Consent Form for Trans-Anal Resection for Benign and Malignant Rectal Lesions
Paul E. Savoca, MD, FACS, FASCRS
The doctor has explained that I have the following condition:
RECTAL POLYP OR TUMOR
The following Procedure will be performed:
TRANS-ANAL EXCISION (Removal of a polyp or tumor in the lower rectum via the anus)
The operation will be performed in the following manner:
- Standard removal: polyp removal done without optical magnification using standard surgical instruments
- Trans-anal endoscopic microsurgical removal (TEM): polyp removal utilizing a magnifying trans-anal microscope and laparoscopic instruments
SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS
The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The doctor has also explained relevant treatment options as well as the risks of not having the procedure.
There are some general risks/complications of this procedure as with any surgical procedure. They include:
- Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
- Clots in the legs (deep vein thrombosis or DVT) with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
- A heart attack because of strain on the heart or a stroke.
- Death is possible due to the procedure.
There are some risks/complications specific to this procedure which include:
- Heavy rectal bleeding may occur during or after the procedure. This may require further surgery and possible blood transfusion.
- The bowel may perforate and further surgery may be necessary.
- All of the tumor may not be able to be removed at one sitting and further surgery may be necessary.
- Recurrence of the tumor which may require more extensive treatment.
- Increased risk in obese people of wound infection, chest infection, heart and lung complications and thrombosis.
- Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.
- There is a remote risk of the need for immediate abdominal surgery if complications arise during the polyp removal due to its size or location. A colostomy may be necessary. In most instances, discussion with the family is possible at this juncture but due to emergency circumstances this may not be possible until the surgery is completed.
PATIENT CONSENT
I acknowledge that:
The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
- I have been given written information regarding the procedure.
- I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
- I understand that the procedure may include a blood transfusion.
- I understand that a doctor other than the Attending Surgeon may be present during the procedure.
- I understand this could be a doctor undergoing further training.
- I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
- The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
- I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. You will not be identified in any photo or video
- I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE
Name of Patient _______________________________________
Signature/Date ________________________________________
Doctor’s Statement
I have…
- Explained the patient’s condition
- Explained the need for treatment
- Explained the procedure and the risks
- Explained relevant treatment options and their risks likely consequences if those risks occur
- Explained the significant risks and problems specific to this patient
- Given the patient an opportunity to ask questions about the above matters
- Given the patient an opportunity to raise any other concerns which I have answered as fully as possible.
I am of the opinion that the patient understood the above information.
Signature_______________________________
Paul E. Savoca, MD, FACS, FASCRS
Date___________________________________