VEIL/RAVEIL Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Robot Assisted Video Endoscopic Inguinal Lymph Node Dissection

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

Lymph nodes are removed from the groin using a minimally invasive robotic/endoscopic approach.

Small incisions are made away from the groin crease with the aim of reducing wound complications.

4. Benefits and Indications

The procedure may be performed when inguinal lymph-node removal is required for cancer treatment and staging.

The intended benefits include:

• Removal of cancer-involved lymph nodes
• Accurate staging
• Improved oncological control and survival in selected patients

No guarantee of cure or long-term outcome can be given.

5. Risks and Complications

• General Risks
  • Bleeding
  • Infection
  • Pain/fever
  • DVT/PE
  • Cardiac or anaesthetic complications
• Procedure-specific Risks
  • Seroma/lymphocele: 30–70%
  • Lower-limb lymphedema: 10–40%, persistent in approximately 5–15%
  • Skin-flap necrosis/delayed healing:
    • Open ILND: 20–50%
    • VEIL/RAVEIL: 5–15%
  • Femoral-vessel injury: <1–2%
  • Nerve injury/numbness/neuropathic thigh pain: 5–15%
  • Wound infection/breakdown:
    • Open: 20–40%
    • VEIL/RAVEIL: 5–15%
  • Prolonged drain requirement
  • Prolonged urinary catheterisation
  • Need for compression garments
  • Recurrence of nodal disease
  • Possible future pelvic lymph-node dissection or adjuvant therapy

6. Postoperative Course

I understand that:

• Drains may remain for several days
• Hospital stay: approximately 3–7 days
• Persistent lymphatic drainage may occur
• Compression stockings/limb care may be required
• Regular wound and oncological follow-up is necessary
• The procedure may be converted to open surgery or extended to deeper ilioinguinal lymph-node dissection if indicated.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Open inguinal lymph-node dissection
• Surveillance in selected low-risk cases
• Radiotherapy
• Systemic therapy depending on disease stage

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: _________________________________________