Surgical consent is one of the pillars of ethical conduct in Western world surgical practice. Recent studies have described the consenting processes for clinical trials in low- and middle-income countries (LMICs), but only a few have explored its practice before surgical procedures. The recent World Medical Association (WMA) Declaration of Lisbon recommends autonomy and independent decision-making. However, informed consent is influenced by cultural background, family structure, socioeconomic status, religion and education. The authors of the paper support the WMA recommendations, but agree the process for obtaining informed consent should be reviewed and developed to integrate in a culturally appropriate manner. This commentary reports the author’s personal experience of surgical consent in Burundi and reviews the literature describing its practice and the specific challenges faced in Sub-Saharan Africa. Its aim is to encourage a debate among surgeons as to how surgical consent can be undertaken in different scenarios of LMICs.