Download Informed Consent – Laparoscopic Cholecystectomy

Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Laparoscopic Cholecystectomy
Your symptoms and physical exam suggest that you have a problem with your gallbladder requiring its
removal. The causes for a problem with the gallbladder are many, including the development of gallstones in
the gallbladder or in the ducts draining the gallbladder. After careful consideration, a laparoscopic
cholecystectomy has been recommended.
Description of the Procedure
The gallbladder is removed in a fashion similar to the traditional method of open cholecystectomy, except that it is
done using a video camera, or laparoscope. After inflating your abdomen with gas, a small incision is made just
above or below your umbilicus (belly button), and a video camera is inserted into the abdomen. Several other
“working holes” are made in the upper and right abdomen, allowing small operating instruments to be placed
inside your abdomen. The gallbladder is removed from its base on the liver and withdrawn from the abdomen
through the umbilicus. The small holes in your abdomen are sewn shut with absorbable suture.
Additional Procedures that may be done while in Surgery
1. Open Cholecystectomy – it is impossible to accurately predict when a laparoscopic operation will be
technically dangerous. Sometimes it is safer to open the abdomen to complete the operation. Our utmost
priority is your safety in the operating room, and while laparoscopic operations are conducted safely in most
people, we remain aware that sometimes an open operation would be better for you.
2. Cholangiogram – this is a dye picture of the ducts draining your gallbladder. We usually like to obtain a
cholangiogram to see if there are abnormalities in your bile ducts, or if there are gallstones lodged in the bile
ducts that are not otherwise detectable.
3. Common duct exploration – if there is a strong suggestion of gallstones in your bile ducts, it would be best to
surgically remove the stones at the time of your cholecystectomy. This often entails opening up the abdomen,
cleaning out the stones, and then leaving a small “T-tube” in the duct. This tube usually remains in for about
three weeks. Another procedure “ERCP” may sometimes be done if the stone is more easily extractable.
Alternative Treatments
There are other treatments available for gallstones. One treatment is the use of pills that dissolve gallstones. We
do not recommend this treatment for you because most people are not helped or are made worse with this
medicine, and the gallstones will usually come back after you stop taking the medicine. It is also possible to
shatter the gallstones using a special machine; this treatment is not readily available, and has been abandoned in
most center because of its expense and because the gallstones usually recur after this treatment.
Benefits of Treatment/Treatment Objective
There are many benefits to having a laparoscopic cholecystectomy. If you are having abdominal pain that is
caused by the gallbladder, this operation will usually relieve that pain. A cholecystectomy will also help avoid the
many potential complications form having gallstones, including cholecystitis (an infection of the gallbladder),
ascending cholangitis (an infection of the bile ducts), or pancreatitis. On occasion, these problems can be so
severe as to lead to death.
Risks/Complications of Treatment
In any medical treatment, it is impossible to predict all the things that could go wrong. Fortunately, complications
are the exception rather than the rule. Every reasonable effort is made to avoid complications. The most common
possible complications are as follows:
Possible complications following any operation
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood transfusion
during or after this operation is uncommon.
2. Infection – we take special care to prevent an infection, but it is always a possibility. An infection may
require prolonged hospitalization and treatment to resolve.
3. Reactions to medications – this could be many things from a minor rash to possible death
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia, sore
throat, or potential death, in rare cases.
5. Poor wound healing – breakdown of the incision, or hernias at the puncture sites
(see other side)
Possible complications following laparoscopic cholecystectomy.
1. Injury to the bile duct – because the operation occurs close to bile ducts, an injury to them (while
uncommon) is possible. Such an injury may not be detected while in the operating room, and necessitate
another operation to be corrected. A bile leak will make you feel worse and worse daily after surgery.
2. Injury to bowel or other abdominal organs – an injury to a portion of the bowel or other organs in
uncommon but possible. Should this occur, we will repair the injury, and may have to complete the
operation “open”.
3. Lack of improvement: 90% of patients with gallstones, 85% without gallstones resolve upper abdominal
pains. Bowel irregularity commonly persists.
4. Pancreatitis: If a small stone passes through the bile system during or after surgery, the pancreas gland
gets irritated, requiring hospitalization.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. You should begin walking on the evening of the surgery.
You should not drive a motor vehicle or dangerous machine for three days following surgery. You should not lift
anything greater than twenty pounds for a few weeks following the operation. After that time, you will only be
restricted from activity that causes discomfort. You will be on unrestricted activity 2-3 weeks following the
operation. Most people are able to return to office work or “light duty” a week following the operation.
Consent for Treatment
I understand my need for a laparoscopic cholecystectomy. I have read and understand the above
explanation of the procedure being proposed. My surgeon has answered my questions, and I choose to
proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act on his
best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding that
complications may arise from that action.
I understand that while most people receiving a laparoscopic cholecystectomy benefit from the operation, I
may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite
to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated recovery
issues for effectiveness of communications. Because of the anesthetic, you may or may not remember these
important details
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on my
behalf.
SIGNATURE _____________________________________________________ DATE _________________
rev 6-04/pjd