Laparoscopic Surgery Consent Form

OPERATIVE LAPAROSCOPY - CONSENT FORM

A. What Is Operative Laparoscopy?

Operative laparoscopy is minimally invasive abdominal surgery performed through small incisions using a camera and specialised instruments. The abdomen is gently inflated with carbon dioxide gas to allow visualisation and access. This consent includes:

• Laparoscopic excision/ablation of endometriosis
• Laparoscopic myomectomy
• Laparoscopic ovarian cystectomy or tumour excision
• Laparoscopic abdominal cervical cerclage

B. Anaesthesia

This procedure is performed under General Anaesthetic. Serious anaesthetic complications are very rare (<1 in 10,000).

C. Benefits of Operative Laparoscopy

• Faster recovery and shorter hospital stay
• Less postoperative pain
• Lower infection risk than open surgery
• May improve fertility (depending on indication)
• Effective treatment of cysts, fibroids, endometriosis

D. How the Procedure Is Performed

Small incisions are made, Carbon Dioxide Gas inflates the abdomen, a laparoscope provides visualisation, and instruments perform treatment. Most procedures are day-case or require one overnight stay.

E. Risks and Complications

1. Conversion to Open Surgery

Conversion to laparotomy may be required if bleeding, scar tissue, or anatomy make laparoscopy unsafe. Estimated risk: 1-5%.

2. Injury to Internal Organs

Major complications occur in approximately 0.1-1% of cases (3-5).

• Bowel injury: 0.1-0.7%
• Bladder injury: 0.1-0.3%
• Ureteric injury: 0.02-0.5%
• Vascular injury: rare but potentially serious (0.01-0.1%)

3. Bleeding

Minor bleeding is common. Significant bleeding requiring transfusion or conversion is uncommon (<1%) (3).

4. Infection

Wound or pelvic infection occurs in 1-3% of cases (4).

5. Venous Thromboembolism (VTE)

Rare: <0.1-0.2%.

6. Gas-Related Risks

Shoulder-tip pain (common). Gas embolism: <0.01% (extremely rare) (4).

7. Adhesions

Adhesions can form after any pelvic surgery, though rates are lower than with open surgery (2).

8. Procedure-Specific Risks

• Laparoscopic Myomectomy: adhesion formation possible; rare uterine rupture in future pregnancy (7).
• Laparoscopic Endometriosis Surgery: disease recurrence possible; deep disease may involve bowel, bladder, ureter.
• Laparoscopic Ovarian Cystectomy: reduced ovarian reserve possible, especially with endometriomas (8).
• Laparoscopic Cervical Cerclage: rare risk of uterine vascular injury; cerclage usually remains for future pregnancies.

9. Failure to Complete Procedure

Occurs in 1-5% due to anatomy, bleeding, or safety concerns (3).

F. Consent Statement

I confirm that I understand the procedure, risks, benefits, and alternatives.

I consent to operative laparoscopy and any additional procedures deemed necessary during the surgery by my treating doctor.

I have viewed the Vitalab online patient information regarding Laparoscopic Surgery.

I have had sufficient opportunity to discuss any concerns and questions with my treating doctor.

I have considered the alternatives to surgical management, including no surgery and I am convinced of my choice.

This is an elective surgery, which is chosen after careful consideration of the explained risks and benefits.

Post-Operative Expectations

Normal Findings

• Mild-moderate abdominal pain or cramping for several days.
• Shoulder or chest-tip pain due to CO₂ gas (common for 48-72 hours).
• Incisional soreness and mild bruising.
• Fatigue lasting 3-7 days or longer depending on procedure.
• Bloating or abdominal distention for several days up to 1-2 weeks.
• Light vaginal spotting (for gynaecologic procedures).
• Nausea related to anaesthesia or pain medications.
• Mild redness around incisions without drainage.
• Temporary constipation or mild bowel habit changes.

Abnormal Findings - Seek Medical Advice

• Fever ≥ 38°C (100.4°F) after the first postoperative day.
• Increasing redness, swelling, pain, or foul-smelling drainage from incisions.
• Heavy vaginal bleeding (e.g., soaking a pad in < 2 hours).
• Severe or worsening abdominal pain not relieved by medication.
• Persistent vomiting or inability to tolerate fluids.
• Inability to pass gas or have a bowel movement after several days, especially with pain.
• Difficulty urinating or significantly reduced urine output.
• Shortness of breath, chest pain, or signs of a blood clot.

REQUIREMENTS FOR INTERPRETER:

REFERENCES

1. 1. Royal College of Anaesthetists - Anaesthesia Explained.
2. 2. ACOG Practice Bulletin - Minimally Invasive Gynaecologic Surgery.
3. 3. RCOG Green-top Guideline - Complications of Laparoscopic Surgery.
4. 4. AAGL Practice Guidelines - Laparoscopic Surgical Safety.
5. 5. Chapron C. Complications of Gynaecologic Laparoscopy. Obstet Gynecol.
6. 6. NICE Clinical Guideline - Venous Thromboembolism in Surgical Patients.
7. 7. Parker WH. Uterine Rupture Risk After Myomectomy. Obstet Gynecol.
8. 8. Somigliana E. Impact of Endometrioma Surgery on Ovarian Reserve. Hum Reprod Update.
9. 9. ACOG Practice Bulletin on Gynaecologic Laparoscopy, American College of Obstetricians and Gynaecologists.
10. 10. SAGES Guidelines for Diagnostic Laparoscopy, Society of American Gastrointestinal and Endoscopic Surgeons.
11. 11. Nelson G. et al., Enhanced Recovery After Surgery (ERAS) Guidelines for Gynaecologic Surgery.
12. 12. Cochrane Reviews on postoperative pain and recovery following minimally invasive surgery.
13. 13. Liu H. et al. Postoperative recovery patterns after laparoscopic procedures, Journal of Minimally Invasive Gynaecology.