Name: neuronavigation and laparoscopy guided ventriculoperitoneal shunt insertion for the treatment of hydrocephalus
Uploaded: 2022-10-14T12:30:00
Description: Watch this Scientific Journal Video about Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus at JoVE.com

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

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
<ol>
	<li>Obtain a preoperative cranial MRI or computed tomography (CT) with the appropriate neuronavigation protocol.</li>
	<li>Place the patient supine on a donut headrest with the head turned toward the con...

<ol>
	<li>Isaacs, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Age-specific+global+epidemiology+of+hydrocephalus:+Systematic+review,+metanalysis+and+global+birth+surveillance.">Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance.</a> PLoS One. 13 (10), 0204926 (2018).</li><li>Rekate, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+contemporary+definition+and+classification+of+hydrocephalus.">A contemporary definition and classification of hydrocephalus.</a> Seminars in Pediatric Neurology. 16 (1), 9-15 (2009).</li><li>Del Bigio, M. R., Di Curzio, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nonsurgical+therapy+for+hydrocephalus:+a+comprehensive+and+critical+review.">Nonsurgical therapy for hydrocephalus: a comprehensive and critical review.</a> Fluids and Barriers of the CNS. 13 (1), 3 (2016).</li><li>Reddy, G. K., Bollam, P., Shi, R., Guthikonda, B., Nanda, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+adult+hydrocephalus+with+ventriculoperitoneal+shunts:+Long-term+single-institution+experience.">Management of adult hydrocephalus with ventriculoperitoneal shunts: Long-term single-institution experience.</a> Neurosurgery. 69 (4), 780-771 (2011).</li><li>Isaacs, A. M., Williams, M. A., Hamilton, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+update+on+treatment+strategies+for+idiopathic+normal+pressure+hydrocephalus.">Current update on treatment strategies for idiopathic normal pressure hydrocephalus.</a> Current Treatment and Options in Neurology. 21 (12), 65 (2019).</li><li>Isaacs, A. M., Krahn, D., Walker, A. M., Hurdle, H., Hamilton, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+echocardiography-guided+ventriculoatrial+shunt+insertion.">Transesophageal echocardiography-guided ventriculoatrial shunt insertion.</a> Operative Neurosurgery. 19 (1), 25-31 (2020).</li><li>Hung, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventriculoatrial+versus+ventriculoperitoneal+shunt+complications+in+idiopathic+normal+pressure+hydrocephalus.">Ventriculoatrial versus ventriculoperitoneal shunt complications in idiopathic normal pressure hydrocephalus.</a> Clinical Neurology and Neurosurgery. 157, 1-6 (2017).</li><li>Kazui, H., Miyajima, M., Mori, E., Ishikawa, M., Investigators, S. -. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lumboperitoneal+shunt+surgery+for+idiopathic+normal+pressure+hydrocephalus+(SINPHONI-2):+An+open-label+randomised+trial.">Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): An open-label randomised trial.</a> Lancet Neurology. 14 (6), 585-594 (2015).</li><li>Khan, F., Rehman, A., Shamim, M. S., Bari, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+affecting+ventriculoperitoneal+shunt+survival+in+adult+patients.">Factors affecting ventriculoperitoneal shunt survival in adult patients.</a> Surgical Neurology International. 6, 25 (2015).</li><li>Lund-Johansen, M., Svendsen, F., Wester, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shunt+failures+and+complications+in+adults+as+related+to+shunt+type,+diagnosis,+and+the+experience+of+the+surgeon.">Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon.</a> Neurosurgery. 35 (5), 839-844 (1994).</li><li>Anderson, I. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+associated+with+30-day+ventriculoperitoneal+shunt+failure+in+pediatric+and+adult+patients.">Factors associated with 30-day ventriculoperitoneal shunt failure in pediatric and adult patients.</a> Journal of Neurosurgery. 130 (1), 145-153 (2018).</li><li>Korinek, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+of+ventricular+cerebrospinal+fluid+shunt+surgery+in+adults:+an+8-year+study.">Morbidity of ventricular cerebrospinal fluid shunt surgery in adults: an 8-year study.</a> Neurosurgery. 68 (4), 985-994 (2011).</li><li>Albanese, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antibiotic-impregnated+ventriculo-peritoneal+shunts+in+patients+at+high+risk+of+infection.">Antibiotic-impregnated ventriculo-peritoneal shunts in patients at high risk of infection.</a> Acta Neurochirurgica (Wien). 151 (10), 1259-1263 (2009).</li><li>Reddy, G. K., Bollam, P., Caldito, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventriculoperitoneal+shunt+surgery+and+the+risk+of+shunt+infection+in+patients+with+hydrocephalus:+Long-term+single+institution+experience.">Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: Long-term single institution experience.</a> World Neurosurgery. 78 (1-2), 155-163 (2012).</li><li>Lundar, T., Langmoen, I. A., Hovind, K. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shunt+failure+caused+by+valve+collapse.">Shunt failure caused by valve collapse.</a> Journal of Neurology, Neurosurgery, Psychiatry. 54 (6), 559-560 (1991).</li><li>Leibold, A. T., Weyhenmeyer, J., Rodgers, R., Lee, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventriculoperitoneal+shunt+valve+fracture+after+traumatic+motor+vehicle+collision.">Ventriculoperitoneal shunt valve fracture after traumatic motor vehicle collision.</a> Interdisciplinary Neurosurgery. 16, 79-81 (2019).</li><li>Sainte-Rose, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shunt+obstruction:+A+preventable+complication.">Shunt obstruction: A preventable complication.</a> Pediatric Neurosurgery. 19 (3), 156-164 (1993).</li><li>Hamilton, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+hydrocephalus+in+adults.">Treatment of hydrocephalus in adults.</a> Seminars in Pediatric Neurology. 16 (1), 34-41 (2009).</li><li>Jaraj, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+idiopathic+normal-pressure+hydrocephalus.">Prevalence of idiopathic normal-pressure hydrocephalus.</a> Neurology. 82 (16), 1449-1454 (2014).</li><li>Williams, M. A., Sharkey, P., van Doren, D., Thomas, G., Rigamonti, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+shunt+surgery+on+healthcare+expenditures+of+elderly+fee-for-service+Medicare+beneficiaries+with+hydrocephalus.">Influence of shunt surgery on healthcare expenditures of elderly fee-for-service Medicare beneficiaries with hydrocephalus.</a> Journal in Neurosurgery. 107 (1), 21-28 (2007).</li><li>Rosenbaum, B. P., Vadera, S., Kelly, M. L., Kshettry, V. R., Weil, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventriculostomy:+Frequency,+length+of+stay+and+in-hospital+mortality+in+the+United+States+of+America,+1988-2010.">Ventriculostomy: Frequency, length of stay and in-hospital mortality in the United States of America, 1988-2010.</a> Journal of Clinical Neurosciences. 21 (4), 623-632 (2014).</li><li>Smith, E. R., Butler, W. E., Barker, F. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In-hospital+mortality+rates+after+ventriculoperitoneal+shunt+procedures+in+the+United+States,+1998+to+2000:+Relation+to+hospital+and+surgeon+volume+of+care.">In-hospital mortality rates after ventriculoperitoneal shunt procedures in the United States, 1998 to 2000: Relation to hospital and surgeon volume of care.</a> Jouranl of Neurosurgery. 100, 90-97 (1998).</li><li>Simon, T. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hospital+care+for+children+with+hydrocephalus+in+the+United+States:+utilization,+charges,+comorbidities,+and+deaths.">Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths.</a> Journal of Neurosurgery: Pediatrics. 1 (2), 131-137 (2008).</li><li>Tullberg, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shunt+surgery+in+idiopathic+normal+pressure+hydrocephalus+is+cost-effective-a+cost+utility+analysis.">Shunt surgery in idiopathic normal pressure hydrocephalus is cost-effective-a cost utility analysis.</a> Acta Neurochirurgica (Wien). 160 (3), 509-518 (2018).</li><li>Tubbs, R. S., Maher, C. O., Young, R. L., Cohen-Gadol, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Distal+revision+of+ventriculoperitoneal+shunts+using+a+peel-away+sheath).">Distal revision of ventriculoperitoneal shunts using a peel-away sheath).</a> Journal of Neurosurgery: Pediatrics. 4 (4), 402-405 (2009).</li><li>Naftel, R. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+insertion+of+the+peritoneal+catheter+in+ventriculoperitoneal+shunt+placement:+Review+of+810+consecutive+cases.">Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: Review of 810 consecutive cases.</a> Journal of Neurosurgery. 115 (1), 151-158 (2011).</li><li>Lind, C. R., Tsai, A. M., Lind, C. J., Law, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventricular+catheter+placement+accuracy+in+non-stereotactic+shunt+surgery+for+hydrocephalus.">Ventricular catheter placement accuracy in non-stereotactic shunt surgery for hydrocephalus.</a> Journal of Clinical Neurosciences. 16 (7), 918-920 (2009).</li><li>Reddy, G. K., Bollam, P., Caldito, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcomes+of+ventriculoperitoneal+shunt+surgery+in+patients+with+hydrocephalus.">Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus.</a> World Neurosurgery. 81 (2), 404-410 (2014).</li><li>Puca, A., Anile, C., Maira, G., Rossi, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cerebrospinal+fluid+shunting+for+hydrocephalus+in+the+adult:+factors+related+to+shunt+revision.">Cerebrospinal fluid shunting for hydrocephalus in the adult: factors related to shunt revision.</a> Neurosurgery. 29 (6), 822-826 (1991).</li><li>Paff, M., Alexandru-Abrams, D., Muhonen, M., Loudon, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventriculoperitoneal+shunt+complications:+A+review.">Ventriculoperitoneal shunt complications: A review.</a> Interdisciplinary Neurosurgery. 13, 66-70 (2018).</li><li>Cozzens, J. W., Chandler, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Increased+risk+of+distal+ventriculoperitoneal+shunt+obstruction+associated+with+slit+valves+or+distal+slits+in+the+peritoneal+catheter.">Increased risk of distal ventriculoperitoneal shunt obstruction associated with slit valves or distal slits in the peritoneal catheter.</a> Journal of Neurosurgery. 87 (5), 682-686 (1997).</li><li>Hayhurst, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+electromagnetic-navigated+shunt+placement+on+failure+rates:+a+prospective+multicenter+study.">Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study.</a> Journal of Neurosurgery. 113 (6), 1273-1278 (2010).</li><li>Shao, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+laparoscopic+approach+to+ventriculoperitoneal+shunt+placement+with+a+novel+fixation+method+for+distal+shunt+catheter+in+the+treatment+of+hydrocephalus.">A laparoscopic approach to ventriculoperitoneal shunt placement with a novel fixation method for distal shunt catheter in the treatment of hydrocephalus.</a> Minimum Invasive Neurosurgery. 54 (1), 44-47 (2011).</li><li>Kestle, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+Hydrocephalus+Clinical+Research+Network+protocol+to+reduce+cerebrospinal+fluid+shunt+infection.">A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection.</a> Journal of Neurosurgery Pediatrics. 17 (4), 391-396 (2016).</li><li>Svoboda, S. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preventing+distal+catheter+obstruction+in+laparoscopic+ventriculoperitoneal+shunt+placement+in+adults:+The+&amp;#34;Falciform+Technique&amp;#34;.">Preventing distal catheter obstruction in laparoscopic ventriculoperitoneal shunt placement in adults: The &amp;#34;Falciform Technique&amp;#34;.</a> Journal of Laparoendoscopy and Advanced Surgical Techiques A. 25 (8), 642-645 (2015).</li><li>Isaacs, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reducing+the+risks+of+proximal+and+distal+shunt+failure+in+adult+hydrocephalus:+A+shunt+outcomes+quality+improvement+study.">Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: A shunt outcomes quality improvement study.</a> Journal of Neurosurgery. 136 (3), 877-886 (2022).</li><li>Relkin, N., Marmarou, A., Klinge, P., Bergsneider, M., Black, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosing+idiopathic+normal-pressure+hydrocephalus.">Diagnosing idiopathic normal-pressure hydrocephalus.</a> Neurosurgery. 57, 4-16 (2005).</li><li>Muram, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+standardized+infection+prevention+bundle+for+reduction+of+CSF+shunt+infections+in+adult+ventriculoperitoneal+shunt+surgery+performed+without+antibiotic-impregnated+catheters.">A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters.</a> Journal of Neurosurgery. , 1-9 (2022).</li><li>Hamilton, M., Fung, A., Liam-Li, D., Isaacs, A., Conly, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+application+of+a+surgical+site+infection+prevention+bundle+for+shunt-related+insertions+and+revisions.">Development and application of a surgical site infection prevention bundle for shunt-related insertions and revisions.</a> Fluids and Barriers of the CNS. 15, (2018).</li></ol>

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 ...

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 [VP] shunt)4,5.
A VP shunt has three subcutaneously located components: a proximal ventricular catheter inserted into a CSF ventricle through a skull burr hole, a valve to regulate the flow, and a distal catheter to connect the valve to the peritoneal cavity where the CSF is deposited and reabsorbed (Figure 1). Alternatively, a shunt can drain into the venous system at the level of the right atrium (ventriculoatrial [VA] shunt)6,7 or divert the spinal CSF from the spine into the peritoneal cavity (lumboperitoneal [LP] shunt)8. There is currently no evidence to support the superiority of VP versus VA versus LP shunt systems. In adults, 15%-25%9,10,11,12 of new VP shunts fail, typically within the first 6 months, and upward of 50% fail in high-risk populations13.VP shunt failure may be secondary to a shunt infection, valve malfunction, or catheter failure at the proximal or distal sites12,14,15,16,17. Each shunt failure requires repeat surgery, which is associated with a cumulative risk for perioperative complications18,19 and stress for patients and families, in addition to increased healthcare infrastructure costs20,21,22,23,24.
The &#34;traditional&#34; VP shunt insertion technique involves freehand insertion of the proximal catheter using surface anatomical landmarks and placement of the distal catheter either via a mini-laparotomy or a trocar conduit25,26,27. These techniques do not allow for real-time tracking or direct visualization of the final location during or after catheter insertion. Failure to achieve an ideal position for these catheters can lead to shunt failure, which is the most frequent long-term complication associated with VP shunt treatment of hydrocephalus10,28. Proximal catheters typically fail due to malposition and/or subsequent occlusion by the choroid plexus tissues or intraventricular debris. The leading causes of distal catheter failure in adults include catheter mispositioning, migration, and/or occlusion by omental tissues, bowel, and intrabdominal debris or adhesions11, 28,29,30,31.
There is recent evidence to suggest that the modification of VP shunt insertion techniques by placing the proximal and distal catheters under neuronavigation and laparoscopic guidance respectively, are associated with reduced risks of shunt failures26,32,33. In addition, compliance with shunt infection reduction protocols has been shown to reduce the risks of shunt failure secondary to infections34. Furthermore, Svoboda et al. described a &#34;falciform technique&#34; where the distal catheter was anchored to the falciform ligament and placed in the perihepatic space away from the omentum, which helped reduce the risk of catheter migration and obstruction by the omentum35. To our knowledge, while the use of neuronavigation and laparoscopy have been independently assessed, their combined benefits have not been reported, and the surgical techniques have not been adequately described in the literature.
We recently completed a 7 year prospective quality improvement study that combined neuronavigation, laparoscopy, the falciform technique and a shunt infection reduction protocol in adult hydrocephalus patients36. With our combined approach, the overall risk of shunt failure was reduced by 44%36. The objective of this paper is to present a surgical video accompanied by a step-by-step guide of the operative techniques to promote a paradigm shift toward the use of these adjuncts to reduce the risks of shunt failures in adults.
The surgical approach presented here can be performed for any VP shunt insertion surgery. We describe the case of a 72-year-old male who was diagnosed with idiopathic normal pressure hydrocephalus (iNPH) and met the criteria for a VP shunt insertion37. The patient presented with a 1 year history of progressive gait and cognitive impairment, with intermittent urinary incontinence. His past medical history was significant for hypertension and the surgical treatment of bladder cancer. A magnetic resonance imaging (MRI) brain evaluation of the patient showed ventriculomegaly with an Evan&#39;s index of 0.41. An MRI evaluation completed 4 years earlier did not demonstrate ventriculomegaly with an Evan&#39;s index of 0.29 (Figure 2). His neurological examination confirmed that he had a wide-based shuffling gait with low steppage and an abnormally slow gait velocity of 0.83 m/s. He had no signs of myelopathy. His Montreal Cognitive Assessment (MoCA) version 7.1 score was 22/30, which confirmed his mild-moderate cognitive impairment. After a 3 day external lumbar drain (ELD) trial with hourly CSF removal to test CSF removal symptom responsiveness, his gait velocity improved to 1.2 m/s and his MoCA score increased by 3 points.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>30-degree angle laparoscope&#160;</td>
			<td>Stryker</td>
			<td>0502-937-030</td>
			<td></td>
		</tr>
		<tr>
			<td>Barium impregnated proximal catheter&#160;</td>
			<td>Medtronic</td>
			<td>41101</td>
			<td></td>
		</tr>
		<tr>
			<td>Bowel grasper</td>
			<td>Richard Wolf</td>
			<td>8393.25</td>
			<td></td>
		</tr>
		<tr>
			<td>Certas Valve inline&#160;</td>
			<td>Codman</td>
			<td>82-8800</td>
			<td></td>
		</tr>
		<tr>
			<td>Chloraprep</td>
			<td>3M</td>
			<td>355-S10325/103.25</td>
			<td></td>
		</tr>
		<tr>
			<td>Electrocautery</td>
			<td>Karl Storz</td>
			<td>28160KA</td>
			<td></td>
		</tr>
		<tr>
			<td>Frameless-based neuronavigation system with magnetic tracking (AxiEM)</td>
			<td>Medtronic</td>
			<td>9735428/9734887</td>
			<td></td>
		</tr>
		<tr>
			<td>Hasson trocar&#160;</td>
			<td>Applied Medical Inc</td>
			<td>C0R95</td>
			<td></td>
		</tr>
		<tr>
			<td>Ioban</td>
			<td>3M</td>
			<td>6661EZ</td>
			<td></td>
		</tr>
		<tr>
			<td>Monocryl</td>
			<td>Ethicon</td>
			<td>D8550</td>
			<td></td>
		</tr>
		<tr>
			<td>Open barium impregnated proximal catheter&#160;</td>
			<td>Medtronic</td>
			<td>23092</td>
			<td></td>
		</tr>
		<tr>
			<td>Pneumatic surgical drill</td>
			<td>Medtronic</td>
			<td>PM100</td>
			<td></td>
		</tr>
		<tr>
			<td>Steri-Strips</td>
			<td>3M</td>
			<td>R1547</td>
			<td></td>
		</tr>
		<tr>
			<td>Video System Endoscopy</td>
			<td>Stryker</td>
			<td>Not Available</td>
			<td></td>
		</tr>
	</tbody>
</table>

neuronavigation and laparoscopy guided ventriculoperitoneal shunt insertion for the treatment of hydrocephalus

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.

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&#39;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 ...

Watch this Scientific Journal Video about Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus at JoVE.com

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

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.

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ...

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