Laparoscopic Management of Abdominal Complications in Ventriculoperitoneal Shunt Surgery

Abstract

Ventriculoperitoneal (VP) shunts are among the most frequently performed operations in the management of hydrocephalus. Abdominal complications, though rare, are reported to occur in 5-47%. VP shunt obstruction or malfunction leads to raised intracranial pressure, which requires immediate intervention. Recently we have used the laparoscope to manage abdominal complications of VP shunt in two patients. The first patient had hydrocephalus secondary to tubercular meningitis. She developed recurrent intraabdominal cerebrospinal fluid (CSF) pseudocysts, possibly due to subtle peritoneal infection. In the second patient, who developed hydrocephalus following subarachnoid haemorrhage, the lower end of the shunt was malfunctioning due to retraction into the extraperitoneal tissues. The distal end of the VP shunt was revised in both patients with the help of a laparoscopically assisted technique. Thus, a conventional laparotomy, along with its various associated postoperative problems, was avoided without compromising the quality of surgery.

Incisional hernia after ventriculoperitoneal shunt

“…The advantages of the laparoscopic approach also include a shorter hospital stay, less post-operative pain, lower chance of incisional hernia formation, and, since the catheter is positioned under direct vision with minimal bowel manipulation, there is a much lower chance of bowel injury and adhesion formation [6,8]. Even when dealing with complications, laparoscopy offers a distinct advantage over laparotomy, especially in terms of superior visualization of the peritoneal cavity, retrieval of displaced shunts, lysis of adhesions, culture of abdominal fluid, repositioning of displaced tubings, and assessing the abdomen for any other pathology [2][3][4]6,8,10]. However, the flip side is that separate incisions (for port and shunt placement) as well as two separate teams (neurosurgical and laparoscopic) are required, which may not be available everywhere.…”

“…Since the first reports by Kausch in the early part of the 20th century of the use of the peritoneal cavity for diverting CSF, ventriculoperitoneal (VP) shunts have become the standard procedure for the treatment of hydrocephalus [1,2]. Like any surgical procedure, VP shunting is also associated with complications; the most common causes of shunt malfunction are proximal obstruction and infection [1] and these usually present with headache, changes in the mental status, and vomiting [3].…”

“…Abdominal complications that have been reported are; shunt infection, development of an inguinal hernia, subcutaneous collections of CSF, peritoneal or omental cyst formation, mesenteric pseudotumors, bowel perforation, intestinal volvulus around the shunt tubing, catheter disconnection; and various types of catheter migrations such as extraperitoneal retraction and displacement, migration of the catheter into the pleural cavity or heart, or protrusion of the catheter through the mouth, umbilicus, bladder, vagina, anus, or scrotum. Knotting of the shunt has also been reported on occasion [1][2][3][4][5][6][7], as have been other less common complications such as adhesive bowel obstruction, intra-abdominal abscesses, cerebrospinal-enteric fistula and intractable CSF ascites [1,3].…”

Formation of Abdominal Cerebrospinal Fluid Pseudocyst

“…2,19) Most reported cases of CSF pseudocysts have occurred in children, with only 29 cases in adults. [1][2][3][4][5]7,[11][12][13]15,[17][18][19][20]23) We describe the formation of an abdominal CSF pseudocyst in an adult, and review all 30 adult cases of abdominal CSF pseudocysts. Neurol Med Chir (Tokyo) 52, November, 2012…”

“…1,15) The advantages of the laparoscopic approach include shorter hospital stay because of less invasiveness and lower risk of forming postoperative adhesions and related complications compared with laparotomy. 1,15) Infection with Staphylococcus epidermis was detected in 3 of 18 cases examined for bacterial infection (excluding one study 19) in which 4 patients had infections, but were not identified as child or adult). Distal externalization of the peritoneal catheter was performed, antibiotic treatment was administered, and then the distal segment of the shunt tube was replaced in the 3 cases in which infection was detected.…”