Laparoscopic Simple Nephrectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Simple Nephrectomy

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

The diseased/non-functioning kidney is removed through small abdominal incisions using laparoscopic instruments. The removed kidney may be sent for histopathology.

4. Benefits and Indications

The procedure may be performed for a non-functioning or poorly functioning kidney associated with:

  • Chronic infection
  • Obstruction
  • Pain
  • Stones
  • Other benign disease

The intended benefits include:

  • Removal of diseased kidney
  • Relief of pain/discomfort
  • Treatment/prevention of recurrent infection
  • Reduction of complications from chronic kidney disease
  • Improvement of symptoms
  • Treatment of selected cases of hypertension related to the diseased kidney

5. Risks and Complications

  • Common
    • Port-site pain
    • Abdominal discomfort
    • Fatigue
    • Nausea/vomiting
    • Temporary activity limitation
  • Less Common
    • Bleeding/haematoma
    • Transfusion
    • Injury to bowel, liver, spleen or pancreas
    • Major vascular injury
    • Ureteric/diaphragm/pleural injury
    • Wound infection
    • UTI
    • Chest complications
    • Ileus
    • DVT/PE
    • Conversion to open surgery
    • Hernia
    • Recurrent infection/abscess
    • Additional procedure
    • ICU requirement
  • Rare but Serious
    • Major bleeding
    • Major vascular/visceral injury
    • Sepsis
    • Significant cardiopulmonary complications
    • Injury to remaining urinary tract
    • Life-threatening complications
    • Death

6. Postoperative Course

I understand that:

  • The duration of hospital stay and recovery depends on postoperative progress.
  • Kidney function will be monitored, with long-term assessment of the remaining kidney and blood pressure as required.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation/conservative treatment
  • Antibiotics where appropriate
  • Ureteric stenting/nephrostomy
  • Drainage
  • Partial nephrectomy in selected cases
  • Open nephrectomy

8. Anaesthesia and Pain Management

I understand the risks associated with local, regional, or general anaesthesia.

Pain management options have been explained.

9. Photography / Data Use

I consent to:

☐ Medical photography/video for academic purposes

☐ Use of anonymized clinical data

10. Intraoperative Decision Consent

I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.

11. Team-Based Care

I understand that supervised residents, fellows, or assistants may participate.

12. Patient Statement

I confirm that:

  • The nature of surgery has been explained.
  • Risks, benefits, and alternatives have been explained.
  • My questions have been answered satisfactorily.
  • I voluntarily consent.

Patient to write in own handwriting:

“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

Signatures

Patient Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Doctor Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

Related Posts