresumeintercourse(vaginalpenetration)untilreleasedtodosobyyoursurgeon.Ifyouhave
suddenonsetofwateryorbloodydischargebeyondwhatalightsanitarypadwouldtakecareof,thencallouroffice.
•Hematoma:Whenasmallbloodvesselcontinuestobleedaftertheprocedureisover,theareaofcollectedbloodis
referredtoasahematoma.Thebodynormallyre-absorbsthiscollectionoverashortperiodoftimebutsurgicaldrainage
maybenecessary,however,thisisrare.
•ChronicPain:Withanyprocedure,apatientcandevelopchronicpaininanareathathasundergonesurgery.
Typically,thepaindisappearsovertime,althoughsomefeelingofnumbnessmaypersist.
•TreatmentFailure:Whileaposteriorrepairhasahighsuccessrate,thereisachancethattheprocedurecanfail
inthemonthsoryearstofollow.Prolapsecouldoccuragaininthefuture,inthesameordifferentpartofthevagina.
•DeepVeinThrombosis(DVT)/PulmonaryEmbolus(PE):Inanyoperation(especiallylongeroperations),youcan
developaclotinaveinofyourleg(DVT).Typically,thispresentstwotosevendayspostopaspain,swellingandtendernessto
touchinthelowerlegarea.Althoughlesslikely,thisbloodclotcanmovethroughtheveinsandblockoffpartofthelung(PE).
Thispresentsasshortnessofbreathandchestpain.Ifyounoticeanyofthesesigns,callouroffice.
•LowerExtremityWeakness/Numbness:Whilethisisrare,itispossiblethatduetothepositioningofyourlegsinthe
lithotomyposition(legsintheair/stirrup)foralongperiodoftimeordirectinjurytonervesbysurgicalinstruments,youmay
developweaknessornumbnessinyourlegs.Itisusuallyself-limited,withareturntobaseline.
•PermanentInjury/Death:Permanentinjuriesfromsurgeryarerarebutdooccur.Permanentinjuriesmayinvolve
removaloforgansnotplannedduringtheoriginalsurgery,painthatdoesnotresolvewithtime,ordiminishedabilitytoenjoy
life.DeathisextremelyrarefromGynecologicsurgerybutdoesoccur.Themostcommonreasonsaremassivebloodloss,
overwhelmingsepsis,heartattack,DVT/Pulmonaryembolus,stroke,andanesthesiacomplications.
AdditionalProcedures/Consultations:Ifthereareunanticipatedfindings,difficultyduringthesurgery,orasituationwhere
yourdoctordoesnotbelievethathehastheexpertisetoaccomplishallofyourcasethenanintra-operativeconsultationmay
benecessary.Intra-operativeconsultationiswhenanotherphysicianorsurgeonisaskedtogiverecommendations,assistor
takeoverasurgicalcase.Thisoccursatyourdoctor’sdiscretionforyoursafetyandwithoutregardtowhethertheother
physicianisonyourinsurancepanel.Bysigningbelowyougiveconsenttointra-operativeconsultationsifnecessary.
Consent:I,Dr._________________________,havecounseled___________________________________________regarding
herplannedsurgery.InmyprofessionalopinionIbelievethatthesurgeryisreasonableandmostlikelywillresultina
beneficialoutcome.Itismybeliefthatthepatienthasconsideredheroptionsandfullyweighedtherisksofsurgery.
Signed__________________________________________________Date____________________Time______________
I,____________________________________________________,believethatthesurgicalprocedurelistedaboveisthebest
optionforme.MysituationisnotanemergencyandIunderstandthatIhaveotheroptions,includingnothavingsurgery.I
understandthatcomplications,badoutcomes,andunanticipatedeventswilloccuroccasionallyduringsurgeryandrecovery.I
understandthatmydoctorandhissurgicalteamarenotperfectandatnopointhaveIbeenguaranteedanyoutcomesor
results.IhavebeengiventheopportunitytoaskallmyquestionsandIbelievethatIhavealltheinformationnecessaryto
makeareasonabledecision.Therefore,Ielecttogivemyconsentandproceedwiththeabovesurgery,aswitnessedbymy
signaturebelow.
PatientSignature___________________________________________________________Date_________________
WitnessSignature___________________________________________________________Date_________________