1101 First Colonial Road, Suite 100
Virginia Beach, Virginia 23454

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Consent To And Request For 
Laparoscopic Surgery*

MY CHOICE: This information about Laparoscopic Surgery is from Raymond C. Lackore MD. I was told that the decision to have this surgery is completely up to me. I was told that I could decide not to have this surgery.
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(Patient Initials)
THE PROCEDURE: I understand that during this procedure the surgeon will first perform a diagnostic examination (look around to see exactly what is present) using a lighted tube instrument called a laparoscope. The surgeon will first place the laparoscope and if necessary, additional probes inside my abdomen. This will require creating one or more incisions (cuts) through the abdomen (belly) near the umbilical area (belly button) and one to three more small incisions in my lower abdomen. These incisions will probably be about one-half inch long, although the length of the cut(s) can vary. What occurs next will depend on the findings during the diagnostic part of the operation. If in the surgeon's judgment treatment can be undertaken using the laparoscope, then the surgeon will use the endoscope to try to correct any problems. The purpose for this surgery may include but is not limited to: 
_____Looking for a cause of pain.
_____Cutting or separating scar tissue in hopes of reducing pain.
_____Using Harmonic or Electrical energy to remove or destroy endometriosis in hopes of reducing pain. 
_____Opening or removing ovarian cysts.
_____Surgically dealing with other findings that may help my condition or 

Other:_________________________________________________________________________________
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(Patient Initials)

ALTERNATIVES: I was told that the following may be alternatives to laparoscopy, and those checked may apply to me:
_____Leave the problem untreated and accept the natural course of the condition.
_____Attempt to control some problems with hormones or other medications.
_____Instead choose major abdominal surgery through a full sized abdominal incision.
_____I understand that I have the right to seek a consultation from a second physician.
_____Combination of any of the above.

Other: ______________________________________________________________________________
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(Patient Initials)

POSSIBLE NEED FOR MAJOR SURGERY:  IF AN EMERGENCY CONDITION IS FOUND OR DEVELOPS, THEN MAJOR SURGERY WITH A FULL SIZED ABDOMINAL INCISION MAY BE REQUIRED IMMEDIATELY. If major open surgery is required (AND IS NOT AN EMERGENCY) then it is usually scheduled at another time following discussion with you the patient. If a hospital stay will be required, it is usually short with laparoscopy, but is likely to be longer if full incision abdominal surgery is required.

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(Patient Initials)

GENERAL RISKS: I understand that laparoscopy is a relatively safe procedure, but it does involve some risks and discomforts. General anesthesia is used. Most patients have surgery with little difficulty, but problems can happen ranging from minor to fatal. These include nausea, vomiting, pain, infection, poor healing, hernia, or formation of adhesions. Unexpected reactions may occur from any drug or anesthetic given. Nerves going from the pelvis to the legs may be injured. Dangerous blood clots may form in the legs or lungs. Allergy to any of the medicines used is also a remote possibility. Infections may occur, although these are seldom serious infections with laparoscopy. I understand death has been reported to rarely result from this procedure. Finally, I understand that it is impossible to list every possible undesirable effect and that the condition for which surgery is done is not always cured or significantly improved, and in rare cases may be even worse.

BOWEL AND URETERAL INJURY RISKS: I understand there is a small possibility of cutting or otherwise injuring my intestines or the ureter (the tube from the kidney to the bladder) which might result in serious interference with the functioning of the organs. Such injuries may sometimes be immediately repaired with little effect. However, If needed, a general surgeon or urologist may be called to assist with any bowel or ureteral injury . It might be necessary to perform a colostomy where a bag is put on the abdomen to divert stool until a permanent repair can later be done. 

BLEEDING RISKS: I understand there is a small possibility of cutting or puncturing blood vessels resulting in heavy bleeding. This may require a large incision and / or a blood transfusion with the risks of transfusion reactions, hepatitis or (extremely rarely) HIV infection.
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(Patient Initials)

REFUSAL: I understand that refusing this procedure might be risky to my health or life. Dr. Lackore may not know what, if anything, is wrong with me without this procedure. If I refuse this procedure I understand possible risks include but are not limited to: worsening pain or worsening undetected disease such as infection, adhesions or (rarely) cancer which may worsen as well as an increasing chance that a major abdominal incision may be required to achieve the surgery in the future.
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(Patient Initials)

I understand that I will be at the surgical site for approximately 3 to 4 hours,

and that I will not be fully recovered from this surgery for 3 to 6 weeks.
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(Patient Initials)

CONSENT AND REQUEST:  Having been informed of the above and after discussing this operation with Dr.Lackore, I request and consent to Raymond C. Lackore M.D. performing the laparoscopic surgical procedures and, if required by emergency or immediate danger, the abdominal surgery (laparotomy). This request and consent extends to the administration of such anesthetics and medicines as may be desirable. I also authorize Dr. Lackore to use his best judgement and to serve as my advocate during the course of this operation to make reasonable changes in the plan or extent of the surgery. I understand that Dr. Lackore cannot guarantee the outcome or success of this treatment. I have had all of my questions answered to my satisfaction. I acknowledge receiving a copy of this consent and request form.

Patient’s Signature: _______________________________ Date:_______________
Witness: _______________________________ Date:_______________
Physician: _______________________________ Date:_______________