PRE-OP NOTE: Surgical Risks/Benefits/Options have been fully discussed and Questions answered

 

• I have had a chance to ask all the questions on the surgery(ies) / procedure(s)

• I have requested and have been satisfied with the answers given.

• I understand what I am having done and the extent of the surgery(ies) / procedure(s) provided.

• I am aware that I am free to ask questions at any time. Contact information has been provided to me. I have no further questions at this time.

The benefits have been fully disclosed and I completely understand them. They include:

• Improved comfort
• Possibly less pain and discomfort

Pelvic surgery may also relieve:

• Abnormal bleeding / Heavy Bleeding
• Pressure / Heaviness / Fullness
• Other symptoms such as urinary and bowel dysfunction

• Improved comfort
• A more pleasing appearance
• Confidence in personal appearance

• Decreased Bleeding
• Decreased Irregular Bleeding
• Possible Decrease in Uterine Discomfort
• Analyze Endocervical and Endometrial tissues

• Decrease pain / discomfort
• Reduced Cyst pain / formation
• Remove / reduce adhesions or lesions

RISKS SPECIFIC TO GYNECOLOGIC SURGERY:
The risks have been fully disclosed and reviewed by me and I completely understand and accept these risks including but not limited to the following:

Anesthesia

• Aspiration
• High Temperature
• Rash
• Difficulty breathing
• Anaphylaxis
• Infection
• Incomplete anesthesia
• Throat Discomfort
• Unknown reaction to anesthetics

Infection

• Need for wound cleaning
• Wound Drainage
• Antibiotics

Bruising, Bleeding/Hemorrhage from vessel damage or clotting problems and the possibility of needing transfusion of blood products or fluid expanders.

• Related risks of transfusion:

  • Anaphylaxis

  • Shock

  • Hepatitis

  • HIV

  • Other unknown organisms

 

Blood clots in the pelvis, lungs, or brain with a need for blood thinners or surgery.

 

Hematoma formation with need for evacuation of large or growing hematomas and the possibility of needing drains.

RISKS SPECIFIC TO GYNECOLOGIC SURGERY:
The risks have been fully disclosed and reviewed by me and I completely understand and accept these risks including but not limited to the following:

 

Damage to internal organs with need for repair or revision

• Bowel: perforation, blockage
• Bladder: perforation, tears, mesh erosion, suture in bladder
• Ureters: occlusion, kinking, transection
• Urethra: occlusion, kinking, perforation, deviant urine flow, urinary retention

 

Hernia formation from surgical sites or recurrence of lesions.

 

Nerve damage

• Loss of sensation or reduced sensation
• Hypersensitivity
• Irritation
• Pain
• Loss of muscle control

 

Suture breakdown and/or rapid suture autolysis and possible need for placement of new or different sutures.

 

Prolonged catheterization or difficulty in emptying bladder may occur, an indwelling catheter may be used and the possibility of urinary retention was also discussed and accepted.

 

Incontinence may occur or get worse from pelvic prolapse repairs.

 

Urge symptoms to urinate may occur.

 

I understand further procedures or surgeries may be needed in the future for

• revision
• repair
• removal
• scar reduction
• band release

 

No guarantees have been implied and/or given to the patient regarding the safety and efficacy of the procedure nor has any guarantees been implied and/or given in regards to results.

 

Surgery may fail and may need to be redone.

 

Death is a possibility with any surgery.

SURGICAL MESH or BIOLOGIC AUGMENTATION
I understand that the use of the surgical mesh for reinforced prolapse repair may not be suitable for every patient and that the potential complications involved with mesh surgery include but are not limited to the following:

• Pelvic pain, need for band or scar release
• Pain with intercourse (Dyspareunia), need for band or scar release
• Scarring of surgical site needing band release or excision of scars
• Bleeding and/or hemorrhage, needing transfusion
• Injury to blood vessels, nerves, bladder, urethra or bowel during mesh placement, which may require surgical repair
• Narrowing and/or shortening of the vagina
• Mesh infection or non- healing
• Inflammation of surgical site
• Mesh may need to be trimmed or removed if pain occurs
• Mesh extrusion from the vagina; need for mesh/biologic trimming or excision
• Mesh erosion into adjacent organs
  • Urethra
  • Bladder
  • Rectum
• Adhesion and/or fistula formation
• Injury and/or damage of rectum, small and large bowel, needing colostomy
• Nerve damage or irritation
  • Pudendal Neuralgia
  • Overactive bladder / Urge symptoms
• Temporary or permanent difficulty with urination or defecation
• Recurrent prolapse
• Failed Repair

The risks listed above have been fully disclosed, discussed and explained to me.
No guarantees have been implied and/or given to me regarding the safety and efficacy of the procedure and the use of mesh; nor has any guarantees been implied and/or given in regards to results. I have reviewed all information and I understand and accept these risks in its entirety and I still authorize Dr. Alinsod’s use of mesh in repairs.

RISKS SPECIFIC TO AESTHETIC VULVOVAGINAL SURGERY:

 

• Improper or unappealing healing with wound edges not perfectly aligned, scalloping of edges, including asymmetric healing where one side may be more or less prominent than the other side

• I understand that every individual heals differently

• I understand that retraction of edges may occur and that even a Rim appearance Post-Op may retract into Barbie appearance later on

• I understand that variable blood supply may hamper proper healing, wound breakdown may occur

• I understand that activities I perform may damage my surgical repair and that strict adherence to my post-op instruction is critical

• I understand that I am not allowed to have sexual relations and I will not engage in sexual activity for at least six (6) weeks; until cleared by Dr. Alinsod

• I understand that scarring from reaction to sutures, infections, keloids may occur and that all scars may not be hidden from view or may actually be more prominent depending on the healing process

• I understand wound revision(s) or resurfacing procedure(s) may be needed to achieve the desired look and appearance

• I understand that Dr. Alinsod performs revisions for $1,500 within one (1) year of his original surgery to cover OR fees. He does not charge a professional fee.

• I understand that consultations and revisions performed by other surgeons are my financial responsibility

• I understand that revisions may not be able to accomplish the cosmetic/functional goals I am seeking

• I understnad that post-operative visits are crucial and Dr. Alinsod cannot be held responsible if he is unable to evaluate my progress

• I fully understand that Dr. Alinsod does not guarantee that he will be able to achieve the results I am seeking. No guarantees have been implied or given.

RISKS SPECIFIC TO AESTHETIC VULVOVAGINAL SURGERY:

 

• I fully understand the ramifications of a vaginoplasty that is too tight
  (i.e. painful intercourse, scars and bands inside the vagina, and the need for revision) and that diligent vaginal softening exercises will be needed to be performed from two (2) weeks to a month or more starting at about the
  sixth (6th) week Post-Op depending on the size desired. Band release may also be needed.

• I fully understand that hymenoplasty may result in painful intercourse initially with the possibility of bleeding and hemorrhage. It is also possible that I may not bleed.

• I also understand that the hymen may need to be incised to release retained fluids or for comfortable intercourse. No guarantees of bleeding during sex are given.

• I have reviewed all information and I understand that no guarantees have been implied and/or given to me regarding the safety and efficacy of the procedure(s); nor have any guarantees been implied and/or given in regards to results.

 

 

DISCLOSURE:

OPTIONS:

• The options of care have been fully discussed. I have had the chance to research other surgeons and surgical approaches and am aware of my options such as:
  
  • outside consultations
  • surgery or no surgery
  • expectant management (wait and see)
  • medical management or
  • to proceed with the agreed upon surgery(ies)/procedure(s)

• I have elected to proceed with the surgery(ies)/procedure(s) willingly and without hesitation at the time frame of my choice; I am also aware that I reserve the right to cancel surgery(ies)/procedure(s).

I understand THIS IS A LEGAL DOCUMENT that is beneficial for all parties involved and that it requires my signature of authorization, consent and acknowledgement.

Dr. Red Alinsod, South Coast Urogynecology, Inc. and/or his employee(s) reserve the right to refuse proceeding with the surgery(ies) / procedure(s) if I refuse to sign this document.

My signature below acknowledges that all Risks/Benefits/Options have been fully discussed and explained to me; I have received and reviewed all Pre-Op and Post-Op Instructions with Dr. Alinsod and/or his employee(s). I understand and accept all information, consents and instructions provided to me in its entirety. I am aware that a copy of this signed consent is available to me upon request.

SURGICAL DOCUMENTATION

I AUTHORIZE Dr. Alinsod and his Staff to take photographs or videos of my surgical procedure(s) and/or
treatment. This includes:

• Pre-Operative / Pre-Treatment
• Intra-Operative / Intra-Treatment
• Post-Operative / Post-Treatment and
• Patient Chart Management

I understand that the photographs and videos are for documenting the surgery and evaluating the results of surgery. I understand that the digital photographs will be stored securely on Dr. Alinsod’s computers and charts with full HIPPA Regulations followed.