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