Laparoscopic Orchipexy Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Laproscopic Orchipexy

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 undescended testis is mobilized laparoscopically and brought into the scrotum, where it is fixed in its normal position.

Depending on intraoperative findings, orchiectomy or staged intervention may be required.

4. Benefits and Indications

The procedure may be performed for an undescended testis, unilateral or bilateral.

The intended benefits include:

  • Placement of the testis in the scrotum
  • Preservation of fertility potential
  • Prevention of torsion
  • Reduction of malignancy risk
  • Cosmetic correction

No guarantee can be given regarding future fertility, testicular size or long-term cancer-risk reduction.

5. Risks and Complications

  • Common
    • Pain
    • Wound/port-site discomfort
  • Less Common
    • Bleeding
    • Injury to vas deferens, bladder or vessels
    • Infection
    • Testicular atrophy
    • Testicular malposition/retraction
    • Hydrocele
    • Recurrent undescended testis
    • Ileus
    • Port-site hernia
  • Rare but Serious
    • Major bleeding
    • Major injury
    • DVT/PE
    • Cardiopulmonary complications
    • Need for ICU care
    • Death

6. Postoperative Course

I understand that:

  • Regular follow-up is required to assess:
    • Testicular position
    • Testicular size
    • Viability
    • Long-term malignancy risk
    • Hypogonadism
  • Clinical examination, blood tests and imaging may be required.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Open orchidopexy
  • Hormonal therapy, with limited efficacy
  • Observation 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: _________________________________________

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