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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Representative Results
  • Discussion
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

Abstract

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

Introduction

Hydrocephalus, a common neurological disorder affecting approximately 175 per 100,000 adults worldwide1 is characterized by the accumulation of cerebrospinal fluid (CSF) within the cerebral ventricles due to an imbalance between CSF production and uptake processes in the brain2. As various non-surgical therapies have been unsuccessful3, the only viable treatment of hydrocephalus is the surgical diversion of the CSF from the cerebral ventricles. The most common approach utilized in adults is the placement of a shunt that drains the ventricular CSF into the peritoneal cavity (ventriculoperitoneal [V....

Protocol

The following protocol follows the guidelines of the University of Calgary Conjoint Health Research Ethics Board. Informed media consent for the procedure was obtained and the patient provided written consent for this publication.

1. Positioning and pre-procedure setup

  1. Obtain a preoperative cranial MRI or computed tomography (CT) with the appropriate neuronavigation protocol.
  2. Place the patient supine on a donut headrest with the head turned toward the con.......

Representative Results

On postoperative day #1, the patient presented in the video underwent a CT of the head and an x-ray of the abdomen (Figure 7). This imaging, respectively, demonstrated optimal proximal catheter placement in the right lateral ventricle and the location of the distal catheter in the peri-hepatic space. At the patient's 3-month and 1-year postoperative clinic assessments following placement of the VP shunt, his gait velocity had improved from a preoperative 0.83 m/s to 1.4 m/s and his MoCA .......

Discussion

Patients tolerate the procedure well, are extubated immediately postop and are suitable for non-acute wards for overnight monitoring. It has been our practice to obtain a plain CT scan of the head the next morning to confirm the proximal catheter placement and as baseline imaging for future management. In addition, we obtain an abdominal x-ray to confirm the postoperative position of the abdominal catheter. The majority of our patients are assessed by both occupational therapy and physiotherapy and deemed safe by allied .......

Acknowledgements

We thank Mr. Quentin Collier for his assistance with the creation of the video.

....

Materials

NameCompanyCatalog NumberComments
30-degree angle laparoscope Stryker0502-937-030
Barium impregnated proximal catheter Medtronic41101
Bowel grasperRichard Wolf8393.25
Certas Valve inline Codman82-8800
Chloraprep3M355-S10325/103.25
ElectrocauteryKarl Storz28160KA
Frameless-based neuronavigation system with magnetic tracking (AxiEM)Medtronic9735428/9734887
Hasson trocar Applied Medical IncC0R95
Ioban3M6661EZ
MonocrylEthiconD8550
Open barium impregnated proximal catheter Medtronic23092
Pneumatic surgical drillMedtronicPM100
Steri-Strips3MR1547
Video System EndoscopyStrykerNot Available

References

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NeuronavigationLaparoscopyVentriculoperitoneal ShuntHydrocephalusIdiopathic Normal Pressure HydrocephalusINPHMagnetic Resonance ImagingMRIEvans IndexGaitCognitive ImpairmentUrinary IncontinenceExternal Lumbar DrainELD TrialCSF RemovalPositioningPre procedureEntry PointTargetProximal Catheter

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