Chapter 4
Patient Preparation
Counseling and consent
Counseling is a totally individual procedure even though all patients must be provided the same information. In other words, the information provided must be tuned to the patient’s intellectual ability to comprehend and include a realistic discussion of what will take place in surgery. The details in which potential complications are described will vary from circumstance to circumstance. Here, local custom will vary greatly. Good medical practice dictates that discussion about common complications takes place. Less common but serious complications also deserve mention. Alternative methods of addressing the patient’s symptomatology also must be discussed as well as the possibility of doing nothing. The possibility of conversion to laparotomy should always be included in preoperative consultation.
A complete record of this discussion must be placed in the patient’s record in addition to the signed consent. The nature and the content of the signed consent differs from country to country. In the absence of local policy on consent, the practitioner can use the Department of Health consent form (available at www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf). In the vast majority of instances, surgery should be limited to the operation and organs discussed during the counseling and listed on the signed consent. Good medical practice also dictates that the patient be evaluated by a member of the anesthesiology team during a preoperative consultation rather than just before the start of the surgery.
The patient has a right to know exactly what will happen to her from the moment of admission to the hospital to the moment of discharge. This can be provided by either the doctor or his/her delegate or on a written form for which patient acknowledges receipt. In either instance, it must be sufficiently detailed to include all the necessary, appropriate and specific interventions (for example, IV cannula, bladder catheter, immediate/subsequent recovery procedures, and diet before and after surgery).
A discussion should be held about image capture and video recording during surgery. The patient’s level of comfort regarding future discussion about the operative findings and the anonymous use of the same for educational purposes should be clearly documented along with the patient’s approval on the signed consent. In the event that the patient does not approve image capture, her wish should be respected.
The authors do not recommend or encourage providing the patient with a complete video recording of the operation as it may be viewed by individuals who are unable to interpret it correctly. On the other hand, it is appropriate to provide intraoperative photographic documentation of anatomy and pathology.
Preoperative instructions
Patients are advised to avoid milk and milk products for 2 days prior to the procedure to minimize gaseous distension. They are also instructed to consume a soft or semisolid diet for 48 hours prior to surgery. Patients are prescribed simethicone 125 mg three times a day for 2 days as an antiflatulent, biscaodyl (Dulcolax®) by mouth 30 mg one at night for 2 days and alprazolam 0.25 mg (Restyl®) one nightly for 2 days. Additionally, patients are told to avoid a non-vegetarian and oily diet for 2 days. Finally, patients are instructed to remain nil by mouth for a minimum of 6 hours prior to the surgery. If abdominal perineal shaving is considered desirable, this should be accomplished 24 hours before the surgery. A deep cleansing of the umbilicus should take place on the 2 days prior to surgery. A vaginal antimicrobial pessary is recommended 4–6 days prior to surgery. Sexual intercourse should be avoided 2 days prior to surgery. A shower and oral hygiene are encouraged the night before the surgery. The patient should bring all the relevant necessary medical records to the hospital. All the above instructions should be provided to the patient in a printed format.