|Year : 2016 | Volume
| Issue : 3 | Page : 495-498
Laparoscopic management of complications in cases of ventriculoperitoneal shunt
Tamer A Sultan1, Ahmed G El Tatawy1, Mohammed A. A. Ali2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Neurosurgery, Sharq El Madina Hospital, Alexandria, Egypt
|Date of Submission||29-Aug-2015|
|Date of Acceptance||22-Nov-2015|
|Date of Web Publication||23-Jan-2017|
Mohammed A. A. Ali
Department of Neurosurgery, Sharq El Madina Hospital, 25th Street, Toson, Alexandria, 21519
Source of Support: None, Conflict of Interest: None
The objective of this study was to assess the value of laparoscopy in the management of the complications that occur after the insertion of the ventriculoperitoneal shunt (VPS).
Materials and methods
Data were obtained from Medline databases (PubMed, Medscape, ScienceDirect), EMF-Portal, and all materials available in the internet from 2014 to 2015. The initial search presented 48 articles, of which 24 met the inclusion criteria. The articles studied the role of laparoscopy in the management of the complications after the insertion of the VPS and different case studies about the role of laparoscopy. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethics approval was gained, eligibility criteria was specified, appropriate controls, and adequate information and defined assessment measures. The study was conducted on 20 patients who were already diagnosed with abdominal complications after previous insertion of VPS. In our study, with regard to the sex, there were 11 male and nine female patients. Age ranged from 29 days to 43 years, and there were 14 children and six adults. All of our 20 patients were examined using abdomen ultrasound (US): 12 of them had positive US findings and the remaining eight cases had no US findings. In our study, the 20 patients with abdominal complications were submitted to laparoscopy as a management tool, and we examined whether the role of laparoscopy was beneficial or not.
A total of 24 potentially relevant publications were included. The studies revealed the experimental trials on using abdominal laparoscopy to deal with the abdominal complications after the insertion of the VPS.
We found that laparoscopy is a useful modality for the treatment of intra-abdominal complications of VPS such as adhesions and pseudocyst. It is effective, and it avoids multiple laparotomies and its attendant complications and future adhesions.
Keywords: hydrocephalus, pseudocyst, ventriculoperitoneal shunt
|How to cite this article:|
Sultan TA, El Tatawy AG, Ali MA. Laparoscopic management of complications in cases of ventriculoperitoneal shunt. Menoufia Med J 2016;29:495-8
|How to cite this URL:|
Sultan TA, El Tatawy AG, Ali MA. Laparoscopic management of complications in cases of ventriculoperitoneal shunt. Menoufia Med J [serial online] 2016 [cited 2020 Feb 26];29:495-8. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/495/198660
| Introduction|| |
Hydrocephalus is impairment in the production, flow, or absorption of cerebrospinal fluid (CSF) that leads to an abnormal increase in CSF volume and, usually, pressure within the brain. Hydrocephalus is a health problem worldwide, with estimated prevalence of 1-1.5%  .
The incidence of congenital hydrocephalus is 0.9-1.8 new cases/1000 births. The term 'hydrocephalus' is derived from the Greek words 'hydro' meaning water, and 'cephalus' meaning head. Hippocrates described hydrocephalus for the first time, but it was not treated effectively until the middle of the 20 th century, when appropriate shunting techniques and materials were developed  .
Ventriculoperitoneal shunt (VPS) placement is a surgical procedure performed to relieve high-intracranial pressure caused by hydrocephalus of diverse etiologies in children and adults. Various extracranial complications of VPS may be seen, such as tube disconnection, infection, omental clogging, abdominal visceral perforation, and bowel obstruction  .
Abdominal CSF pseudocyst is a rare but important complication of VPS, with its incidence ranging from less than 0.33 to 6.8%. This complication is characterized by the collection of CSF in the peritoneal cavity containing the distal end of the VPS catheter and is surrounded by a wall composed of fibrous tissue without an epithelial lining. This complication is extremely rare in adults, with most cases reported in children  .
The continuous flow of CSF within a confined space leads to increased pressure within the abdominal cavity, reducing forward pressure gradient and, eventually, shunt malfunction. These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion. Exploratory laparotomy with a partial excision pseudocyst and placement of a catheter in a quadrant of the abdomen is also an option  .
The aim of this study is to define the role of laparoscopy in the management of complications in cases of VPS.
| Materials and Methods|| |
We reviewed papers on the role of laparoscopy in the management of the complications that occur after the insertion of the VPS from Medline databases (PubMed, Medscape, ScienceDirect) and also materials available on the internet. We used abdominal complications after VPS insertion and the laparoscopic management of the abdominal complications as searching terms. In addition, we examined references from the specialist database EMF-Portal ( http://www.emf-portal.de ). The search was performed in the electronic databases from 2014 to 2015.
All the studies were independently assessed for inclusion. They were included if they fulfilled the following criteria:
- Published in English language
- Published in peer-reviewed journals
- Focused on the abdominal complications after VPS insertion
- Discussed the value of laparoscopy in the management of the complications
- If a study had several publications on certain aspects, we used the latest publication giving the most relevant data.
If the studies did not fulfill the above criteria, they were excluded: central nervous complications such as meningitis and obstructed shunt with hydrocephalus, as well as other abdominal complications not related to the VPS.
The analyzed publications were evaluated according to evidence-based medicine criteria using the classification of the US Preventive Services Task Force and UK National Health Service protocol for evidence-based medicine in addition to the Evidence Pyramid ([Figure 1]).
The classification of US Preventive Services Task Force is as follows:
- Level I: Evidence obtained from at least one properly designed randomized controlled trial
- Level II-1: Evidence obtained from well-designed controlled trials without randomization
- Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
- Level II-3: Evidence obtained from multiple time series with or without the intervention. Marked results in uncontrolled trials might also be regarded as this type of evidence
- Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
The quality of all the studies was assessed. Important factors included study design, attainment of ethical approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, and adequate information and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis made in addition to an explanation of missing data.
A structured systematic review was performed with the results tabulated.
| Results|| |
In our study, regarding the sex, there were 11 (55%) male and nine (45%) female patients. Age ranged from 29 days to 43 years, with 14 (70%) children and six (30%) adults, with a mean value of 10.71 ± 14.11, as shown in [Table 1].
|Table 1 Distribution of the studied cases according to demographic data (n=20) |
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In our study, the 20 patients were already diagnosed with a history of VPS insertion and with abdominal complications such as acute abdomen, manifestations of peritonitis, abdominal swelling, and CSF leakage out of an external opening in the skin, as shown in [Table 2].
|Table 2 Distribution of the studied cases according to clinical presentation (n=20) |
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All of our 20 patients were examined using abdomen ultrasound (US), with four of them diagnosed with intraperitoneal CSF cyst, three with pseudocyst, three with internal opening of fistula, and two with suspicious obstruction of the lower end of the shunt, whereas the remaining eight cases had no US findings, as shown in [Table 3].
|Table 3 Distribution of the studied cases according to ultrasound findings (n=20) |
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In our study, the 20 patients with the previously mentioned abdominal complications were submitted to laparoscopy as a management tool, and we examined whether the role of laparoscopy is a beneficial management technique or not; among 20 patients, only one (5%) patient had a negative outcome, and the other 19 were examined with the diagnostic laparoscope. Two (10%) of them were diagnosed with obstruction of the lower end of the shunt and delayed for surgical revision of the shunt, and the remaining 17 (85%) were diagnosed and treated by laparoscopy, as shown in [Table 4].
|Table 4 Distribution of the studied cases according to the role of laparoscopy (n=20) |
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| Discussion|| |
Insertion of a VPS is the preferred and most successful method for the management of congenital hydrocephalus. In the setting of a VPS, the frequency of abdominal CSF pseudocyst formation is ∼3.2%  .
The time from the last shunt procedure to the development of the abdominal CSF pseudocyst ranges from 3 weeks to 5 years  . A chest and abdominal radiograph visualizes the position of the thoracoabdominal part of the VPS. A provisional diagnosis can be made by plain abdominal radiograph  . Pathi et al.  reported that US and computerized tomography features of the VPS floating in the thickened sac wall would allow early recognition of this complication.
Different treatment modalities for the abdominal CSF pseudocyst are available. These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion  . Moreover, exploratory laparotomy with partial excision and marsupialization of pseudocyst and placement of a catheter in a quadrant of abdomen has been done  . An extensive review revealed the increasing use of laparoscopic management of this complication. Using the technique of laparoscopy, Kim et al.  excised a portion of the CSF pseudocyst, removed the shunt catheter from the residual cavity, and repositioned it within the peritoneal cavity in a 12-year-old boy. There was no recurrence after 12 months of follow-up.
Oak et al.  found that the laparoscopic management of CSF pseudocyst, accomplished through 3-5-mm ports with the help of delicate laparoscopic instruments, minimizes the risk of a laparotomy, and the formation of intraperitoneal adhesions. Furthermore, laparoscopy allows visual confirmation of the adequate flow of the CSF from the end of the catheter after it is repositioned. However, the greatest advantage of laparoscopy lies in its ability to assess the entire abdominal cavity for the presence of adhesions and undertake adhesiolysis when necessary. This allows placement of the catheter in the quadrant of the abdomen with the maximum absorptive surface. Martin et al.  performed laparoscopy in VPS revision for pseudocyst in two cases and reported the use of extensive adhesiolysis for decreasing the risk of future adhesive obstruction and extending shunt life and thus recommended laparoscopy for VPS revisions. Brunori et al.  performed the laparoscopic drainage of a pseudocyst containing 2 l of fluid and retrieved the catheter from the peritoneal cavity. Kavic et al.,  recommended that laparoscopy is a safe procedure in patients with abdominal complications of VPSs, especially in adhesions and pseudocyst formation.
On extensive search and review of literature, we found that minimally invasive technique is a useful modality for the treatment of this complication. However, the management of this complication is generally done using three ports (one camera port and two working ports). We recommend that even giant pseudocysts can be managed by the two-port laparoscopic technique as done in another child with giant CSF pseudocyst as well  .
| Conclusion|| |
To summarize, laparoscopy is a useful modality for the treatment of intra-abdominal complications of VPS such as adhesions and pseudocysts. It is effective, and it avoids multiple laparotomies and its attendant complications and future adhesions. It is feasible to manage this complication by using only the two-port laparoscopic technique.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
A, Shida D, Tsutsumi K. Abdominal cerebrospinal fluid pseudocyst occurring 21 years after ventriculoperitoneal shunt placement: a case report. BMC Surg 2013; 13
RF Jr, Marchan EM, Oh MY, Kylekim D, Fredrickson AM, Pelz G, Uchal M. Laparoscopically assisted peritoneal shunt insertion for hydrocephalus. Br J Neurosurg 2009; 23
SM, Segan RD, Taylor MD, Roth JS. Treatment approaches for abdominal migration of peritoneal catheter of ventriculoperitoneal shunt. JSLS 2007; 11
Rustum NR. Laparoscopy 2003: oncologic perspective. Clin Obstet Gynecol 2003; 46
R, Sage M, Slavotinek J, Hanieh A. Abdominal cerebrospinal fluid pseudocyst. Australas Radiol 2004; 48
Erºahin Y, Mutluer S, Tekeli G. Abdominal cerebrospinal fluid pseudocysts. Childs Nerv Syst 1996; 12
HB, Raghavendran K, Kleinhaus S. Management of an abdominal fluid pseudocyst using laparoscopic techniques. Surg Laparosc Endosc 1995; 5
SN, Parelkar SV, Agrawal P. Laparoscopic management of pseudocyst and adhesions as a complication of ventriculoperitoneal shunt placement. Pediatr Endosurg Innov Tech 2003; 7
K, Baird R, Farmer J, Emil S, Laberge JM, Shaw K, et al.
The use of laparoscopy in ventriculoperitoneal shunt revisions. J Pediatr Surg 2011; 46
Brunori A, Massari A, Mascarone-Palmieri R, Benini B, Chiappetta F. Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt. Minim Invasive Neurosurg 1998; 41
[Table 1], [Table 2], [Table 3], [Table 4]