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International Journal of Surgery Case Reports logoLink to International Journal of Surgery Case Reports
. 2013 Jan 19;4(3):330–333. doi: 10.1016/j.ijscr.2013.01.005

Laparoscopic cecal cancer resection in a patient with a ventriculoperitoneal shunt: A case report

Takayuki Torigoe 1,⁎, Shiro Koui 1, Tomohito Uehara 1, Koichi Arase 1, Yoshifumi Nakayama 1, Koji Yamaguchi 1
PMCID: PMC3604664  PMID: 23416501

Abstract

INTRODUCTION

The presence of a ventriculoperitoneal shunt has been considered to be a contraindication for laparoscopic surgery till date; however, laparoscopic cholecystectomy was recently reported as safe for patients with this shunt.

PRESENTATION OF CASE

We present the first case, to the best of our knowledge, of laparoscopic colectomy for cecal cancer in a patient with a ventriculoperitoneal shunt. A 59-year-old woman with a ventriculoperitoneal shunt for hydrocephalus was referred to our hospital with cecal cancer. Laparoscopic cecal cancer resection was performed successfully and uneventfully by manipulating the shunt.

DISCUSSION

Clamping of the shunt catheter at the subcutaneous region was performed before insufflation of carbon dioxide to prevent adverse effects from the pneumoperitoneum.

CONCLUSION

We believe that laparoscopic colectomy for colon cancer can be performed safely in patients with a ventriculoperitoneal shunt by optimal manipulation of the shunt.

Keywords: Ventriculoperitoneal shunt, Colon cancer, Laparoscopic surgery

1. Introduction

The ventriculoperitoneal (VP) shunt procedure has become the most common neurosurgical method for hydrocephalus because it considerably improves a patient's prognosis.1 It is anticipated that the use of intra-abdominal surgery will increase in patients with a VP shunt. The presence of a VP shunt has been considered to be a contraindication for laparoscopic surgery because of shunt malfunction/infection caused by the pneumoperitoneum; therefore, open laparotomy with externalization of the distal shunt catheter is usually performed in such patients despite the possibility of postoperative dense adhesions that may lead to loculations in the peritoneal cavity. Laparoscopic cholecystectomy with no externalization of the shunt catheter in an adult patient with a preexisting VP shunt was recently reported with good results2,3; this procedure is reported to decrease shunt malfunction caused by adhesions leading to loculations in the peritoneal cavity.2 However, there are no previous reports concerning laparoscopic colectomy in patients with a VP shunt. Here we report the first case, to the best of our knowledge, of laparoscopic cecal cancer resection without externalization of the distal shunt catheter in a patient with a VP shunt.

2. Presentation of case

A 59-year-old woman was referred to our hospital with cecal cancer that was detected by colonoscopy performed during examination for iron deficiency anemia. She had previously been diagnosed with an ependymoma in the IVth ventricle and had received a VP shunt for subsequent hydrocephalus. Radiographs and computed tomography (CT) revealed that the VP shunt catheter was routed subcutaneously through the right thoracic region into the abdominal cavity at the epigastric region. Colonoscopy and barium enema revealed a tumor measuring 3 cm in diameter in the cecum below Bauhin's valve (Fig. 1). On the basis of a tentative diagnosis of TNM stage I (T2, N0, M0) cecal cancer according to the 7th edition of the UICC TNM classification, we conducted a laparoscopic colectomy with clamping of the subcutaneous portion of the shunt catheter after consulting with a neurosurgeon regarding the VP shunt.

Fig. 1.

Fig. 1

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Diagnostic methods. Colonoscopic examination (A) and barium enema (B) reveal an ulcerative and localized tumor measuring 3 cm in diameter in the cecum below Bauhin's valve (arrow).

Laparoscopic colectomy was performed using a standard 5-port technique with induction of an 8-mmHg pneumoperitoneum after clamping of the shunt catheter with atraumatic forceps at the subcutaneous region under radiographic guidance (Fig. 2A and B). This was done to prevent pneumocephalus or retrograde infection caused by the pneumoperitoneum. We shifted the peritoneal end of the shunt catheter to the left subdiaphragmatic region, away from the surgical field, to prevent damage to the shunt or infection (Fig. 2C). A formal right colectomy with D3 lymphadenectomy was successfully performed. The umbilical port wound was expanded to a diameter of 3 cm and extracorporeal ileocolonic anastomosis using a stapling device was performed to prevent intra-abdominal contaminations. Clamping on the shunt catheter was released after verifying that the catheter was not twisted or obstructed and intra-abdominal carbon dioxide (CO2) was desufflated. No hemodynamic instability as a sign of elevated intracranial pressure (ICP) occurred during surgery. Second-generation cephalosporin at a dose of 2 g/day was intravenously administrated as a prophylactic measure from the day of surgery to postoperative day 3. The patient's postoperative course was uneventful with no neurological deficit, and follow-up head CT did not detect hydrocephalus or pneumocephalus 9 days after surgery. The patient was discharged after achieving complete recovery on postoperative day 13.

Fig. 2.

Fig. 2

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Surgical findings. A ventriculoperitoneal (VP) shunt catheter (arrow) was detected at the subcutaneous region under radiographic guidance (A), and it was clamped with atraumatic forceps before carbon dioxide insufflation for the pneumoperitoneum (B). The peritoneal end of the shunt catheter was shifted away from the surgical field (C).

3. Discussion

Laparoscopic surgery is contraindicated for patients with a VP shunt because of the possibility of increased ICP, pneumocephalus, or infectious meningitis caused by the pneumoperitoneum. With regard to open laparotomy in such patients, it is assumed that a distal shunt catheter should be removed from the abdominal cavity during the perioperative period. However, laparoscopic cholecystectomy with no externalization of the shunt catheter in the presence of a VP shunt was recently reported with a positive result in terms of safety.2,3 Various strategies have been introduced to prevent serious complications such as pneumocephalus or retrograde meningitis caused by the pneumoperitoneum, including the use of less intra-abdominal pressure and clamping of the distal shunt catheter.2,3 Furthermore, the standard laparoscopic cholecystectomy technique without shunt manipulation has been performed safely in the presence of a VP shunt because of the presence of a unidirectional valve.4–6 The shunt infection rate associated with this procedure is similar to that reported after shunt insertion or revision, although there is a higher rate of conversion to open surgery when a VP shunt is present than when it is absent.6 In contrast, externalization of the distal shunt catheter during laparoscopic procedures is necessary to prevent serious complications that can develop because of the pneumoperitoneum.7 Therefore, the safety of laparoscopic surgery without shunt manipulation in patients with a VP shunt remains controversial.

Gastrointestinal cancer surgery in patients with a VP shunt is associated with dense adhesions due to the shunt, but no increased risk of postoperative complications has been reported.8 Nevertheless, there have been no previous report on laparoscopic colorectal cancer resection in patients with a VP shunt. Here we reported the first case, to the best of our knowledge, of laparoscopic right colectomy for cecal cancer in a patient with a VP shunt. Laparoscopic surgery as a treatment for colorectal cancer is widespread because of its minimal invasiveness and cosmetic benefit. Several large-scale randomized controlled trials have reported that short-term outcomes do not differ between laparoscopic and conventional open surgery for colorectal cancer.9,10 In Japan, low postoperative complication rates have been reported in association with laparoscopic surgery for colon cancer: 1.47% for anastomotic leakage, 0.20% for intra-abdominal abscess, and 0.33% for postoperative bleeding.11 Moreover, others have reported that the anastomotic leakage rate is significantly lower for a right colectomy than for a left colectomy.12 Therefore, we considered that laparoscopic right colectomy for cecal cancer in patients with a preexisting VP shunt could be safely conducted by minimizing risks caused by the pneumoperitoneum.

Clamping/externalization of the distal shunt catheter has been attempted during laparoscopic procedures to prevent serious complications caused by the pneumoperitoneum in patients with a VP shunt.2,3,7 However, no shunt manipulation has been performed recently.4–6 Laparoscopy-induced pneumocephalus during bilateral salpingo-oophorectomy without clamping of the shunt catheter in a patient with a VP shunt was reported as the first example of forced retrograde air through a VP shunt catheter after a laparoscopic procedure.13 In the present case, the shunt catheter was clamped with atraumatic forceps at the subcutaneous region before CO2 insufflation was undertaken to prevent serious complications caused by the pneumoperitoneum. Moreover, we shifted the peritoneal end of the shunt catheter to the left subdiaphragmatic region, away from the surgical field, to prevent iatrogenic shunt damage or infection. Clamping of the distal shunt catheter may have exacerbated the increase in ICP; however, Kerwat et al. reported that shunt clamping for as long as 3 h does not cause problems.2 In addition, no signs of elevated ICP, such as hemodynamic instability, appeared during the 3-h period during which the VP shunt was clamped in the present case. Moreover, follow-up postoperative head CT demonstrated no findings of hydrocephalus or pneumocephalus.

Right colectomy for cancer is associated with a lower risk of anastomotic leakage/intra-abdominal abscess compared with left colectomy.12 However, complications may occasionally cause a fatal course in uncommon VP shunt cases; therefore, attention should be paid to this phenomena and other severe complications. Moreover, if the possibility of anastomotic leakage/intra-abdominal abscess is suspected, the VP shunt should be externalized immediately to prevent shunt infection. In addition, the influence of a pneumoperitoneum during laparoscopic surgery in patients with a VP shunt should be considered because iatrogenic spread of cancer cells can occur because of the pneumoperitoneum in such patients. A rare case of pancreatic cancer detected by skin metastases along the VP shunt catheter has been reported as an unfortunate consequence.14 Therefore, pneumoperitoneum by CO2 insufflation may encourage VP shunt-related subcutaneous seeding of cancer cells, as port-site metastasis is peculiar to laparoscopic surgery. The incidence of port-site metastasis following laparoscopic colon cancer surgery is believed to be low; however, patients who develop port-site metastasis tend to have advanced disease such as large tumors or Dukes’ C cancers.15 Therefore, we are cautious about the use of laparoscopic surgery for clinical stage T4 tumors with serosal involvement, as Dukes’ C cancers in patients with a VP shunt may encourage VP shunt-related skin metastases. Further case reports and investigations on this procedure with special reference to safety are warranted in future.

4. Conclusion

We described the first case, to the best of our knowledge, of laparoscopic colectomy without externalization of the distal shunt catheter in a patient with cecal cancer and a VP shunt. The safety of this procedure remains controversial. However, we believe that laparoscopic colectomy can be performed safely in patients with a VP shunt by optimal manipulation of the shunt followed by close observation during the perioperative period.

Conflict of interest statement

None.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contributions

Takayuki Torigoe, Shiro Koui, Tomohito Uehara and Koichi Arase performed surgery; Takayuki Torigoe, Yoshifumi Nakayama and Koji Yamaguchi contributed for writing this manuscript.

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