Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentationrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation. Methods: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement. Results: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required. Conclusions: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments. Received: 19 March 1999/Accepted: 23 June 1999/Online publication: 10 April 2000     

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 procedures in adults with ventriculoperitoneal shunts

Until recently, the presence of a ventriculoperitoneal shunt (VPS) was considered an absolute contraindication to laparoscopy. In some cases, intraabdominal insufflation causes a rapid, sustained increase in intracranial pressure (ICP). Such intracranial hypertension may result in hindbrain herniation. To prevent this, the use of lower abdominal pressures, intraoperative ICP monitoring, intraoperative ventricular drainage, and distal shunt catheter clamping/externalization has been reported in some studies. However, other studies show that laparoscopy is safe even without VPS catheter clamping and with only routine anesthetic monitoring. Moreover, the risk of retrograde failure of the valve system has been shown to be minimal even with intraabdominal pressures as high as 80 mm Hg. We report how we managed a hydrocephalic adult with a VPS shunt undergoing laparoscopic cholecystectomy in the hope that our experience contributes to the successful management of such patients in the future.     

Efficacy of Lumbo-Peritoneal Versus Ventriculo-Peritoneal Shunting for Management of Chronic Hydrocephalus Following Aneurysmal Subarachnoid Haemorrhage

Summary ? Background. The clinical usefulness of lumboperitoneal (LP) shunts in selecting patients with communicating hydrocephalus after aneurysmal subarachnoid haemorrhage (SAH) was compared with that of ventriculoperitoneal (VP) shunts.  Method. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus which lasted 3 weeks or longer after the original haemorrhage and which required shunting. Indications for a CSF shunt were assessed on the basis of neurological symptoms and signs, CT findings, and isotope cisternogram findings. The patients were treated with either LP or VP shunts. A significant response to shunting was defined as an improvement of function to a higher grade. The functioning of the shunt was evaluated by the location of the catheter on x-ray studies, CT features, and isotope cisternograms. The operation groups were checked for comparability of demographic and clinical variables including age, Fisher grade, hypertension, vasospasm, shunt interval, preshunt functional grade, and CT findings. A comparative analysis of the outcome was carried out between the two operation groups.  Findings. Fifty-six patients underwent shunt placements (LP shunts: 22, VP shunts with medium pressure valve: 2, VP shunts with high pressure valve: 32). There was no statistically significant difference in patient demographics and clinical characteristics between the patients with LP shunts and those with VP shunts. A follow-up time of 3 months to 8 years revealed clinical improvement in 11 cases (50.0%) of patients with LP shunts and 31 cases (91.1%) in VP shunts was seen (Fisher's exact test, P<0.005).  Interpretation. These findings suggest that VP shunts are a better choice of treatment than LP shunts in treating chronic hydrocephalus after aneurysmal SAH.     

Ventriculoperitoneal Shunt Failure as a Complication of Laparoscopic Surgery

Objective:

The authors report the first documented case of laparoscopically induced Ventriculoperitoneal (VP) shunt failure.

Summary Background Data:

Laparoscopic surgery has become a preferred method of accessing and treating a variety of intraperitoneal pathology.Surgeons can expect to encounter patients who have previously under-gone placement of cerebrospinal fluid (CSF) shunts who present as candidates for laparoscopic procedures. Currently, the presence of a CSF shunt is not considered to be a contraindication to laparoscopy. We report the first documented case of laparoscopically induced VP shunt failure.

Clinical History:

A patient with shunt-dependent hydrocephalus underwent laparoscopic placement of a feeding jejunostomy. Postoperatively, clinical and radiographic evidence of shunt failure was noted. The patient under-went emergent shunt revision. Intraoperatively, an isolated distal shunt obstruction was encountered. Gentle irrigation cleared the occlusion. We believe that this shunt dysfunction was secondary to impaction of either soft tissue or air within the distal catheter as a consequence of peritoneal insufflation.

Conclusions:

It is concluded that laparoscopic surgery may represent a potential danger in patients with pre-existing CSF shunts. The risk of neurological injury faced by this patient population during laparoscopy is derived from peritoneal insufflation and relates to two primary concerns. The first is impaired CSF drainage due to a sustained elevated distal pressure gradient or, as in our case, an acute distal catheter obstruction. The second concern relates to the potential for retrograde insufflation of the CSF spaces through an incompetent shunt valve mechanism. Distal shunt catheter externalization performed in conjunction with a neurosurgeon during the laparoscopic procedure would prevent these complications. Internalization of the distal shunt catheter would then be performed at the completion of the laparoscopic procedure.     

A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts

Background: During the last two years, laparoscopy has been utilized to facilitate the rapid, safe and direct placement of the abdominal component of ventriculoperitoneal shunts. This study was undertaken to review the feasibility, benefits, technique, and clinical application of laparoscopically assisted ventriculoperitoneal (LAVP) shunt placement. Methods: A retrospective analysis of the records of six patients who underwent LAVP shunt placement was undertaken. The sex, age, technique, indication for surgery, comorbid conditions, complications operative time, results, and mortality were noted. Results: All patients underwent successful shunt placement. This included placement in the face of previous abdominal surgery, including a percutaneous gastrostomy. The one major complication, hemothorax, was not associated with the laparoscopic portion of the procedure. Conclusions: Using basic laparoscopic skills and nonspecialized equipment, laparoscopic assistance in ventriculoperitoneal shunt placement offers easy, direct placement of the intraabdominal portion of the catheter in most situations and provides definite patient benefits.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Low pressure hydrocephalus: issues of diagnosis and treatment in five cases

Five patients with hydrocephalus who failed to respond to apparently adequate CSF drainage via a functioning shunt (four cases) or external ventricular drain (one case) are described. In three of the four shunted cases, the shunt was ventriculoperitoneal with a medium pressure valve, and in one a combination of peritoneal and atrial shunts both with low pressure valves. All five patients were tested for possible low pressure hydrocephalus by a period of external ventricular drainage at heights of 0 to -5 cm H2O below the reference point (external auditory meatus--EAM). Four of the five patients showed rapid and significant clinical improvement and went on to shunt revision (three) or insertion (one). The shunts were then all peritoneal, of which three were valveless, whilst one had a Sophy programmable valve at the lowest setting. In all four patients the improvement was sustained and was associated with a radiological (CT or MRI) improvement which varied from marked to slight. In the fifth patient there was no improvement with low pressure external drainage and no shunt revision was undertaken. On the basis of these cases the possible entity of low pressure hydrocephalus is discussed with particular reference to mechanism, recognition and management.     

Laparoscopic management of ventriculoperitoneal and lumboperitoneal shunt complications.

BACKGROUND AND OBJECTIVES: Minimally invasive approaches for the initial placement of ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts have been well described. A laparoscopic approach has multiple advantages over open techniques, including decreased morbidity, more rapid recovery, and ability to visually assess catheter function. However, few series have addressed the role of laparoscopy in the management of VP and LP shunt complications. METHODS: We present here the largest published series of laparoscopic treatment of VP and LP shunt complications in adults, by retrospectively reviewing all cases performed in a 1-year interval by a single surgeon. RESULTS: Ten patients presented with complications of previous shunting; all were managed laparoscopically. Eighty percent of these patients had a successful single laparoscopic intervention. One patient developed a cerebrospinal fluid leak from the lumbar wound, and 2 patients required additional laparoscopic shunt revisions. CONCLUSIONS: We conclude that laparoscopy has great utility in the assessment of shunt function. Laparoscopic techniques should be considered not only for placement of peritoneal catheters, but also for the management of distal shunt malfunction and diagnosis of abdominal pain in these patients.     

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.     

Laparoscopic-assisted lumboperitoneal shunt: a simplified technique.

OBJECTIVES: Lumboperitoneal shunt has been advocated as a better alternative to ventriculoperitoneal shunt in communicating hydrocephalus. To minimize the morbidity of subcutaneous tunneling or an open abdominal wound, we developed a simplified technique for laparoscopy-assisted placement of lumboperitoneal shunts. METHODS: Patients deemed candidates for lumboperitoneal shunts underwent laparoscopy-assisted lumboperitoneal shunt placement. Using a Tuohy needle, the neurosurgeon obtains access to the lumbar subthecal space. Simultaneously, the laparoscopist obtains access to the peritoneal cavity with two 5-mm ports for the take down of the descending colon, clearing the way for the passage of the shunt passer from the back into the peritoneal cavity. RESULTS: Over the last 5 years, 45 patients have undergone laparoscopy-assisted lumboperitoneal shunt placement. Patients have been followed with neuropsychiatric examinations, imaging studies, and repeated neurological examinations. No complications related to the laparoscopy have occurred. Neurosurgical complications included postural headaches caused by overdrainage in 4 patients requiring laparoscopic modification of the shunt slit and in 1 patient with acquired Arnold-Chiari I malformation. CONCLUSION: Laparoscopy-assisted lumboperitoneal shunt offers many advantages over percutaneous ventriculoperitoneal or laparoscopic transabdominal lumboperitoneal shunts. The procedure can be performed in less than 30 minutes by any practicing laparoscopist.     

Assessment of a Quick Reference Table Algorithm for Determining Initial Postoperative Pressure Settings of Programmable Pressure Valves in Patients With Idiopathic Normal Pressure Hydrocephalus: SINPHONI Subanalysis

BACKGROUND:: Management of overdrainage complications in shunted patients with idiopathic normal pressure hydrocephalus (INPH) remains a difficult task despite the use of programmable pressure valves. OBJECTIVE:: To assess the usefulness of a quick reference table (QRT) algorithm for achieving a suitable initial programmable pressure valve setting in INPH patients who participated in the Study for INPH on Neurological Improvement (SINPHONI). METHODS:: One hundred registered patients diagnosed with probable INPH were treated with ventriculoperitoneal shunts using Codman-Hakim programmable valves (CHPVs). In this series, the initial CHPV setting was decided prospectively according to the QRT algorithm. Shunt effectiveness, complications, and the number of CHPV readjustments during follow-up periods were investigated. RESULTS:: Eighty patients were considered better than shunt responders (more than 1 point improvement in modified Rankin Scale at any follow-up period). Readjustments of CHPVs within 3 months after treatment with ventriculoperitoneal shunt were performed 56 times in 44 cases (44%, 0.56 times/patient). Low-pressure headache occurred in 9 patients, all of whom improved by readjustment alone. Nontraumatic subdural fluid collections and chronic subdural hematomas occurred in 15 cases (15%); however, most of the cases were subclinical and improved after CHPV readjustments alone. Burr hole irrigation was necessary in only 1 case. CONCLUSION:: Use of the QRT algorithm was associated with a decrease in postoperative CHPV readjustments and serious overdrainage complications during the follow-up period. The QRT algorithm is an easy, safe, and effective method for determining the initial CHPV pressure setting in INPH patients. ABBREVIATIONS:: CHPV, Codman-Hakim programmable valveCSDH, chronic subdural hematomaGR, good recoveryIAP, intra-abdominal pressureICP, intracranial pressureINPH, idiopathic normal pressure hydrocephalusLPH, low pressure headachemRS, modified Rankin ScaleNR, nonresponderPPV, programmable pressure valveQRT, quick reference tableSFC, subdural fluid collectionSINPHONI, Study for Idiopathic Normal Pressure Hydrocephalus on Neurological ImprovementSR, shunt responderVP, ventriculoperitoneal.     

Laboratory Testing of Hydrocephalus Shunts – Conclusion of the U.K. Shunt Evaluation Programme

Summary.  16 models of valves, currently in use in the U.K., have been tested long-term in the U.K. Shunt Evaluation Laboratory according to the protocol based on the new ISO 7197 standard. Valves tested were:  Medtronic PS Medical: Delta Valve, Flow Control and Lumbo-Peritoneal Shunt  Heyer-Schulte Nero-Care: In-line, Low Profile and Pudenz Flushing Valve  Codman: Codman-Hakim Programmable, Hakim Precision, Accu-Flo, Holter, Uni-Shunt, and siphon-preventing device – SiphonGuard  NMT: Orbis-Sigma Valve, Omni-Shunt and Hakim Valve  Sophysa: Sophy Programmable Valve  Radionics: Contour-Flex Valve.  The majority of the valves had a non-physiologically low hydrodynamic resistance (with the exception of Orbis-Sigma, PS Lumbo-Peritoneal and Heyer-Schulte In-Line). This may result in overdrainage both related to posture and during nocturnal cerebral vasogenic waves. A long distal catheter increases the resistance of these valves by 100–200%. Drainage through valves without siphon-preventing mechanism is very sensitive to body posture. This may produce grossly negative intracranial pressure after implantation. A few shunts (Delta, Low Profile and Pudenz-Flushing with Anti-Siphon Devices) offer a reasonable resistance to negative outlet pressure, and hence potentially might prevent complications related to overdrainage. On the other hand, valves with siphon-preventing devices may be blocked by raised subcutaneous pressure (exception: SiphonGuard, but this device may block the drainage because of its faulty design). In most of the silicone-diaphragm valves, closing pressure varied and reached values lower than that specified by the manufacturer (exception: Heyer-Schulte Pudenz Flushing Valve). All programmable valves are susceptible to overdrainage in the upright body position. Programmed settings may be changed by external magnetic fields. Most shunts are very sensitive to the presence of small particles in the drained fluid.  The behavior of a valve revealed during such testing is of immediate relevance to the surgeon and may not be adequately described in the manufacturer's product information. These results are also relevant to the assessment of shunt function in-vivo using an infusion test. Published online June 20, 2002     

Invagination of a shunt valve: an unusual complication--case report.

The authors present an unusual case of ventriculoperitoneal shunt failure due to invagination of a valve in the proximal portion of the silicone casing of the shunt system. The shunt had been in place for 5 years and the 57-year-old male patient had incurred no head injury during that period. The valve failure was discovered during evaluation of his gradual deterioration, which culminated in his functional incapacitation. Nine such cases have been reported in the literature. This complication is specifically associated with the Holter and Hakim valves and seems to a primary mechanical failure attributable to the structure of these two valves.     

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 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.     

Shunt tube problems due to placement of valves on the chest wall--three case reports

Programmable valves are often used for ventriculoperitoneal (VP) shunts with the shunt valve positioned on the chest wall. Three cases of shunt problems occurred due to placement of the valve on the chest wall. A 43-year-old male was treated with a VP shunt, and suffered shunt malfunction due to dislocation of the ventricular tube. A 21-year-old male was treated with a VP shunt, and suffered shunt malfunction due to disconnection of the shunt tube. A 4-day-old female neonate was treated with a VP shunt, and suffered migration of the shunt valve. The shunt system has two anchor sites on the head and chest wall, with the neck between the two anchor sites. High tension is sometimes caused in the shunt tube between the two points due to movement of the neck or growth, and may induce such dislocation and disconnection of the shunt tube. We recommend a longer shunt tube in such cases.     

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval,diagnostic laparoscopy and hernia repair

BackgroudVentriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.MethodsWe describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.ResultsPrompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.ConclusionIn the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.     

A laparoscopic approach to ventriculoperitoneal shunt placement in adults

Background: Ventriculoperitoneal shunts have been used for the treatment of hydrocephalus for years. In the past, the abdominal portion of this technique has required mini-laparotomy. We present a series of 10 consecutive patients in which ventriculoperitoneal (VP) shunts were placed with laparoscopic assistance. Materials and methods: At Lankenau Medical Center for July 1996 to January 1998, 10 patients (aged 22–81) with normopressure hydrocephalus underwent laparoscopic VP shunt placement. The neurologic portion of the procedure is begun simultaneously with the abdominal procedure. After pneumoperitoneum is established using a miniport disposable 2-mm introducer at the umbilicus, a 2-mm camera is introduced into the peritoneal cavity through the same port. A needle is introduced into the peritoneal cavity under direct visualization. Once the catheter is placed ventricularly, it is tunneled subcutaneously to the abdomen. Using the Seldinger technique, the VP catheter is introduced under direct visualization through a sheath into the peritoneal cavity toward the pelvis. Positioning and function are also confirmed under direct visualization. Results: All patients tolerated this procedure well, and there were no complications. The benefits of this procedure include direct visualization of catheter placement and smaller incisions than necessary for an open procedure. Conclusion: We recommend laparoscopic-assisted placement of the VP shunt in normopressure hydrocephalus patients as a good alternative to the open technique. Received: 30 June 1998/Accepted: 25 November 1998     

Programmable shunt valves: in vitro assessment of safety of the magnetic field generated by a portable game machine

Cerebrospinal fluid (CSF) shunts are frequently used to treat hydrocephalus. The use of a programmable shunt valve allows physicians to easily change the opening pressure. Since patients with adjustable CSF shunt valves may use portable game machines, the permanent magnets in these machines may alter the shunt valve programmed settings or permanently damage the device. This study investigated the risk of unintentional valve adjustment associated with the use of game machines in patients with programmable CSF shunt valves. Four adjustable valves from 4 different manufacturers, Sophysa Polaris model SPV (Polaris valve), Miethke proGAV (proGAV), Codman Hakim programmable valve (CHPV), and Strata II small valve (Strata valve), were evaluated. Magnetic field interactions were determined using the portable game machine, Nintendo DS Lite (DS). The maximum distance between the valve and the DS that affected the valve pressure setting was measured by x-ray cinematography. The Polaris valve and proGAV were immune to unintentional reprogramming by the DS. However, the settings of the CHPV and Strata valves were randomly altered by the DS. Patients with an implanted shunt valve should be made aware of the risks posed by the magnetic fields associated with portable game machines and commonly used home electronics.