Elevation of Sunken Flap Due to Ventriculo‐Peritoneal Shunt

Dear Editor,

In relation to the article “Surgical Practice in Resource‐Limited Settings: Perspectives of Medical Students and Early Career Doctors: A Narrative Review” [1], we would like to mention how resource constraints affect surgical practice directly by modification of: (1) presurgical lesion localization technique (e.g., skin marking is used before breast surgery, instead of parenchymal marking with hook wire, partially due to resource constraint [2]); (2) storage and retrieval of investigation reports (handwritten‐papers in case file/notebook with patient, electronic medical records); (3) surgical technique, as in the following case.

A patient had normal contour of surgical flap after resection of intracranial tumor and ventriculo‐peritoneal (VP) shunt placement (Figure 1). When she came for follow‐up MRI after 7 months, we noticed that the surgical flap was depressed/sunken (Figure 2). Since she had new neurological deficits; bone flap elevation was done. After the flap elevation surgery, most of her new symptoms resolved and MRI showed an elevated flap (Figure 3).

Figure 1.

Normal contour of surgical flap (after resection of intracranial tumor and ventriculo‐peritoneal shunt placement).

Figure 2.

Abnormal contour due to depressed/sunken surgical flap.

Figure 3.

Almost normal contour due to elevated flap.

Sinking/depression of the surgical flap is a known issue after placement of VP shunts for decreasing hydrocephalus.

Since programmable shunts cost around one lakh INR and nonprogrammable shunts cost around 6000 INR, usually nonprogrammable shunts are used in resource‐constrained setting.

Management depends on whether the

• a.patient has neurological symptoms
• b.patient is concerned about the cosmetic impact (some patients manage by hiding the depressed scalp under cap).

Asymptomatic patients, unconcerned about the cosmetic impact, do not require any intervention.

Management options in symptomatic patients/patients concerned about the cosmetic impact are

• 1.if programmable shunts have been used, adjusting the pressure within shunt, can reverse the sinking.
• 2.nonprogrammable shunts require a minor surgical procedure (flap elevation by adjusting plate and screws) to reverse sinking.

Author Contributions

Anitha Sen: conceptualization, validation, visualization, writing – original draft, writing – review and editing. Krishnakumar Kesavapisharady: writing – review and editing, validation, methodology. Rajeev Kavalakara Raghavan: Writing – review and editing, validation, resources.

Acknowledgments

The authors have nothing to report.

Ethics Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Consent

Informed consent was obtained from all individual participants included in the study. No AI tools were used for article preparation.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.