Laparoscopically Assisted Ventriculoperitoneal Shunt Placement: A Prospective, Randomized Two-arm Study

Background

Ventriculoperitoneal shunting (VPS) as diversionary procedure in patients with hydrocephalus was first described in 1908. After the introduction of silastic catheters during the 1970s this method has become the treatment of choice for children and adults with communicating hydrocephalus. However, the average patient having had VPS will undergo 2.1 shunt revisions every 3 years of life, with a wide range from no revisions during the first decade to up to 21 revisions within the first year. For this reason technical improvements impacting positively on the revision rate and on the surgical burden are strongly needed.

In the standard VPS procedure the proximal part of the shunt is first placed in one of the lateral ventricles. The distal part of the shunt is then tunneled subcutaneously from the head to the abdomen, where 20-25 cm of the distal catheter and the tip are introduced in the peritoneal cavity through a paraumbilical mini-laparotomy. The intraperitoneal placement of the distal catheter is performed blindly, whereby the tip of the catheter is directed caudally in direction of the pelvis in order to avoid kinking and potential strangulation of the catheter. In this setting the functionality of the system can be estimated by feeling the resistance to out- and inflow while manually pumping the reservoir near the valve at the cranial level.

Distal shunt failure has been reported to occur in 10-30% of cases. Secondary dislocation of the peritoneal catheter in the subcutaneous tissue or its improper placement in the peritoneal cavity during the procedure both contribute to this high shunt failure rate. Furthermore, blind catheter placement in obese patients and in patients with adhesions from previous abdominal surgery can be a challenge and may lead to injuries of the intra-abdominal organs.

In 1993, Bassauri et al reported on the laparoscopic placement of the peritoneal catheter in VPS. Since then several, small retrospective series have shown good results in laparoscopic VPS, both in terms of efficacy and safety, in adults and in children. Two larger series were published recently. Schubert et al. reported a prospective study on 50 adult patients using the laparoscopically assisted peritoneal shunt insertion. A retrospective cohort of 50 matched patients served as a control. They reported no intraoperative complications, a longer operation time in the laparoscopic group (59 versus 49 minutes), 2 malfunctions (4%) and 1 infection in the laparoscopic group (2%) and 6 malfunctions (12%) and 6 infections (12%) in the historic cohort, the difference being statistically significant in favour of the laparoscopic group. In the most recent and largest series published to date, Bani et al. report on their experience with 151 patients, where the peritoneal catheter was implanted using a laparoscopic technique. They also used a retrospective cohort of 50 non-laparoscopy patients as a control. The operation time was slightly longer using the laparoscopic technique (35-130 versus 30-120 minutes), the infection rate was 2% in both groups. They describe no dislocation of the distal catheter in the abdominal wall and no malpositioning of the distal catheter in the laparoscopic group and 4 such cases in the non-laparoscopy group (8%).