All Purpose Surgery Consent Form
This is the form we use to consent patients for surgery. It is tailored to the specific patient's specific surgery.
Please understand that this document is meant to be comprehensive and conservative. That means we try to cover all possible complications and to address the worse case scenarios. When going over your consent, please ask your surgeon to help you understand the true balance between the benefits and risks of your particular case for you.
- Patient understands the nature of the case and the general nature of how it is done including the range of possible incisions. Patient understands that any laparoscopic case may have to be converted midway to and abdominal procedure and that safety will be paramount in such decisions. Patient understands the risks benefits complications and alternatives to the case including but not limited to infection bleeding or damage to nearby structures, intraoperative and postoperative complications, anesthesia reactions, drug reactions or thromboembolic phenomena such as clots in the leg or the lungs. She understands smoking and obesity worsen all results and increase the risk of complications.
- Patient understands any case, however small may entail the possible need for a transfusion or blood or blood products. If she does not wish to receive these, it is documented on the chart.
- In the case of repeat Cesarean section patient is aware whether or not a VBAC is an option. She is aware of her factors for or against such a plan. She knows that higher order C-sections carry increasing risk due to scarring and risk of abnormal placentation. Such surgery may involve extra time, possible blood transfusion, inadvertent cystotomy, requiring prolonged postoperative catheterization, and rarely Cesarean hysterectomy to which she consents.
- Patient understands any surgery done for pain may have unpredictable efficacy or results despite being optimally performed. Patient understands the basis of pain is neurologic and not anatomic and that pain may be relieved some, a lot, or not at all. Patient understands pain could be made worse. Patient knows that even if her pain is helped, she will need to resolve her postop pain.
- Provisions for incontinence surgery: Patient understands she may be helped, worsened or left the same by such procedure and if helped, the result may be temporary, at most 10 years durable. She knows any kind of mesh or tape might erode. She knows incontinence procedures entail the risk of bladder injury requiring prolonged postoperative catheterization.
- Patient understands a hysterectomy made predispose her to pelvic relaxation such as vaginal cuff prolapse in the future.
- Provisions for pelvic relaxation surgery: The patient understands pelvic relaxation is an ongoing inherent tendency and that operative results to repair it may not be permanent. The patient understands urinary continence may be affected by repair of pelvic organ prolapse. Patient understands overweight, smoking and constipation worsen all results of prolapse surgery.
- Regarding sterilization patient understands there is a risk of pregnancy or ectopic (tubal) pregnancy, heavy or crampier periods. Any coils are hardware placed could migrate and cause damage.
- Provisions for new technology: the practice of evidence-based medicine sometimes requires the adoption of new methods and technology. Patient understands her case maybe part of a learning curve with higher complication rates and accepts this is part of participating in modern medicine.
- The patient understand she may require a bowel prep (cleanout) . Instructions for this are reviewed verbally and in writing.
- Preop ureteral stents placed by a Urologist may be needed. These have an unlikely set of complications of their own which should be discussed with the Urologist.
- The patient has received orders for labs and studies and understands the purpose for all of these.
- The patient is told about the postop phases and that there will be instructions with which she must comply. She knows to call with any questions or concerns anytime.
- The patient understands that with a history of prior C-section or other abdominal or pelvic surgeries she may have scarring (adhesions) in the abdomen, pelvis or between the lower uterine segment in the bladder. She understands it in the course of taking down such adhesions, inadvertent injury to nearby tissues may rarely occur.
- Signing consent: the above indicated has been discussed with the patient, she appears to understand and has signed consent.
Even after your post op visit, you are encouraged to call in with any questions you may have.