Robert C. Wright, MD, PS
Informed Consent – Abdominal Exploration or
Diagnostic Laparoscopy
Your symptoms, physical exam and laboratory studies suggest that you have a disorder within your
abdomen. The causes for a problem in the abdomen are many, including cancer, inflammatory and infectious
diseases, to name a few. After careful consideration, an abdominal exploration is the procedure that has been
recommended.
Description of the Procedure
An exploration of the abdomen is diagnostic in nature. This operation can be performed open, but sometimes
can also be performed using a video laparoscope. For an open exploration, the incision is placed in the
middle of your abdomen. The contents of the abdomen are carefully inspected and felt for disease.
Treatment will be rendered as indicated by the disease that is found. A laparoscopic exploration entails
making a small incision below the umbilicus (belly button), inserting a video laparoscope through the
incision into the abdomen, inserting additional instruments into the abdomen through small stab wounds, and
then examining the abdomen for disease.
Additional procedures that may be done while in surgery
It is impossible to accurately predict what we will see or encounter when we do this operation, especially
since the nature of the disease process may not be known prior to the time of operation. Should an
unexpected procedure be necessary, we will make every attempt to notify a responsible relative or friend of
our actions. The following procedures will be performed only if necessary:
1. Colostomy or ileostomy formation – there are times when it is deemed necessary to remove or
decompress a piece of bowel, necessitating the formation of a colostomy or ileostomy. We may not always
know that preoperatively. Sometimes, the colostomy can be reversed at a second operation.
2. Resection of organs – if the surgery demonstrates a diseased abdominal organ, removal may be necessary.
This may consist of removing part of the liver, gall bladder, stomach, intestine, pancreas, urinary bladder,
diaphragm, abdominal wall, kidney or the spleen.
3. Oophorectomy – we recommend prophylactic removal of your ovaries when it is technically feasible
during the operation if you are postmenopausal, or are a woman with an abdominal cancer.
4. Appendectomy – if you are considered to be high risk for appendicitis, the appendix will be removed
during the operation if deemed safe.
Alternatives/Benefits of Treatment
Alternative treatments and benefits for surgery will depend upon the disease process. Because the operation
is diagnostic in nature, it is possible that the operation may be of no benefit to you.
Risks/Complications of Treatment
In any medical treatment, it is impossible to predict all the things that could go wrong. Fortunately,
complications are the exception rather than the rule. Every reasonable effort is made to avoid complications.
The most common possible complications are as follows:
Possible complications following any operation
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion during or after this operation is uncommon.
2. Infection – we take special care to prevent an infection, but it is always a possibility. An infection
may require prolonged hospitalization and treatment or re-operation to resolve.
3. Reactions to medications – this could be many things from a minor rash to possible death
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
5. Poor wound healing – breakdown of the incision or development of hernias.
(see other side)
Possible complications following an abdominal exploration
1. Bowel or abdominal organ injury – an injury to a portion of the intestines, pancreas, or other
abdominal organs is uncommon but possible during this operation. Should this occur, we will repair
the injury. Re-operation may be required.
2. Inability to identify or treat the disease – it is possible to find a completely normal abdomen without
evidence of disease. It is also possible to find an abdomen with disease that is too advanced to be
able to treat surgically. If cancer is found, further treatments and possibly further surgery.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Hospitalization is sometimes required. Restrictions
on lifting and strenuous physical activity may extend for six weeks. Most people can return to work for
“light duty” in two to three weeks. Dietary restrictions will entail liquid to soft meals initially, advancing to
regular food over 1-2 months.
Consent for Treatment
I understand my option for an abdominal exploration. I have read and understand the above
explanation of the procedure being proposed. My surgeon has answered my questions, and I choose to
proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving an abdominal exploration benefit from the operation, I
may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on
my behalf.
SIGNATURE _____________________________________________________ DATE _________________
04/04rev