Endoscopically aided retroperitoneal placement of a lumboperitoneal shunt. Technical note

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better

Background

Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods.

Case Description

A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt).

Conclusion

A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.

Lumboperitoneal Shunts - Patient Selection, Technique, and Complication Avoidance: An Experience of 426 Cases

Background

Lumboperitoneal shunt is a known procedure for communicating hydrocephalus. Being an extracranial procedure, it can also be utilized in normal-sized ventricles.

Objective

To report our experience of lumboperitoneal shunt done with a minimal follow-up of 12 months with an emphasis on patient selection, technique, and complication avoidance.

Methods

This was a retrospective analysis of patients who underwent LP shunt during October 2014-October 2019 at the authors' institute. Inclusion criteria were patients with communicating hydrocephalus due to tubercular meningitis, normal pressure hydrocephalus, idiopathic intracranial hypertension, and postoperative refractory cerebrospinal fluid leaks. Data were collected for demographics, Glasgow coma scale and Glasgow outcome scale, vision, gait, memory, urinary incontinence, failed attempts, and complications.

Results

A total of 426 patients underwent the LP shunt procedure. The commonest indication was tubercular meningitis followed by idiopathic intracranial hypertension and normal pressure hydrocephalus. Age ranged from 16 to 72 years. There were 255 male and 171 female patients. The mean follow-up was 41 ± 8 months. Overall, 301 patients (70.6%) had neurological improvement. Shunt-related complications occurred in 112 (26.29%) patients, of which shunt block was the commonest. Other complications were infection in 17 (3.9%) patients and extrusion in four (0.9%) patients. Transient postural headache was seen in 46 (10.7%) patients, which gradually improved.

Conclusion

Lumboperitoneal shunt was found to be a safe and effective treatment in appropriately selected communicating hydrocephalus patients. A meticulous technique reduces the complication rate.

Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers

INTRODUCTION

Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging.

OBJECTIVE

The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients.

MATERIAL AND METHODS

A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8-10cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4cm in diameter into the visceral layer was also performed. A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented.

RESULTS

Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications.

CONCLUSIONS

VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications.

Ventriculoportal Shunt, a New Transomphalic Extraperitoneal Surgical Technique in Treatment of Hydrocephalus

AIM

The aim of this article was to report a new transomphalic extraperitoneal surgical technique for treatment of hydrocephalus, called ventriculoportal shunt.

MATERIALS AND METHODS

We performed ventriculoportal shunt on an experimental animal (pig). The particularity of ventriculoportal shunt consists in the fact that the distal end of the catheter is inserted transomphalic extraperitoneally in the portal system through reopened umbilical vein. We present technical details regarding this new surgical technique.

RESULTS AND DISCUSSION

The animal had favorable outcome, without any postoperative early or late morbidity. We discuss indications, contraindications, possible complications in humans and advantages of ventriculoportal shunt compared with ventriculocardiac and ventriculoperitoneal drainages and possibilities to avoid complications specific to classic shunt procedures.

CONCLUSIONS

Ventriculoportal shunt is a new surgical technique for treatment of hydrocephalus. The distal end of the catheter introduced into reopened umbilical vein, drains cerebrospinal fluid into the portal system. Ventriculoportal shunt is safe and easy to perform. With ventriculoportal shunt specific complications of ventriculoperitoneal or ventriculocardiac drainages can be potentially avoided. Ventriculoportal shunt combines advantages of vascular shunt with those of having an immunological barrier for cerebrospinal fluid before entering the systemic circulation. Theoretically, indications for surgery are extended, and ventriculoportal shunt can be performed in patients former contraindicated for ventriculoperitoneal shunt. Further research is needed and this surgical technique must be performed on human subjects with hydrocephalus.

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.

Lumboperitoneal shunt placement using computed tomography and fluoroscopy in conscious patients

The authors have developed a minimally invasive lumboperitoneal shunt placement procedure conducted after administration of a local anesthetic. The procedure involves placing a guide wire and a peel-away sheath under fluoroscopic and CT guidance. Between June 2004 and August 2006, 40 patients (21 men and 19 women; mean age 72.5 years [range 33-86 years]) underwent surgery. A Codman Hakim programmable valve system (82-3844, Codman & Shurtleff, Inc.) was used for the procedure. The mean operating time was 53 minutes, and 7 patients (17.5%) developed shunt dysfunction complications. These complications comprised an infected shunt valve in 2 patients, postoperative lower-limb pain in 1 patient, and shunt obstruction (caused by debris and hemorrhage) at the ventral and lumbar ends in 2 patients each. This procedure is less invasive than conventional lumboperitoneal shunt insertion and could be performed as an outpatient surgery for treatment of idiopathic normal-pressure hydrocephalus.

The ventriculoomental bursa shunt

OBJECT

The aim of this study is to access the efficacy of the omental bursa (lesser sac) as a receptacle of cerebrospinal fluid (CSF) and to use it as an alternative to the ventriculoatrial or ventriculopleural shunts when the peritoneum reduces or loses its CSF absorption capacity.

METHODS

Three patients with hydrocephalus presented with malfunctioning of ventriculoperitoneal shunts, secondary to peritoneal blockage caused by previous episodes of shunt infections in two and peritonitis in one patient. All patients underwent previous shunt revisions due to ventriculitis and shunt obstruction ranging from three to eight times. In order to keep the peritoneal cavity as the main receptacle of CSF absorption site, the distal catheter was inserted in the omental bursa, through the foramen of Winslow, jointly by a pediatric surgeon. We denominated this new technique of CSF diversion as ventriculoomental bursa (VOB) shunting. The children have been followed at least for 1 year (range 12 to 28 months) with no recurrence of shunt.

CONCLUSIONS

VOB shunting may be considered an acceptable technique to CSF shunting when the anterior peritoneum loses or decreases its CSF absorption capacity.