Informed Consent for Laparoscopic Appendectomy Surgery

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending General Surgeon

Patient Full Legal Name

Date of Birth

Surgical Urgency

Section 2text block

Section 3list block

Section 4list block

Section 5text block

Section 6text block

Section 7signature block

Patient / Legally Authorized Representative Signature

Consenting Surgeon Signature

Witness Signature

Date and Time of Consent

Informed Consent for Laparoscopic Appendectomy Surgery

Patient and Surgical Team Details

Surgical Facility Name

Attending General Surgeon

Patient Full Legal Name

Date of Birth

Surgical Urgency

Nature and Purpose of the Procedure

A laparoscopic appendectomy is a surgical procedure performed to remove an inflamed or infected appendix (appendicitis). Under general anesthesia, the surgeon makes several small keyhole incisions (typically 3) in the abdominal wall. Carbon dioxide gas is insufflated to inflate the abdomen, providing a clear working space. An endoscope (camera) and thin laparoscopic instruments are inserted. The surgeon isolates the appendix, seals its blood vessels, cuts it from the colon, and removes it through one of the incisions. The abdomen is then irrigated, the gas is released, and the incisions are closed with sutures or skin glue. In cases of severe infection, perforation (ruptured appendix), or anatomical difficulty, the surgeon may convert the procedure to an open surgical approach (laparotomy) requiring a larger incision. The procedure typically takes 30 to 60 minutes.

Material Risks and Potential Complications

Surgical site infection: including superficial skin infection at the trocar sites, or deep intra-abdominal abscess formation due to bacterial leakage, which may require drain placement or IV antibiotics.

Bleeding or hematoma formation, which may require blood transfusion or secondary surgery to control hemorrhage.

Injury to nearby organs including the cecum, small intestine, urinary bladder, or major blood vessels during trocar placement or dissection.

Bowel obstruction or postoperative ileus (temporary paralysis of bowel movement) due to tissue manipulation or intra-abdominal adhesions forming after surgery.

Conversion to open surgery (laparotomy) if appendiceal rupture, severe scarring, or severe bleeding makes laparoscopic surgery unsafe.

Incisional hernia at the trocar sites, particularly at the larger umbilical insertion point.

Reasonable Alternatives

Non-operative medical management: intensive intravenous antibiotic therapy alone in highly selected patients with uncomplicated appendicitis. There is a 20 to 30 percent risk of appendicitis returning within one year.

Primary open appendectomy: performing the procedure via a standard lower right quadrant incision instead of laparoscopically.

No treatment: refusing care. This is life-threatening, as appendiceal rupture will lead to diffuse peritonitis, severe sepsis, shock, and death.

Expected Benefits

The primary expected benefit of appendectomy is the complete removal of the diseased appendix, resolving active abdominal pain, preventing appendiceal rupture, peritonitis, abdominal abscess, and life-threatening systemic infection (sepsis).

Questions and Understanding Confirmation

I confirm that I have had the opportunity to read this consent form and discuss it with my surgeon. I understand that the surgery may need to be converted to an open procedure for my safety. I believe I am making an informed and voluntary decision.

Signatures and Verification

Patient / Legally Authorized Representative Signature

Consenting Surgeon Signature

Witness Signature

Date and Time of Consent

Document ID: CC-PENDING

CONSENTCOLLECT