Laparoscopic Ventriculoperitoneal Shunts: Benefits to Resident Training and Patient Safety.

2011·0.07 MB·English

by  Stoddard, Tiffany

S P
CIENTIFIC APER
Laparoscopic Ventriculoperitoneal Shunts: Benefits to
Resident Training and Patient Safety
Tiffany Stoddard, MD, Stephen M. Kavic, MD
ABSTRACT accomplishing both goals of improved outcomes and
quality surgical education.
Background and Objectives: Symptomatic hydroceph-
alus is a surprisingly common clinical condition. Neuro- Key Words: Surgical education, Laparoscopy, Shunts,
surgeons are expert at ventriculostomy, but minimally Hydrocephalus, Laparoscopy, Ventriculoperitoneal.
invasive peritoneal access is outside the realm of their
current training. We have adopted a multidisciplinary ap-
proach, with general surgeons positioning the distal
shunt.Ourobjectivewastoreviewthisrecentexperience. INTRODUCTION
Methods: All distal shunts were placed by a single sur-
Drainageofcerebrospinalfluid(CSF)iswidelyutilizedbyneu-
geon with resident assistance. After ventriculostomy, the
rosurgeons to treat hydrocephalus, and in the setting of most
shunt tubing was tunneled onto the anterior abdominal
chronicconditions,thepreferredrouteistotheperitonealcav-
wall. A Veress needle was placed through the tunnel
ity.Laparoscopyhasbeenusedtoaidintheabdominalplace-
incision and the abdomen insufflated. A 5-mm optical
ment of ventriculoperitoneal (VP) shunts since 1993.1-3 These
access trocar and camera were introduced via a separate
earlyseriessuggestedthatlaparoscopywassafeandeffective
stabincision.Theshunttubingwasthendirectedintothe
andprovideddirectvisualconfirmationofshuntpositionand
abdominal cavity using a Hickman introducer kit, with
function. Comparative studies of minimally invasive shunt
flow confirmed visually.
placement versus traditional open techniques have suggested
laparoscopy is not only a reliable technique, but it has fewer
Results:Studypatientswhohadbetween0and10previous
complicationsaswell.4,5
abdominal operations received 111 consecutive shunts.
There was one intraoperative complication, a colon injury Althoughtherearesomebarrierstowidespreadadoption,
during trocar placement. In this case, the colotomy was a multidisciplinary approach to placement of catheters
repaired and the shunt placed in the pleural space. There seems ideal. At our institution, the preferred approach is
werenoconversionstotheopenabdominalapproach.Post- to have neurosurgeons, skilled and practiced in ventricu-
operatively, there were no wound infections, no cases of lostomy, place the proximal catheter. General surgeons,
shuntmalpositioning,andtherewerenodeaths. more comfortable with minimally invasive abdominal ac-
cess, position the distal portion. This technique is not
Conclusions: Laparoscopic placement of ventriculoperi-
unique to our center, but what has not been appreciated
toneal shunts is feasible, safe, and carries a low rate of
to date is the utility of this procedure in the realm of
complications. The value to resident education in the
resident education. We have recognized the value of this
practice of this procedure has not been previously em-
procedure for teaching residents, including junior level
phasized. In the era of increased awareness of patient
residents,ratherthanaspecializedproceduretoremainin
safety, laparoscopic VP shunting serves as a model for
thehandsoffacultymembers.Wepresenthereourrecent
experience with surgical trainees and laparoscopic-
Department of Surgery, University of Maryland School of Medicine, Baltimore,
Maryland,USA(allauthors). assisted VP shunt placement.
Presentedasanoralpresentationatthe19thSLSAnnualMeetingandEndoExpo,
NewYork,NewYork,USA,September1-4,2010. MATERIALS AND METHODS
Addresscorrespondenceto:StephenM.Kavic,MD,AssistantProfessor,Depart-
mentofSurgery,AssociateProgramDirector,GeneralSurgeryResidency,Uni- We conducted a retrospective review of all adult patients un-
versityofMarylandBaltimore,22SouthGreeneStreet,S4B09,Baltimore,MD dergoinglaparoscopicplacementofVPshuntsatasingleaca-
21201, USA. Telephone: [phone], Fax: [phone], E-mail:
demic institution over a 2-year period. The results include all
[email protected]
consecutive cases from September 2007 through September
DOI:10.4293/108680811X13022985131093
2009.Datacollectedincludedage,sex,diagnoses,indications
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. forsurgery,operativedetails,andshort-termresults.
38 JSLS(2011)15:38–40
Operative Technique The operative time for the distal placement was brief,
oftenlessthan10minutes.Shuntplacementwassuccess-
Each patient is placed in supine positioning after induc-
ful in all patients as documented by the laparoscopic
tionofgeneralanesthesia,withtheheadturnedslightly.A
visualization of CSF draining from the end of the shunt
scalp flap is raised, and a burr hole created in the skull.
tubingatthetimeoftheoperation.Residentparticipation
The ventricle is accessed, and the shunt tubing inserted.
included all PGY levels (intern through chief resident).
The tubing is connected via a one-way valve to the distal
catheter, tunneled from a 1-cm incision on the abdominal Complications were also minimal. There were no deaths
walljustbelowthecostalmargin. in the series. There were no wound complications, no
intraabdominal abscess, and no malpositioned shunts.
Placement is performed with standard technique, a varia-
Therewerenoaccess-relatedvascularcomplications,with
tion of that has been previously reported.6 Pneumoperi-
no patient requiring a blood transfusion.
toneumisestablishedtoapressureof10mmHgto15mm
Hg using a Veress needle through the tunnel site. After In one patient, the trocar violated the right colon. Given
insufflation, a 5-mm optical access camera and trocar are thatthepatienthadpriorsurgeryandadhesions,weoptedto
placed through a separate stab incision approximately repairthecolotomyin2layersusingalimitedmidlinelaparot-
10cmawayfromthetunnelsite.Typically,adequateperi- omy.Theshunttubingwasplacedintothepleuralspaceonthe
toneal surface is confirmed during a brief diagnostic lap- rightsiteoftheabdomen.Thepatienthadanuneventfulrecov-
aroscopy. A 10-French Hickmann peel-away introducer ery,withgooddrainageofCSF,andnoabdominalsequelae.
sheath is then used to place the tubing in the peritoneal
cavity.Thetippositionmayneedtobealtered,andcanbe
DISCUSSION
repositioned through use of the camera tip itself. Flow of
CSFthroughthecatheteristhenvisuallyconfirmedwhile Thetraditionalopentechniqueforplacementoftheshunt
palpating the proximal valve (Figure 1). The abdomen involves creating a limited laparotomy and blindly intro-
may be desufflated, and the trocar site and tunnel site ducing the catheter into the abdominal cavity. Laparos-
closed with absorbable subcuticular stitch. copy has been well described for the placement of ven-
triculoperitoneal shunts, using a variety of techniques.
Initial reports utilized a 3-trocar technique with good re-
RESULTS
sults.1,2Theuseofapeel-awayintroducersheathtoinsert
We performed 111 de novo ventriculoperitoneal shunt the tubing through the abdominal wall greatly facilitates
placementsduringthestudyperiod.Ofourpatients,56% the procedure.4 Single trocar techniques have been de-
werefemale,withanaverageageof55.2years(range,19 scribed with equal success.7
to86).Theaveragebodymassindex(BMI)was29.8,but
Thecommondenominatorinthelaparoscopicapproachisthat
ranged from 15 to 49.6. The indication for shunt place-
itbenefitsthepatientinprovidingaguaranteeoftheadequacy
mentwasalwayshydrocephalus.Themostcommoncon-
oftheshunt.First,theshunttubingisconfirmedtobelocated
dition requiring initial shunt placement was intracranial
within the peritoneal cavity. Secondly, shunt function is con-
hemorrhage, but other diagnoses included normal pres-
firmedbyvisualizationofdrainageofCSFfromtheshunttub-
sure hydrocephalus, intracranial tumor, syringomyelia,
ing.Last,theoverallrateofwoundcomplicationsismarkedly
and spina bifida, among others.
decreasedovermoretraditionalincisions.
For the neurosurgeon, confidence in the placement, po-
sition, and flow through the catheter is also important.
However, they enjoy a freedom from the procedure out-
sidetheirareaofinterestandexpertise.Further,thisinter-
action in the operating room builds rapport, and increases
collegialityacrossthedisciplines.Someneurosurgeonsmay
prefer to place their own shunts; however, we have found
that an available and interested general surgery team has
beenwelcomed.
Figure1.Flowofcerebrospinalfluidisconfirmedvisuallyafter Mostimportantly,however,thereistheperspectiveofthegen-
lumboperitonealshuntplacement. eral surgery resident. Of course, performing any procedure
JSLS(2011)15:38–40 39
LaparoscopicVentriculoperitonealShunts:BenefitstoResidentTrainingandPatientSafety,StoddardTetal.
addstotheoverallexperienceoftheresidency.However,there critical data inappropriately. At our institution, we have
isanaspectoftrainingthathasbeenlargelyoverlooked.There foundthatbothservicestendtobemoreinvolved,perhaps
areseveralcharacteristicsofanidealteachingexercise:safety, providing additional layers of thought and concern toward
standard of care, rapidity, reproducibility/consistency, fre- theindividualpatient.Finally,wedidnotformallystudythe
quency,applicabilitytootherprocedures. resident attitudes or aptitude in performing the shunting
procedure.Itisourintenttobuildonthisinitialexperience
The VP shunt meets each of these criteria as an optimal
bycorrelatingthisaccessprocedurewithtasksinoursimu-
learning experience.
lationcenterinthefuture.
Atourcenter,theprocedureissafeandsupervised.Itisa
well-established, standardized procedure with an excel- CONCLUSION
lent track record both in the literature as well as locally.
Inthecurrentseries,wehaveconfirmedthatMIStechniques
Further, it occurs frequently enough (approximately one
canbeappliedtowardneurosurgicalprocedures,specifically
perweek)toallowresidentstheopportunitytolearnand
the placement of ventriculoperitoneal shunting. Although
thenpracticetheproceduremultipletimesduringagiven
thishasbeenpreviouslydemonstrated,thevaluetoresident
rotation. It is also rapid, typically taking a few minutes of
educationhasnotbeenemphasized.Intheeraofincreased
operativetime.Thisdoesnotinterferewithschedulingof
awarenessofpatientsafety,laparoscopicVPshuntingserves
other operative cases, or provide a substantial drain on
as a model for accomplishing both goals of improved out-
resident manpower.
comesandqualitysurgicaleducation.
InthecaseofVPshunts,theaccessitselfistheessenceof
theprocedure,makingthiscasetheclosesttotheoptimal References:
training model for peritoneal access. In the example of a
1. Armbruster C, Blauensteiner J, Ammerer HP, Kriwanek S.
laparoscopic colectomy, port placement and access is a
Laparoscopically assisted implantation of ventriculoperitoneal
necessary but very initial part of the procedure. There is
shunts.JLaparoendoscSurg.1993;3:191-192.
some element of impatience in the access portion, as the
bulkoftheprocedureremainstooccur.Thefocusonthe 2. BausuariL,SelmanJM,LizanaC.Peritonealcatheterinsertion
educational aspect of the case lies in dissection or anas- usinglaparoscopicguidance.PediatrNeurosurg.1993;19:109-110.
tomosis rather than access. 3. Schievink WI, Wharen RE Jr., Reimer R, Pettit PD, Seiler JC,
Shine TS. Laparoscopic placement of ventriculoperitoneal shunts:
Additionally, the skills required for laparoscopic placement
preliminaryreport.MayoClinicProceed.1993;68:1064-1066.
of shunts translate well to other minimally invasive proce-
dures. Of course, this naturally includes the laparoscopic 4. Cuatico W, Vannix D. Laparoscopically guided peritoneal
managementofshuntcomplications,whichhasbeenprevi- insertion in ventriculoperitoneal shunts. J Laparoendosc Surg.
ouslydescribedbyusandothers.8,9However,thisprocedure 1995;5:309-311.
serves as a platform for the broader category of peritoneal 5. Schubert F, Fijen BP, Krauss JK. Laparoscopically assisted
access,applicabletomosteveryabdominalprocedure.Fur- peritonealshuntinsertioninhydrocephalus:aprospectivecon-
ther,thismethodofaccesstotheperitoneummaybeintro- trolledstudy.SurgEndosc.2005;19:1588-1591.
duced at an early level of training, at the intern or second-
6. Roth JS, Park AE, Gerwitz R. Minilaparoscopically assisted
yearlevel,suchthatitiswellpracticedbythetimeresidents
placementofventriculoperitonealshunts.SurgEndosc.2000;14:
approachthesenioryearsofresidency.Itisremarkablethat
461-463.
this procedure provides for better resident training while
7. Fanelli RD, Mellinger DN, Crowell RM, Gersin KS. Laparo-
improvingpatientoutcomesandsafety.
scopic VP shunt placement: a single trocar technique. Surg
The disadvantages to this procedure are few. The general Endosc.2000;14:641-643.
surgery team needs to be available on a semi-urgent basis,
8. Kavic SM, Segan RD, Taylor MD, Roth JS. Laparoscopic
which leads to occasional practical, logistical difficulties.
managementofventriculoperitonealandlumboperitonealshunt
Theseproblemscanlargelyberesolvedbyhavingboththe
complications.JSLS.2007;11:14-19.
neurosurgeonsandgeneralsurgeonscommittedtothepro-
9. Klee VM, Kraft RO, Zimmerman RS, Harold KL. A laparo-
cedureandtheapplicationofminimallyinvasivetechniques.
scopic technique for retrieval and prevention of migration of
Inaddition,thereisthepotentialforlossofownershipofthe
ventriculoperitonealshunttubing.JSLS.2009;13:101-103.
patients,withthepotentialbetween2servicestoeachignore
40 JSLS(2011)15:38–40