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     

The use of laparoscopy in ventriculoperitoneal shunt revisions

Introduction

Ventriculoperitoneal shunts (VPSs) are routinely placed in children with hydrocephalus. However, they often encounter problems, and revisions are frequent. We sought to evaluate our institutional experience with laparoscopic-assisted VPS revisions.

Methods

With institutional review board approval, a retrospective chart review of 17 consecutive patients who underwent 19 laparoscopic-assisted VPS revisions was conducted. Data extracted included patient demographics, indications for laparoscopic-assisted revision, complications, and shunt outcomes.

Results

The median age at revision was 12 years (0.4-20 years). Ten children (58.8%) had 2 or more previous VPS revisions. Indications for laparoscopic revision included adhesive obstruction, broken shunt retrieval, cerebrospinal fluid pseudocyst, diagnostic laparoscopy, and conversion from ventriculoatrial shunt to VPS. Three patients required repeat VPS revision for distal shunt failure, whereas 2 patients required repeat VPS revision for proximal dysfunction. Failures occurred 5 to 258 days after laparoscopic-assisted revision. Median follow-up was 21 weeks (interquartile range, 6-57 weeks). No patients developed abdominal infections postoperatively.

Conclusion

Laparoscopy is useful in select patients with distal VPS failure. Patients with multiple previous revisions, prior abdominal surgery, previous intraperitoneal infections, broken devices, or cerebrospinal fluid pseudocysts may benefit from this approach. Further prospective studies with long-term follow-up are needed to determine which patients benefit most from the laparoscopic-assisted approach.     

In vitro assessment of back pressure on ventriculoperitoneal shunt valves

Background: Whereas there are case reports of laparoscopy in patients with ventriculoperitoneal shunts, there are no studies assessing the potential failure of shunt valves with the increased intra-abdominal pressure of laparoscopy. This study aims to assess this factor. Methods: An in vitro model was used to assess the potential for retrograde failure of ventriculoperitoneal shunt valves in a commonly used shunt. Nine shunts were subjected to graded increases in back pressure and observed for retrograde valve leak. Results: None of the shunts tested showed any signs of leak associated with the increased back pressure. However, disruption of shunt seals was noted in seven of the nine shunts, occurring at the minimal pressure of 80 mmHg. Conclusions: There appears to be minimal risk of retrograde failure of the valve system in the ventriculoperitoneal shunt tested. However, tests on different types of ventriculoperitoneal shunts would be needed to confirm these results if laparoscopy is to be considered safe in patients with ventriculoperitoneal shunts in situ. Received: 2 February 1998/Accepted: 6 July 1998     

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.     

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     

Hydrothorax: Unusual complication of ventriculoperitoneal shunts

Summary A case is presented in which puncture of the pleura and hydrothorax occurred during placement of a ventriculoperitoneal shunt. Treatment of this complication is outlined.     

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.     

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.     

腹腔镜辅助下阴式子宫切除术54例临床分析

目的:总结腹腔镜辅助下阴式子宫切除术(LAVH)的安全性、可行性、价值、并发症及手术技巧。方法:为54例患者行LAVH,对患者的临床资料、手术方式及随访结果进行总结。结果:除2例因盆腔严重粘连中转开腹外,其余全部行LAVH或LAVH+单侧或双侧附件切除术。平均手术时间132m in,术中平均出血量150m l。无并发症发生。结论:LAVH手术具有开腹手术及阴式手术共同的优点,既有开腹手术清晰的视野,又避免了阴道手术处理附件较困难、对盆腔情况缺乏全面的评估等弊病,具有广阔的应用空间及发展前景。     

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.     

Sclerosing encapsulating peritonitis--a rare complication of ventriculoperitoneal shunts

Sclerosing encapsulating peritonitis (SEP) is a rare cause of bowel obstruction, most commonly associated with chronic ambulatory peritoneal dialysis. It has not previously been reported as a complication of ventriculoperitoneal (VP) shunts. We describe the clinical features of shunt-associated SEP and the important management considerations. Two children presented with small bowel obstruction after long-standing VP shunting of hydrocephalus. Neither had a history of recent shunt infection/revision nor evidence of shunt malfunction. In each case, the bowel was “cocooned” in a fibrous sheath with a notable absence of parietal adhesions. Both children were managed by meticulous adhesiolysis accompanied by shunt exteriorization. Both had prolonged ileus and required total parenteral nutrition. One required further laparotomy at which adhesiolysis was accompanied by irrigation with icodextrin 4% and systemic high-dose methylprednisolone. Weaning of steroids was accompanied by the introduction of azathioprine. A notable feature of intestinal obstruction because of SEP was severe pain despite adequate decompression. The restrictive “cocoon” that envelops the bowel prevents bowel dilatation and accounts for atypical radiologic findings in these cases.     

One-trocar laparoscopy

Background: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). Materials and Methods: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. Results: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. Conclusions: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.     

腹腔镜辅助阴式全子宫切除术112报告

目的:探讨腹腔镜辅助阴式全子宫切除术(laparoscopiclly assisted vaginal hysterectomy,LAVH)的临床疗效及安全性。方法:回顾分析为112例有子宫切除指征的患者行LAVH的临床资料,术后应用抗生素规范治疗。观察术中、术后患者一般情况、手术时间、出血量、住院时间、并发症及术后随访等。结果:112例均顺利完成手术,无一例中转开腹,术后患者临床症状完全消失。6例术后阴道残端出血,经再缝扎宫颈残端后治愈;无一例发生术后腹壁切口感染、泌尿系感染、膀胱及直肠破裂、尿路刺激症状、尿潴留、术后阴道膀胱瘘等并发症。远期随访效果均满意。结论:LAVH治疗妇科良性疾病临床疗效显著,安全性高,是目前较理想的治疗方法,值得推广应用。     

Transumbilical laparoscopically assisted appendectomy in children

BACKGROUND: Two different laparoscopic appendectomy (LA) techniques, one performed with staplers (LAS) and the other using loops (LAL), were compared with transumbilical laparoscopically assisted appendectomy (TULAA). METHODS: A total of 72 children, 55 with a diagnosis of uncomplicated acute appendicitis and 17 with recurrent right lower abdominal pain, underwent operation during the period 2003-2006. The procedures used were: 34 LAS, 9 LAL, and 29 TULAA. Measured outcomes were operative time, postoperative complications, need for rescue analgesics, length of hospital stay, and procedure cost reflected by supplies used. The staplers, endoloops, clips, and sutures used to manage appendectomy were listed at current prices, summarized as number consumed per case, and compared. Data were analyzed by Fisher's exact test and the Mann-Whitney U-test where appropriate. Statistical significance was determined as p < 0.05. RESULTS: Average price of materials used was 113.5 USD for LAS, 91 USD for LAL, and 14 USD for TULAA. Wound infections were recorded in two patients (4.6%) in the LA group and in four patients (13.7%) in the TULAA group (p = 0.17). One patient in the LAL group developed an abdominal abscess that was managed conservatively. Median operating time was 39 (24-66) min in the LA group versus 33 (25-55) min in the TULAA group (p < 0.05). Rescue analgesia was administered in 19/43 (44%) of LA patients and 9/29 (31%) of TULAA patients (p = 0.19). The length of hospital stay was 3.1 days for LA patients and 3.0 days for TULAA patients (p = 0.43). Two TULAA procedures (6.4%) were finished with additional port/s. CONCLUSIONS: In this study, the cost of TULAA is 7.8 times lower than the cost of LA, 8.1 times lower than LAS, and 6.5 times lower than LAL. Higher cost of laparoscopy is solely attributable to the purchase price of the supplies used. Overall postoperative morbidity, the incidence of wound infection, the length of hospitalization, and the need for rescue analgesia did not show a statistical difference in comparing LA/TULAA. Operative time was shorter in the TULAA group. In terms of limited resources, TULAA could be the most appropriate minimally invasive technique for appendectomy in children.     

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.     

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.     

脑室-腹腔分流术141例并发症分析

目的 探讨脑室-腹腔分流术后并发症及防范措施。方法 回顾性分析2000年12月至2011年3月间连续的141例行“脑室-腹腔分流术”的临床资料,探讨并发症的发生和防范措施。结果 术后总并发症发生率为9.93%,其中堵管5例（3.55%）,感染3例（2.13%）,低颅压综合症3例（2.13%）,术后胃肠道反应2例（1.42%）,引流管意外出1例（0.71%）,颅内血肿1例。结论 严格无菌操作、提高手术技巧、选择合适的分流装置等措施可有效减少手术并发症。     

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.     

腹腔镜脑室腹膜分流术治疗脑积水并发症的临床体会

目的:探讨腹腔镜脑室腹膜分流术治疗脑积水的临床应用价值,总结并发症发生的原因及预防措施.方法:回顾分析60例患者行腹腔镜脑室腹膜分流术的临床资料.结果:60例患者无一例手术死亡,40例术后临床症状较术前明显改善,14例发生并发症,发生率约23.3%,其中分流管梗阻6例,感染4例,硬膜下积液4例.结论:严格掌握手术指征,...