I {patientsFull}, have reviewed drawings of hiatal hernia repair and fundoplication surgery that diagrammatically show the main characteristics of the operation. I have had the chance to express to the surgeon my acid reflux symptoms, and their effect on my quality of life. Surgeon has helped me to personally conclude as to the most appropriate acid reflux treatment for me, factoring in my acid reflux symptoms and stage, as well as response to lifestyle changes and medical treatment. The surgeon has counseled me regarding my decision, has made professional recommendations, and we have together agreed on the planned procedure as acceptable and appropriate.
I {patientsFull}, hereby authorize Dr. Elias Darido and any associates or assistances the doctor deems appropriate, to perform Laparoscopic hiatal hernia repair, Nissen or Toupet fundoplication, possible Open Laparotomy. The doctor has explained to me the risks and the benefits of surgery. I also authorize the administration of sedation and/or anesthesia as may be deemed advisable or necessary for my comfort, wellbeing and safety.
Risk/Possible Complications
Dr. Darido has explained to me that there are risk and potential undesirable consequences associated with a Laparoscopic hiatal hernia repair, Nissen or Toupet fundoplication, including, but not limited to:
- Adverse reaction to anesthesia (Headache, muscle pain, nausea)
- Anaphylaxis (Severe allergic reaction)
- Bleeding, blood transfusion, and associated risks
- Blood clots, including pulmonary embolus (blood clot migrating to the heart and lungs)
- Cardiac arrest, myocardial infarction
- Stroke
- Death
- Hernias, incisional (including the port sites for laparoscopic access)
- Vagal nerve injury and gastroparesis (Impaired gastric emptying)
- Injury to the bowels, blood vessels, bile duct, and other organs
- Injury to adjacent structures, including the spleen, liver, diaphragm, pancreas and colon
- Possible removal of the spleen
- Fever
- Perforations (leaks) of the stomach or intestine
- Pleural effusions (fluid around the lungs)
- Hypotension (low blood pressure)
- Pressure sores
- Pulmonary edema (fluid in the lungs)
- Skin breakdown
- Hypoxemia (low oxygen in the blood)
- Diarrhea
- Infection
- Dysphagia (Difficulty swallowing)
Alternative Procedure. In permitting my doctor to perform this procedure, I understand that unforeseen conditions may necessitate change or extension of the original procedure(s), including completing the operation by way of the conventional open surgical approach, or a different procedure from what was explained to me. I therefore authorize and request that the above-named physician, his assistants or designees to perform such procedure(s) as may be necessary and desirable in the exercise of his/her professional judgment. The reasonable alternative(s) to the procedure(s), as well as the risks to the alternatives, have been explained to me. These alternatives include, but are not limited to, laparoscopic Collis gastroplasty in case of a short esophagus. I hereby authorize the disposal of removed tissues resulting from the procedure(s) authorized above. I consent to the photographing or videotaping of the procedure(s) that may be performed, provided my identity is not revealed by the pictures or by descriptive text accompanying them.
By signing below, I certify that I have had an opportunity to ask the doctor all my questions concerning surgery, benefits, risk factors, and alternative therapies, and all my questions have been answered to my satisfaction.