Laparoscopic Placement of Ventriculoperitoneal Shunts: An Innovative Simplification of the Existing Techniques

Abstract

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.

Key words

Hydrocephalus - laparoscopic placement - ventriculoperitoneal shunt - peritoneal catheter

References

• 1 Box JC, Young D, Mason E, Angood P, Yancey M, Shiess R, Duncan T, Lucas GW. A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts.  Surg Endosc. 1996;  10 311-313
• 2 Lockhart C, Selman W, Rodziewicz G, Spelger RF. Percutaneous insertion of peritoneal shunt catheters with the use of Veress needle.  J Neurosurg. 1984;  60 444-446
• 3 Cuatico W, Vannix D. Laparoscopically guided peritoneal insertion in ventriculoperitoneal shunts.  J Laparoendosc Surg. 1995;  5 309-311
• 4 Bryant MS, Bremer AM, Tepas JJ, Mollitt DL, Nquyen TZ, Talbert JL. Abdominal complications of ventriculoperitoneal shunts.  Am Surg. 1988;  54 50-55
• 5 Armbruster C, Blauensteiner J, Ammerer HP, Kriwanek S. Laparoscopically assisted implantation of ventriculoperitoneal shunts.  J Laparoendosc Surg. 1993;  3 191-192
• 6 Hay SA, Hay AA, Moharram H, Salama M. Endoscopic implantation and patency evaluation of lumboperitoneal shunts. An innovative techique.  Surg Endosc. 2004;  18 482-484
• 7 Khaitan L, Brennan JR. A laparoscopic approach to ventriculoperitoneal shunt placement in adults.  Surg Endosc. 1999;  13 1007-1009
• 8 Khosrovi H, Kaufman HH, Hrabovsky E, Bloomfield SM, Pradhu V, Kadi HA. Laparoscopic assisted distal ventriculoperitoneal shunt placement.  Surg Neurol. 1998;  49 127-135
• 9 Hassan HM. Modified instrument method for laparoscopy.  Am J Obst Gynecol. 1971;  110 886-887
• 10 Roth JS, Park AE, Gewirtz R. Minilaparoscopicaly assisted placement of ventriculoperitoneal shunts.  Surg Endosc. 2000;  14 461-463
• 11 Fanelli RD, Mellinger DN, Crowell RM, Gersin KS. Laparoscopic ventriculoperitoneal shunt placement.  Surg Endosc. 2000;  14 641-643
• 12 Gersin KS, Heniford BT, Area MJ, Ponsky JL. Alternate side entry for laparoscopy in patients with previous abdominal surgery.  J Laparoendosc Surg. 1998;  8 125-130

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