Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Appendectomy
We have determined that you should have your appendix removed. There are several reasons why we may be
offering this operation to you. The appropriate reasons will be indicated below.
siticidneppa fo noicipsuS ‫—ڤ‬after examining your abdomen, I feel that there is a strong chance that you may
have appendicitis. The appropriate treatment is to remove your appendix.
xidneppa lamron a fo lavomer evitcelE ‫—ڤ‬there are times when we may remove your appendix when we are
inside your abdomen for other reasons. This will prevent you from ever getting appendicitis.
xidneppa desaesid a fo lavomer evitcelE ‫—ڤ‬you may either have had an episode of appendicitis that was
treated with antibiotics, or an X-ray may suggest a mass or stone (appendicolith) in your appendix, suggesting
that your appendix be removed.
Description of the Procedure
There are two methods by which we may perform an appendectomy: through the laparoscope (video surgery) or
through a small incision in your abdomen. The appendix is a small piece of bowel located in the right lower side of
your abdomen and is attached to the cecum (the first part of the large intestine). It has no known function.
Laparoscopic Appendectomy
A small incision is made in the area of your umbilicus (belly button), your abdomen is inflated with gas, and a video
camera is inserted into your abdomen. Several other small puncture wounds are made in your abdomen to allow us to
operate on the appendix. The appendix is removed from the cecum and removed from the abdomen. We may
occasionally need to convert to an open appendectomy to complete the operation safely.
Open Appendectomy
A small incision is made in the lower abdomen to expose the appendix. The appendix is removed at its base. The
wound is closed.
Additional Procedures that may be done while in Surgery
It is impossible to predict all of the variations that may be encountered during an operation. The following procedures will be
performed in addition to the appendectomy, if deemed necessary:
1.
2.
3.
Abdominal exploration—we occasionally operate for appendicitis and find that some other disease process is occurring
that has led to pain that mimics appendicitis. In order to further diagnose or treat you, we may need to enlarge the
incision or place a second incision on your abdomen. Various further treatments may be cholecystectomy (removal of
the gallbladder), removal of a piece of bowel, removal of a Meckel’s diverticulum, drainage of an abscess, or removal of
an ovary.
If we find that the appendix is perforated, we will need to irrigate out your entire abdomen. In this circumstance, we
often do not close your skin, but instead pack it with dressings. This will prevent a serious infection from occurring.
Drain tubes may be required to treat an abdominal abscess.
Colostomy—occasionally a colostomy may be necessary.
Alternatives for Treatment
There are no other alternatives recommended for the treatment of appendicitis. A normal appendix in young patients carries a risk
for subsequent appendicitis. A diseased appendix is also at increased risk for problems.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and those that are specific
for an appendectomy. In any medical treatment, it is impossible to predict all the things that could go wrong.
(see other side)
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 of major surgery
1.
Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood transfusion is rare.
2.
Infection – we take special care to prevent an infection, but it is always a possibility.
3.
Reactions to medication – 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.
Possible complications of appendectomy
1.
Hernia – a small percentage of patients will develop a hernia in the wound within months or years after surgery. It
will need to be repaired.
2.
Wound hematoma – occasionally a large bruise will form over the wound. If this is severe or happens soon after
surgery, we may need to re-explore the wound in the operating room.
3.
Prolonged numbness/pain in the incisional area – a patient may, on rare occasion, note prolonged numbness or pain
in the surgical area from nerve injury or scar entrapment.
4.
Bowel or bladder injury – an injury to a portion of the bowel or urinary bladder is uncommon but possible during
this operation. Should either occur, necessary steps will be taken to repair the injury. It may also be necessary to
have a second operation for this purpose.
Anticipated Recovery/Expected Rehabilitation
When appendicitis is associated with an abscess or peritonitis, antibiotics will be required for a week or more following surgery.
Recovery is quite variable, depending on the individual. You will recover faster if you begin walking on the evening of surgery.
For your safety, do not drive a motor vehicle or operate dangerous machines for a week following surgery, or while on pain
medication. Also do not lift anything greater than fifteen pounds for several weeks after surgery. Then you will only be restricted
from activity that causes discomfort, and this usually ends six weeks following surgery.
Consent for Treatment
I understand my need for an appendectomy and am aware of its risks if untreated. 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 findings. 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 appendectomy benefit from the operation, I may not. My condition may
not improve, and it may worsen. No absolute guarantee can be made.
HIPAA: 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__________________________________________________________________________
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 ______________
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