Hernia- Open Inguinal Hernia Repair PROCEDURAL CONSENT FORM. A. Interpreter / cultural needs. B. Condition and treatment

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1 DO NOT WRITE IN THIS BINDING MARGIN v /2011 SW9317 Hernia- Open Inguinal Hernia Repair Facility: A. Interpreter / cultural needs An Interpreter Service is required? Yes No If Yes, is a qualified Interpreter present? Yes No A Cultural Support Person is required? Yes No If Yes, is a Cultural Support Person present? Yes No B. Condition and treatment The doctor has explained that you have the following condition: (Doctor to document in patient s own words) This condition requires the following procedure. (Doctor to document - include site and/or side where relevant to the procedure) The following will be performed: Open surgery to repair the weakness in the groin area. A small cut is made at the site of the hernia. The weak area is reinforced with stitches or mesh. URN: C. Risks of an open inguinal hernia repair There are risks and complications with this procedure. They include but are not limited to the following. General risks: Infection can occur, requiring antibiotics and further treatment. Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin). Small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy. Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis. Heart attack or stroke could occur due to the strain on the heart. Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break off and go to the lungs. Death as a result of this procedure is possible. Specific Risks: Trouble passing urine after the operation due to spasm of the bladder sphincter. Swelling of the testicle and scrotum in male patients. Also the penis may show bruising. The testicle may stop making sperm and it may shrink. Family name: Given name(s): Address: (Affix identification label here) Date of birth: Sex: M F I The tube carrying sperm from the testicle to the prostate may be injured. This results in partial vasectomy and may reduce fertility. One of the small nerves in the groin can be cut or caught in a stitch or scar causing long term burning and aching in the groin. The testicle may sit a little higher in the scrotum after surgery. Adhesions (bands of scar tissue) may form and cause bowel obstruction. The scar can thicken, turn red and may be painful. This is permanent and can be disfiguring. The hernia may come back. Further surgery may be needed to repair the hernia. Hernia formation where instruments were passed into the abdomen. D. Significant risks and procedure options (Doctor to document in space provided. Continue in Medical Record if necessary.) E. Risks of not having this procedure (Doctor to document in space provided. Continue in Medical Record if necessary.) F. Anaesthetic This procedure may require an anaesthetic. (Doctor to document type of anaesthetic discussed) PROCEDURAL CONSENT FORM Page 1 of 2

2 (Affix identification label here) URN: Hernia- Open Inguinal Hernia Repair Family name: Given name(s): Address: Facility: G. Patient consent I acknowledge that the doctor has explained; my medical condition and the proposed procedure, including additional treatment if the doctor finds something unexpected. I understand the risks, including the risks that are specific to me. the anaesthetic required for this procedure. I understand the risks, including the risks that are specific to me. other relevant procedure/treatment options and their associated risks. my prognosis and the risks of not having the procedure. that no guarantee has been made that the procedure will improve my condition even though it has been carried out with due professional care. the procedure may include a blood transfusion. tissues and blood may be removed and could be used for diagnosis or management of my condition, stored and disposed of sensitively by the hospital. if immediate life-threatening events happen during the procedure, they will be treated based on my discussions with the doctor or my Acute Resuscitation Plan. a doctor other than the Consultant may conduct the procedure. I understand this could be a doctor undergoing further training. I have been given the following Patient Information Sheet/s: About Your Anaesthetic OR Epidural & Spinal Anaesthesia I was able to ask questions and raise concerns with the doctor about my condition, the proposed procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand I have the right to change my mind at any time, including after I have signed this form but, preferably following a discussion with my doctor. I understand that image/s or video footage may be recorded as part of and during my procedure and that these image/s or video/s will assist the doctor to provide appropriate treatment. On the basis of the above statements, Date of birth: Sex: M F I Page 2 of 2 I request to have the procedure Name of Patient:... Signature:... Patients who lack capacity to provide consent Consent must be obtained from a substitute decision maker/s in the order below. Does the patient have an Advance Health Directive (AHD)? Yes No Location of the original or certified copy of the AHD:... Name of Substitute Decision Maker/s:... Signature:... Relationship to patient:... Date:... PH No:... Source of decision making authority (tick one): Tribunal-appointed Guardian Attorney/s for health matters under Enduring Power of Attorney or AHD Statutory Health Attorney If none of these, the Adult Guardian has provided consent. Ph 1300 QLD OAG ( ) H. Doctor/delegate Statement I have explained to the patient all the above points under the Patient Consent section (G) and I am of the opinion that the patient/substitute decisionmaker has understood the information. Name of Doctor/delegate:... Designation:... Signature:... I. Interpreter s statement I have given a sight translation in... (state the patient s language here) of the consent form and assisted in the provision of any verbal and written information given to the patient/parent or guardian/substitute decision-maker by the doctor. Name of Interpreter:... Signature:... DO NOT WRITE IN THIS BINDING MARGIN

3 1. What do I need to know about this condition? A hernia, sometimes referred to as a rupture, occurs when a part of an internal organ, sometimes the bowel, pushes through a weak point in the abdominal wall. Consent Information - Patient Copy 5. What are some alternative treatments? A truss may be worn which applies support to the weak area. The truss is not a cure and can be uncomfortable. It may cause pressure sores and is not always effective. The proper use of a truss requires medical advice. 6. My anaesthetic This procedure will require an anaesthetic. See About Your Anaesthetic OR Epidural and Spinal Anaesthesia for information about the anaesthetic and the risks involved. If you have any concerns, discuss these with your doctor. If you have not been given an information sheet, please ask for one. An inguinal hernia Inguinal hernia is the most common type of hernia, and twenty times more common in men than in women. It is likely that about 1 in 20 men will develop an inguinal hernia. The inguinal canal is in the groin. The first signs of a hernia are pain and/or a lump. 2. What do I need to know about this Procedure? Open surgery is performed under a general, spinal or local anaesthetic to repair the weakness in the abdominal wall. A small cut is made at the site of the hernia. The weak area is repaired. Sometimes the weak area is reinforced with mesh. 3. What are the benefits of having this The pain and lump will be relieved by the surgery. Planned surgical treatment of a hernia is much safer than leaving the hernia until an emergency happens. 7. What are the risks of this specific There are risks and complications with this procedure. They include but are not limited to the following. General risks: Infection can occur, requiring antibiotics and further treatment. Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin). Small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy. Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis. Heart attack or stroke could occur due to the strain on the heart. Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break off and go to the lungs. Death as a result of this procedure is possible. Specific risks continues in the table on the next page - 4. What are the risks of not having this The hernia will probably get bigger. Inside, the bowel may become trapped and blocked or gangrenous (that part of the bowel dies). This can be very dangerous and will need emergency treatment. Treatment may require extensive surgery to the bowel. Page 1 of 3

4 Consent Information - Patient Copy 7. What are the risks of this specific (Continued) The risk What happens What can be done about it Trouble passing urine after the operation Swelling of the testicle and scrotum Injury to sperm tube (Vas Deferens) Ongoing pain or discomfort in groin Change to testicle Wound infection Bleeding into the wound The wounds may not heal normally Bands of scar tissue - adhesions Hernia comes back Hernias at the wound sites Increased risk in smokers A temporary problem due to spasm of the bladder muscles in 1 in 100. More common in elderly males. In male patients, the testicle and the contents of the scrotum may swell due to tissue damage during surgery or bleeding during or after surgery. Also the penis may show bruising. The tube carrying sperm from the testicle to the prostate may be injured which may reduce fertility in 1 in 100. One of the small nerves in the groin can be cut or caught in a stitch or scar causing long term burning and aching in the groin in 1 in 50. The testicle may sit a little higher in the scrotum after surgery. The wound may become infected. The rate of risk is estimated at about 1% or 1 in 100. Possible bleeding into the wound after the surgery in 1 in 30. The scars can thicken and turn red and may be painful. Bands of scar tissue can form inside the abdomen, which may cause bowel blockage and possible bowel damage. The hernia may come back in 1 in 30 to 1 in 100. Hernias may form where instruments were passed into the abdomen. Smoking slows wound healing and affects the heart, lungs and circulation. A catheter (plastic tube) is put into the bladder to drain the urine away. The swelling of the scrotum may be drained using a needle. The testicle may stop making sperm and it may shrink (1 in 3000 to 1 in 200 for primary repairs and 1 in 20 to 1 in 120 for recurrent repairs). Results in partial vasectomy. This may happen straight after surgery or months or years later. A change in physical appearance. Wound infections are usually treated with dressings and/or antibiotics. Swelling, bruising, blood stained discharge, which may cause pain, or become infected. Treatment is usually antibiotics and/or drainage by further surgery. This is permanent and can be disfiguring. It is more frequent in recurrent hernias. Further surgery may be necessary. Further surgery to repair the hernia. This may need further surgery. Giving up smoking before the operation will help reduce the risk. Death Death is extremely rare due to hernia repair - less than 1 in 10,000. Page 2 of 3

5 8. What do I need to know about recovering from this After the operation the nursing staff will closely watch you until you have recovered from the anaesthetic. You will then go back to the ward where you will rest until you are well enough to go home. Young, fit patients may be able to go home the same day. Other patients usually go home 24 hours after surgery. If you have any side effects from the anaesthetic, such as headache, nausea or vomiting, you should tell the nurse looking after you, who will be able to give you some medication to help. Pain You can expect to have pain in the operation site. The nurse can give you painkillers for this, so it is important to let the nurse know. Your pain should wear off within 7-10 days. If it does not, you must tell your doctor. Diet You may have a drip in your arm, this will be removed soon after you recover from the anaesthetic. To begin with, you can take small sips of water, and then slowly take more until you are eating normally. Wounds Your wound may have a small dressing, which will be removed the day after surgery. You can shower the day after surgery. Your wound will be protected with a dressing, which is either stick-on or spray-on. Stick-on dressings should be replaced if they become dirty or are falling off. Continue to keep your wound clean and protected until healed and no seepage is present. Your lungs and blood supply It is very important after surgery that you start moving as soon as possible. This is to prevent blood clots forming in your legs and possibly going to your lungs. This can be fatal. Also, you need to do your deep breathing exercises. Take ten deep breaths every hour to prevent secretions in the lungs becoming stagnant. If this happens, you may develop a chest infection. At all costs, avoid smoking after surgery as this increases your risk of chest infection. Coughing is painful after abdominal surgery. Exercise Expect to feel tired for a few days after surgery. You need to take things easy and gradually return to normal duties, as you feel able to. It usually takes about 2-3 weeks to recover after open repair. You should not drive during the first week. Do not lift heavy weights for at least six weeks after surgery. This is to prevent a rupture where the cuts were made and allow healing to take place inside. Consent Information - Patient Copy 9. What do I need to tell my doctor? Tell your doctor if you have large amounts of bloody discharge from the wound/s. fever and chills. pain that is not relieved by prescribed pain killers. swollen abdomen. swelling, tenderness, redness at or around the cut/s. Notes to talk to my doctor about: Page 3 of 3

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