Informed Consent Form For Surgery

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Laparoscopic Sleeve Gastrectomy

Procedure Type

Laparoscopic Sleeve Gastrectomy as a primary bariatric procedure( 31575)

Other possible incidental procedures:

Repair of paraoesophageal hiatus hernia (31468)
Division of adhesions from previous surgery (30722 or 30724)

Additional anticipated procedures:

Repair of ventral or umbilical hernia (30651 or 30621)Cholecystectomy and cholangiogram (30445)Gastroscopy (30473)

Other variations to procedure (surgeon to complete)

Indication for surgery:

• Morbid Obesity

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

To learn more about obesity please follow this link https://www.thescienceofobesity.com.au/

Alternatives to this procedure:

• May include Gastric Bypass 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 majority of the stomach will be permanently removed using a surgical stapling device, calibrated around a narrow tube approximately the width of an index finger.
The remaining stomach will be a narrow tube shape.
Sutures are placed to anchor the oesophagus to the diaphragm hiatus, and if a hiatus hernia is present here it will
also be repaired. This may help to prevent reflux.
This can sometimes cause temporary discomfort with swallowing or breathing.
Sutures are placed to anchor the sleeve to prevent twisting and reinforce the staple line.
A surgical glue may be used also to prevent bleeding.

Please click on this link to watch a video on the sleeve gastrectomy being performed by Dr Wong

(please note that this video does contain graphic real life surgery)

Alternatively a brief animated video is available by clicking here.

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.

Declaration Of Understanding *

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 I am required to stay locally in Brisbane after surgery for at least 10 days for my own safety.I do not accept the surgery that has been proposed and do not wish to proceed.

Potential risks of surgery

Sleeve gastrectomy surgery is considered safe and has a very low risk of serious complications. Revision surgery and 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.

Serious complications - (rare <1%)

Damage to other structures or organs

Major Bleeding

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

Death

Uncommon complications

Reflux symptoms (only 3-4% of my patients have reflux symptoms which is significantly lower than 20-30% which is often reported in literature).

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

Sleeve 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.

Dumping syndrome.

Post-prandial reactive hypoglycaemia.

Twisting of the sleeve.

Narrowing of the sleeve.

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.

Please visit these sites to read more about bariatric surgery and sleeve gastrectomy:

Bariatric Surgery Source - this is an American site and is very informative although some of the information is tailored for USA and their regulations. https://www.bariatric-surgery-source.com/

Gastroscopy Information

The oesophagus, stomach and first part of the small intestine called the duodenum are inspected with a gastroscopy. Therefore any abnormalities occuring on the inside of these organs on their lining can potentially be identified, biopsied and sometimes removed using a flexible camera known as an endoscope.

It is the recognised investigation for a variety of conditions and symptoms such as gastroesophageal reflux, hiatus hernia, swallowing problems, iron deficiency anaemia, weight-loss, bloating, upper abdominal discomfort or pain, food intolerances and more.

How is the gastroscopy performed?

The procedure is planned to be done immediately before your Sleeve procedure once you have been anaesthetised.

The procedure only takes a few minutes.

The gastroscope is a flexible tube about as wide as your little finger, that is passed down your throat through your mouth, to inspect the food pipe (your oesophagus), the stomach and first part of the small intestine. Some biopsies may be taken.

There is a very very small chance (less than 2 in 1000 chance) of finding something abnormal which might mean that your surgery would not proceed.

Click HERE to watch an animation about how a gastroscopy is performed

Risks of a gastroscopy

The procedure is very safe.

Occasionally damage can occur to teeth, lips, gums from the scope or mouth piece to protect the scope.

Missed pathology, causing bleeding or perforation are all rare and unlikely risks.

Discomfort, bloating, sore throat are all possible side effects from the procedure.

Sometimes a second procedure may be required.

Aspiration pneumonia is uncommon.

Declaration of Understanding of Surgical Risk *

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 do not accept these risks and do not wish to proceed with surgery

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 Dr Wong and his nurse 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.I DO NOT accept these obligations as a patient and would like to discuss things further or not proceed with surgery.

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. This sort of recording is also useful for education purposes.

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 my surgeon 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 maintains his own prospective database on every patient that he performs surgery on to enable him to track his case numbers and surgical outcomes for quality control, audit and potentially research study purposes.

Consent to Data Collection *

I consent to Dr Wong and Dr Lim collecting and submitting data to the Bariatric Surgery Registry and I have been provided further information about this.I consent to Dr Wong and Dr Lim collecting data to monitor my outcomes from surgery.I DO NOT consent to Dr Wong and Dr Lim 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 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 personel may also be present in theatre to observe Dr Wong and 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.

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

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 *

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Date of Consent *

Consenting Doctor

Dr Jason Wong (Signature to confirm at sign-in)

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Private Hospital

Consenting Doctor

Dr Aaron Lim (Signature to confirm at sign-in)

General, Upper GI and Bariatric Surgeon

Operating out of North West Private Hospital and Mater Private Hospital

Dr Wong Signature

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Dr Lim Signature

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Please sign here if you have been asked to re-confirm your surgical consent

Patient Re-Consent Signature

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Date of Re-Consent

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