Laparoscopic Cholecystectomy in a Patient with a Ventriculoperitoneal Shunt

Abstract

With the advent of ventriculo-peritoneal shunting and improved medical therapies, patients with hydrocephalus are living longer and presenting with unrelated medical problems. It can be disconcerting to discover that the patient who needs a routine laparoscopic procedure also has a ventriculoperitoneal (VP) shunt. Although the literature is limited there is a small body of evidence indicating that it is safe to perform laparoscopic surgery on these patients with routine anesthetic monitoring. The authors report the case of a laparoscopic cholecystectomy in a patient with a VP shunt.

Case Report

A 71-year-old Japanese man with known cholelithiasis, who had been managed conservatively for several years, presented with complaints consistent with obstructive jaundice. His primary complaint was a 1-month history of postprandial nausea and emesis, initially one to two times per week, but now daily. Due to the symptoms the patient was restricting his meals to clear liquids and reported a 10-pound weight loss during this time frame. He also described intermittent fevers as high as 100.5° F, “dark” urine and pale stools. The patient's wife noted that his head and back had developed a yellow tinge in the last week.

The patient's medical history was remarkable for a hemorrhagic cerebrovascular accident (CVA) 10 years prior requiring a left frontal temporal craniotomy, gastrostomy tube placement, and VP shunt placement. Two years after the stroke the patient had an episode of abdominal pain and was found to have gallstones. Due to the CVA and his lengthy recovery the decision was made to manage the patient non-operatively. He underwent endoscopic retrograde pancreatogram (ERCP) with sphincterotomy and had been asymptomatic up until the episode described above. His only other surgical history was a distant open appendectomy. His family history included diabetes mellitus, a sister with ovarian cancer and his father, who died of a ruptured cerebral aneurysm. The patient had a 100 pack-year history of smoking but quit at the time of his stroke.

Physical exam revealed jaundice, scleral icterus, and tenderness to deep palpation in the right upper quadrant of the abdomen. His neurologic exam was unremarkable except for a previous frontal craniotomy scar and a palpable shunt in this region.

Laboratory evaluation showed the following: white blood cell count 9,400/mcL, total bilirubin 8.7 mg/dL, alkaline phosphatase 277 U/L, aspartate aminotransferase 91 U/L, alanine aminotransferase 145 U/L, cytosine arabinoside (CA) 19-9, 386 U/mL, amylase 321U/L, and lipase 1026 U/L. Abdominal sonography demonstrated cholelithiasis, gallbladder wall thickening, a common bile duct dilated to 1.2 cm, and a possible small calculus in the distal common bile duct. Computerized tomography of the abdomen also showed a dilated common bile duct, mildly dilated intrahepatic ducts, and probable stones at the distal common bile duct. ERCP revealed a mildly dilated common bile duct, but no calculi were identified. Prior to ERCP the patient's bilirubin was noted to have decreased to 2.9 mg/dL. He was treated with brief bowel rest, intravenous hydration, antibiotics for presumed cholangitis and pancreatitis.

A neurosurgeon was consulted and a shunt series was obtained. This included plain radiographs of the head, chest, and abdomen to evaluate the VP shunt tubing. The imaging demonstrated an intact left VP shunt with the tip of the catheter seen within the left mid abdomen as shown in Figure 1.

Figure 1.

A. Radiograph of the Head with the Course of the VP Shunt Indicated by the Arrows; B. Radiograph of the Abdomen with the VP Shunt (indicated by the arrows) Seen on the Patient's Left Side with the Intraperitoneal Yip at the Midline

After the workup described above a laparoscopic cholecystectomy was performed in the standard fashion. The path of the VP shunt was carefully palpated, based on the plain radiographs and care was taken to avoid trocar insertion near these sites. Upon insertion of the laparoscope into the abdomen the VP shunt was noted to be in the left lower quadrant and the intraperitoneal portion appeared intact but adherent to the omentum. The patient tolerated the pneumoperitoneum and the procedure with no hemodynamic instability to suggest increased intracranial pressure. Post-operatively, the patient remained neurologically intact and was discharged home on the day after surgery.

Discussion

Ventriculoperitoneal shunts are silicone catheters placed from a lateral brain ventricle, through a subcutaneous tunnel and into the peritoneal space in order to drain excess cerebrospinal fluid in the ventricular system. They are used to treat hydrocephalus, primarily in children, due to a variety of causes but typically subarachnoid hemorrhage, meningitis or tumor. The first VP shunt procedure was performed in 1908 and since then has become a common neurosurgical procedure.¹ In 1995, an estimated 70,000 patients developed hydrocephalus in the United States and nearly 33,000 of these required VP shunting.² Mortality from this procedure is quite low, reported as 0.1%, but 3-15% of the shunts become infected and about 50% of them fail after 2 years.^3,4

The decision to perform a laparoscopic cholecystectomy with routine anesthetic monitoring in a patient with a VP shunt is supported by the two largest case series currently published. Collure et al. published data in 1995 on a series of four patients and Jackman et al. published a series of 18 patients in 2000.^5,6 Both authors concluded that laparoscopic surgery was safe in patients with VP shunts. The primary concerns with performing laparoscopic surgery in the presence of a VP shunt are clinically significant increases in intracranial pressure (ICP) and retrograde shunt failure. Uzzo et al. observed transient increases in ICP during laparoscopic procedures on two children with VP shunts.⁷ As a result, they advised routine ICP monitoring in patients with VP shunts undergoing laparoscopic surgery. This effect has also been shown in animal models.^8,9 However, this increase in ICP has never been shown to be clinically significant and the risks of invasive ICP monitoring likely outweigh any risk of adverse events.

Retrograde shunt failure resulting in pneumocephalus is another concern, but to-date there are no reports of this in the literature. Multiple methods have been described to reduce the risk of retrograde shunt failure, including clamping or clipping of the intraperitoneal end of the catheter, exposure and clamping of the subcutaneous portion of the catheter, and externalization of the intraperitoneal portion of the shunt for the duration of the case.^10–12 Based upon in vitro testing of VP shunts however these procedures appear to be unnecessary.¹³ Of nine shunts tested to retrograde pressures of 350 mm Hg none resulted in failure of the valve. There was noted to be deformation in the shape of some shunts at pressures as low as 80 mm Hg, but the actual risk of reflux of carbon dioxide across the shunt at the pressures used in laparoscopy seems minimal. In fact, in the case series reported by Collure et al., drainage of cerebral spinal fluid from the intraperitoneal end of the catheters was noted during laparoscopy in all four patients.⁵ The lack of reports in the literature of retrograde shunt failure and the in vitro testing would suggest that clamping or externalization of the shunt catheter is probably unnecessary. One might postulate that clamping of the shunt could actually exacerbate increases in ICP.

The review of the literature did reveal two case reports of complications related to laparoscopic surgery in patients with VP shunts. In one case a patient undergoing laparoscopic cholecystectomy ten days after placement of a VP shunt developed subcutaneous emphysema along the catheter tract.¹⁴ In a second case a patient with a VP shunt placed five days prior developed lethargy and apnea after laparoscopic jejunostomy tube placement.¹¹ The shunt failure was determined to be a distal occlusion that resolved with irrigation. Although the patient underwent an emergent neurosurgical procedure to resolve the occlusion the author indicates that active pumping of the shunt reservoir probably would have cleared the obstruction. Both cases emphasize that elective laparoscopic cases should probably be delayed in patients with recently placed VP shunts.

Conclusion

Laparoscopic surgery in adults with established VP shunts utilizing routine anesthetic monitoring appears to be safe. Currently there is no evidence to suggest that clamping or externalization of the catheter is necessary. A neurosurgery consult prior to surgery to verify the proper functioning of the VP shunt is recommended. The surgeon should note the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement. In addition, the surgical team and the anesthesiologist should be aware of the location of the shunt reservoir so it can be pumped if necessary. Finally, it is important to ensure that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen.