Laparoscopic ventriculoperitoneal shunt placement: a single-trocar technique

The Prognostic Impacts of Body Mass Index and Distance to the Peritoneal Bottom on Laparoscopic Ventriculoperitoneal Shunt Placement

OBJECTIVE

Laparoscopic ventriculoperitoneal shunt surgery has been reported to have several advantages in selected patients. However, the prognostic factors have been understudied specifically for this surgery. We sought to investigate the factors influencing the complications after the laparoscopic ventriculoperitoneal shunt placement.

METHODS

All surgeries in this prospective study were performed by the same team of neurosurgeons and general surgeons. Clinical parameters as well as potential risk factors for postoperative complications were analyzed. The endpoint was overall complications requiring surgical revision within the follow-up period after surgery.

RESULTS

Ninety-nine patients (51 male and 48 female) scheduled for laparoscopic-assisted ventriculoperitoneal shunt surgery between 2019 and 2021 were included. Overall shunt complication rate was 9% (9 of 99 cases), and there was 1 patient (1%) who had distal dysfunction among them. Body mass index ≥27 kg/m² (hazard ratio 4.87; 95% confidence interval 1.05-22.57; P = 0.043), and nonprogrammable shunts (hazard ratio 7.91; 95% confidence interval 1.51-41.50; P = 0.014) were significantly associated with an increased risk of complications. Among 75 patients who received programmable shunts, the vertical distance from the distal tip to the presumed bottom of peritoneal cavity was significant positively associated with the number of pressure adjustments (R² 0.511, adjusted R² 0.504, and P < 0.001).

CONCLUSIONS

Ventriculoperitoneal shunt surgery provided benefits with little complication rate, whereas patients treated with nonprogrammable shunts and obese patients had less favorable outcome. A positive correlation between the vertical distance from the distal tip to the bottom of peritoneal cavity and pressure adjustments inferred to the advantage of the laparoscopic method.

Transumbilical single-incision laparoscopically assisted ventriculoperitoneal shunting: a minimal invasive technique

OBJECTIVE

Hydrocephalus is not rare in the child. Ventriculoperitoneal shunt (VPS) is still the gold standard in treating non-obstructive hydrocephalus in children. Several approaches have been described and in modern surgery, in which lesser invasive techniques are predominant. This study aims at presenting a minimally invasive technique for the placement of the abdominal part of the catheter.

METHODS

We describe a minimally invasive approach for the placement of the abdominal part of the catheter using a single-incision laparoscopic technique (SILS). Furthermore, considerations about complications, follow-up, and advantages and disadvantages of the above mentioned technique will be discussed.

RESULT

These surgeries were performed successfully without any conversion. The operation time was 60 min, and the abdominal procedure was 11 min. The patient had the oral fluid intake 12 h later with the average hospitalization of 3 days after the surgery. During a 2-month follow-up, favorable cosmetic results were obtained with no relevant complications occurred.

CONCLUSION

Single-incision laparoscopically assisted VPS is feasible and safe in the treatment of hydrocephalus with less invasive and better cosmetic results from the preliminary experience.

Minimal exposure maximal precision ventriculoperitoneal shunt: how I do it

BACKGROUND

Ventriculoperitoneal shunt is among the most frequent neurosurgical procedures, complicated by infection and obstruction. The first is influenced by number of skin incisions, catheter exposure and manipulation, and the latter by catheter position.

METHOD

Presenting our neuronavigated laparoscopic-assisted minimal exposure shunt technique performed on 40 consecutive adults. No patient presented infection or distal catheter migration (mean follow-up 12 months). Ventricular catheter malpositioning associated with electromagnetic neuronavigation inaccuracy occurred in two patients with slit ventricles.

CONCLUSION

This technique demonstrates low infection/malfunction rate, postoperative pain, and cosmetic advantages. Limiting factors are availability of laparoscopic surgeons and neuronavigation if not familiar with the approach.

LAPAROSCOPIC-ASSISTED INSERTION OF A VENTRICULOPERITONEAL SHUNT IN A RESCUED ASIATIC BLACK BEAR (URSUS THIBETANUS) IN LAOS

A 3-yr-old Asiatic black bear (Ursus thibetanus), weighing 68 kg, underwent a laparoscopic-assisted placement of a ventriculoperitoneal shunt for hydrocephalus in the Lao People's Democratic Republic. Rescued as a young cub with a notably domed head, the bear's condition had deteriorated with age, but euthanasia was not a viable option because of cultural issues. Surgery was attempted as a palliative measure. The bear had ventrally orientated crossed eyes (abducens nerve palsy and dorsal midbrain syndrome), papilledema, severe rhinorrhea, depressed mentation, lethargy, a very poor appetite, and was stunted. Hydrocephalus was confirmed via intraoperative 2.0-5.0 MHz head ultrasound, as no magnetic resonance imaging was available in the country. Surgery was planned via 3D modeling of museum skulls and brain cavity, and ultrasound examination of formalin-preserved brains of other carnivores with hydrocephalus. The bear demonstrated a notable improvement in mentation, appetite, and behavior, maintained for 4 yr following surgery.

Laparoscopically assisted ventriculoperitoneal shunt placement: a prospective randomized controlled trial

OBJECT

In ventriculoperitoneal (VP) shunt surgery, laparoscopic assistance can be used for placement of the peritoneal catheter. Until now, the efficacy of laparoscopic shunt placement has been investigated only in retrospective and nonrandomized prospective studies, which have reported decreased distal shunt dysfunction rates in patients undergoing laparascopic placement compared with mini-laparotomy cohorts. In this randomized controlled trial the authors compared rates of shunt failure in patients who underwent laparoscopic surgery for peritoneal catheter placement with rates in patients who underwent traditional mini-laparotomy.

METHODS

One hundred twenty patients scheduled for VP shunt surgery were randomized to laparoscopic surgery or mini-laparotomy for insertion of the peritoneal catheter. The primary endpoint was the rate of overall shunt complication or failure within the first 12 months after surgery. Secondary endpoints were distal shunt failure, overall complication/ failure, duration of surgery and hospitalization, and morbidity.

RESULTS

The overall shunt complication/failure rate was 15% (9 of 60 cases) in the laparoscopic group and 18.3% (11 of 60 cases) in the mini-laparotomy group (p = 0.404). Patients in the laparoscopic group had no distal shunt failures; in contrast, 5 (8%) of 60 patients in the mini-laparotomy group experienced distal shunt failure (p = 0.029). Intraoperative complications occurred in 2 patients (both in the laparoscopic group), and abdominal pain led to catheter removal in 1 patient per group. Infections occurred in 1 patient in the laparoscopic group and 3 in the mini-laparotomy group. The mean durations of surgery and hospitalization were similar in the 2 groups.

CONCLUSIONS

While overall shunt failure rates were similar in the 2 groups, the use of laparoscopic shunt placement significantly reduced the rate of distal shunt failure compared with mini-laparotomy.

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.

Laparoscopic ventriculoperitoneal shunts: benefits to resident training and patient safety

This analysis suggests that laparoscopic ventriculoperitoneal shunting may serve as a model to accomplish the goals of improved patient outcomes and quality surgical education.

Background and Objectives:

Symptomatic hydrocephalus is a surprisingly common clinical condition. Neurosurgeons are expert at ventriculostomy, but minimally invasive peritoneal access is outside the realm of their current training. We have adopted a multidisciplinary approach, with general surgeons positioning the distal shunt. Our objective was to review this recent experience.

Methods:

All distal shunts were placed by a single surgeon with resident assistance. After ventriculostomy, the shunt tubing was tunneled onto the anterior abdominal wall. A Veress needle was placed through the tunnel incision and the abdomen insufflated. A 5-mm optical access trocar and camera were introduced via a separate stab incision. The shunt tubing was then directed into the abdominal cavity using a Hickman introducer kit, with flow confirmed visually.

Results:

Study patients who had between 0 and 10 previous abdominal operations received 111 consecutive shunts. There was one intraoperative complication, a colon injury during trocar placement. In this case, the colotomy was repaired and the shunt placed in the pleural space. There were no conversions to the open abdominal approach. Postoperatively, there were no wound infections, no cases of shunt malpositioning, and there were no deaths.

Conclusions:

Laparoscopic placement of ventriculoperitoneal shunts is feasible, safe, and carries a low rate of complications. The value to resident education in the practice of this procedure has not been previously emphasized. In the era of increased awareness of patient safety, laparoscopic VP shunting serves as a model for accomplishing both goals of improved outcomes and quality surgical education.

Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases

Object

Traditional ventriculoperitoneal (VP) shunt surgery involves insertion of the distal catheter by minilaparotomy. However, minilaparotomy may be a significant source of morbidity during shunt surgery. Laparoscopic insertion of the distal catheter is an alternative technique that may simplify and improve the safety of shunt surgery.

Methods

The authors performed a retrospective review of hospital records of all patients undergoing new VP shunt insertion at a tertiary care center between 2004 and 2009. Patient characteristics and outcomes were compared between patients undergoing open or laparoscopic insertion of the distal catheter. Independent variables in the analysis included age, sex, race, body mass index, surgical technique, previous VP shunt placement, previous abdominal procedures, American Society of Anesthesiology (ASA) score, and indication for shunt placement. Dependent variables included the occurrence of shunt failure, cause of shunt failure, complications, length of stay (LOS), LOS after shunt placement, estimated blood loss, and operative time.

Results

The authors identified 810 patients who met the inclusion criteria; open or laparoscopic distal catheter insertion was performed in 335 and 475 patients, respectively. There were no significant differences between the groups regarding age, race, ASA score, or indication for shunt placement. The most common indication was hydrocephalus due to subarachnoid hemorrhage, followed by tumor-associated hydrocephalus, normal pressure hydrocephalus (NPH), and hydrocephalus due to trauma. The incidence of shunt failure was not statistically different between cohorts, occurring in 20.0% of laparoscopic and 20.9% of open catheter placement cases (p = 0.791). With analysis of causes of shunt failure, shunt obstruction occurred significantly more often in the open surgery cohort (p = 0.012). In patients with a known cause shunt obstruction, distal obstruction occurred in 35.7% of the open cohort obstructions and 4.8% of the laparoscopic cohort obstructions (p = 0.014). The relative risk of distal obstruction in open cases compared with laparoscopic cases was 7.50. Infections occurred in 8.2% of laparoscopic cases compared with 6.6% of open cases (p = 0.419). Within the NPH subgroup, the laparoscopically treated patients had significantly more overdrainage (p = 0.040), whereas those in the open cohort experienced significantly more shunt obstructions (p = 0.034). Laparoscopically treated patients had shorter operative times (p < 0.0005), inpatient LOS (p < 0.001), and inpatient LOS after VP shunt placement (p = 0.01) as well as less blood loss (p = 0.058).

Conclusions

To our knowledge this is the largest reported comparison of distal VP shunt catheter insertion techniques. Compared with minilaparotomy, the laparoscopic approach was associated with decreased time in the operating room and a decreased LOS. Moreover, laparoscopy was associated with fewer distal shunt obstructions. Laparoscopic shunt surgery is a viable alternative to traditional shunt surgery.

Distal revision of ventriculoperitoneal shunts using a peel-away sheath

The authors describe a new technique for revision of an occluded distal ventriculoperitoneal shunt catheter that obviates the need for laparotomy or trocar insertion into the peritoneal cavity. The authors review their early experience with 34 patients suffering from a distal ventriculoperitoneal shunt failure and treated with this technique. There were no incidents of intraabdominal injury or wound complications. In 2 patients conversion to a minilaparotomy was required for safe placement of the shunt. Proper peritoneal placement was confirmed with abdominal radiographs in all cases. This technique has been safe and effective and may be considered an alternative to traditional laparotomy or laparoscopic methods.

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.

INTRA-ABDOMINAL VASCULAR INJURY DURING TROCAR-ASSISTED VENTRICULOPERITONEAL SHUNTING

OBJECTIVE

Laparoscopic trocar injury is a relatively well-described complication of cholecystectomies and gynecological procedures. However, this type of injury has not been reported in association with adult neurological surgery. To increase awareness of this very serious risk, we report a case of intra-abdominal vascular injury during a shunt procedure involved with a common neurosurgical procedure.

CLINICAL PRESENTATION

A 76-year-old man with no previous abdominal surgical history presented with probable normal pressure hydrocephalus.

INTERVENTION

After an appropriate preoperative workup confirming probable normal pressure hydrocephalus, the patient consented to placement of a ventriculoperitoneal shunt with a programmable valve. During placement of the distal catheter using an abdominal trocar, the aorta was punctured inadvertently, necessitating emergency laparotomy for vascular repair.

CONCLUSION

An abdominal trocar should be used with caution in ventriculoperitoneal shunt surgery. Even with meticulous technique, vascular injury can occur with any trocar-based abdominal procedure. The neurosurgeon who uses this technique must be prepared to initiate emergent vascular access and repair, with a vascular surgery team available should such an injury occur. Alternatively, open placement of peritoneal catheters avoids blind peritoneal instrumentation and is an effective method for minimizing potentially catastrophic vascular injuries.

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.

Laparoscopy-assisted ventriculoperitoneal shunt surgery in children: a series of 11 cases

OBJECT

The use of laparoscopy-assisted placement of the distal catheter of a ventriculoperitoneal (VP) shunt has been well described in the literature, and several advantages of laparoscopy over laparotomy have been documented.

METHODS

The authors retrospectively reviewed the charts of 11 consecutive children with hydrocephalus of various origins who underwent surgery for initial VP shunt placement or for revision of an existing VP shunt system between July 1, 2006, and December 31, 2006. The peritoneal catheter in all of these cases was implanted using a laparoscopic procedure and with the aid of a pediatric general surgeon. Laparoscopy-assisted placement of the distal catheter was successful in all patients. There were no periprocedural complications. There was one complication, an incisional hernia, noted in the short-term follow-up period.

CONCLUSIONS

The authors illustrate that laparoscopy-assisted implantation of a peritoneal catheter is a safe, effective, minimally invasive, and technically easy approach for VP shunt placement or revision in children. It allows accurate placement of the distal catheter in the peritoneal cavity, enables retrieval of fractured catheter segments, and allows confirmation of the patency of the shunt system.

Minimally invasive implantation of the peritoneal catheter in ventriculoperitoneal shunt placement for hydrocephalus: analysis of data in 151 consecutive adult patients

Object

The authors report on their experience with laparoscopy-guided implantation of a peritoneal catheter in ventriculoperitoneal shunt placement procedures in adults.

Methods

In performing the conventional method of shunt placement in 2001, 8% of the cases resulted in malposition and dislocation of the distal catheter; therefore, the authors together with personnel from the Department of General Surgery decided to utilize an interdisciplinary approach involving laparoscopy-guided implantation of the catheter. Between October 2001 and January 2005, 202 ventriculoperitoneal shunt placement procedures were conducted in adult patients for hydrocephalus of various origins.

In 152 patients, laparoscopy-guided implantation of the distal catheter was performed. In all except one of these patients, implantation was successful. Laparoscopy and the cranial part of the surgery were performed simultaneously. There was an 8% rate of malposition of the distal catheter in the nonlaparoscopy group. In contrast, there was no dislocation or malposition of the distal catheter in the laparoscopy group. Two cases (1.3%) of shunt infection occurred in the laparoscopy group.

Conclusions

Laparoscopic implantation of a distal catheter is a simple, minimally invasive, and easy procedure to perform and allows exact localization of the peritoneal catheter and confirmation of its patency.

Single Trocar Laparoscopically Assisted Placement of Central Nervous System–Peritoneal Shunts

BACKGROUND

Lumbar peritoneal and ventriculoperitoneal shunts are widely used for the treatment of hydrocephalus. In the past, the abdominal portion of these procedures required laparotomy. With the advent of minimally invasive techniques, laparoscopically assisted placement of the distal catheter has been tried.

MATERIALS AND METHODS

We performed 10 shunt procedures (3 lumbar peritoneal, 6 ventriculoperitoneal, and 1 meningomyelocele-peritoneal) in 10 patients (mean age 56; age range, 30-78 years). Four patients had undergone previous open shunt placement that failed. The abdominal portion of the procedure was performed using a 5-mm trocar and a 10Fr introducer for camera and catheter insertion. In 3 cases, an additional 5-mm port was necessary for lysis of adhesions. These access punctures did not require fascial closure and caused minimal pain and limitation.

RESULTS

No intra- or postoperative complications were encountered in this small patient group. At a median follow-up of 50 months (range, 3-56 months) all patients had functioning shunts.

CONCLUSION

Single trocar laparoscopically assisted placement of central nervous system-peritoneal shunts is safe and simple, and should be considered the procedure of choice. This technique is also suitable for repositioning migrated catheters and other catheter-tip manipulations.

Laparoscopy-guided insertion of peritoneal catheters in ventriculoperitoneal shunt procedures: analysis of 39 children

Ventriculoperitoneal shunting is the mainstay in the treatment of hydrocephalus in childhood. Repeated shunt revision and previous laparotomy may complicate the implantation of the distal catheter. We describe our experience with laparoscopic insertion of peritoneal catheters in 21 male and 18 female children with an age range from 3 months to 18 years, operated between 2002 and 2004. Fourteen patients (36%) had laparotomy due to previous shunt operations and 5 patients (13%) due to other reasons. Laparoscopy was carried out concurrently with the cranial part of the procedure. In all cases, successful insertion of the peritoneal catheter was carried out with visual documentation of the patency of the distal catheter. There were no procedure-related complications. We recommend this minimally invasive procedure for all children with a body weight >5 kg, especially in cases of repeated shunt operations with intraperitoneal adhesions.

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.

One trocar laparoscopic placement of peritoneal shunt for hydrocephalus: A simplified technique

Peritoneal catheter placement for the treatment of hydrocephalus can nowadays be performed laparoscopically. We report our experience using a single trocar technique, with emphasis to a modification applied especially for the obese patients.

Use of percutaneous endoscopy to place syringopleural or cystoperitoneal cerebrospinal fluid shunts

✓ The authors describe a technique for percutaneous endoscopic shunt placement to treat clinically symptomatic spinal cysts. Seven patients underwent the procedure—five with syringomyelia, one with a symptomatic perineurial cyst, and one with a large arachnoid cyst. In all patients the shunt was successfully placed, and clinical improvement occurred in six. In four patients the entire procedure was performed endoscopically, whereas in three conversion to an open surgical exposure was required for safe access of a syrinx cavity. Overall, however, the pleural or peritoneal catheter was successfully placed endoscopically in all seven patients. There were two cases of postoperative positional headaches of which one required valve revision. In one case the catheter migrated and required repositioning. Percutaneous endoscopic shunt placement appears feasible in appropriately selected patients.

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.