Dear Patient, Dear Parent/Guardian
My doctors, who diagnosed me as “ANAL FISSUR ” as a result of the examinations and tests, recommended “Lateral internal sphincterotomy” surgery for my treatment. It is your most natural right to be informed about the medical / surgical treatment and diagnostic procedures recommended to you for the treatment of your medical condition and disease. After learning the benefits and possible risks of medical treatment and surgical interventions, it is up to you to consent to the procedure or not. In the light of this information, it will be appropriate for you to decide about your treatment with your free will. You can withdraw from your treatment decision at any time. The purpose of this statement is not to scare or alarm you, is to involve you more consciously in the decisions to be taken on matters related to your health. If you wish, all information and documents related to your health can be given to you or a relative you deem appropriate. This form has been prepared to help the physician following you to inform you about the risks of the planned treatment/intervention and alternative treatment methods. Please read this form completely and carefully and sign this consent form after you have read the form and all your doubts about the relevant procedure have been cleared by the physician. Information about other health institutions that can perform this surgery was also given. What you need to know about your disease: Anus crack, breech tear, or in medical terms ‘anal fissure’, rectal pain in the skin covering the anus (breech) area, It is a small tear or crack that causes bleeding and itching. Generally, the fissure starts superficially and heals quickly. Sometimes it can deepen and reach the underlying breech inner muscle (sphincter muscle). In this case, the disease has become chronic. Likewise, if the breech crack formation period exceeds 6 weeks, it is called chronic breech fissure (anal fissure). The main cause of breech fissure (anal fissure) is increased resistance (hypertonicity) and thickening (hypertrophy) in the breech inner muscle (sphincter muscle). It is not known for certain why some anal fissures heal on their own while others do not, but it is thought that the persistence of constipation or diarrhea causes this condition.
What can happen if the attempt is not made?: It is a known fact that many patients continue their lives with anal fissures and apply self-treatment with creams or drugs that they randomly provide (advice from a friend or pharmacy, etc.). Here, the main reason is ignoring the problem, refraining from seeing a doctor (feeling of shame, privacy, etc.) and such reasons. Since it is known that the symptoms of anal fissure can be confused with many diseases, it is very inconvenient to apply this type of treatment without consulting a physician and may lead to the progression of the underlying disease.
Anal fissures can heal spontaneously if no treatment is applied, or medical treatment methods (such as botox, cream, pomade) can be applied.
What kind of treatment/intervention will be applied (It should contain information about alternative treatments): Today, lateral internal sphincterotomy is the most commonly used technique in the surgical treatment of breech fissure (anal fissure). In other words, it is the process of cutting the inner region of the breech region. This cutting process can be done completely or partially.
Fissurectomy: It is the process of surgically removing the anal fissure. Anus dilation (anal dilation) is a viable treatment option. Apart from these, “pressure controlled sphincterotomy”, “Fissurectomy and sliding (flap) technique”, fissure burning with laser, sphincterotomy with radiofrequency, botox application are other treatment options. Common side effects-complications (undesirable negative results):
As with any surgery, general anesthesia can have complications. During surgery
1. The patient will be given narcosis and a tube will be placed in the trachea and breathing will be provided from there. Removal of the tube after this procedure may be delayed or not possible. In this case, the patient is treated in the intensive care unit. Again, as a result of anesthesia-related complications, there may be a death risk of less than 1 in 1000. The operation is performed with spinal or epidural anesthesia, that is, with a needle from the waist. Again, as a result of anesthesia-related complications, there may be a death risk of less than 1 in 1000. The operation is performed with spinal or epidural anesthesia, that is, with a needle from the waist.If it is done, headache, bleeding, inability to urinate and infection-related problems may occur at very low rates. In case of inability to urinate, a catheter can be inserted. Detailed information about the complications related to anesthesia will be obtained from the anesthesia team and the responsibility for these matters belongs to the anesthesia team.
2. Clots that may form in the deep vein system during and after the surgery may break off from there and cause a clot to be thrown into the lungs (embolism). Since the risk of embolism is practically non-existent in this surgery, no precautions will be taken with any medication.
3. Gas and fecal incontinence: 12-27% after gas incontinence, anal fissure surgeries. While stool incontinence or light soaking (soiling) is seen at a rate of 10-15%. Naturally, this is the complication that patients fear the most, because it causes an urgent need to go to the toilet while in a social environment.
4. Infection: Infection is rarely seen after anal fissure surgery. It is known that breech abscess can develop in 1-2% in general.
5. Development of breech fistula: After the opening of the intestinal surface (mucosa) during surgery, breech fistula (perianal fistula) develops and is seen in less than 1% of patients.
6.There may be bleeding from the rectum.
7.Recurrence of anal fissure: Post-operative recurrence or recurrence is seen in 1-6% of patients.
8.Although the duration of the operation is variable, it varies between approximately 20 minutes and 1.5 hours. At least one of the doctors of our clinic will enter your surgery. You can get information about the type of surgery from your doctor. Information was also given about other doctors and health institutions who performed this surgery.
The points that the patient should pay attention to before the intervention: Following your admission to the clinic, your doctor will prepare your file and, if necessary, you will be re-examined. In the meantime, please answer the questions asked by your doctor completely. The anesthesiologist will give you a separate form like this one about which method will be applied and their risks. Anesthesiologists will explain to you the points that you need to pay attention to before, during and immediately after the operation in terms of anesthesia. You should not have taken solid food by mouth for at least 6 hours before the surgery. It is expected from you to inform your doctor about the drugs you use (especially those that prevent blood clotting such as aspirin), your current or past important diseases and your allergy situation, It is to make your toilet before going to the operating room, and to remove all metal and other jewelry and materials on you while going to the surgery. After the surgery decision is made, you will be taken into surgery according to the availability of the operating room. You can wait in your clinic for a while. If your previous surgeries are prolonged, your surgery may be delayed.
The points that the patient should pay attention to after the operation: Immediately after the operation, you will stay for a while in the operation room and recovery room. Explanations about these points will be made by anesthesiologists. You will not feel the need to eat immediately after the surgery. Appropriate medications will be given by your doctors for your pain and other needs. Please do not use any medicine other than what your doctor and nurse give you. You can apply to your nurse and doctor for the situations that you have in mind. If spinal anesthesia has been applied, you may have difficulty urinating for the first time. In this case, your urine will be taken temporarily with the help of a catheter. Your doctor will tell you when you can take liquid and solid food based on your examination and other findings. In the postoperative period, you should get up and walk around and do breathing exercises as soon as your doctor and nurse allow. Your discharge day will be determined according to your condition. Before leaving the hospital, you will be told which medications you will use, when you will come for a check-up and when you will have your stitches removed. If this is not told to you, please warn your doctors.
• I was informed about my co-morbidities other than my illness. The negativities that these co-morbidities may cause me during or after the operation were explained in detail.
• I was informed about following my pathology report after the surgery and applying to the polyclinic with the result.
• I was given the detailed information above about my disease and the planned intervention, and possible complications and risks were explained in full. It has been reported to me that if these develop, treatments including surgery may be required, but in some cases, good or complete cure may not be achieved.
• All my hospital data and records; I consent to the use of my blood and tissue samples for scientific studies.
• When a previously unknown pathology is detected at the time of surgery, I allow my doctors to change and implement the operation strategy, completely in my favor.
• I was informed that, as well as the clinician and assistant doctor could enter my operation, other doctors could be called to attend my operation if necessary.
• I accept the implementation of the above-mentioned intervention and other additional interventions that may be required as a medical necessity during the intervention. I will not resort to legal action due to the complications that develop due to the surgery, provided that the above-mentioned disease and the acceptable complications specific to the treatment are not excluded.
• All of the medical and surgical procedures that will be applied for my treatment, with my own consent,
My doctor explained to me why the intended treatment is needed, the risks involved, undesirable consequences (complications), unexpected situations and problems that may occur, changes that may occur during my treatment and events that may occur during my recovery, and I accept these. In addition, we talked with my doctor about the examination/medical intervention/treatment/surgery and anesthesia options, benefits, undesirable results, risks, unexpected situations and events that could occur if I did not receive treatment, my questions were answered adequately and I was given sufficient information on these issues. In case my doctor finds or develops something that cannot be detected beforehand, during or after the examination/medical intervention/treatment/surgery and anesthesia procedures, I allow additional or different examinations/medical interventions/treatments/surgeries and anesthesia applications that my doctor decides will be beneficial for me, and the consultations that my doctor deems necessary. I accept that this treatment and the examination/intervention/treatment/surgery and anesthesia procedures to be performed are done with the aim of improving my health, but this result cannot be guaranteed and I am aware of the unexpected situations, undesirable results and risks that may occur. Help my doctor during examination/medical intervention/treatment/surgery and anesthesia procedures by other physicians, nurses, health officers, technicians, health workers, interns, interns and health education recipients (assist-support-collaboration) can be done.
Except for the cases that are legally obligatory and the negative consequences that may arise, on my own; We were told that I have the right to refuse or stop the examination/medical intervention/treatment/surgery and anesthesia procedures that are planned or applied, and that if I refuse or stop these procedures, the consequences that will arise as a result of being untreated.
I approve the use of blood, which is prepared in accordance with the legal regulations in the blood bank before the surgery and is suitable to be given to me, during medical intervention/treatment/surgery and anesthesia procedures. I was informed about the risks that may occur in case of using blood. I accept the use of instruments-devices, healing materials and drugs provided by the hospital within the legal legislation in examination/medical intervention/treatment/surgery and anesthesia procedures.
(For female patients only) If I am pregnant, I have been informed that my unborn child carries a risk during examination/medical intervention/treatment/surgery and anesthesia procedures, primarily radiological procedures. I do not have menstrual delay or pregnancy.
My signature below is that I have read, understood all the information on the front and back of this form and that it is explained to me in a way that I can understand, all that I have asked and wanted to know.

PATIENT’S CONSENT
I was given the above detailed information about my disease and the planned intervention, and the possible complications and risks were fully explained. I was informed that if these develop, treatments, including surgery, may be required, but in some cases, complete cure or recovery cannot be achieved. I accept the implementation of the above-mentioned intervention and other additional interventions that may be required as a medical necessity during the intervention.
to this section;
The statement “I READ, I UNDERSTOOD, I GOT A COPY” written in the patient’s or Legal Representative’s own handwriting will be written..……………………………………………………………………………………..……………………
TO BE FILLED BY THE PATIENT:
Date of Consent:……………………………
Time :………………………………………………
Signature:…………………………………………………………………………………………
Patient’s (guardian or guardian for restricted and minors) Name and surname:……………………………
TO BE FILLED BY THE DOCTOR INFORMING THE PATIENT AND TAKING THE PATIENT’S CONSENT:
Title, Name and Surname of the Physician Receiving Consent:…………………………………………………..

Signature:……………………………………………………………………………………………

TAKING MEDICAL INTERVENTION
Name Surname Title:……………………………………………………………………..

Signature:……………………………………………………………………………………