Educational purposes
Tube-like structure between small and large intestine
Medical record
Risks
Risks to blood/blood vessels
Embolism
This can lead to stroke, pulmonary embolism (blockage of the main artery of the lung), and injury to organs or extremities
An object that moves through my body in your blood stream. e.g. blood clot, bubble, piece of fat.
Bleeding
I may need blood transfusion or other treatment
Damage, blockage, or sudden closure of blood vessels
Wound infection, poor healing, or reopening
Can lead to collection of blood or other fluids at wound sites
Death
Lighted instrument with camera
A larger cut will be used
Physician
Rupture of my appendix
Risks to lungs/heart
Breathing problems
I may need a breathing tube or other treatment
Rapid or irregular heartbeat
Chest Pressure
Chest pain
Pump CO2 into the abdomen
Appendicitis (Pain/infection in the abdomen)
Alternative treatments
Open procedure
Choosing not to have this procedure
Antibiotics
Incisions on the skin
Stitches, staples, and stripes of tapes after the surgery
Spreading of infection
Scope
Benefits
helps
Symptoms in the abdomen
relieves
Pain
removes
Infected organ
Temporary drain after the surgery
Skin on the abdomen over the appendix
Visibility and more room to work
General Risks
Fistula
Abnormal connection between channels in your body
Burning injuries
Caused by instruments and equipment used to control bleeding
Incisional hernia
Weak scar tissue causing tissue to bulge through the cut
Scar (s)
Unattractive appearance
Limit function or range of motion
Painful
Pain, numbness, swelling, or scarring where tissue is cut
I may not get cured
My condition and symptoms may remain the same or worsen
I may need additional tests or procedures
Another source of my problem may be found
Gas can get trapped in tissues
Can effect blood flow and heart function
My doctor may not complete the procedure using a scope
Risks to urinary tract/bowel/intestines
Damage to the intestines and nearby structures
Bladder problems
Urinary tract problems
Damage to the bowel or nearby structures
Bowel obstruction
Leakage of bowel contents at the procedure site
Illness/medical condition
Laparoscopic surgery
during which
Nearby structures are checked
Attachments of the appendix are cut and sealed
Passing tools
Appendix
Hollow tubes (ports)
My consent
allows the presence of
Vendors/technical representatives of medical products
requested by
necessary for
Knowledge of medical products
to provide
Support services
Medical personnel/trainees
to observe
My procedure
with
My physician's permission
to
Advance medical education
allows to perform
Appendectomy
allows to
Film/videotape
approved by
Hospital
My physician
allows to involve in my care
Medical practitioners other than my doctor
to perform
Implanting devices
Harvesting grafts
Altering tissue
Removing tissue
Dissecting tissue
Opening and closing incision
including
Registered nurses
Physician's assistants
Nurse practitioners
Anesthetists
allows the removal of identification, disposal, and use of removed
specifies that I was informed and I understand that
My physician can perform additional surgery if needed
The surgery may not improve my condition
Typical risks for surgeries
Severe life threatening situation
Severe blood loss
Infection
