A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts

Modern paradigm for peritoneal catheter insertion: single port optical access laparoscopic shunt insertion

BACKGROUND

Ventriculoperitoneal shunting is one of the most commonly performed neurosurgical procedures. Typically, for insertion of the peritoneal catheter, a mini-laparotomy technique is used. Although generally safe, it can be cosmetically undesirable and time consuming. Complications include malpositioning, bowel injury, and delayed hernias. Laparoscopic techniques have been advocated to address these issues, but have been slow to gain traction with neurosurgeons.

OBJECTIVE

To describe our experience with single port optical access laparoscopy for placement of ventriculoperitoneal shunts. Our technique simplifies adoption of a laparoscopic technique for neurosurgeons looking to incorporate its benefits.

METHODS

All ventriculoperitoneal shunts placed by the senior author since April 2011 were retrospectively reviewed. Surgical and perioperative complications, length of postoperative stay, and need for revisions were analyzed.

RESULTS

Fifty-six patients were included in the study. There were no cases of peritoneal catheter misplacement. One intraoperative complication occurred early in the series, in which there was an injury to the gallbladder necessitating cholecystectomy. There were 7 cases followed by shunt revision inclusive of the abdomen. In 3 cases, pseudocysts were noted.

CONCLUSION

Single port optical access laparoscopy is a fast and minimally invasive technique that allows direct visualization of the layers of the abdominal wall as they are traversed and visualization of the peritoneal catheter during placement. It uses a small cosmetic incision and obviates the need for postoperative abdominal radiographic studies. The procedure has a modest learning curve, but can be safely used without the assistance of an assist surgeon after the skills are acquired.

Laparotomy versus Laparoscopic Placement of Distal Catheter in Ventriculoperitoneal Shunt Procedure

OBJECTIVE

Traditionally, peritoneal catheter is inserted with midline laparotomy incision in ventriculoperitoneal (V-P) shunt procedures. Complications of V-P shunt is not uncommon and have been reported to occur in 5-37% of cases. The aim of this study is to compare the clinical outcomes and the operation time between laparotomy and laparoscopic groups.

METHODS

A total of 155 V-P shunt procedures were performed to treat hydrocephalic patients of various origins in our institute between June 2006 to January 2010; 95 of which were laparoscopically guided and 65 were not. We reviewed the operation time, surgery-related complications, and intraoperative and postoperative problems.

RESULTS

In the laparoscopy group, the mean duration of the procedure (52 minutes) was significantly shorter (p < 0.001) than the laparotomy group (109 minutes). There were two cases of malfunctions and one incidence of diaphragm injury in the laparotomy group. In contrast, there were neither malfunction nor any internal organ injuries in the laparoscopy group (p = 0.034). There were total of two cases of infections from both groups (p = 0.7).

CONCLUSION

Laparoscopically guided insertions of distal shunt catheter is considered a fast and safe method in contrast to the laparotomy technique. This method allows the exact localization of the peritoneal catheter and a confirmation of its patency.

Laparoscopic placement of distal ventriculoperitoneal shunt catheters

OBJECT

Ventriculoperitoneal shunts (VPSs) are commonly placed into the peritoneal cavity via a small laparotomy or blindly by using a split trocar. Larger patients require larger incisions, and placement is made more difficult by previous abdominal operations and obesity. For general surgeons, laparoscopy has become the first-choice approach for abdominal procedures, using 1 or several very small incisions. The authors discuss their pediatric series of patients in whom laparoscopy was used to place distal shunt catheters.

METHODS

The authors reviewed the medical records accrued over a 9-year period, noting VPS operations performed using laparoscopy. Complications, morbidity, and alterations of planned management were noted.

RESULTS

One hundred thirty-seven VPS operations in 126 patients were identified, 92 performed by the senior author (M.H.H.) alone and 45 conducted with the assistance of a general surgeon. A second port was placed for lysis of adhesions or retrieval of old catheters in 7 cases. There were no immediate complications. The infection rate was 6.6%, comparable with the institutional norm (6.3%) over an 8-year period. There were 3 early failures due to abdominal malabsorption without infection. Five catheters later broke at the level where they were introduced into the abdomen due to shearing by the abdominal trocar.

CONCLUSIONS

Laparoscopic placement of distal VPS catheters is relatively safe and allows insertion via inconspicuous incisions. It can allow for inspection or lysis of adhesions and removal of foreign bodies, help determine if and where the abdomen can absorb shunt fluid, and make VPS surgery in the obese patient easier.

Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis

BACKGROUND

Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance.

METHODS

A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance.

RESULTS

The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity.

CONCLUSIONS

Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.

Laparoscopic Peritoneal Catheter Placement: Results of a New Method in 111 Patients

Objective:

Although cerebrospinal fluid shunting remains one of the most common neurosurgical procedures, it is fraught with high infection, blockage, and reoperation rates. It has been estimated that the economic cost of ventriculoperitoneal shunting exceeds $1 billion annually. A new laparoscopic technique that eliminates abdominal incisions overlying shunt hardware was applied to 111 patients requiring ventriculoperitoneal shunts in an effort to decrease the morbidity associated with shunting.

Methods:

All patients who required ventriculoperitoneal shunt insertion were eligible for this surgical technique. Patient selection was based on availability of both surgical teams (general surgery and neurological surgery) at the time of surgery. Using this technique, the distal shunt catheter is tunneled directly from the head into the peritoneal cavity under laparoscopic guidance without a skin incision directly overlying the distal catheter insertion site. Patients were followed prospectively for signs and symptoms related to shunt dysfunction, shunt infection, and incision morbidity.

Results:

One hundred eleven patients underwent 113 laparoscopic ventriculoperitoneal shunt surgeries between February 2003 and December 2004. The average follow-up period was 21.7 months (range, 12–34 mo). Nearly half of the patients (49%) were discharged the next morning and the majority (81%) was discharged within 2 days of surgery. Overall, 15 patients experienced complications requiring reoperation (13.5%) with a 1-year shunt survival rate of 91%. One patient (0.9%) acquired a new shunt infection, whereas two patients (1.8%) developed recurrence from a previous shunt infection. There were no abdominal incision-related complications.

Conclusion:

This simplified laparoscopic shunt placement technique, which requires no overlying abdominal incisions, can be performed quickly with high shunt survivability and low infection rates. Furthermore, the laparoscopic method has the advantage of fast recovery time, elimination of preperitoneal or misplaced catheters, and decreased abdominal incision morbidity. The procedure can be performed by either a multidisciplinary team or entirely by neurosurgeons.

Laparoscopically assisted peritoneal shunt insertion in hydrocephalus: a prospective controlled study

BACKGROUND

Shunting of cerebrospinal fluid to the peritoneal cavity is standard therapy for the management of hydrocephalus. Common problems, however, are infection and shunt malfunction, which frequently is related to the peritoneal end of the catheter. Laparoscopic revision of distal shunt malfunction has become popular, but endoscopic techniques for primary placement of the peritoneal catheter are not performed often. This study aimed to compare laparoscopically assisted peritoneal catheter placement with the conventional minilaparotomy technique.

METHODS

In the prospective arm of the study, 50 patients underwent laparoscopic distal shunt placement. The findings were compared with those for another group of 50 patients who underwent surgery by the standard transrectal or pararectal approach. Both groups were similar with regard to age, gender, American Society of Anesthesiologists (ASA) scores, indications for surgery, and frequency of previous abdominal operations.

RESULTS

No intraoperative complications occurred. The mean time for surgery was 59 min in the laparoscopically assisted treatment group and 49 min in the standard group. During follow-up assessment, 3 instances of distal catheter malfunction or infection (2 malfunctions and 1 infection) occurred in the endoscopic group, and 12 instances (6 malfunctions and 6 infections) occurred in the control group. This difference was statistically significant.

CONCLUSIONS

The findings from this prospective controlled study indicate that the risk for long-term complications attributable to distal shunt malfunction is reduced when laparoscopic techniques are used to place the peritoneal end of the shunt catheter.

CSF shunts in children: endoscopically-assisted placement of the distal catheter

OBJECTIVES

Ventriculoperitoneal shunting is the most common treatment for hydrocephalus. Repeated shunt revisions and other previous surgical procedures can complicate the placement of the distal catheter. Occasionally, when conventional sites like the abdominal cavity and the right atrium are used up or unavailable, a ventriculopleural shunt can be inserted.

MATERIALS AND METHODS

Between April 2001 and August 2002, 7 children ranging in age from 5 months to 17 years underwent ten endoscopically-assisted cerebrospinal fluid shunt insertions. All patients had had previous multiple shunt revisions and other abdominal operations. In addition 4 children had suffered from severe peritonitis, 1 of them with a subsequent adhesion ileus. In 9 cases the terminal portion of the shunt was inserted with laparoscopic assistance and in 1 case with thoracoscopic assistance. The latter had previously undergone two conventional intercostal thoracotomies for shunt insertions. Placement of the shunt was performed in a suitable area under direct laparoscopic or thoracoscopic vision by a peel-off needle into the peritoneal or pleural cavity. In 2 children repeated endoscopic approaches were necessary for shunt replacement due to infections.

RESULTS

We used this procedure successfully in each case without operation-related complications. Neither new adhesions nor difficulties in laparoscopic replacement of the shunt were observed.

CONCLUSION

Laparoscopic and thoracoscopic assistance in the placement of the distal catheter has the benefit of allowing a safe and precise insertion with visual control of shunt function, even in patients with prior surgical interventions. Additionally, this minimally invasive technique appears to prevent new adhesions arising in the peritoneal cavity.

Laparoscopically Guided Distal Ventriculoperitoneal Shunt Placement

In standard techniques for performing ventriculoperitoneal shunts, the peritoneal catheter is threaded more or less blindly into the peritoneal cavity. Using laparoscopic techniques allows accurate peritoneal placement, without a large incision, even in replacement procedures and in patients with previous abdominal operations. We performed 28 laparoscopically guided ventriculoperitoneal shunt placements and shunt revisions in 24 patients with hydrocephalus (aged 6-80 years). Sixteen of 24 patients (67%) had previous abdominal surgery. Laparoscopic shunt placement was successful in all patients. Mean operative time was 63 +/- 34.9 minutes (range 15-150 minutes). In 2 patients, broken and disconnected distal parts of previously inserted shunts were removed from the abdomen. One shunt was removed following infection and other one was revised due to shunt malfunction. Three patients required revision of the cranial part of the shunt. Laparoscopically guided distal ventriculoperitoneal shunt placement provides definite patient benefits: it allows shunt placement under direct vision, associated with reduced trauma to the abdominal wall, and avoids a consequent risk of intra-abdominal adhesions.

Laparoscopic surgery in children with ventriculoperitoneal shunts

BACKGROUND/PURPOSE

Children with ventriculoperitoneal shunts may require laparoscopic surgery. The authors aimed to determine if this group of children are at greater risk for complications or technical problems.

METHODS

Children with ventriculoperitoneal shunts who underwent laparoscopic surgery between 1995 and 1998 were reviewed. In addition, the subset of children undergoing laparoscopic fundoplication were compared with the group of children without shunts who- had the same operation during the same period.

RESULTS

Ten children with ventriculoperitoneal shunts underwent laparoscopic surgery. Three had complications, none of which were caused by the shunt. None had any evidence of shunt dysfunction related to the laparoscopic procedure. The 6 children with shunts who underwent laparoscopic fundoplication were compared with 17 similar children without shunts who underwent the same operation during the same period. There were no differences between the groups with respect to operating time, conversion to an open approach, or complications.

CONCLUSION

Laparoscopic surgery can be performed safely and effectively in children with ventriculoperitoneal shunts.

Laparoscopic placement of PAP catheters for intraperitoneal chemotherapy in ovarian carcinoma

OBJECTIVE

To our report our experience with the laparoscopic placement of peritoneal access ports and to compare it to our experience with placement at laparotomy.

METHODS

Patients with advanced ovarian carcinoma were enrolled in a study to receive intraperitoneal paclitaxel in combination with intravenous cisplatin and cyclophosphamide as first- or second-line chemotherapy. Patients had a PAP catheter placed at primary laparotomy or by a separate laparoscopic procedure under general anesthesia.

RESULTS

In 13 patients a PAP catheter was placed during primary laparotomy, without complications. Thirteen patients had laparoscopic catheter placing, using routine Veress needle insufflation. After a bowel perforation at insertion of the umbilical trocar had occurred in one patient, due to extensive adhesions, we decided to use only an open laparoscopic procedure. No other procedure or catheter-related complications occurred.

CONCLUSION

Laparoscopic-assisted placement of PAP catheters is feasible, but should preferably be performed by an open laparoscopic procedure in this patient population at risk for intraabdominal adhesions.