Diagnostic Laparoscopy for Intraabdominal Evaluation and Ventriculoperitoneal Shunt Placement in Children: A Means to Avoid Ventriculoatrial Shunting

Abstract

Background:

Laparoscopic assistance for the placement of a ventriculoperitoneal shunt (VPS) has been shown to be a safe, effective, and minimally invasive approach for distal peritoneal shunt placement. The purpose of our study was to review our experience with laparoscopy for VPS placement in patients with a potential hostile abdomen.

Materials and Methods:

After institutional review board approval, a retrospective analysis of all patients who underwent diagnostic laparoscopy for VPS placement from March 2009 to March 2013 was performed. Patient demographics and outcomes were analyzed.

Results:

Twenty-seven patients underwent diagnostic laparoscopy for VPS placement at a mean age of 7.7±6.8 years. Twenty-five patients had previous shunts placed in the peritoneum, whereas 2 underwent initial placement. Sixteen patients (59%) had undergone previous non-shunt abdominal operations. Twenty-three patients (85%) had successful peritoneal shunt placement. Distal peritoneal shunt placement was unsuccessful at the time of laparoscopy in 4 patients (15%) secondary to adhesions. Of the 23 patients who had successful peritoneal shunt placement, 57% did not require further shunt intervention, 22% underwent conversion to a ventriculoatrial shunt, 17% underwent re-externalization, and 4% required distal shunt revision. Of the 4 patients who required externalization, 3 underwent a second laparoscopic procedure with successful peritoneal shunt placement.

Conclusions:

Diagnostic laparoscopy eliminated the need for ventriculoatrial shunt placement in 85% of patients with a potentially hostile abdomen. Sixty percent required no further shunt revision. Laparoscopic-assisted peritoneal shunt insertion is a safe, minimally invasive technique in children with the added benefit of allowing full exploration and adhesiolysis.

Introduction

Ventriculoperitoneal shunt (VPS) placement is one of the most common treatments for hydrocephalus in children.^1–3 The literature has reported VPS failure to be up to 40% within the first year.^4,5 A VPS may fail proximally at the level of the ventricle or distally within the peritoneal cavity, with distal failures accounting for up to 43% of occurrences.^5,6 Some causes of VPS failure include obstruction, infection, pseudocyst formation, disconnection, migration, or fracture of the tubing.^2–5

Given the high rate of failure and complications associated with VPS, many patients require multiple operations to replace the distal portion of the shunt. Historically, laparotomy was used for placement and revisions of VPS; however, with the advancements in minimally invasive surgery, laparoscopic-assisted placement has become an alternative approach. Studies have shown that laparoscopic assistance for the placement of VPS is a safe, effective, and minimally invasive approach for distal peritoneal shunt placement.^1–3,7

Until recently, previous abdominal surgery was considered a relative contraindication for the use of laparoscopy. However, the literature has shown laparoscopy to be feasible, with minimal incidence of complications or conversions in children who have undergone prior abdominal surgeries.^3,8,9 This has been shown to also hold true for children undergoing laparoscopic-assisted placement of VPS.^5,10,11 In an effort to reduce the need for ventriculoatrial shunt placement, laparoscopy has been used for both diagnosis and intervention, allowing for visualization of the distal catheter placement and for performance of adhesiolysis. The purpose of our study was to review our experience with diagnostic laparoscopy for VPS placement in patients with a potential hostile abdomen.

Materials and Methods

After institutional review board approval (approval number 12-0477), a retrospective analysis of all patients who underwent diagnostic laparoscopy for VPS placement from March 2009 to March 2013 was performed. Laparoscopic-assisted VPS placements were performed jointly by a pediatric neurosurgeon in collaboration with one of three general pediatric surgeons for patients with a history of intraabdominal sepsis or previous operations. We define a hostile abdomen as one that has undergone previous surgical intervention or has a history of intraabdominal sepsis or peritonitis. Patient demographics were collected, including age at diagnostic laparoscopy, gender, diagnosis or indication for shunt placement, previous shunt placement, prior abdominal operations or procedures, and cause of shunt failure. Outcomes measured and analyzed included need for further shunt intervention and length of shunt patency. Descriptive statistical analysis was performed, and results are reported as mean±standard deviation, median, and range.

Procedure details

After informed consent was granted, the planned operation was performed with the patient under general anesthesia. Patients were placed in a supine position with the head turned to the appropriate position. The head, neck, and abdomen were prepped and draped in the standard sterile fashion. The cranial and laparoscopic portions were performed simultaneously by the pediatric neurosurgeon and pediatric general surgeon. The proximal catheter was placed into the ventricle, and the catheter was tunneled from the head to the abdomen in a subcutaneous fashion. For the laparoscopic procedure, a curvilinear incision was made at the umbilicus. A trocar was placed into the peritoneal cavity through the umbilical incision either by an open technique under direct visualization or by a closed technique using a Veress needle, based on surgeon preference. The abdomen was insufflated with CO₂ as per standard laparoscopy protocol. A 5-mm, 30° laparoscope was inserted to inspect the peritoneal cavity, and adhesiolysis was performed as needed. Additional 5-mm trocars are placed, if needed, to perform optimal adhesiolysis. If indicated, previously placed shunt catheters were retrieved. After a suitable site was chosen for catheter placement, a shunt trocar was placed under visualization, and the distal catheter was inserted into the peritoneal cavity. Once the catheter was placed in the ideal desired position and flow of cerebrospinal fluid was confirmed under laparoscopic observation, the laparoscope was removed, and the abdomen was desufflated. Absorbable braided suture was used to close the umbilical port site fascia and to approximate the superficial skin edges.

Results

During the 4-year study period, in total, 27 patients underwent diagnostic laparoscopy for VPS placement at a mean age of 7.7±6.8 (range, 0.2–20.5) years. Females comprised 59% of the population. Medical indications for initial shunt placement included hemorrhagic hydrocephalus (40.7%), congenital hydrocephalus (22.2%), spina bifida (18.5%), myelomeningocele (11.1%), and arachnoid cyst (7.4%). Twenty-five patients who underwent diagnostic laparoscopy for VPS placement had previous shunts placed in the peritoneum, with an average of 1.6±0.8 prior shunts per patient. Two patients underwent initial peritoneal shunt placement. Of these, 1 patient had undergone previous Nissen fundoplication, gastrostomy tube placement, exploratory laparotomy with colostomy, and subsequent reversal of the colostomy. The second patient had an initial laparoscopic-assisted pseudomeningocele peritoneal shunt placed. Fifteen patients (55.6%) had undergone previous non–shunt-related abdominal operations. Procedures are listed in Table 1.

Table 1.

Non–Shunt-Related Prior Abdominal Surgeries

Nissen fundoplication

Gastrostomy tube

Percutaneous endoscopic gastrostomy

Peritoneal drain for bowel perforation

Bowel resection for necrotizing enterocolitis

Antegrade colonic enema

Exploratory laparotomy, colostomy, and reversal of colostomy

Exploratory laparotomy, reduction of internal hernia, lysis of adhesions

Exploratory laparotomy, repair of duodenal perforation

Exploratory laparotomy, repair of duodenal and jejunal perforation

Laparoscopic removal of ventriculoperitoneal shunt

Diagnostic laparoscopy, umbilical hernia repair

Laparoscopic cholecystectomy

Open cholecystectomy

Ostomy revision

Indications for shunt externalization prior to diagnostic laparoscopy included infection (n=10), malfunction (n=10), and pseudocyst formation (n=5). Twenty-three (85%) patients underwent successful peritoneal shunt placement. There were 4 patients (15%) in whom peritoneal shunt could not be placed at the time of laparoscopy secondary to extensive adhesions. Of the 23 patients who had successful peritoneal shunt placement, 13 (57%) did not require further shunt intervention, 5 (22%) underwent conversion to a ventriculoatrial shunt, 4 (17%) underwent re-externalization, and 1 (4%) required distal shunt revision (Fig. 1). Of the 4 patients who required externalization, 3 underwent a second diagnostic laparoscopic procedure with successful peritoneal shunt placement. Mean length of follow-up after diagnostic laparoscopy was 1.6±1.1 years. Two patients (7.4%) were lost to follow-up.

FIG. 1.

Outcomes algorithm for patients undergoing diagnostic laparoscopy for ventriculoperitoneal (VP) shunt placement. VA, ventriculoatrial.

Discussion

Historically, patients with a potentially hostile abdomen were not considered candidates for VPS placement, with ventriculoatrial shunt placement being the alternative option. Ventriculoatrial shunts have known risks of endocarditis, atrial fibrillation, thromboembolic events, and complications related to direct manipulation of the blood vessels.^11,12 In an effort to reduce the need for ventriculoatrial shunt placement, laparoscopy has been used as it provides both a diagnostic and interventional option for the placement of peritoneal shunts. Some of the benefits associated with a laparoscopic approach for the placement of a VPS include direct visualization of the distal catheter placement, the ability to perform adhesiolysis, verification of cerebrospinal fluid flow, and the retrieval of nonfunctioning catheters.^3,5,7,13

One retrospective cohort study of 579 patients (16–90 years of age) comparing the laparoscopic with the open approach for VPS placement showed no difference in complications between the two groups, although operative time, blood loss, and length of stay were lower in the laparoscopic group.¹³ A second retrospective cohort of 810 patients (15–87 years of age) comparing the laparoscopic with the open approach for VPS placement showed no difference in the incidence of shunt failure between the two (20% laparoscopic versus 20.9% open), with significantly lower rates of distal malfunction in the laparoscopic group. There were no differences in the incidence of infections, and it was noted that the laparoscopic group had shorter operative times, shorter inpatient length of stay, and less blood loss after VPS placement.¹⁴

Peritoneal catheter failure is reported to be the cause of shunt malfunction in up to one-third of children.¹⁵ Many pediatric patients will undergo multiple distal shunt revisions during their lifetime, with the literature reporting between 1.6 and 3.6 shunt revisions for hydrocephalic patients.¹⁶ The traditional open, minilaparotomy approach is associated with an increased risk of adhesions, visceral injury, postoperative hernia, larger incision, and increased postoperative pain.¹⁷ Therefore, laparoscopic VPS placement is of increased benefit for this patient population, with the approach becoming more common in the management of hydrocephalus.¹⁷ Studies specifically focusing on pediatric patients undergoing laparoscopic VPS placement have shown the technique to be safe in this patient population for both initial placement and revision of the peritoneal shunt.^2,5,8,15,17

There is concern with the use of laparoscopy in patients with previous abdominal surgery, and until recently this was considered a relative contraindication for the use of laparoscopy. However, the literature has shown laparoscopy to be feasible with minimal incidence of complications in children who have undergone prior abdominal surgeries.^3,8,9 There are some reports evaluating laparoscopic VPS placement with a focus on children who have undergone multiple abdominal surgeries. These studies have determined the technique to be safe and effective in pediatric patients.^9–12 One retrospective review of 8 patients showed no mechanical failures of the VPS placed into a virgin area of the abdomen, with 2 patients having functioning shunts after a follow-up of greater than 40 months. Many patients were found to have dense adhesions; however, none required conversion to open surgery, and there were no reported complications as a result of laparoscopy.¹⁰ A second retrospective study focused on laparoscopic VPS placement in children weighing less than 10 kg. Again, all patients underwent successful laparoscopic adhesiolysis and VPS placement with no noted complications. At a median follow-up of 10 months, only 1 patient required a repeated intervention for shunt malfunction.¹¹

Our results support that laparoscopic VPS placement in children with a history of previous abdominal procedures is feasible, with 85% undergoing successful laparoscopic peritoneal shunt placement. Over 90% of patients had previous shunts placed in the peritoneum, and more than half had undergone previous non–shunt-related abdominal operations. Although 43% of patients required further shunt intervention, 75% who required shunt externalization underwent a successful second laparoscopic VPS placement. There were no conversion to open surgery and no complications associated with laparoscopy. This further illustrates the potential benefit of a laparoscopic approach for those patients with multiple prior abdominal surgeries.

Conclusions

Use of diagnostic laparoscopy for VPS placement eliminated the need for ventriculoatrial shunt in 85% of patients. Sixty percent of patients required no further shunt revision, and this resulted in an overall long-term shunt patency of 70%. Laparoscopic-assisted peritoneal shunt insertion in pediatric patients is a safe and minimally invasive technique, with no conversions to open surgery or complications associated with laparoscopy in this series. It also has the additional benefit of peritoneal exploration to determine suitability of shunt placement, adhesiolysis in patients who have undergone prior surgery, the ability to inspect the catheter for appropriate function after placement, and improved cosmesis.

Footnotes

Disclosure Statement

No competing financial interests exist.

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