Laparoscopic Adrenalectomy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laparoscopic Adrenalectomy

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

Laparoscopic adrenalectomy is a minimally invasive procedure in which one or both adrenal glands are removed through small abdominal incisions.

The approach is planned laparoscopically; however, conversion to open surgery may be necessary depending on operative findings.

4. Benefits and Indications

The procedure may be performed for:

• Adrenal tumours
• Phaeochromocytoma
• Cushing’s syndrome
• Other adrenal masses
• Functioning or potentially malignant adrenal lesions

The intended benefits include:

• Removal of the adrenal tumour or mass
• Resolution of hormone-related symptoms
• Prevention of tumour growth or malignancy
• Treatment of the underlying adrenal condition

Complete cure, normalization of hormones or prevention of recurrence cannot be guaranteed.

5. Risks and Complications

• Common / Expected
  • Pain at surgical or port sites
  • Wound infection
  • Urinary tract infection
  • Haematoma or seroma
  • Temporary ileus
• Less Common
  • Bleeding and need for blood transfusion
  • Injury to kidney, liver, spleen, pancreas or blood vessels
  • Adrenal vein injury
  • Conversion to open surgery
  • DVT / pulmonary embolism
  • Cardiopulmonary complications
  • Need for ICU care
  • Hormonal imbalance requiring medication
  • Port-site/incisional hernia
• Rare but Serious
  • Adrenal insufficiency, particularly following bilateral adrenalectomy
  • Major bleeding
  • Severe infection
  • Life-threatening complications
  • Death

6. Postoperative Course

I understand that:

• Follow-up evaluation and hormone monitoring are necessary after adrenalectomy. Hormone replacement may be required if adrenal function is inadequate. Additional procedures may be required depending on complications or postoperative findings.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Observation for selected small, non-functioning adrenal masses
• Open adrenalectomy
• Medical management of hormonal disorders in selected cases

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: _________________________________________