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Concent Form for Laparoscopic Surgery
Discussion in 'All Categories' started by Sushrut Shekhar Puranik - May 24th, 2014 11:28 pm.
Sushrut Shekhar Puranik
Sushrut Shekhar Puranik
Can you give me the consent Form used in Laparoscopic Surgery.
re: Concent Form for Laparoscopic Surgery by Dr Ramadevi wani - May 25th, 2014 7:03 am
Dr Ramadevi wani
Dr Ramadevi wani
Can you please send me the laparoscopic surgery consent form
re: Concent Form for Laparoscopic Surgery by Dr R K Mishra - May 25th, 2014 11:26 am
Dr R K Mishra
Dr R K Mishra
An informed written consent is very important to take from the patient. Following important point should be present in a consent form of laparoscopic surgery.


An Interpreter Service is required or not. If yes, is a qualified Interpreter present or not. A Cultural Support Person is required or not. If yes, is a Cultural Support Person should be present.


The Laparoscopic Surgeon has explained that I have the following condition: (Laparoscopic Surgeon to document in patient own Words).

The following procedure will be performed:

1. An inspection and surgical procedure of the abdominal cavity
2. Laparoscopically i.e. with the help of a video camera
3. Through tubes in four very small cuts in the abdomen
4. Four tubes (Trocar) will be put through these cuts
5. The Laparoscopic Surgeon will make these hole to pass the camera and instruments through.
6. The Laparoscopic Surgeon will fill the abdominal area with carbon dioxide
7. CO2 gas will be introduced to allow access for the operation. The Laparoscopic Surgeon
8. May need to to perform more extensive surgery in my favor
9. It pay create problems in the abdominal cavity.


They include:

(a) Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
(b) Clots in the legs (deep vein thrombosis) with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
(c) A heart attack, due to strain on the heart or a stroke.
(d) Death is possible due to the procedure.


There are some risks/ complications, which include:

(a) Damage to large blood vessels causing bleeding which could require an emergency blood transfusion and abdominal surgery.
(b) Damage to gut and/or bladder when the instruments are inserted. This usually needs corrective surgery.
(c) Rarely, gas fed into the abdominal cavity can cause heart and breathing problems.
(d) The television method may not work and the surgeon may need to do open surgery, which will require a larger cut in the abdomen.
(e) Deep bleeding in the abdominal cavity could occur and this may need fluid replacement or further surgery.
(f) Infections such as pus collections can occur in the abdominal cavity. This may need surgical drainage.
(g) Infection in the wound causing redness, pain and possible discharge or abscess. This may need antibiotics.
(h) Possible bleeding into the wound with swelling and bruising and possible blood stained discharge.
(i) The wound may not heal normally. The wound can thicken and turn red. The scar may be painful.
(j) A weakness can happen in the wound with the development of a hernia. Further surgery may be needed to correct this.
(k) Symptoms experienced before surgery may persist after the surgery.
(l) Adhesions may form and cause bowel obstruction. This can be a short term or a long term complication and may need further surgery.
(m) Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
(n) Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.



The Laparoscopic Surgeon has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The Laparoscopic Surgeon has also explained relevant treatment options as well as the risks of not having the procedure.

(Laparoscopic Surgeon to document in Medical Record if necessary.



D.O.B. SEX M / F:


I acknowledge that: The Laparoscopic Surgeon has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The Laparoscopic Surgeon has explained other relevant treatment options and their associated risks. The Laparoscopic Surgeon has explained my prognosis and the risks of not having the procedure. I have been given a Patient Information Sheet on Anesthesia. I have been given a Patient Information Sheet about the procedure and its risks. I was able to ask questions and raise concerns with the Laparoscopic Surgeon about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.

I understand that the procedure may include a blood transfusion. I understand that a Laparoscopic Surgeon other than the Consultant Surgeon may conduct the procedure. I understand this could be a Laparoscopic Surgeon undergoing further training.

I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.

The Laparoscopic Surgeon has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly. I understand that photographs or video footage may be taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video).

I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the previous statements, I REQUEST TO HAVE THE PROCEDURE.

Name of Patient/ Substitute:
Decision maker and relationship:

If the patient is an adult and unable to give consent, an authorized decision- maker must give consent on the patient behalf.


I have given a translation in my language (State the patients language here) of the consent form and any verbal and written information given to the patient / parent or guardian / substitute decision maker by the Laparoscopic Surgeon.



I have explained the patient condition and need for treatment, the procedure and the risks, relevant treatment options and their risks, likely consequences if those risks occur, the significant risks and problems specific to this patient.
I have given the patient / substitute decision maker an opportunity to ask questions about any of the above matters raise any other concerns which I have answered as fully as possible. I am of the opinion that the patient / substitute decision-maker understood the above information.


re: Concent Form for Laparoscopic Surgery by Ankita Thakur - May 26th, 2014 7:28 am
Ankita Thakur
Ankita Thakur
This is a nice consent form but the question is after going through this consent form will any patient become ready for laparoscopic surgery?? They will be so scared that they will run away. I do not think it is practical. May be good in developed country but in developing country where majority of patients are not very educated will they understand all these complications.
re: Concent Form for Laparoscopic Surgery by Dr R K Mishra - May 26th, 2014 8:04 am
Dr R K Mishra
Dr R K Mishra
Although the written consent form dully filled and taken from patient before the laparoscopic surgery is a legally effective document, but the process and complexity of documentation is inconsistent and this may leave many laparoscopic surgeons and gynecologists in a vulnerable position.
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