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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_________________