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OBSTETRICS - GYNECOLOGY - INFERTILITY |
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I authorize Dr._________________ and those other persons, chosen by him or her, to perform an operation called LAPAROSCOPY-PELVISCOPY. A laparoscopy is an operation by which pelvic and abdominal structures can be visually examined through a fiberoptic light cable directed through a telescope. The telescope is inserted into the abdomen through a small incision in the lower edge of the navel. Pelviscopy is an operation by which endometriosis, tubal and ovarian adhesions, some uterine tumors, tubal pregnancy and other less common conditions are treated by using additional instruments through multiple small abdominal incisions usually in conjuction with a carbon dioxide (or other) laser. POSSIBLE BENEFITS: I am satisfied with my understanding of the reason(s) for laparoscopy-pelviscopy. Diagnostic laparoscopy allows a more exact diagnosis, while pelviscopy allows actual complete or partial treatment of several gynecologic diseases. GENERAL RISKS AND COMPLICATIONS: I am satisfied with my understanding of the specific risks and discomforts of the laparoscopy-pelviscopy procedure including the following: The first step in doing a laparoscopy is the insertion of a large needle into the abdomen through the navel or abdominal wall. Carbon dioxide gas is introduced into the cavity of the abdomen so that the pelvic organs can be seen through the gas filled area. The needle is then removed, and a large, sharp-pointed instrument, called a trochar, is forced through the lower edge of the navel into the abdomen. Since both the needle and trochar are forced through the abdominal wall, damage to abdominal structures (blood vessels, bowel, etc.) is possible (1% with laparoscopy; 2-5% with pelviscopy). In such cases immediate major operation may be necessary followed by hospitalization. Carbon dioxide is absorbed into the blood by the abdominal lining and in excessive quantities can cause heart irregularities and even cardiac arrest. For this reason the anesthesia doctor will probably put a tube into your windpipe during the operation in order to pump oxygen into the lungs and pump carbon dioxide out. Sore throat and slight hoarseness can therefore be expected. Carbon dioxide is pushed out of the abdomen on completion; however, some gas may remain and cause pain in the upper abdomen, shoulder and neck due to irritation of the diaphragm. LENGTH OF HOSPITALIZATION: My doctor has informed me that my approximate length of stay is 2-6 hours unless one of the above major complications occurs. LENGTH OF RECOVERY: My doctor has informed me that my approximate length of recovery is 1-2 days for laparoscopy and 1-7 days for pelviscopy. ALTERNATIVE METHODS OF TREATMENT: I am satisfied with my understanding of alternative procedures or treatments and their possible benefits and risks. ANESTHESIA: I understand that I will probably receive a general anesthetic. I understand the anesthesiologist or certified registered nurse anesthetist will select and administer my anesthetic. I understand I should discuss with them the risks and benefits associated with the anesthesia they select. NO TREATMENT: I am satisfied with my understanding of the possible consequences, outcomes or risks if no treatment is rendered. SECOND OPINION: I have been offered the opportunity to seek a second opinion concerning the need for my laparoscopy-pelviscopy. ADDITIONAL OR DIFFERENT PROCEDURES DURING CARE AND TREATMENT: I understand that unforeseen conditions may arise and that it may be necessary to perform operations and procedures different from, or in addition to, the procedures described. I authorize and consent to the performance of such additional or different operations and procedures as are considered necessary and advisable. FEES: My doctor has informed me that his or her fee for laparoscopy is approximately .. and for pelviscopy is variable from .. to .. assuming no unforeseen complications. I understand that in addition to my doctor's fee, there will be other charges, such as facility costs, anesthesiologist's fee, laboratory and possible other physicians'fees. I understand that not all of these charges may be paid by my insurance company and that I am responsible for paying any part of these charges not paid by my insurance company. FREE TO WITHHOLD OR WITHDRAW CONSENT: I understand that I am free to withhold or withdraw my consent at any time before the operation without affecting the right to future care or treatment and without loss of withdrawal of any state or federally funded program benefits to which I might otherwise be entitled. NO GUARANTEES: I understand there are risks involved in any procedure or treatment, and it is not possible to guarantee, warrant or in any way to give an assurance of a successful result. OTHER QUESTIONS. I am satisfied with my understanding of the nature of the procedure and all of my questions about the procedure have been answered. I have read and been given a copy of the form.
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