Consent Form for Surgery or Special Treatment Diagnostic or Therapeutic Procedure(s)

Consent for Surgery or Special Treatment Diagnostic or Therapeutic Prodecure Patient Name: Sarah Jenkins Date of Birth: 15/03/1985 Patient Identifier: SJ850315 Procedure Name: Laparoscopic Cholecystectomy Nature and Purpose of Procedure: This procedure involves the surgical removal of the gallbladder using a minimally invasive laparoscopic technique. The purpose is to alleviate symptoms such as severe abdominal pain, nausea, and indigestion caused by gallstones and inflammation of the gallbladder (cholecystitis). Risks and Complications (Common): * Bleeding: Minor bleeding is common; rarely requires transfusion. * Infection: Risk of wound infection or deeper intra-abdominal infection. * Pain: Post-operative pain, usually managed with medication. * Bile leak: Small risk of bile leaking from the liver or bile ducts. * Injury to adjacent organs: Rare but possible injury to the bowel or liver. Risks and Complications (Serious/Rare): * Bile duct injury: Can lead to jaundice, infection, and may require further surgery. * Retained gallstones: Rarely, a gallstone may be left in the bile duct, requiring further intervention. * Allergic reaction to anaesthesia: Rare but potentially serious. * Hernia at incision sites: Can develop over time. * Conversion to open surgery: If technical difficulties arise, the procedure may need to be converted to traditional open surgery. Expected Benefits of Procedure: * Resolution of gallstone-related symptoms (pain, nausea, indigestion). * Prevention of future complications such as acute cholecystitis, pancreatitis, or cholangitis. * Improved quality of life. Alternatives to Procedure: * Watchful waiting: For asymptomatic gallstones, but symptoms may develop or worsen. * Medical management: For specific types of gallstones (e.g., cholesterol stones) using oral dissolution therapy, but this is often ineffective and takes a long time. * Endoscopic Retrograde Cholangiopancreatography (ERCP): For bile duct stones, but does not remove the gallbladder itself. Opportunity to ask questions: The patient confirms they have had ample opportunity to ask questions about the proposed procedure, its risks, benefits, and alternatives, and that these questions have been answered to their satisfaction. Patient Consent: I, Sarah Jenkins, consent to the performance of the Laparoscopic Cholecystectomy by "Dr. Thomas Kelly" and his surgical team. I understand the nature, purpose, risks, and benefits of the procedure, as well as the available alternatives. I confirm that I have read and understood the information provided and that my consent is given freely. Patient Signature: Sarah Jenkins (signed electronically) Date: 1 November 2024 Time: 10:30 AM Witness Signature: Emily White (Clinic Nurse) Date: 1 November 2024 Time: 10:30 AM Surgeon's Declaration: I, "Dr. Thomas Kelly", confirm that I have explained the procedure, its risks, benefits, and alternatives to the patient, Sarah Jenkins, to the best of my knowledge and belief, and that the patient appeared to understand the information provided. Surgeon's Signature: Dr. Thomas Kelly (signed electronically) Date: 1 November 2024 Time: 10:30 AM