Medical Consent For Hysterectomy Form - Caring For Women printable pdf download

Joseph Valenti, MD, FACOG

Caren Reaves, MD, FACOG

Monica Popov, MD, FACOG

Laura Finger, MD, FACOG

Amy Lungren, MD FACOG

Rachel Osborn, MD, FACOG

Holly Groom, RN, CNM

Kathy Ellis, RN, CNM

Shirley Marion, RN, CNM

Elizabeth Malone, RN, WHNP-BC

Alexandria DeVaughn, RN, WHNP-BC

Ebony Midcalf, WHNP-BC

Consent for Hysterectomy

To the patient: You have the right, as a patient, to be informed about your condition and the recommended surgical,

medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after

knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, it is simply an effort to make you

better informed so you may give or withhold your consent to the procedure. Notice: Refusal to consent to a hysterectomy will

not result in the withdrawal or withholding of any benefits provided by programs or projects receiving federal funds or

otherwise affect your right to future care or treatment.

The purpose of a hysterectomy is to remove the uterus as a way of treating problems that affect the uterus. This procedure

involves removal of the entire uterus including the cervix. Depending on your condition, the fallopian tubes and ovaries may

be removed at the time of hysterectomy. When both ovaries are removed you will become surgically menopausal.

There are several approaches to a hysterectomy and the one recommended for you is based on your reason for needing a

hysterectomy, as well as any other factors that might make one approach safer or better for you than another. Sometimes we

have to convert from one to another in the operating room. The approach recommended for you is:

_____Total Abdominal Hysterectomy (TAH) --- An incision is made in the lower abdomen and your uterus and cervix are

removed through the incision. It usually requires 2-3 days in the hospital and a 4-6 week recovery.

_____Total Vaginal Hysterectomy (TVH) --- The entire uterus and cervix are removed from the vagina, without incision on

the abdomen. This is not always an appropriate approach if you have prior abdominal surgery, pelvic pain, or pelvic masses.

This can often be completed as an outpatient surgery, or an overnight stay. Recovery is usually within 2 weeks.

_____Laparoscopically Assisted Vaginal Hysterectomy (LAVH) --- Small incisions are made in the belly button and in

the lower abdomen and then minimally invasive instruments are used to separate the uterus and cervix and then they are

removed through the vagina. This can usually be performed as an outpatient or overnight stay, and recovery is usually about

2 weeks.

_____Robotically Assisted Total Hysterectomy --- With the DaVinci robot, we perform a total hysterectomy through

several small incisions on the abdomen, often even if the uterus is extremely large, or other pathology is expected, such as

extreme endometriosis or scar tissue. This can also often be performed on an outpatient or overnight basis, with about a 2-

week recovery.

Conditions that affect the uterus may be treated with medicine or various types of surgery including hysterectomy. The

choice to perform a hysterectomy has been made based on the nature and extent of your condition and your particular needs.

It is important that you understand your preoperative diagnosis and the conservative versus surgical procedures that are

available to you.

Medical Consent For Hysterectomy Form - Caring For Women