Laparoscopic management of distal ventriculoperitoneal shunt complications

Background: The traditional management of hydrocephalus still is the placement of ventriculoperitoneal (VP) shunts. However, the majority of patients require one or more revisions over their lifetime. Revisions may be required for infections, proximal site malfunction, or distal catheter complications. The authors present their experience with distal catheter complications managed laparoscopically. Methods: Patients with recurrent symptoms of increased intracranial pressure or abdominal complaints were evaluated for shunt malfunction. Similar radiographic imaging was performed for all the patients, including computed tomography (CT) of the head and abdomen, shunt series, and/or ultrasound of the distal catheter. Results: From April 2003 to July 2005, 13 patients with distal VP shunt complications were managed laparoscopically. On the basis of preoperative cerebrospinal fluid (CSF) cultures, all the patients were determined not to have an infection. Radiographic imaging showed the patients to have distal catheter problems. Preoperatively, five abdominal CT scans, six shunt series, and four abdominal ultrasounds were obtained. All studies singly and positively identified the appropriate abdominal catheter defect except in three patients who required multiple sequential radiographic studies for final determination of the diagnosis. In four patients (30.8%), the distal catheter was found to be in the extraperitoneal space. Another four patients (30.8%) had intraabdominal CSF pseudocysts. Five patients (38.4%) had issues with the position of the intraabdominal catheter: four of them subdiaphragmatic and one on the dome of the bladder. Laparoscopic repositioning was successful for all 13 patients. Conclusion: Regardless of the patient's presenting symptoms, appropriate imaging studies should be obtained preoperatively in a sequential manner. Distal VP shunt complications can be safely and effectively managed laparoscopically. This approach allows the intraabdominal portion of the catheter to be assessed and problems to be managed, thereby salvaging the existing shunt and avoiding the potential morbidity associated with additional VP shunt placement.