Consent and communication
Consent is a conversation about what matters to this patient, not a signature on a list of risks.
Reviewed against its sources on 3 November 2026.
- Consent is a conversation about what matters to this patient (Montgomery), with risks as plain frequencies.
- Say in advance what may change: subtotal, drain, conversion, stopping and referral.
- After an injury: tell them yourself, early and plainly; apologise; say what happens next; document it.
01What consent is for
- Consent is a conversation that lets the patient decide whether to have the operation, when, and from whom.
- Montgomery (2015): tell the patient every material risk, one a reasonable person in their position would attach significance to, or that this particular patient would. That means the common risks, the rare serious ones (bile duct injury), the alternatives including doing nothing, and asking what matters to this patient.
- The GMC 2020 guidance and the Royal College of Surgeons say the same; the Indian exams expect consent that is informed, voluntary and from a competent patient, with material risks and alternatives disclosed.
- Taken by someone who can do the operation or is trained to consent for it, in clinic or at pre-assessment, with time to think, confirmed on the day. A signature on the morning of surgery from a junior who has never seen the operation is not consent.
Source
GMC, Decision making and consent, 2020. Regulatory guidance A professional singer cares about the airway, a self-employed builder about time off work.
02What to tell the patient
Give the frequency and what it would mean. “About one in 300 to 500 patients has an injury to the main bile duct; if that happens you may need a bigger operation by a specialist liver surgeon, and there can be long-term problems” says more than “0.3 percent bile duct injury”.
| Item | What to say | Basis |
|---|---|---|
| The operation | Keyhole removal of the gallbladder under general anaesthetic, about an hour, four small cuts, because the stones have caused symptoms and will cause more, including infection or pancreatitis | |
| Effect on symptoms | Most lose their attacks. At five years about a third of patients operated on for pain with gallstones still have some abdominal pain, usually because the stones were not the only cause | SECURE 2024 |
| Bile duct injury | About 1 in 300 to 500, higher with bad inflammation. May need a second, larger operation by a specialist; can cause long-term problems | Pucher 2018; AMBROSE 2025 |
| Bile leak | About 1 in 100. A drain, sometimes a telescope test (ERCP) and a stent; rarely another operation | AMBROSE 2025 (1.3%) |
| Bleeding, infection, bowel injury | Each uncommon (serious bleeding and bowel injury under 1 in 100; wound infection a few in 100). Occasionally another operation | Complications |
| Conversion to open | Under 1 in 100 in large recent series of planned, low-risk operations; a few in 100 across all cholecystectomies; 1 in 10 or more in severe inflammation. A larger cut, longer stay and recovery. For safety, not a failure | Neel 2026; Sinha 2013; unit data |
| Subtotal cholecystectomy | If the anatomy cannot be made safe, part of the gallbladder is left behind on purpose. Safer than persisting. More chance of a leak, may need a stent, small chance of more treatment later | Johnson 2026 |
| Retained duct stones | About 1 to 2 in 100, treated by ERCP | Complications |
| Anaesthetic and general risks | Chest infection, clots, heart problems, in proportion to fitness. Death very rare in planned surgery (under 1 in 1,000); higher in the frail and in emergencies | Pucher 2018; AMBROSE 2025 (0.4% overall including emergencies) |
| Recovery | Home the same day or next; normal activities in one to two weeks; looser stools for a while in some; no long-term diet | Day case |
| Alternatives | No operation and treating attacks as they come (reasonable for a single mild episode and for the frail); a drain into the gallbladder for the unfit with infection; no effective drug treatment for most | |
| Who will operate | Which surgeon, and whether a trainee operates under supervision. Patients are entitled to know | GMC 2020 |
Record what was discussed, including the specific risks, and give written information. Patients remember a fraction of what is said: the leaflet and a second conversation on the day are not duplication.
Sources
SECURE, JAMA Surg 2024; Pucher et al., Surg Endosc 2018; AMBROSE 2025; Neel et al., JAMA Surg 2026; Johnson et al., JACS 2026. The Royal College of Surgeons and the British Association of Day Surgery provide patient leaflets; a unit leaflet with local numbers is better.
03Consenting for the difficult case
- When the predictors say difficult (cholecystitis beyond a few days, thick-walled contracted gallbladder, previous cholecystostomy, Mirizzi on imaging, cirrhosis), the conversation changes in emphasis, not in kind.
- Quote the higher rates of conversion, subtotal, leak and injury as higher, and explain the plan in advance: “If the view is not safe I will leave part of the gallbladder behind rather than risk the bile duct. That is a deliberate choice and it is the safe one.”
- A patient who heard this in clinic is not frightened by it on the ward. One who hears it for the first time with a drain in is.
- In an emergency the same conversation happens in less time. Without capacity: best interests, family informed, document who was present and what was said.
04Telling a patient about a bile duct injury or a conversion
Examined directly in MRCS Part B and FRCS stations, and done badly by most surgeons the first time.
- Yourself, early, in person, sitting down, with a nurse and a relative if wanted. Not from the ward round, the drain or the transfer.
- Plain words. “During your operation the main bile duct was injured. That is a known but uncommon complication. We are reviewing exactly how it happened, and I will tell you what we find.” Not “a small nick” or “a slight problem with the tube”.
- What it means and what happens next. “You will be looked after by a specialist liver surgeon and will probably need another operation to repair the duct. We have already spoken to them and you will be transferred today. Until then the drain keeps bile out of your abdomen.”
- Apologise. “I am sorry this has happened to you.” Not an admission of negligence. The UK duty of candour (statutory since 2014) and the GMC require it; in India the Medical Council’s ethics regulations and consumer law make honesty the safest as well as the right course.
- Invite questions, say what you do not know, come back. “I do not yet know whether the repair will be straight away or in a few weeks; the specialist will decide. I will see you again this evening.”
- Document who was present, what was said, what was asked, the plan. File an incident report. Inform your consultant and governance.
For a conversion or a subtotal, the conversation is shorter and framed as the safe decision it was: the stay, the drain, the wound, the chance of a leak or a stent. Patients accept this well when explained, and badly when discovered.
05Four things to say, in plain words
Starting points, not scripts to recite. Say them in the patient’s own language, then check what was understood. Expert opinion
A subtotal cholecystectomy
“Sometimes taking out every last part of the gallbladder is not safe, because the bile duct is too close or too hard to see. If that happens I will leave a small piece behind on purpose, to protect the duct. You may then need a drain for a few days, and occasionally a telescope test later.”
Afterwards: what was left, whether the stump was closed or open, whether a drain is in, which symptoms mean it needs looking at
A drain
“The drain lets any fluid come out where we can see it, instead of collecting inside. We will look at how much comes out and what it looks like, and at how you are feeling, before deciding when it comes out. It should not hurt and does not stop you walking about.”
The real reason for this drain, who reviews it, no fixed day promised; a drain does not rule out a problem
Conversion to open
“If I cannot see well enough with the keyhole camera, or there is bleeding or scarring that makes it unsafe, I will make a larger cut below the ribs to finish the operation safely. That means a longer stay and a slower recovery, but it is done for your safety, not because something has gone wrong.”
Afterwards: why, what was found, and what was done to make it safe; a bigger cut does not by itself clarify the anatomy
A suspected bile duct injury
“During your operation we became concerned that the main bile duct was injured. We stopped the part of the operation that could make it worse, we have put in a drain so that bile does not collect inside, and we have spoken to the specialist liver surgeons who will look after this. I am sorry this has happened.”
Use “injury” once confirmed. Say what is known and not known, when the specialist will come, when you will be back. Do not guess at cause, blame or promise an outcome
Source
The GMC expects a patient to hear about a change of plan from the operating surgeon, promptly and in person (GMC 2020).
06What examiners ask
- Take consent for a laparoscopic cholecystectomy (OSCE: structure, risks with figures, alternatives, check understanding).
- What does Montgomery mean for the risks you discuss?
- Tell this patient that their bile duct was injured yesterday (OSCE).
- A patient whose pain has persisted asks whether the operation was necessary. What do you say?
- What is the duty of candour and when does it apply?
Test yourself further: Practise questions on Consent and communication in the Exam zone.