Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Umbilical Hernia Repair
Your symptoms and physical exam suggest that you have an umbilical hernia. A hernia is a defect or rupture
in the normal abdominal wall. After careful consideration, an umbilical hernia repair has been recommended.
Risks of an Untreated Hernia
There are several reasons why we advise an umbilical hernia repair soon after the hernia is detected.
First, bowel or other abdominal organs could get trapped in the hernia sac like a noose, leading to the
need for emergency surgery, possibly with severe complications. Second, the hernia will not go
away with time; it will only get bigger. And third, there are no other adequate treatments for hernia.
Description of the Procedure
An umbilical hernia repair is performed by making an incision (usually a smile) in the abdominal wall just
below the umbilicus (belly button), identifying the hernia sac (if there is one) and tying it off; and then closing
the hole (or rupture) in the abdominal wall.
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 umbilical herniorrhaphy, if deemed necessary:
1.
Mesh placement – if the abdominal wall is weak, artificial mesh may need to be placed to buttress
the hernia and prevent its recurrence.
2.
Drain placement – sometimes we may need to place suction drains below the skin over the hernia
repair in order to prevent a blood or fluid collection.
Alternatives for Treatment
At this time, there are no effective alternative treatments for an umbilical hernia.
Benefits of Treatment
The overwhelming majority of people undergoing an umbilical hernia repair will not have the hernia recur.
The risks of avoiding repair outweigh the risks of the surgery for most people.
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 the hernia repair operation. 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 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. An infection
is a special concern if mesh is placed to help reinforce the hernia repair.
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.
Possible complications of hernia repair surgery
1.
Hernia recurrence – a small percentage of patients will notice a recurrence of their hernia, within
months or years after the repair. It will need to be repaired again. Physical restrictions given to
you after surgery will help minimize the risk of recurrence.
(see other side)
2.
3.
4.
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.
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.
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
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, and 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 condition to be an umbilical hernia 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 umbilical hernia repair benefit from the proposed
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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