Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature

Abstract

Purpose Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures. Methods We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed. Results 28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively. Conclusion Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

Endoscopic third ventriculostomy complications: avoidance and management in a stepwise manner

“…It is important to make use of the pericranium as well that overlies the burr hole. In addition, using dural sealants or bone dust to plug the burr hole with the addition a titanium burr hole cover as a support will also help facilitate tight closure [37,38].…”

Reply to the letter to the editor from Lo WB, Afshari FT, Rodrigues D and Kulkarni AV regarding the article “Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature”

“…It is clear that similar technical principles are utilized across our institutions to minimize cerebrospinal fluid (CSF) leak, including multilayered closure methods which both exploit and reinforce natural anatomical barriers to possible CSF leakage. We were also pleased to report the success of our technique in relation to clinical outcomes in 28 patients, with 0% CSF leak and complication rates in relation to this component of the procedure [2].…”