A Laparoscopic Technique for Retrieval and Prevention of Migration of Ventriculoperitoneal Shunt Tubing

Abstract

A 31-year-old female with a history of pseudotumor cerebri presented with headache and abdominal discomfort after placement of a ventriculoperitoneal (VP) shunt. The VP shunt was placed after prior failure and revision of a lumbar peritoneal shunt. Computed tomography demonstrated shunt migration into the subcutaneous tissue. Laparoscopy was used to reposition the VP shunt, directing the shunt toward the pelvis. The patient presented for further evaluation one month later, at which point the shunt was shown to have migrated into the subcutaneous tissue once again. Laparoscopy was again used to reposition the shunt and affix it to the abdominal wall by using polytetrafluoroethylene (PTFE) mesh.

INTRODUCTION

Ventriculoperitoneal (VP) shunting is commonly utilized as a diversion procedure for patients with hydrocephalus. Multiple techniques for initial placement of the catheters have been described, including conventional minilaparotomy, peel-away introducer sheaths,^1,2 as well as full laparoscopic approaches.^3,4 VP shunts fail for a variety of reasons, including failure secondary to disconnection of abdominal tubing with migration of the tubing, most commonly further into the peritoneal cavity; this occurs in 2.5% to 4% of shunts placed according to current published series.^2,5 Initial shunt failure rates continue to be high, with a reported failure rate of 31% at 6 months and an infection rate of 7%.⁶ Common presenting features of shunt failure include headache, mental status changes, and vomiting.³ Laparoscopy avoids laparotomy and may provide improved confirmation of shunt functionality and placement at the time of revision. This has been shown to be especially beneficial in obese patients with BMI>40.⁷

CASE REPORT

A 31-year-old obese female was initially treated for pseudotumor cerebri with placement of a lumbar peritoneal shunt in 2003. After 5 failed revisions for nonfunction, a ventriculoperitoneal shunt was placed in September 2007. The patient subsequently presented 11 days postoperatively with headaches, dizziness, and formation of a seroma in her right upper quadrant. CT scan revealed the VP catheter tubing coiled in the subcutaneous tissue of the right upper quadrant. Laparoscopy was used to reposition the tubing into the peritoneal cavity. Four 5-mm titanium clips were placed on the catheter in an attempt to prevent repeated migration of the tubing. One month later, the patient presented with recurrence of headaches, nausea, and right upper quadrant abdominal pain. CT scan was again obtained, revealing that the shunt tubing had migrated back into the subcutaneous tissue (Figure 1).

Figure 1.

CT abdomen showing ventriculoperitoneal tubing coiled in subcutaneous space.

A laparoscopic approach was again utilitzed for retrieval and attempted improved fixation of the VP shunt. After insufflation with a Veress needle, three 5-mm trocars were placed. Adhesions were taken down at the original entry site of the shunt, revealing a 2-cm fascial defect in the abdominal wall with the shunt tubing coiled within it (Figure 2). The tubing was brought down through the defect out of the subcutaneous space and into the peritoneal cavity (Figure 3). One port was upsized to 10mm, and the tubing was externalized through the port and secured to a 3-cm x 10-cm piece of PTFE mesh with 3–0 Prolene sutures (Figure 4). CSF flow was confirmed, and the tubing attached to the mesh was reintroduced into the peritoneal cavity. The mesh was secured to the abdominal wall by using spiral tacks and 0 Gore-Tex sutures (Figure 5). The separate 2-cm fascial defect was repaired with a 10-cm x 10-cm piece of PTFE mesh placed as an onlay with the VP shunt exiting from its inferior border. It was secured with spiral tacks and 0 Gore-Tex sutures for transabdominal fixation (Figure 6). Flow of CSF through the shunt was again confirmed by direct visualization. The patient tolerated the procedure well. Postoperatively, she had resolution of her neurologic symptoms. The patient was seen in follow-up 7 months postprocedure and reported no recurrence of her symptoms.

Figure 2.

Laparoscopic view of CT tubing coiled in subcutaneous tissue.

Figure 3.

Ventriculoperitoneal tubing returned to the abdominal cavity.

Figure 4.

Ventriculoperitoneal shunt tubing sutured to PTFE mesh extracorporeally.

Figure 5.

PTFE mesh tacked to abdominal wall.

Figure 6.

Fixation of ventriculoperitoneal shunt tubing and incisional hernia repair.

DISCUSSION

VP shunts are a well-established modality for treatment of hydrocephalus. Traditionally, laparotomy was necessary for both peritoneal shunt placement as well as subsequent shunt revisions. The advent of laparoscopy has afforded a minimally invasive approach that has resulted in decreased patient morbidity related to shunt placement.⁸ Retrieval and repositioning of a displaced VP shunt in the peritoneal cavity using laparoscopic techniques has been previously described.² In the present case, an initial laparoscopic revision of the migrated VP shunt failed within 30 days. Our subsequent laparoscopic approach utilized PTFE mesh, well described in the use of laparoscopic ventral hernia repair, to fixate the tubing to the abdominal wall to prevent further tubing migration. This approach also allowed us to simultaneously repair the fascial defect associated with the shunt entry site into the peritoneal cavity, allowing us to reap the benefits of decreased recurrence and decreased patient morbidity associated with this technique.⁹ The technique described was well tolerated without complication and resulted in improvement of clinical symptoms.