Informed Consent Form For Surgery

Full Name *

Date of Birth

Email Address *

Who is your surgeon? *

Dr Jason WongDr Aaron Lim

Laparoscopic One-Anastomosis Gastric Bypass

Also referred to as Mini Gastric Bypass, Omega loop, Single anastomosis gastric bypass

Procedure

Laparoscopic One-Anastomosis Gastric Bypass (31581) as a primary bariatric procedure

- This procedure is a variant of gastric bypass surgery with biliopancreatic diversion without duodenal switch

Other possible incidental procedures:

Repair of paraoesophageal hiatal hernia (31468)
Division of adhesions (30722 or 30724)

Addition of Gastric Calibration Ring

No RingMid-Cal RingMinimizer Ring

Additional anticipated procedures:

Repair of ventral or umbilical hernia (30651 or 30621)Cholecystectomy and cholangiogram (30445)

Other Surgery Details

Final check of consent and procedure on day of surgery

Date of surgery

Final patient signature on day of surgery

Draw signature|Type signatureClear

Final surgeon signature on day of surgery

Draw signature|Type signatureClear

Indication for surgery:

• Morbid Obesity

• Failed weight-loss through non-surgical means or failed previous weight-loss procedure

Alternatives to this procedure:

• May include Roux-en-Y Gastric Bypass, Sleeve Gastrectomy or Lap Band Surgery and Non-surgical weight-loss including medication

How is the procedure performed?

A gastroscopy is usually performed in the work-up before surgery, sometimes weeks prior or on the day.
Surgery is performed under General Anaesthesia.
The surgery is performed using key-hole surgery and there will usually be 5 small incisions.
The stomach will be stapled into two separated compartments with food passing into the “gastric pouch” which is quite similar to a sleeve gastrectomy in size.
The majority of the stomach is “bypassed” or excluded from ingested food.
150-200cm of small intestine is also bypassed and then connected to the bottom of the gastric pouch for food to
pass into and be absorbed by the body,
You may be offered the option of a fixed-ring around the gastric pouch to prevent pouch dilatation over time and possibly better sustained weight loss. Examples of these rings are the mid-cal ring and minimizer ring. However, there are potential risks to the ring also such as erosion and functional obstruction causing food tolerance problems.
A surgical glue may be used also to prevent bleeding.
After surgery
- Pain around the wounds and shoulder tip are to be expected following surgery.
- Swallowing fluids and eventually food may feel different after surgery.
- Most patients will be discharged home after 1 or 2 nights stay in hospital.
- You will need to remain on anti-acid medication (Pantoprazole or another proton-pump inhibitor) for 3 months after surgery.
- You will be on vitamin supplements for the rest of your life.
- You will require blood test nutritional monitoring for the rest of your life.
- You will be on a modified post-surgery diet which will be instructed by the dietitian.
- It is recommended that you take two weeks off work to recovery from surgery.
- You will not be able to drive for at least 7 days after surgery. 
If you live more than 1 hour drive from Brisbane, you will need to stay locally in the greater Brisbane Region after surgery for your recovery for at least 10 days after surgery, in case you were to develop early complications.

Please click on this link to view an educational video on the One-Anastomosis Gastric Bypass

https://www.youtube.com/watch?v=aTxZFcTc6SM

Declaration Of Understanding *

My surgeon has explained the indications for surgery, about the procedure to me in language I can understand.I accept the surgery that has been proposed, and other reasonable alternatives have also been considered.I understand the indications for surgery being performed.I understand about the surgery that is to be performed, including pre-operative investigations and recovery after surgery.I understand that it is recommended for me to stay locally in Brisbane after surgery for at least 1 week for my own safety.

Potential risks of surgery

Gastric bypass surgery is considered safe and has a very low risk of serious complications. Revision surgery, surgery in smokers, patients on medication that affects healing or blood clotting, or other significant medical conditions may have a higher risk of complications with surgery.

Gastric bypass surgery will usually NOT be offered to patients who smoke or use nicotine products because of the risk of complications and marginal ulceration. If you are a smoker or nicotine user, you are required to stop AS SOON AS POSSIBLE, as you need to be completely nicotine-free for 30 days before the surgery. There are blood and urine tests that are able to be done to test compliance.

You may be required to prove your commitment to remaining smoke free for a period of time, if you are a recently quit smoker. If you are a smoker, vaper or nicotine user and have not discussed this with your surgeon, you are advised to declare this to a member of the BGOS team immediately.

Serious complications - (rare <1%)

Damage to other structures or organs.

Major Bleeding.

Staple line leak – which can result in serious illness requiring further interventions.

Anastomotic leak - which can result in serious illness requiring further interventions.

Death

Uncommon complications

Reflux symptoms which may be acid reflux or bile reflux. This can require further surgery to remedy if medication cannot adequately treat the reflux symptoms.

Difficulty swallowing, or feeling that things don't pass down the oesophagus as well.

Pouch or anastomosis dilatation over time with loss of restriction.

Weight regain.

Poor weight loss or excessive weight loss - the ultimate result varies between people.

Malnutrition – Iron, Vitamin B12, Vitamin D, Zinc, Protein.

Dumping syndrome.

Post-prandial reactive hypoglycaemia.

Internal hernia (twisted bowel).

Loose bowel motions or constipation.

Twisting of the gastric pouch.

Narrowing of the gastric pouch.

Other General Risks

Wound infection.

Incisional hernia.

Gallstones developing (approx 30%), which may require further surgery.

Venous thromboembolism.

Pneumonia.

Complications related to anaesthesia or medications including a severe allergic reaction.

Other Risks or Complications discussed by your surgeon

Declaration of Understanding of Surgical Risk *

My surgeon has gone through the risks of the surgery with me in language that I can understand.I understand that this is a major surgical procedure, and that complications can occur. Whilst these are uncommon or rare, the implications can be significant and can include requiring further interventional procedures, prolonged stay in hospital (weeks or months), long-term disability and even death.I understand that all relevant and significant complications that are often seen or known about have been explained and understood, and that it is not possible for every single possible complication that could happen to be covered.I understand that I cannot be a smoker for at least 30 days prior to surgery, and smoking may result in cancellation of surgery with loss of deposit.

My Obligations and Responsibilities when having Bariatric surgery

Having bariatric surgery is not just about losing weight, but also committing to looking after your own health and well-being. There are a number of follow-up appointments with the surgical and multidisciplinary support team that you will be expected to participate in as part of your follow-up pathway. These follow-up appointments have been explained to you previously, and a schedule of your appointments will be provided to you after your surgery. Because some of these appointments are arranged months or even a year in advance, it is expected that you make arrangements in your timetable to fit these in around work and other commitments.

There is risk of malnutrition or nutritional deficits after having bariatric surgery, and one of the most important aspects about having surgery is learning about the types of food you should be eating, the amounts and frequency, drinking enough fluids and taking vitamins and other supplements as directed.

You will need to take vitamins and other supplements for the rest of your entire life. You will also need to undergo blood tests to monitor your nutritional status for the rest of your entire life.

The pathway to have surgery requires multiple steps, which most people are not familiar with. It is our aim to provide you with as much information about everything, and we will communicate these things with you via email. It is your responsibility to read the emails and information that is provided to you, if you ever are wondering what to do next.

Acknowledgement of my obligations as a patient

I acknowledge and accept the responsibility and commitment that is required of me as a patient when undergoing bariatric surgery.I understand that there will be a number of appointments I need to attend or participate in.I understand the importance of dietitian care in learning about how I should be eating after surgery.I understand that I will need to take vitamins and other supplements for the rest of my life.I understand that I will need to get blood tests to monitor my nutrition for the rest of my life.I understand that all important information regarding my care pathway will be sent to me via email.

Clinical Photography and Video

It is standard practice for Dr Wong and Dr Lim to capture images whilst performing surgery using the laparoscopic camera system. These photographs document key parts of the surgical procedure and form part of the clinical records for your surgery, stored with the hospital and your surgeon's practice.

Occasionally, de-identified clinical images are required for research study or teaching purposes and if one of the images captured from your surgery depicts a particular teaching point well, it may be used for this with your permission.

Your surgeon may also record parts of or the entire surgical procedure. This is so that if there are any complications that occur during your surgery, the footage can always be reviewed to try to identify a cause.

Consent for Clinical Photography and Video *

I consent to the use of imaging for medical record-keeping.I consent to the use of imaging for teaching purposes and to help explain the surgery to other patients.I consent to the use of imaging in medical publications, including medical journals, textbooks, and electronic publications.I consent to Dr Wong recording my surgery for potential future reference and teaching purposes.I DO NOT consent to any recordings being made during my surgery.

Blood Transfusions and Blood Products

A blood transfusion is not expected to be needed as part of surgery, however in an urgent situation it may be advised. Please state whether you consent to a blood transfusion being given if required.

You are encouraged to consent to blood transfusion unless you have a strong reason not to, and understand the consequences of refusing blood transfusion.

Blood transfusion is when you’re given blood, or components of blood such as red blood cells, plasma or cells called platelets, from someone else (a donor). It is a very safe procedure that can be lifesaving. It may be required if there is significant bleeding during or following the operation.

Compared to other everyday risks, the likelihood of getting an infection from blood transfusion is very low.

Donors and blood donations are screened for a number of infections which can be transmitted through blood, but it is not practical or even possible to screen donations for all infections, therefore, there will will always be a small risk associated with having blood transfusion.

Reactions can also occur despite best measures having been made to administer blood that is compatible with your blood type. Because of the strict processes and pathways that exist to match blood type, the check-points to eliminate error, serious blood incompatability reactions are very rare. Occasionally, mild reactions can occur such as fever.

Consent for Blood Products *

I consent to a blood transfusion or blood products if it is required.I DO NOT consent to a blood transfusion or blood products, and understand that declining this in the setting of serious bleeding could threaten my health and life.

Data Collection

Dr Wong and Dr Lim submits data to the Bariatric Surgery Registry through Monash University. This data is de-identified, and enables important statistics on bariatric surgery to be kept in Australia to provide information about how many procedures are done per year and surgical outcomes and complications.

Dr Wong and Dr Lim also maintain their own prospective databases on patients they perform surgery on, for the purposes of measuring outcomes, quality control, audit and potentially research study purposes.

Consent to Data Collection *

I consent to my surgeon collecting and submitting data to the Bariatric Surgery Registry and I have been provided further information about this.I consent to my surgeon collecting data to monitor my outcomes from surgery.I DO NOT consent to my surgeon collecting any data for any purposes.

Third Parties present in the operating theatre

Industry product support specialists may be present in the operating theatre with your surgeon, to provide support to Dr Wong, Dr Lim and the theatre team for various pieces of equipment such as the laparoscopic camera, stack and screen, surgical devices and instruments or adjunctive agents used such as staple-line reinforcement, sutures or surgical glue.

Other surgical or medical personnel may also be present in the theatre to observe Dr Wong or Dr Lim operating to learn about bariatric surgery. Such persons may include other surgeons, doctors, nurses, dietitians, medical or nursing students and paramedics. These persons are there purely to learn and observe, and will not have any role in performing or assisting the surgery. Every effort is made to ensure that these attendees are not causing any distraction.

Consent to Third Parties being present in theatre *

I consent to third parties being present in the operating theatre.I DO NOT consent to any third parties being present in the operating theatre.

Patient Consent

I am covered for the proposed surgery by a private health insurance fund

YesNo

Patient Declaration

I am aware the Fee Estimate related to the proposed treatment may change as a result of variations in the actual treatment provided based on clinical judgement at time of surgery.I have been advised that other health professionals may be involved in my treatment and I understand that this estimate does not include their fees or charges unless specifically stated otherwise.I am aware I may receive separate accounts from other service providers associated with my treatment, including from my surgeon, surgical assistant, anaesthetist, hospital, pharmacy, allied health and other physicians who may be involved in my care.I understand that as a private patient I am responsible for all hospital, diagnostic and prosthetic costs that are not covered by my health fund or Medicare. - this can include but is not restricted to pathology, blood tests and medical imaging.The patient or nominee named herein undertake to pay the patient payment as indicated, together with any unforeseen costs which may arise as a consequence of the procedure(s).I agree for eligible follow-up appointments to be "bulk-billed" to Medicare and the benefit to be assigned to Dr Wong or Dr Lim.I understand the Financial Information and Fee Estimate that I have been issued, and accept to pay all costs related to my operation as disclosed above and in those documents. I understand that the quoted Fee Estimate is valid for 6 months.

Final Consent

I have a good understanding of the surgery that has been offered to me.I have a good understanding and acceptance of the risks of having surgery.I accept my obligations and responsibilities as a patient undergoing bariatric surgery.

Patient Name *

Patient Signature *

Draw signature|Type signatureClear

Date of Consent *

Consenting Doctor

Dr Jason Wong

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital, Mater Private Hospital, Mater Private Rockhampton, Peninsula Private Hospital

Consenting Doctor

Dr Aaron Lim

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Private Hospital

Please sign here if you are needing to re-confirm your surgical consent

Patient Re-Consent Signature

Draw signature|Type signatureClear

Date of Re-Consent

Save and Complete Later