Laparoscopic Urachal Cyst Excision Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Urachal Cyst Excision

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 urachal cyst/remnant between the umbilicus and bladder dome is dissected and removed.

If the cyst is adherent to or communicates with the bladder, part of the bladder may need to be removed and repaired.

A urinary catheter may be placed temporarily.

4. Benefits and Indications

The procedure may be performed for a urachal cyst/remnant causing:

  • Pain
  • Discharge
  • Recurrent infection
  • Abscess formation
  • Persistent urachal remnant requiring assessment

The intended benefits include:

  • Removal of urachal cyst
  • Relief of pain/discharge
  • Reduction in recurrent infection
  • Prevention of recurrent abscess
  • Prevention of complications from a persistent urachal remnant
  • Assessment/exclusion of malignancy where clinically indicated

5. Risks and Complications

  • Common
    • Port-site pain
    • Abdominal discomfort
    • Mild haematuria if bladder is entered
    • Nausea/vomiting
    • Temporary urinary symptoms
  • Less Common
    • Bleeding/transfusion
    • Bladder, bowel or vascular injury
    • Difficulty with complete excision
    • Bladder injury requiring repair
    • Urinary leak
    • UTI
    • Wound infection
    • Ileus
    • Urgency/frequency
    • Conversion to open surgery
    • Recurrence
    • Port-site hernia
    • DVT/PE
    • Additional procedures
  • Rare but Serious
    • Major bleeding
    • Major bowel/bladder/vascular injury
    • Sepsis
    • Persistent urinary leak
    • Cardiopulmonary complications
    • ICU requirement
    • Life-threatening complications
    • Death

6. Postoperative Course

I understand that:

  • A urinary catheter may be maintained temporarily to allow bladder healing when the bladder has been entered or repaired. Further treatment may be required depending on histopathology or postoperative findings.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Observation in selected asymptomatic cases
  • Antibiotics/drainage for infection
  • Percutaneous drainage in selected cases
  • Open urachal cyst excision

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: _________________________________________

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