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

我们感谢昆廷·科利尔先生协助制作录像。

以下协议遵循卡尔加里大学联合健康研究伦理委员会的指导方针。获得了该程序的知情媒体同意，患者为本出版物提供了书面同意书。
1. 定位和前程序设置
<ol><li>使用适当的神经导航方案进行术前颅脑 MRI 或计算机断层扫描 （CT）。</li>
	<li>将患者仰卧位放在甜甜圈头枕上，头部转向对侧，并放置肩部滚动以增加枕部区域的暴露（图3）。</...

<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>

患者对手术耐受性良好，术后立即拔管，适合非急性病房进行过夜监测。我们的实践是第二天早上进行头部的普通CT扫描，以确认近端导管的位置，并作为未来治疗的基线成像。此外，我们获得腹部X射线以确认腹腔导管的术后位置。我们的大多数患者在出院前都通过职业治疗和物理治疗进行评估，并由专职卫生人员认为是安全的。首次出院后评估通常发生在手术后 4 周。
<stro...

脑积水是一种常见的神经系统疾病，影响全世界约 100，000 名成年人中的 175 人， 其特征是脑室内脑脊液 （CSF） 积聚，这是由于脑中脑脊液生成和摄取过程之间的不平衡2。由于各种非手术疗法均不成功3，脑积水唯一可行的治疗方法是脑脊液从脑室手术转移。成人最常用的方法是放置分流器，将心室脑脊液引流到腹膜腔（脑室腹腔 [VP] 分流）4，5。
VP 分流器有三个皮下位置的组件：通过颅骨毛刺孔插入脑脊液心室的近端心室导管、调节血流的瓣膜和将瓣膜连接到腹膜腔的远端导管，其中脑脊液沉积并重新吸收（图 1）。或者，分流器可以在右心房水平处引流到静脉系统（心室心房 [VA] 分流）6，7 或将脊髓 CSF 从脊柱转移到腹膜腔（隆腹膜 [LP] 分流）8。目前没有证据支持 VP 与 VA 相比优于 LP 分流系统。在成人中，15%-25%9，10，11，12的新VP分流失败，通常在前6个月内，在高危人群中超过50%失败13。VP 分流失败可能继发于近端或远端部位的分流感染、瓣膜故障或导管衰竭12，14，15，16，17。每次分流失败都需要重复手术，这与围手术期并发症的累积风险18，19以及患者和家庭的压力有关，此外还增加了医疗保健基础设施成本20，21，22，23，24。
“传统”VP分流插入技术涉及使用表面解剖标志徒手插入近端导管，并通过小型剖腹手术或穿刺导管25，26，27放置远端导管。这些技术不允许在导管插入期间或之后实时跟踪或直接可视化最终位置。未能达到这些导管的理想位置可导致分流失败，这是与脑积水VP分流治疗相关的最常见的长期并发症10，28。近端导管通常由于错位和/或随后被脉络丛组织或脑室内碎片阻塞而失败。成人远端导管衰竭的主要原因包括导管错位、迁移和/或网膜组织、肠道和节内碎片或粘连的阻塞11，28，29，30，31。
最近的证据表明，通过将近端和远端导管分别置于神经导航和腹腔镜引导下来修改VP分流插入技术，可降低分流失败的风险26，32，33。此外，遵守分流感染减少方案已被证明可以降低继发于感染的分流失败风险34。此外，Svoboda等人描述了一种“假形技术”，其中远端导管固定在假形韧带上，并放置在远离网膜的肝周间隙中，这有助于降低导管迁移和网膜阻塞的风险35。据我们所知，虽然神经导航和腹腔镜的使用已经过独立评估，但它们的综合益处尚未报道，并且文献中也没有充分描述手术技术。
我们最近完成了一项为期7年的前瞻性质量改善研究，该研究结合了神经导航，腹腔镜检查，恶性畸形技术和成年脑积水患者的分流感染减少方案36。通过我们的联合方法，分流失败的总体风险降低了44%36。本文的目的是提供一个手术视频，并附有手术技术的分步指南，以促进使用这些辅助工具的范式转变，以降低成人分流失败的风险。
这里介绍的手术方法可以用于任何VP分流插入手术。我们描述了一名 72 岁男性的病例，他被诊断为特发性正常压力脑积水 （iNPH）， 并符合 VP 分流插入的标准37.患者有 1 年进行性步态和认知障碍病史，伴有间歇性尿失禁。他过去的病史对高血压和膀胱癌的手术治疗具有重要意义。对患者的磁共振成像（MRI）脑部评估显示脑室肿大，Evan指数为0.41。4年前完成的MRI评估未显示脑室肿大，Evan指数为0.29（图2）。他的神经学检查证实，他有一个宽基的洗牌步态，步进页数低，异常缓慢的步态速度为0.83 m/s。他没有脊髓病的迹象。他的蒙特利尔认知评估（MoCA）版本7.1得分为22/30，这证实了他的轻度至中度认知障碍。经过为期3天的腰椎外引流（ELD）试验，每小时取出脑脊液以测试脑脊液切除症状的反应性，他的步态速度提高到1.2 m/s，MoCA评分增加了3分。

<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

脑积水是一种常见的成人神经外科疾病，通常需要脑脊液 （CSF） 分流术治疗，其中脑室腹腔 （VP） 分流术是最常见的类型。不幸的是，VP分流术的失败率高得惊人，高达50%的患者需要在2年内进行翻修手术。VP 分流失败可能由感染或导管错位、迁移和闭塞引起。我们在一项为期 7 年的前瞻性非随机连续质量改进队列研究中开展了联合神经外科和普通外科合作，以降低三级医疗机构 224 名成年患者的脑室腹腔 （VP） 分流失败的发生率。该倡议结合使用电磁立体定向神经导航来指导近端导管的放置，并结合腹腔镜将远端导管置于直接可视化之下。在腹腔镜的帮助下，远端导管通过畸形韧带上形成的小孔固定，并放置在右侧肝后空间，没有可能阻塞导管尖端的网膜，粘连或肠道。手术使用分流感染预防方案进行，以降低分流感染的风险。在这里，我们展示了外科手术的术中视频。在成人 VP 分流手术中，遵守分流减少策略以及联合使用神经导航和腹腔镜技术，可使总体分流失败的风险降低 44%。在使用这种策略接受VP分流手术的患者中，对无分流的患者结局产生了重大的积极影响，这强调了在VP分流手术期间使用这些现代术中技术和跨专业合作的相关价值。

在术后第1天，视频中出现的患者接受了头部CT和腹部X射线检查（图7）。该影像学检查分别显示了右外侧心室的近端导管放置和远端导管在肝周间隙中的最佳位置。在放置VP分流术后的3个月和1年术后门诊评估中，他的步态速度从术前0.83 m/s提高到1.4 m/s，他的MoCA评分从术前22/30的评分正常化为29/30。
本文介绍的手术方法的可行性和患者结局在一项为期7年?...

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

脑室腹腔 （VP） 分流手术（成人脑积水的主要治疗方法）的患者结局较差，因为分流失败率高。我们使用神经导航和腹腔镜引导提供 VP 分流插入术中录像，目的是分别降低近端和远端分流导管失败的风险。

神经导航和腹腔镜引导脑室腹腔分流插入治疗脑积水

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

引言 我们描述了一名72岁男性的病例，他被诊断为特发性正常压力脑积水（iNPH），他符合心室腹膜分流术的插入标准。患者有一年进行性步态和认知障碍以及间歇性尿失禁病史。他过去的病史对高血压和膀胱癌的手术治疗具有重要意义。脑部磁共振成像（MRI）显示脑室肿大，埃文斯指数为0.41。四年前完成的MRI评估未显示脑室肿大，Evans指数为0.29。他的神经系统检查证实他有宽基拖曳步态，步步低，步速异常缓慢，为每秒 0.83 米。他没有脊髓病的迹象。他的蒙特利尔认知评估（MoCA）是30分中的22分，这证实了他的轻度至中度认知障碍。进行了为期三天的腰外引流，也称为ELD试验，每小时切除一次脑脊液，以测试脑脊液去除症状的反应。ELD试验后，他的步速提高到每秒1.2米，他的MoCA分数提高了三分。鉴于对暂时切除脑脊液的反应良好，患者接受了脑室腹腔分流手术。所提供的协议和视频遵循卡尔加里大学联合健康伦理研究委员会的指导方针，并获得了知情媒体的同意，并且患者对本出版物提供了书面同意。协议 这里介绍的手术方法可用于任何脑室腹腔分流插入手术。定位和术前设置 将患者仰卧放在甜甜圈头枕上，头部转向对侧，然后放置肩部滚动以增加枕部区域的暴露。获取术前颅脑 MRI 或计算机断层扫描 （CT），并采用适当的神经导航方案。上传患者术前颅脑MRI或CT，并注册到神经导航系统，完成神经导航工作站规划。选择近端导管的入口点和目标。在患者头皮上标记选定的进入部位位置。根据标准，除非患者情况排除，否则首选右侧后路入路。标记一个倒U形或马蹄形切口以合并入口点。用剪刀剃掉切口周围的任何头发。用局部麻醉剂浸润头皮切口。用2%葡萄糖酸氯己定和酒精溶液准备整个手术区域。必须遵守严格的感染预防方案，通常称为捆绑包。在手术悬垂之前，所有擦洗过的手术人员必须戴上双层手套，并在完成患者悬垂后更换外手套换成新手套。用抗菌切口帘覆盖整个手术区域，这也可以帮助将布条固定到位并减少手术团队与皮肤的直接接触。应用标准的腹腔镜悬垂，并将颅骨方向的开口延伸到悬垂的边缘，以允许颅骨和胸部手术区域暴露。颅骨暴露 使用15号手术刀对马蹄形切口进行划痕。使用细尖单极烧灼加深切口，确保保留骨膜层。用自固定牵开器缩回皮肤边缘，并在中心做一个十字骨膜切口，使用单极烧灼术暴露颅骨。在骨膜暴露的中心开一个大约两厘米的毛刺孔，确保保留下面的硬脑膜。皮下远端置管 将剑胸骨下切开一个旁中线切口，直至筋膜周围脂肪层。钝性在颅方向解剖皮下组织2-3厘米。小心地将隧道式探针引导到皮下层内包裹的塑料鞘内，并将其通向颅切口，注意保持在肋骨和锁骨上方，避免刺穿皮肤。一旦颅切口的下侧被隧道掘进机刺穿，撤回探针，将塑料护套留在原位。在塑料鞘周围的颅组织下边缘创建一个胆下袋，其大小足以埋葬分流阀。使用单极烧灼和凯利镊子钝性解剖。从无菌包装中取出远端导管并将其放入无菌盐水中。将远端导管穿过隧道塑料鞘从颅骨到尾部方向，尽量减少分流组件与窗帘的接触，然后取出塑料护套。用无菌盐水灌注系统以去除任何空气。阀门附件 如果使用可编程分流阀，则应将其编程为所需的设置，然后再将其从包装中取出并进入操作区域。在使用前，将阀门从无菌包装中取出，放入无菌盐水中，并用无菌盐水灌注。将瓣膜的远端端口连接到远端导管的近端。用丝带固定导管两次，并用无菌盐水灌注系统以去除任何残留空气。心室或近端导管插入 在需要之前，从无菌包装中取出心室导管，并将其放入无菌盐水中。创建一个位于中央的圆形硬膜切开术，相当于包含底层软脑膜和蛛网膜的近端导管的直径。使用细尖或针尖单极烧灼来做到这一点。将导航探针放置在近端导管内，并将导管插入同侧心室，沿预先编程的轨迹实时导航到目标深度。通常在大约5厘米的深度有脑脊液流动。然而，将导管推进到大约 8 至 10 厘米的深度是合适的。到达目标深度后，从心室导管上取下探针，并确认脑脊液自由流动。此时，用卡扣夹住导管，使用短靴保护导管。修剪近端导管，从颅骨外表边缘多留出约两厘米。将导管的远端连接到瓣膜的近端出口，并用两条丝带固定。小心地将瓣膜放入胆下袋中，并用4-0丝缝线将瓣膜套固定在保存的骨膜上。在腹部切口处对远端导管进行轻柔牵引，以确保不存在导管扭结。确认分流系统远端的自发脑脊液血流。腹腔内或远端导管放置 远端导管在腹腔镜下放置在腹膜腔内，最好由普通外科医生放置。用 15 刀片手术刀做一个曲线脐周切口，然后钝性解剖到腹壁筋膜。用焦化钳抓住每侧的筋膜，并以垂直方式切开以确保进入腹膜腔。将 2 多乳糖留在另一侧的切开筋膜上，然后插入钝的哈桑穿刺器。通过 Hassan 穿刺器检修口插入 30 度角腹腔镜。在直视下以标准方式放置一个 5 毫米的端口，通常在左侧，但该位置可能因腹膜间粘连的密度和位置而异。进行可能需要的任何粘连裂解。使用电烙术和腹腔镜梅岑鲍姆剪刀的组合，从韧带左侧在镰状韧带上开一个小孔。镰状韧带上的孔必须尽可能靠近肝脏和横膈膜，以允许导管充分和适当的定位。使用电烙钩，通过先前创建的剑胸下切口创建一个横向腹腔隧道，远端VP导管通过皮下腔排出。将远端腹膜分流导管通过 11 法式剥离鞘引入器创建的路径插入腹膜腔。一旦导管用腹腔镜在腹腔中可视化，抓住它并将其定位通过镰状韧带上的孔。导管应在腹腔镜下修剪，以适合患者的解剖结构并按描述放置导管。应该注意的是，导管没有预定长度。导管的最后休息地点必须在肝后间隙。理想情况下，导管的最终位置应低于膈肌，上部和后部应位于动员的肝脏。它应该立即优于右结肠旁沟。通过导管的脑脊液流量可以通过腹腔镜直接观察来确认。通过五毫米端口移除导管的残余修剪部分。缓慢而谨慎地放气腹部，以确保导管不会迁移。然后取出所有仪器。伤口闭合 分层闭合颅骨伤口。使用3-0 聚乳糖简单中断不同的缝合线在盖尔层和钉子为皮肤层。使用先前放置的聚乳酸保持缝合线关闭腹部筋膜，然后进行4-0 polyglecaprone 25皮下缝合线和丙烯酸粘合剂用于皮肤闭合。应用手术敷料。代表性结果 在术后第一天，该视频中出现的患者接受了头部CT和腹部X光检查。头部 CT 显示右侧心室内近端导管的最佳位置。腹部 X 线检查显示远端导管位于肝周间隙。在患者术后3个月和1年的门诊评估中，放置VP分流后，其步速从术前0.83米/秒提高到每秒1.4米。他的MoCA评分从术前的22分恢复到29分，超过30分。这里介绍的手术方法的可行性和患者结果在一项为期七年的前瞻性持续质量改进研究中进行了检查，该研究现已发表在《神经外科杂志》上。总结该报告，连续224名成年患者在三级中心入组。主要目的是确定颅骨术中导航和腹腔镜检查与分流感染预防策略的综合作用，以减少VP分流插入失败的发生率。在这些患者中，115例在没有神经导航和/或腹腔镜辅助的情况下接受了VP分流插入术，129例患者接受了此处介绍的手术方法的治疗。我们发现，在分流减少感染方案的背景下，联合神经导航和腹腔镜检查与总分流失败率从一年时的37%降低到14%、两年时的45%到22%以及三年时的51%到29%有关，风险比为0.44。使用神经导航时，没有近端导管故障。未接受联合神经导航腹腔镜引导手术的患者的两年远端导管失败率为42%，而接受联合神经导航腹腔镜引导VP分流手术的患者仅为20%。结论 在成人VP分流手术中，结合分流感染和复位策略、神经导航和腹腔镜技术可显著改善分流无故障患者的结局。在该协议中，我们结合了所有三种策略，包括将远端导管固定在镰状韧带上，以帮助放置在远离网膜的肝后间隙中。我们观察到感染率降低，随着时间的推移，整体分流失败的风险降低了44%。

Research

JoVE Journal

Medicine

Thermal Ablation for the Treatment of Abdominal Tumors

热消融治疗腹部肿瘤

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

科研

医学

The Measurement and Treatment of Suppression in Amblyopia

测量和制止在弱视治疗

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current ...

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Goeckerman方案用于治疗中度至重度牛皮癣

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

3D-Neuronavigation In Vivo Through a Patient's Brain During a Spontaneous Migraine Headache

3D-Neuronavigation In Vivo Through a Patient's Brain During a Spontaneous Migraine Headache

3D-神经导航<em&gt;在体内</em&gt;通过患者的大脑在一个自发性偏头痛

A growing body of research, generated primarily from MRI-based studies, shows that migraine appears to occur, and possibly endure, due to the alteration ...

The Rabbit Blood-shunt Model for the Study of Acute and Late Sequelae of Subarachnoid Hemorrhage: Technical Aspects

蛛网膜下腔出血急性和后遗症的研究兔血分流型号：技术问题

Early brain injury and delayed cerebral vasospasm both contribute to unfavorable outcomes after subarachnoid hemorrhage (SAH). Reproducible and ...

MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder

MRI引导dmPFC-rTMS治疗作为治疗难治性抑郁症

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

在耐药性颞叶癫痫患者卵圆孔电极记录的网络分析

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Transvaginal Mesh Insertion in the Ovine Model

经阴道网格插入在牛模型中

This protocol describes mesh insertion into the rectovaginal septum in sheep using a single vaginal incision technique, with and without the trocar-guided ...

Predicting Treatment Response to Image-Guided Therapies Using Machine Learning: An Example for Trans-Arterial Treatment of Hepatocellular Carcinoma

用机器学习预测图像引导疗法的治疗反应--肝细胞癌的跨动脉治疗实例

Intra-arterial therapies are the standard of care for patients with hepatocellular carcinoma who cannot undergo surgical resection. The objective of this ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

经腋窝第一肋骨切除术治疗胸廓出口综合征

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...