Laparoscopic ventriculoperitoneal shunt placement - A single-trocar technique

Ventriculoperitoneal shunt (VPS) placement is an important therapeutic technique. Placement of the abdominal portion of VPS can be difficult in the setting of previous abdominal surgery, prior failure of VPS, or obesity. Even under ideal circumstances, standard mini laparotomy does not allow precision in VPS positioning. We describe a single-port technique for VPS placement. While the neurosurgeon places a right frontal ventricular catheter and valve, an infraumbilical trocar is placed utilizing the open Hasson technique. A 12-mm operating laparoscope with an 8-mm channel is used to inspect the abdomen and identify the VPS entry site. Adhesions interfering with shunt placement can be lysed through the working channel of the laparoscope. Under laparoscopic visualization, an 18-gauge needle is introduced through a 5-mm incision in the right upper quadrant and the VPS tubing is tunneled to that site. A J-tipped guidewire is introduced, and the needle is exchanged for a dilator and peel-away sheath. The VPS is delivered through the sheath, which is sectioned and removed. An atraumatic grasper, placed through the laparoscope, directs the VPS to the desired intraabdominal location. Function of the VPS is assessed visually while compressing the valve. Suture closure of the trocar site and VPS entry site completes the procedure. We used this method successfully in a series of five patients with excellent outcome. A 14-month follow-up has revealed no failures or postoperative complications. This method is less invasive than mini-laparotomy, allows for precision placement of the abdominal portion of VPS, and confirms appropriate function.