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 removal of dislocated ventriculoperitoneal shunts

In two patients the dislocated abdominal catheter of a ventriculoperitoneal (VP) shunt was successfully removed from the abdominal cavity by laparoscopy. Avoiding laparotomy, only two small abdominal incisions were necessary to insert the laparoscope and the grasping forceps. Postoperative course was uncomplicated except for protrusion of a part of the greater omentum through the umbilical incision in one patient. Both patients were mobilized on the operative day. Surgery required only 10 min, provided an excellent view of the entire abdomen, and led to prompt identification and removal of the lost catheter.     

Laparoscopic cholecystectomy in patients with ventriculoperitoneal (VP) shunts

Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO₂ insufflation pressure was as high as 10–15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.     

Laparoscopic cholecystectomy in patients with ventriculoperitoneal shunts: A case series

Introduction

Patients with ventriculoperitoneal shunts (VPS) are at risk of associated complications during laparoscopic surgery. Although these cases are rare, the surgeon should be aware of the pathophysiology of such complications in order to recognize and avoid them.

Case presentation

Three patients with a VPS who underwent laparoscopic cholecystectomy are presented. Two of the patients suffered from symptomatic gallstone disease, and the third, the oldest, from acute calculus cholecystitis. All patients had a VPS because of hydrocephalus. There were no intraoperative complications in this series.

Discussion

This small case series presents a rare condition that can be the cause of complications during laparoscopic surgery. Septic complications, including VPS infection and cerebrospinal fluid (CSF) infection, pneumocephalus, CSF pseudocyst, and adhesions due to the presence of the VPS, are all possible occurrences. These are discussed, with a short literature review.

     

Laparoscopic surgery in patients with ventriculoperitoneal shunts: safety and monitoring

PURPOSE: It was suggested that patients with a ventriculoperitoneal shunt are at risk for increased intracranial pressure during pneumoperitoneum. Shunt pressure monitoring and ventricular drainage to maintain normal pressure were recommended. We evaluated a series of patients with a ventriculoperitoneal shunt who underwent laparoscopic surgery to determine the clinical indications of increased intracranial pressure. MATERIALS AND METHODS: We reviewed the anesthesia records of 12 females and 6 males with a mean age of 13.2 years who had a ventriculoperitoneal shunt and underwent a total of 19 consecutive laparoscopic operations. Data on operative time, carbon dioxide level, pulse, blood pressure and any untoward anesthetic events were obtained. Postoperative records were assessed for evidence of neurological change. RESULTS: Mean operative time was 7 hours 13 minutes and estimated mean laparoscopic time was 2 hours 52 minutes. Average insufflation pressure was 16 mm. Hg (range 12 to 20). There was no evidence of a trend to combined bradycardia and hypertension or surgically related neurological deterioration and no untoward anesthetic events. Ventriculoperitoneal shunt revision was done in 3 cases, a rate consistent with that in the literature. Mean followup was 23.4 months (range 1 to 58). CONCLUSIONS: There was no evidence of clinically significant increased intracranial pressure in our series or in the literature in patients with a ventriculoperitoneal shunt who undergo laparoscopy. Invasive methods for shunt monitoring are not without risk. Routine anesthetic monitoring should remain the standard of care in the absence of clear evidence to the contrary.     

Laparoscopic guidance or revision of ventriculoperitoneal shunts in children.

BACKGROUND: Ventriculoperitoneal shunt is the preferred treatment for hydrocephalus. Known complications include infection, obstruction, and disconnection with the fractured fragment migrating in the peritoneal cavity. We report 17 cases of laparoscopic evaluation and revision of ventriculoperitoneal shunts in children. METHODS: From January 2000 through October 2002, we retrospectively reviewed our experience with laparoscopy and ventriculoperitoneal shunts. RESULTS: Laparoscopy was performed in 17 children with a malfunctioning shunt, presumed shunt dislodgment or disconnection, reinsertion of a shunt after externalization, and primary shunt placement. Six patients (35%) were converted to an open laparotomy due to dense adhesions. Eleven patients (65%) underwent successful laparoscopic-assisted ventriculoperitoneal shunt placement: 5/11 (45%) had lysis of adhesions or pseudocyst marsupialization with repositioning of a functional shunt, or both; 3/11 (27%) had successful retrieval of a disconnected catheter with reinsertion of a new catheter; 2/11 (18%) had laparoscopic confirmation of satisfactory placement and function, requiring no revision; 1/11 (9%) had an initial shunt placed with laparoscopic guidance due to the obesity. Operative time for the laparoscopic procedure ranged from 30 minutes to 60 minutes. All laparoscopic procedures used 1-mm or two 5-mm ports. Perioperatively, no adverse neurological sequelae occurred due to the pneumoperitoneum. CONCLUSIONS: Laparoscopic guidance or revision of ventriculoperitoneal shunts permits (1) direct visualization of catheter insertion within the peritoneal cavity, (2) satisfactory positioning, (3) lysis of adhesions or marsupialization with catheter repositioning, or both, and (4) retrieval of fractured catheters.     

Laparoscopic ventriculoperitoneal shunts: benefits to resident training and patient safety

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.     

Cholecystectomy in patients with prior ventriculoperitoneal shunts

Background

There is little published evidence regarding intraoperative and postoperative complications in patients with ventriculoperitoneal shunts who undergo cholecystectomy.

Methods

Nationwide Department of Veterans Affairs databases were searched to identify patients with International Classification of Diseases, 9th revision, Clinical Modification codes for a VP shunt who later had a cholecystectomy during fiscal years 1994 to 2003. Charts on these patients were obtained and reviewed.

Results

Twenty-three patients were deemed evaluable. Of these, 8 had laparoscopic converted to open cholecystectomies. All conversions were owing to dense adhesions. There were 2 cases of postoperative shunt infection that required shunt removal and replacement.

Conclusions

The rate of conversion from laparoscopic to open cholecystectomy was 57% in this study, significantly higher than the reported rate of conversion for patients without shunts in Department of Veterans Affairs Medical Centers (5%). Cholecystectomy in adult patients with a preexisting ventriculoperitoneal shunt appears to result in a shunt infection rate similar to that reported after shunt insertion or revision.     

Successful laparoscopic fundoplication in children with ventriculoperitoneal shunts

We reported successful laparoscopic fundoplication in 2 pediatric cases with VPS and discuss the safety and feasibility of the procedure. Case 1: A 13-year-old girl with VPS underwent laparoscopic fundoplication. Case 2: a 9-year-old boy with VPS underwent laparoscopic fundoplication. In both cases, laparoscopic Nissen fundoplication was performed with a standard five-port technique with a low pressure of a pneumoperitoneum. The VPS system had no effect on port layout and intraabdominal manipulation and no adverse complications were observed in either case. The effect of a pneumoperitoneum in the VPS system remains controversial, however, the author emphasized that advanced laparoscopic surgery can be performed safely with creating a low pressure of a pneumoperitoneum.     

Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) may be required in neurosurgical patients with a persistently depressed neurological status or severe lower cranial nerve palsies. Such patients may have a coexisting hydrocephalus requiring cerebrospinal fluid (CSF) diversion. Despite the risk of infection resulting from exposure to oropharyngeal flora by the pull-through PEG technique and the secondary pneumoperitoneum seen in one-third of patients, simultaneous peritoneal placement of CSF shunt catheters with PEG is the current practice. The aim of the study was to determine the frequency of CSF diversionary procedures in neurosurgical patients undergoing PEG insertion and the occurrence of infective complications in patients with simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt. METHODS: This was a retrospective review of all neurosurgical patients undergoing PEG. The presence of hydrocephalus, mode of CSF diversion and the development of subsequent infection in those having coexistent distal peritoneal catheter placement and PEG were determined. RESULTS: PEGs were placed in 42 neurosurgical patients (9.3 per cent of all PEGs inserted), of whom 21 had a coexisting hydrocephalus. Eight of 16 shunts with distal catheter placement in the peritoneal cavity developed infection requiring revision. Infections occurred with greater frequency in patients with a tracheostomy. There were no shunt infections requiring revision in a second group of 21 patients who had a coexisting shunt and tracheostomy without PEG. CONCLUSION: Simultaneous placement of a PEG and a VP shunt should be avoided in the acute phase of a patient's hospital admission.     

Colonic perforation by ventriculoperitoneal shunts

Two cases of colonic perforation by a ventriculoperitoneal shunt are presented. One was diagnosed by routine abdominal roentgenograms, the other by instilling metrizamide into the distal shunt tubing. A review of the 32 previously reported cases revealed a mortality of 15%. Bowel perforation from a ventriculoperitoneal shunt should be managed with intravenous antibiotics as well as removal of the shunt. If the patient has a benign abdominal examination and no prior history of abdominal complications from a ventriculoperitoneal shunt then the abdominal catheter can be removed percutaneously. However, in the presence of severe peritonitis, or a previous history of serious abdominal problems from the shunt catheter, such as an infected pseudocyst or other intraabdominal pathology, such as active regional enteritis or an abscess, we recommend laparotomy for removing the catheter with primary closure of the bowel perforation.     

Colonic complications of ventriculoperitoneal shunts

Late perforation of the large bowel by the abdominal catheter of a ventriculoperitoneal (VP) shunt is extremely rare. Four of the five reported patients subsequently died. We report here three patients who presented with this complication and were treated successfully. Bowel perforation by a VP shunt catheter should be considered when a shunt infection is secondary to gram-negative enteric organisms. It can occur without evidence of peritonitis, and the abdominal catheter can be removed percutaneously, thus avoiding a laparotomy.     

Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts

To determine the significance of cerebrospinal fluid (CSF) eosinophilia, the charts of 106 patients treated with shunt-related procedures during the calendar year 1985 were reviewed. Sixty-nine patients presented for a shunt revision; their charts were retrospectively reviewed from the time of shunt insertion until January, 1988. The remaining 37 patients had a ventriculoperitoneal shunt inserted during the study period and were subsequently followed to January, 1988. A total of 558 shunt-related procedures were performed on these patients during the study period, with a mean follow-up period of 6.9 years. The infection rate was 3.8%. Eosinophilia was diagnosed when eosinophils accounted for 8% or more of the total CSF white blood cell count. Ventricular CSF eosinophilia occurred in 36 patients sometime during their clinical course. These 36 patients required a mean of 8.5 shunt revisions, while the remaining patients required a mean of 2.5 revisions (p less than 0.001). Shunt infections were also more frequent in patients with eosinophilia (p less than 0.01). In no case was peripheral eosinophilia or a parasitic infection present. This study demonstrates that CSF eosinophilia is common in children with shunts. Children with this laboratory finding will experience more shunt failures. In addition, the new appearance of eosinophilia in the CSF of a patient with a shunt in place suggests the possibility of a shunt infection.     

The acute abdomen in patients with ventriculoperitoneal shunts.

A rationale for management of the patient with an acute adbomen and a ventriculoperitoneal shunt is presented in relation to eight patients. In two patients peritonitis was due to perforation of an abdominal viscus, not shunt related, and six were due to infections of ventriculoperitoneal shunts. Resolution of abdominal symptomatology occurs within six hours after the distal end of the shunt catheter is removed from the abdomen and placed in a drainage bottle. In four of these six, infection was limited to the peritoneal end of the catheter. The ventricular fluid was sterile.     

Laparoscopic placement of ventriculoperitoneal shunts: an innovative simplification of the existing techniques.

Ventriculoperitoneal shunting (VPS) remains one of the alternative choices for the surgical treatment of hydrocephalus. During the last two decades laparoscopy has been utilized to facilitate the placement of the abdominal portion of the shunt. We describe a minimally invasive laparoscopic technique, which facilitates the rapid, safe and direct placement of the peritoneal component of the VPS. A side frontal ventricular catheter is placed through a small burr hole and connected to the valve at the postauricular region. An infra-umbilical trocar is placed, using the Hasson technique, and after the pneumoperitoneum is established, a 10-mm laparoscope is introduced for identification of a VPS entry side free of adhesions. A 5-mm skin incision is made at the decided point of catheter insertion, usually at the right upper quadrant. Using a tunneler, the VPS catheter is placed subcutaneously from abdomen insertion point, to the postauricular region, where it is connected to the valve. A split type, 10-12 Fr and 12-15 cm long metallic puncture cannula, like those used for suprapelvic percutaneous bladder drainage, is introduced into the abdomen. Under direct laparoscopic vision the peritoneal portion of the VPS is passed into the abdomen through the cannula. The catheter is leaded to a desirable location by pointing the needle accordingly. Alteration of the position of the catheter can also be attained by entraining the catheter with the laparoscope and without using auxiliary graspers. The function of the VPS is confirmed under direct visualization. Suturing the abdominal and cranial incisions completes the procedure. We used this technique in a series of 12 patients with excellent outcome. There were no intra- or postoperative complications and no mortalities. Our technique is less invasive than a minilaparotomy, embraces all laparoscopic benefits and does not require auxiliary forceps or guidewires. It uses easy available materials with low cost, and attains an easy, rapid, and safe placement of the abdominal portion of the VPS.     

Abdominal complications of ventriculoperitoneal shunts in Nigerians

During a period of 12 years, 154 hydrocephalic children were treated with ventriculoperitoneal CSF shunting operations. The abdominal complications thus far encountered include development of a peritoneal fibrous pouch, deliberate extraction of the tube by mothers who mistook it for an Ascaris worm, failure of CSF absorption by the peritoneum giving rise to ascites, spontaneous extrusion of the abdominal tube, bowel perforation and volvulus.     

Minilaparoscopically assisted placement of ventriculoperitoneal shunts

Background: Ventriculoperitoneal (VP) shunting remains the preferred treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion of the catheter have been reported previously. We describe a minilaparoscopic VP shunt (MLVPS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in most patients, including those with obese abdomens previously subjected to surgery. In this study we review our experience with MLVPS placement. Methods: All cases of MLVPS insertions at the University of Kentucky Medical Center and Lexington VA Hospital performed between February 1998 and March 1999 were reviewed retrospectively. A total of 27 patients (13 males and 14 females) ranging in age from 4 to 81 years (mean, 41 years) underwent VP shunting. The MLVPS insertion was performed via a 2-mm laparoscope and a separate 2-mm incision for catheter insertion using a venous introducer kit. In patients who had prior abdominal surgery, a 5-mm direct-view trocar was used. Results: The MLVPS procedure was successful in 27 patients (100%). The mean number of prior shunts was 2 (range, 0–28). Of the 27 patients, 16 (59%) had undergone previous abdominal surgery. The mean operative time was 76 min (range, 19–155 min). There were no intra- or postoperative complications, and no mortalities. The follow-up period extended from 1 to 12 months. Conclusions: Findings show MLVPS placement to be safe and feasible. It allows accurate, directed placement of the VP shunt with a 2-mm laparoscope and a second 2-mm incision for shunt insertion. The procedure is associated with reduced trauma to the abdominal wall and minimal postoperative ileus. Long-term follow-up assessment of shunt function is planned. Received: 30 April 1999/Accepted: 27 October 1999/Online publication: 17 May 2000     

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.     

Frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles: a simple modification to free-hand procedures

The aim of this report is to introduce a simple modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles. In this technical note, we describe our experience with ventricular catheter placement in two children suffering from shunt dependent idiopathic intracranial hypertension using an image-guided instrument holder with a catheter guide. In both patients, the surgical procedure proved to be easy and accurate, with good initial clinical results. The use of an image-guided instrument holder is a modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles.