Robotic-assisted hysterectomy in a patient with a ventriculoperitoneal shunt

There are several articles in the literature reporting laparoscopic surgery in patients with ventriculoperitoneal shunts (VPSs). Although the majority of these conclude that a pneumoperitoneum in these patients is safe, there are other reports indicating possible complications of the insufflation. This is the first known report of a robotic-assisted hysterectomy performed on a patient with a VPS and the management of the shunt during the procedure.     

Acute abdomen in the patient with a ventriculoperitoneal shunt

When patients who have a ventriculoperitoneal shunt present with an acute abdomen, shunt infection may be the cause. The authors relate the cases of three such patients. Two underwent a laparotomy which failed to show any abnormality and which in retrospect might have been avoided. They review the literature and present a systematic approach to the diagnosis and management of this problem. Specific clues from the patient's history, physical examination and further investigation may clarify the diagnosis. When shunt infection cannot be excluded and the clinical setting does not warrant immediate laparotomy, shunt externalization, cerebrospinal fluid culture, empiric antibiotic therapy and close observation of the patient are recommended.     

Abdominal pseudocyst in a patient with ventriculoperitoneal shunt. A case report

Since 1905, the abdominal cavity has been used for absorption of cerebrospinal fluid in patients with hydrocephalus. Among complications in its use is formation of abdominal pseudocysts. We describe the case of a patient with hydrocephalus who developed an abdominal pseudocyst. The main complaint of the patient was abdominal pain and fever. During physical examination, a 15-cm abdominal tumor was detected. The patient underwent abdominal surgery for excision of the pseudocyst and peritoneal shunt was relocated to right atrium. Recovery was uneventful. Incidence of abdominal pseudocyst ranges from 1-4.5%. Principal symptoms are related with intracranial hypertension. The patient usually requires surgical exploration to resolve the illness, and in presence of infection the shunt should be changed.     

Ventilatory impairment during laparoscopic cholecystectomy in a patient with a ventriculoperitoneal shunt.

A patient with a recently placed ventriculoperitoneal shunt suffered ventilatory impairment due to decreased thoracic compliance related to massive subcutaneous emphysema during laparoscopic cholecystectomy. The patient recovered uneventfully; however, recently established closed communication between the peritoneal cavity and the subcutaneous space may be a relative contraindication to laparoscopic surgery.     

Liver abscess secondary to ventriculoperitoneal shunt

Liver abscess is a rare complication following the ventriculoperitoneal (V-P) shunt operation. There has been only one case reported in the literature. We present a case of liver abscess developed about 3 months after V-P shunt operation. A 31-year-old female was admitted to our hospital in comatose condition due to second bleeding from an aneurysm of the right internal carotid artery on January 1, 1984. Obliteration of the aneurysm was performed on the following day. She received V-P shunt operation for the marked hydrocephalus on February 4, but she developed low spinal fluid pressure syndrome. She was able to walk by herself after the replacement of shunt valve on March 4. In the middle of April, she suffered from abdominal pain with a pyrexia for about 5 days. On May 13, a new peritoneal tube was placed in another part of the peritoneal cavity because of the recurrence of hydrocephalus. On the following day, she developed severe abdominal and back pains with a high fever. Abdominal CT scans and ultrasonogram were performed on May 22, showing a well-defined, cystic mass lesion in the liver and the peritoneal tube lying just beneath the mass lesion. Approximately 100 ml of white creamy pus was aspirated from the cystic mass by ultrasound-guided percutaneous puncture, and a 8.3 French pigtail nephrostomy catheter was left in place for 9 days until purulent drainage stopped. Microbiologic examination demonstrated staphylococcus epidermidis in the cerebrospinal fluid (CSF) from the shunt tube but was negative in the abscess fluid. The ventricular fluid was drained externally with the V-P shunt tube for a while, but the new ventricular drainage was instituted because of continuous positive cultures in the CSF from the shunt tube. Thereafter, the cultures of the CSF became negative and ventriculoatrial (V-A) shunt operation was performed on July 2. Postoperative course was uneventful. It is considered that the formation of the liver abscess seems to be caused by the focal injury to the liver surface by the insidiously infected peritoneal tube with St. epidermidis, and by the decrease in systemic resistance to infection. Percutaneous aspiration and drainage under the guidance of abdominal computed tomography or ultrasonography are very useful and efficient for the diagnosis and the treatment of liver abscess. When patients show signs of infection to the V-P shunt, we should remove the shunting system and place a new external ventricular drainage, and institute a V-A shunt after confirming negative cultures of the CSF.     

Laparoscopic hysteropexy in a patient with spina bifida and ventriculoperitoneal shunt

Laparoscopic repair of pelvic organ prolapse in patients with ventriculoperitoneal shunts has not been previously described. The optimum management of patients with ventriculoperitoneal shunts undergoing laparoscopy is uncertain. We describe the case of a 21-year-old female patient with spina bifida and ventriculoperitoneal shunt who underwent laparoscopic hysteropexy for severe pelvic organ prolapse. The implications of performing laparoscopy on patients with ventriculoperitoneal shunts are reviewed along with strategies to reduce potential intraoperative complications.     

Anesthetic management of laparoscopic surgery in a patient with a ventriculoperitoneal shunt

With advanced knowledge of management of hydrocephalus, patients with ventriculoperitoneal shunts are expected to enjoy a longer lifetime. Developments in both instrumentations and surgical techniques have led to increasing popularity of laparoscopic surgery in many surgical subspecialties. Therefore, it is not a surprising event that a patient with a ventriculoperitoneal shunt is scheduled for a laparoscopic surgery under anesthesia. Until now, there is no uniformized protocol for anesthetic management of a patient with a ventriculoperitoneal shunt undergoing laparoscopic surgery. Increased intracranial pressure may occur intraoperatively and be a major concern. We report here our experience in anesthetic management of such a patient and discuss the anesthetic considerations and the potential complications.     

Laparoscopic surgery in a patient with ventriculoperitoneal shunt: monitoring of shunt function with transcranial Doppler

We describe the use of transcranial Doppler (TCD) monitoringduring laparoscopic resection of an ovarian cyst in a youngwoman who previously underwent ventriculoperitoneal shuntingfor hydrocephalus. Shunt function was not altered by pneumoperitoneum,except during transient episodes of high intra-abdominal pressure.The role of TCD monitoring during laparoscopic procedures inpatients with cerebrospinal fluid shunt is discussed. Br J Anaesth 2004; 92: 434–7     

Bacterial peritonitis in patients with ventriculoperitoneal shunt.

Bacterial peritonitis is an unusual complication of ventriculoperitoneal (VP) shunt for hydrocephalus. This complication, usually associated with peritoneal cysts of perforated viscus, may occur as the first manifestation of shunt infection. Early recognition of this form of bacterial peritonitis and appropriate antibiotic therapy may avert major abdominal surgery in selected cases.     

Laparoscopic cecal cancer resection in a patient with a ventriculoperitoneal shunt: A case report

INTRODUCTIONThe presence of a ventriculoperitoneal shunt has been considered to be a contraindication for laparoscopic surgery till date; however, laparoscopic cholecystectomy was recently reported as safe for patients with this shunt.PRESENTATION OF CASEWe present the first case, to the best of our knowledge, of laparoscopic colectomy for cecal cancer in a patient with a ventriculoperitoneal shunt. A 59-year-old woman with a ventriculoperitoneal shunt for hydrocephalus was referred to our hospital with cecal cancer. Laparoscopic cecal cancer resection was performed successfully and uneventfully by manipulating the shunt.DISCUSSIONClamping of the shunt catheter at the subcutaneous region was performed before insufflation of carbon dioxide to prevent adverse effects from the pneumoperitoneum.CONCLUSIONWe believe that laparoscopic colectomy for colon cancer can be performed safely in patients with a ventriculoperitoneal shunt by optimal manipulation of the shunt.     

Acute appendicitis in children with a ventriculoperitoneal shunt

Acute appendicitis in children with ventriculoperitoneal shunts can be misdiagnosed and mismanaged. The peritoneal catheter should be removed only after injection with contrast material shows that there is no perforation of the bowel. If the abdominal symptoms do not subside within 4 to 6 hours following removal of the catheter and the beginning of antibiotic treatment, a laparotomy is indicated. Shunt dependency should be evaluated following appendectomy.     

Otogenic tension pneumocephalus complicated by eustachian tube insufflation in a patient with a ventriculoperitoneal shunt. Case report

Spontaneous tension pneumocephalus (TPC) related to shunt surgery has sometimes been reported with reference to the Valsalva maneuver and osseous defects of the tegmen tympani. Here, the authors report on a case of TPC complicated by eustachian tube (ET) insufflation and a ventriculoperitoneal (VP) shunt. This 78-year-old man had undergone VP shunt insertion 3 weeks before readmission to the hospital with a diagnosis of TPC, a left temporal porencephalic cyst, and air accumulation and late leakage of cerebrospinal fluid (CSF) into the left tympanic cavity. The TPC was controlled successfully by ligation of the shunt tube. The authors discuss the pathophysiology of this complicated TPC case, which illustrates the risk of ET insufflation in patients undergoing CSF shunt surgery.     

Spontaneous pneumocephalus in the posterior fossa in a patient with a ventriculoperitoneal shunt: case report

OBJECTIVE AND IMPORTANCE: A unique case of spontaneous pneumocephalus is described. It appeared a few years after the uneventful introduction of a cerebrospinal fluid shunt and was probably attributable to a defect of the posterior mastoid plate. CLINICAL PRESENTATION: A 65-year-old man presented with a subacute onset of vertigo, vomiting, and atactic gait instability. The patient had undergone a ventriculoperitoneal shunt implantation 2 years previously for communicating hydrocephalus. A computed tomographic scan revealed a posterior fossa pneumatocele without hydrocephalus. INTERVENTION: A simple mastoidectomy was performed. Detection of the area of the bone defect was followed by mastoid obliteration with abdominal fat. CONCLUSION: Clinicians should be aware that pneumocephalus can occur spontaneously, with or without obvious shunt problems. Treatment should be directed toward the area through which air penetrated the posterior fossa.     

Metastasis via ventriculoperitoneal shunt in patients with medulloblastoma.

The authors have routinely inserted a ventriculoperitoneal shunt in all patients with a posterior fossa tumor and hydrocephalus some 7-10 days prior to craniotomy. Forty-one patients with medulloblastoma were treated in this fashion and of these, four metastasized through the shunt and died of systemic metastases without evidence of recurrent tumor in their central nervous system. A millipore filter which can be incorporated in the shunt has been used by the authors during the past 18 months in an effort to prevent metastatic spread through the shunt.