Consent Form for Single-Port Laparoscopic ( ) Hysterectomy and Anesthesia
This is the consent form required for your surgery. After receiving an explanation, please ask your medical team any questions you may have and complete the form.
PATIENT CONDITION / MEDICAL HISTORY
Past Medical History Allergies
Constitutional abnormalities Diabetes mellitus
Hypertension/Hypotension Respiratory Disease
Heart Disease Thyroid Disease
Liver Disease Bleeding Tendency
Kidney Disease Smoking
Cerebrovascular disease CurrentMedications
Drug Side Effects Other
◈ Laparoscopic surgery
Description For the name of the new year
1.Need for surgery
Using a laparoscope inserted through a minimally invasive incision, the intra-abdominal lesion is identified and removed.
This surgery is necessary to improve symptoms caused by the lesion (heavy menstrual bleeding, menstrual pain, lower abdominal discomfort), and to examine the removed tissue for accurate diagnosis.
2. Method and content of surgery
1) When the patient arrives in the operating room, preoperative preparation and anesthesia are performed.
2) To facilitate uterine manipulation during surgery, a uterine elevator is inserted through the vagina.
3) After disinfecting the surgical site, an approximately 2.5 cm incision is made at the umbilicus. A single-port device is inserted, and gas is insufflated to create working space. A laparoscope is inserted through this port to identify the lesion.
4)( ) Hysterctomy is performed to remove the lesion. If adhesions between pelvic organs and the surgical site are present, adhesiolysis is performed to separate the adherent organs before removing the lesion.
***If necessary for the safety and effectiveness of the surgery, additional ports (instrument entry pathways) may be created besides the umbilical port.
5)Hemostasis is performed, and the abdominal cavity is irrigated. After confirming no abnormalities, the procedure is completed.
6)After removing intra-abdominal gas, the single-port device is removed and the incision site is sutured.
3.Postoperative Complications or Side Effects
수술자세
1) Complications related to laparoscopic technique (very rare)
①Umbilical hernia and scarring:
Although single-port surgery has cosmetic and pain-related advantages, umbilical hernia may rarely occur and may require repair surgery.
②Bowel injury:
If adhesions exist beneath the umbilicus, bowel injury may occur when inserting the single-port device. In this case, repair surgery may be required.
③Conversion to open surgery:
If surgical manipulation is limited due to a large lesion, if severe adhesions are present, or if unexpected bleeding obscures the surgical field, conversion to open surgery may be necessary.
④Complications related to gas insufflation:
Carbon dioxide gas used during surgery may cause temporary cardiopulmonary dysfunction due to absorption or diaphragmatic pressure. Gas embolism is extremely rare because an automatic gas pressure controller regulates insufflation.
⑤Complications related to surgical positioning:
To secure the surgical field, the patient is placed in a steep Trendelenburg position (head lowered, pelvis elevated). Shoulder and leg supports are used for stabilization.
a.Nerve compression:
Rare cases of temporary sciatic or brachial nerve palsy may occur due to pressure from supports. Most cases recover spontaneously, but severe cases may take 3–6 months and require treatment.
b.Shoulder pain:
Shoulder discomfort from shoulder supports may persist for several days (common).
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2) Complications inherent to surgery
①Organ injury:
During adhesiolysis, injury to the bladder, bowel, or ureter may occur. Repair surgery may be necessary (very rare).
②Bleeding:
a)Unexpected significant bleeding may require transfusion.
b)If bleeding prevents visualization, conversion to open surgery may be required (very rare).
c)In some cases, a drain may be inserted to evacuate accumulated blood.
d)Very rarely, postoperative bleeding may occur after surgery has been completed, requiring reoperation.
③Infection:
Wound infection, urinary tract infection, or intra-abdominal infection may occur in 4–6% of cases.
Preventive antibiotics are given, but additional antibiotics or prolonged hospitalization may be necessary if infection occurs.
④Postoperative pain:
Pain is usually severe for 1–2 days and then improves. Patient-controlled analgesia (PCA) is provided, but pain control may vary among individuals and additional medications may be required.
⑤Ileus (bowel obstruction):
Paralytic ileus or mechanical obstruction due to postoperative adhesions may occur, requiring fasting, imaging studies, or additional surgery. (See precautions)
⑥Thromboembolism (e.g., pulmonary embolism):
This very rare complication occurs when small blood clots obstruct vessels in the lung, brain, heart, or extremities.
Mild cases cause leg swelling or pain; severe cases may lead to paralysis or cardiac arrest. (See precautions)
⑦Need for additional surgery or testing:
Depending on pathology results, further evaluation or treatment may be necessary.
⑧Infertility: Pregnancy is no longer possible because the uterus has been removed.”
⑨During hysterectomy, the vaginal cuff is incised where the uterus was attached and the vaginal mucosa is sutured. While the sutures are dissolving, an increased amount of vaginal discharge may be present for 1–2 months.”
◈ Anesthesia
1. Need for anesthesia
Anesthesia is necessary to induce sensory nerve blocks, motor nerve blocks, and reflex nerve blockades to maintain the optimal physiological state necessary for surgery.
2. Method and content of anesthesia
가. Spinal anesthesia + epidural anesthesia + sleep anesthesia
1) When the patient arrives at the operating room, the basic monitoring device
(Patient condition monitoring) will be attached and anesthesia will be administered.
2) Spinal anesthesia for stable anesthesia during surgery
and at the same time for painless therapy after surgery
Epidural anesthesia will be performed
3) Sleep anesthesia was administered immediately before surgery.
It eliminates the patient's anxiety during surgery.
3. Anesthesia sequelae or side effects
가. Switching to general anesthesia
It may be changed to general anesthesia if the patient's physical situation and condition preclude spinal or epidural anesthesia and if unexpected anesthetic complications occur.
나. Switch to venous analgesia
If epidural anesthesia is not feasible due to the patient's physical situation and condition, analgesia will be converted to venous analgesia.
다. side effect
Hypotension, nausea, vomiting, bleeding, pruritus, low back pain, dysuria, postdural puncture headache
라. Very rare side effects
Epidural intravacuum, coffa equina syndrome, nerve damage. Respiratory depression, anaphylaxis, heart attack
Cauda Equina Syndrome
Definition: A rare neurologic injury caused by sensitivity to spinal anesthetic agents or compression from an epidural hematoma affecting the nerve roots of the cauda equina.
Symptoms:
Sudden or rapid onset of leg pain/radicular pain, saddle anesthesia (perineum, vulva, anus), decreased leg strength or reflexes, urinary or fecal dysfunction.
Incidence: Extremely rare (1 per tens of thousands).
Ways to Reduce Risk:
1. Inform your physician if you take anticoagulants (increases hematoma risk) or have spinal stenosis (increases neurotoxicity risk).
2. Immediately notify medical staff if any symptoms appear.
Treatment:
1. Surgical evacuation of epidural hematoma, if present.
2. No specific treatment is available for toxicity from local anesthetics.
The person (representative) is responsible for the current condition of the person (patient), the need for surgery, the method and content of the surgery, and the possible sequelae of surgery.
Or I listened to detailed explanations from the medical staff in charge about side effects, what to do if they occur, what patients should follow before and after surgery, and the risks and benefits of anesthesia. I (the representative) was informed by the medical staff that I had the opportunity to ask additional questions during the explanation process, and there were no restrictions on doing so. In addition, we fully understood that force majeure complications that may occur due to this surgery and the patient's unique constitution may cause unexpected accidents. Accordingly, I (the representative) agree to entrust the medical treatment following the surgery to the judgment of the attending physician and perform surgery and anesthesia.
Consent form preparation date
patient Full Name (Signed)
date of birth Contact Number HP
protector
or
agent
※ If the patient is unable to sign, please indicate the ∨ in the appropriate field.
□ Do not understand the contents of the agreement as a minor (under the age of 19 under the Civil Code)
□Unable to understand the contents of the agreement due to the patient's physical or mental disability.
□If there is a concern that explaining the contents of the consent form will have a significant impact on the patient's mind and body.
□The patient himself delegates the authority regarding the concession to a specific person. (In this case, a separate power of attorney must be attached to this agreement.)
□When it is difficult to obtain the consent of the person in an emergency situation
□ Others ( )
*I agree to collect the following personal information for the purpose of verifying the identity of the guardian or representative.
Date of Birth / Gender . . . /(Male, Female)
Telephone / Mobile Phone Tel : /HP:
Main
Official / Name / (Signature)
Consent for the use of photographs taken during surgery
During the treatment process, before and after photos will be taken to record the treatment and results of the operation, and for the purpose of providing information.
It is planned to be used (do not use the patient's mobile phone, social security number, personal information, etc.), and can be used for medical-related materials. This is only used with the consent of the person and can be withdrawn at any time.
If you would like to give your consent, please sign it.
Full Name: (Signed)
