CONSENT INFORMATION - PATIENT COPY NEUROENDOSCOPY

PLEASE READ THIS SHEET BEFORE YOU CONSENT TO YOUR SURGERY

This information sheet provides general information to a person having a Neuroendoscopic Procedure. It does not provide advice to the individual. It is important that the content is discussed between you and your doctor who understands your level of fitness and your medical condition.

What is Neuroendoscopy? Neuroendoscopy utilizes small telescopes and high resolution video cameras to look into the skull, brain, and spine. Working with these endoscopes, it is now possible to perform many microsurgical operations. When is it used? Examples of common neuroendoscopic

Tumor biopsy and excision

Transphenoidal procedures (for pituitary tumors, etc.) Colloid cyst excision Fenestration and excision of arachnoid cysts Spinal discectomy Carpal tunnel release What are the advantages of this procedure?

procedures include: Ventriculoperitoneal placement and revision Removal catheters Third ventriculostomy Fenestration of the septum pellucidum (septostomy) Fenestration ventricular cysts Choroid plexus coagulation / Choroid plexectomy
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(VP)

shunt This minimally invasive neurosurgery has the ventricular distinct advantages of a small incision site and minimal trauma to the brain or spinal cord. This results in a shorter hospital stay for patients, as well as a quicker return to normal activities. Neuroendoscopy allows the neurosurgeon to perform delicate procedures deep within the brain, typically through small burr holes in the skull. Although most brain tumors cannot be treated endoscopically, some are ideally treated using this technique. The most frequent indication for

of

retained

of

multi-loculated

MSSH/Physician/Consent Neuroendoscopy/Ver.1/Oct.2007

endoscopic management is tumors located within or immediately adjacent to the ventricles of the brain.

You become short of breath. Unmanageable pain, as well as symptoms that are progressive or abnormal, should be reported to the doctor immediately.

How is it done? Endoscopes are small telescopes that can be introduced into the brain through tiny openings in the skull. It is performed under general anesthesia. The hair is shaved only along the planned incision which in most cases is hidden just behind the hairline. The standard incision is approximately 1-2 inches followed by a small 1/2 inch opening in the skull. Through this opening the endoscope is inserted into the ventricles where visualization is then made of the tumor, cyst or third ventricle. A variety of very small instruments are then used to perform the procedure. Depending upon the goal of surgery the operation usually ranges from 15 minutes for ETV or cyst fenestration, to one hour for colloid cyst tumor removal. Most patients are discharged from the hospital the day following surgery After the surgery contact your Doctor if: You develop a fever over 100F

General Risks of having an Operation: These have been mentioned in the Anesthesia Consent Form. Please discuss this with your Anesthetist before signing the Anesthesia Consent Form. What are the risks of the procedure? While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below: Infection Bleeding which may warrant open procedure CSF leak Inadequate removal of the lesion Worsening of the existing neurological deficit or development of fresh deficit

(37.8C). You become dizzy or faint. You have nausea and vomiting. You have headache.
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10. Consent Acknowledgement: The doctor has explained my medical condition and the proposed surgical procedure.

MSSH/Physician/Consent Neuroendoscopy/Ver.1/Oct.2007

I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure. I have been given an Anesthesia Informed Consent Form. I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks. I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand that the procedure may include a blood / blood product transfusion. I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital. The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate.

It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable. On the basis of the above statements, I REQUEST TO HAVE THE PROCEDURE. Name of Patient/Substitute Decision Maker. Relationship . Signature Date Name of the Witness Relationship/Designation Signature.. Date REFERENCES

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MSSH/Physician/Consent Neuroendoscopy/Ver.1/Oct.2007

INFORMED CONSENT: NEUROENDOSCOPY

Patient Identification Label to be affixed here:

A. INTERPRETER An interpreter service is required Yes____No_______ If Yes, is a qualified interpreter present Yes_____No______ B. CONDITION AND PROCEDURE The doctor has explained that I have the following condition: (Doctor to document in patients own words) and I have been advised to undergo the following treatment/ procedure........................................ . See patient information sheet- "Neuroendoscopy for more C.ANAESTHETIC Please see your Anesthesia Consent Form. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist. OPERATION: The hair is shaved only along the planned incision which in most cases is hidden just behind the hairline. The standard incision is approximately 1-2 inches followed by a small 1/2 inch opening in the skull. Through this opening the endoscope is inserted into the ventricles where visualization is then made of the tumor, cyst or third ventricle. A variety of very small instruments are then used to perform the procedure.

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MSSH/Physician/Consent Neuroendoscopy/Ver.1/Oct.2007

D.RISKS OF THIS PROCEDURE While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below: Infection Bleeding which may warrant open procedure CSF leak Inadequate removal of the lesion Worsening of the existing neurological deficit or development of fresh deficit

E.SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The doctor also has explained relevant treatment options as well as the risks of not having the procedure. (Doctor to document in medical record if necessary. Cross out if not applicable) F.PATIENT CONSENT I acknowledge that: The doctor has explained my medical condition and proposed procedure. I understand the risks of the procedure including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks. The doctor has also explained the risks of not having the procedure. I have been given the Anesthesia informed consent form. I have been given the patient information sheet regarding the condition, procedure, risks and other associated information. I was able to ask questions and raise concerns with the doctor the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand that the procedure may include a blood/blood product transfusion. I understand that if organs or tissues are removed during the surgery that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
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The doctor explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly. It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.

On the basis of the above statements, I hereby authorize Drand those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure.. I REQUEST TO HAVE THE PROCEDURE Name of Patient/Substitute Decision Maker Relationship . SignatureDate. Name of the Witness Relationship/Designation SignatureDate REFERENCES G.INTERPRETERS STATEMENT I have given a translation in Name of interpreter. SignatureDate H. DOCTORS STATEMENTS I have explained The patient s condition Need for treatment The procedure and the risks
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 Relevant treatment options and their risks Likely consequences if those risks occur The significant risks and problems specific to this patient I have given the Patient/ Guardian an opportunity to: Ask questions about any of the above matters Raise any other concerns, which I have answered as fully as possible. I am of the opinion that the Patient/ Substitute Decision Maker understood the above information. Name of doctor.. Designation SignatureDate..

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MSSH/Physician/Consent Neuroendoscopy/Ver.1/Oct.2007