The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results

Transcription

1 J Neurosurg Pediatrics 11: , 2013 AANS, 2013 The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results Clinical article Pablo F. Recinos, M.D., 1,3 Jonathan A. Pindrik, M.D., 1 Mazen I. Bedri, M.D., 2 Edward S. Ahn, M.D., 1 George I. Jallo, M.D., 1 and Violette Renard Recinos, M.D. 3 Divisions of 1 Pediatric Neurosurgery and 2 Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 3 Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio Object. The aim of this study was to examine the feasibility and safety of ventriculoperitoneal (VP) shunt placement using a periumbilical approach for distal peritoneal access. By using this minimally invasive approach, the authors hypothesized that the cosmetic outcomes would be better than could be achieved by using a traditional minilaparotomy and that clinical results would be comparable. Methods. A periumbilical approach was used for distal catheter insertion during a first-time VP shunt placement in 20 patients (8 males and 12 females). Median age at time of surgery was 3.0 months (range 7 days 11.9 years) and mean follow-up time was 17.8 months (range months). The median weight of the patients was 3.99 kg (range kg). A single incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1-mm incision made while the patient was temporarily held in a Valsalva maneuver. A peritoneal trocar was then inserted through the fascial incision and the distal catheter was passed into the peritoneal space. Results. The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients families. Mean operative time was 35 minutes. Eight patients required revision surgery. One distal failure occurred when the distal shunt tubing retracted and became coiled in the neck; this was repaired by conversion to a minilaparotomy for distal replacement. There was 1 shunt infection (5%) requiring shunt removal and replacement. One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system, and another patient underwent a conversion to a ventriculoatrial shunt due to poor peritoneal absorption. In the remaining 4 patients who required operative revision, the peritoneal portion of the shunt was not involved. Conclusions. The periumbilical approach for peritoneal access during VP shunt placement is technically feasible, has low infection rates, and has cosmetically appealing results. It may be considered as an alternative option to standard VP shunt placement techniques. ( Key Words ventriculoperitoneal shunt periumbilical approach hydrocephalus minimally invasive neurosurgery infraumbilical incision cosmesis A standard surgical treatment for hydrocephalus is placement of a VP shunt. The distal VP shunt catheter is commonly inserted via a minilaparotomy. However, significant morbidity can result secondary to using a traditional laparotomy, including adhesion formation, visceral injury, postoperative hernia formation, and increased postoperative pain. 12 In addition, the minilaparotomy incision leads to cosmetically unfavorable Abbreviation used in this paper: VP = ventriculoperitoneal. results. Given that patients who undergo shunt placement are living longer and distal revisions are less common than proximal revisions, minimally invasive approaches to the peritoneum are preferred for cosmetic reasons and are increasingly being used. 6,18,19 Several groups have reported less invasive approaches using laparoscopy for placement of the peritoneal portion of a VP shunt. 1,9,18 20 The purported advantages of this technique are increased visualization to ensure correct placement of the distal catheter, decreased blood loss, shorter operative time, and minimal scar formation. 18, J Neurosurg: Pediatrics / Volume 11 / May 2013

2 Periumbilical approach for shunt placement However, a disadvantage of this technique is the need for laparoscopic instruments, which increases setup time and equipment expense. In addition, a skilled endoscopic general surgeon must be available to place the peritoneal portion of the shunt. We hypothesized that the peritoneal portion of a VP shunt could be safely placed through a minimally invasive periumbilical approach. Such an approach would be cosmetically favorable and would have advantages similar to laparoscopic shunt placement, but without the need for additional equipment or surgeons. We describe the technique for placing the peritoneal portion of a VP shunt through a periumbilical approach and present long-term follow-up results in a pediatric cohort of 20 patients. Methods Study Design A prospective, observational study was conducted to study patients who underwent VP shunt placement utilizing a periumbilical approach for distal catheter placement. Inclusion criteria were as follows: 1) treatment of hydrocephalus using a VP shunt, 2) age less than 18 years old, and 3) surgery performed by a pediatric neurosurgeon at the Johns Hopkins Hospital. Patients were excluded from the study if they 1) had a history of prior shunt placement (with the exception of a temporary ventriculosubgaleal shunt), 2) had a history of abdominal infection, and/or 3) had an umbilical hernia. Basic demographic information, total operative procedure time, and complications occurring in the follow-up period were noted. Prior to the initiation of the study, a goal follow-up time of 6 months was set to allow adequate time for monitoring the development of any complications. The study was approved by the Johns Hopkins Medicine Institutional Review Board. Patient Population A total of 20 patients (8 males and 12 females) were included in the study. At the time of VP shunt placement, the mean patient age was 10.5 months and median age was 3.0 months (range 7 days 11.9 years). The mean follow-up time was 17.8 months (range months). One patient was lost to follow-up after 1.2 months. The median patient weight was 3.99 kg (range kg) (Table 1). Operative Technique After induction of general anesthesia using endotracheal intubation, patients were positioned supine with a shoulder bolster ipsilateral to the side of shunt placement. All patients received a dose of antibiotics within 1 hour prior to skin incision and for 24 hours postoperatively. The bladder was emptied using a Credé maneuver or straight catheterization. Patients were prepared and draped in a standard manner for routine VP shunt placement. Ventricular catheters were placed either in a frontal or occipital location. Frontal catheters were placed through an incision and bur hole corresponding to the Kocher point. A second incision was made behind the ear to allow anterior and superior redirection of the distal catheter to connect it to the valve. Occipital catheters were placed through an J Neurosurg: Pediatrics / Volume 11 / May 2013 incision and bur hole at the Dandy point, without the need for a second incision to connect the system. Insertion of the ventricular catheter and passage of the shunt tubing to the abdomen was performed using standard techniques. 3 Peritoneal access through a periumbilical approach was performed concurrently with the placement of the ventricular catheter. A 1-cm incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1 2-mm incision made. A temporary Valsalva maneuver was induced and a peritoneal trocar was then passed through the fascia, using gentle downward pressure to advance it into the peritoneal space (Fig. 1). The trocar was angled away from the midline during insertion to avoid vascular or visceral injury. The stylet was removed and the shunt tubing was subsequently guided into the peritoneum using bayonet forceps (Fig. 2). If resistance was encountered while passing the catheter, the trocar was redirected until the catheter glided easily into the peritoneum. In cases where continued resistance was encountered, the trocar was removed and reinserted into the peritoneum using the initial insertion technique. Results The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients families (Fig. 3). The mean (± SD) operative time for all patients was 35 ± 11 minutes. Fifteen patients underwent VP shunt placement only, while 5 patients had removal of a previously placed ventriculosubgaleal shunt in addition to placement of a new VP shunt. Eight patients required revision surgery during the follow-up period (Table 2). One patient (Case 11) experienced a case of distal failure in which the distal tubing retracted and became coiled under the shunt valve in the neck. The shunt was revised by an adult neurosurgeon through conversion to a minilaparotomy for replacement of the distal catheter. One shunt infection (5%) occurred requiring removal of the shunt system with delayed replacement after treatment with antibiotics (Case 14). One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system (Case 2). Of note, the previous periumbilical incision was used to replace the peritoneal portion of the shunt system. One patient had conversion to a ventriculoatrial shunt due to poor peritoneal absorption (Case 16). The remaining 4 patients who required an operative revision did not undergo surgery that involved removal or manipulation of the peritoneal portion of the shunt system. Notably, 1 patient (Case 13) developed a left inguinal hernia and required laparoscopic repair of the hernia and mobilization of the distal shunt catheter tip from the scrotum to the peritoneum. A transumbilical approach was used for the inguinal hernia repair and was not affected by the previous infraumbilical incision. Discussion Use of a periumbilical approach has been shown to 559

3 P. F. Recinos et al. TABLE 1: Patient demographics and type of hydrocephalus treated* Case No. Age at Op, Sex Weight (kg) Hydrocephalus Type mos, M 9.90 congenital (schizencephaly) 2 13 days, F 2.31 congenital (Dandy-Walker) mos, F 5.30 congenital (myelomeningocele) 4 12 days, F 2.56 congenital (myelomeningocele) mos, F 4.00 congenital (hydranencephaly) mos, F 5.23 congenital (hydranencephaly) yrs, F 57.0 communicating mos, M 9.50 acquired (post-ivh) mos, M 5.17 congenital days, M 3.45 congenital (myelomeningocele) mos, F 5.28 acquired (post-ivh) mos, F 3.98 acquired (post-ivh) days, M 2.60 acquired (postinfection) mos, F 2.75 acquired (post-ivh) mos, F 11.1 acquired (posterior fossa tumor) days, M 2.03 acquired (post-ivh) 17 7 days, F 2.62 congenital mos, M 1.95 acquired (post-ivh) mos, F 5.70 congenital mos, M 3.95 congenital (large posterior encephalocele) * IVH = intraventricular hemorrhage. be safe, efficacious, and to have superior cosmetic outcomes in treating various pediatric disease processes. A periumbilical approach was first used in children by Tan and Bianchi 17 to treat infantile hypertrophic pyloric stenosis. In their approach, a 310 incision was made around the umbilicus, which provided adequate exposure to perform a pyloromyotomy. Out of 40 patients treated with this approach, 3 patients (7.5%) had a mild wound infection and 1 patient (2.5%) had purulent drainage. The authors noted a superior cosmetic outcome, especially when compared with the standard right hypochondrial incision. Soutter and Askew 16 reported a series of 42 infants who were treated for a variety of abdominal pathologies, including intestinal atresia and volvulus, through a 350 periumbilical approach. There were 2 patients who had a superficial wound infection and there were no problems with umbilical necrosis. Lin at al. 8 reported a series of 6 full-term infants with ovarian cysts ranging in size from cm that were removed through a semicircular, infraumbilical incision. There were no reported complications and all patients were discharged within 24 hours after surgery. In the present series, we demonstrated that obtaining peritoneal access when placing a VP shunt through a periumbilical approach is feasible and cosmetically favorable. Simon et al. 15 reported an 11.7% infection rate per patient after initial shunt placement across pediatric hospitals in the US over a mean follow-up time of 24 months. Infection risk was found to be progressively increased with younger patient age, as follows: 48 months (8.29%), 6 48 months (12.3%), 1 6 months (15.0%), and < 30 days (16.5%). The infection rate in our patient cohort of 5% was comparable to our previously reported series and lower than the national average. 7,10,14,15,22 Notably, 70% of our patients (14 of 20) were younger than 6 months of age, which corresponds to the 2 groups with the highest infection rates. However, our study had a small number of patients and was limited to a single center so these results should be interpreted within this context. Our study s follow-up duration also allowed us to evaluate how the periumbilical approach would affect management of other complications. We reused the infraumbilical incision in the replacement of the whole shunt system in 1 case without complications. It was also notable that a previous periumbilical approach did not affect subsequent transumbilical laparoscopy. In the patient who developed an inguinal hernia (Case 13), the distal shunt catheter was laparoscopically removed from the scrotum, replaced into the peritoneum, and the hernia was repaired without complications. A transumbilical approach is another feasible option for placement of the peritoneal portion of a VP shunt in pediatric patients. Scavarda et al. 13 reported a series of 8 patients with a mean age of 15 months (range 6 weeks 47 months) who had initial VP shunt placement. They used an open transumbilical approach to place the peritoneal portion of the VP shunt with excellent cosmetic results. During an average follow-up time of 6 months, 1 patient required shunt replacement due to infection, which was performed through the same approach. In addition, the authors have used the open transumbilical approach for VP shunt revision cases with good success (D. Scavarda, 560 J Neurosurg: Pediatrics / Volume 11 / May 2013

4 Periumbilical approach for shunt placement Fig. 1. Intraoperative photos demonstrating the distal shunt insertion technique using a periumbilical approach. After a 1-mm incision is made into midline fascia, a peritoneal trocar is inserted using gentle downward pressure (A). The stylet is removed and the distal catheter is passed using bayonet forceps (B). The catheter should glide easily during the entire passage of the entire length of tubing (C). If resistance is met, the trocar should be repositioned until the tubing passes easily. The trocar sleeve is removed as the final portion of tubing is inserted into the peritoneum (D). Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography All Rights Reserved. personal communication, 2011). Tubbs and coworkers19 reported a series of 25 patients with a mean age of 1.2 years (range 6 days 5 years) who had initial VP shunt placement via an open transumbilical approach. They experienced no infections and had 1 coiled distal catheter requiring revision over an average follow-up time of 3.2 years, confirming the safety of the open, transumbilical approach. Tormenti and colleagues18 reported a series of 6 patients with an average age of 6 years (range 1 day 16 years) who had initial VP shunt placement using a laparoscopic transumbilical approach. They described no perioperative infections or distal obstructions, although the total follow-up time was not reported. Laparoscopic placement of the peritoneal portion of a VP shunt is becoming more common in the management of hydrocephalus. In a series of 800 adult patients, Naftel et al.9 found that patients who had a VP shunt placed laparoscopically had significantly lower rates of distal malfunction. The effect was even more significant for patients with previous abdominal surgery. In addition, VP shunt placement using laparoscopy required significantly less operative time than minilaparotomy (43.5 minutes vs 55.6 minutes, respectively; p < ). Laparoscopy is also an ideal approach in managing complications after VP shunt placement, including bowel obstruction, inguinal hernia, peritoneal abscesses, and CSF pseudocysts.4,11 In the pediatric population, however, the advantages of J Neurosurg: Pediatrics / Volume 11 / May 2013 Fig. 2. Illustration depicting the distal shunt tubing insertion into the peritoneum. The trocar is passed gently so that the fascia is completely penetrated (A) and the trocar sleeve lies in the peritoneum (B). The trocar sleeve serves as a channel to pass the shunt tubing into the peritoneum (C). The tubing should pass easily so that a significant length of redundant catheter is placed in the peritoneum (D). Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography All Rights Reserved. laparoscopy during initial VP shunt placement are less clear. Children without a history of peritoneal infection or surgery generally do not have abdominal adhesions. Therefore, placement of the catheter into the peritoneum does not require visualization of the entire intraabdominal contents. In neonates, a transumbilical approach requires dissection of the remnant umbilical vessels, which can be avoided by using a periumbilical approach.18 Given the mean operative times we noted in this series (35 ± 11 minutes) and the small exposure needed for a periumbilical approach, it is likely that the operative time required to use a periumbilical approach is at least comparable to that needed for laparoscopy. In addition, using laparoscopy for VP shunt placement requires greater setup time, a skilled laparoscopic surgeon, and additional equipment, which all add significant cost to the procedure. There are limitations of the periumbilical approach and critical technical details that must be considered. There is a potential risk for enterotomy or vascular injury, although these are also known complications of peritoneal entry during laparoscopic procedures.2,5,21 Although we did not experience an intraabdominal complication, immediate visualization of an intraabdominal injury is a significant advantage of laparoscopic approaches, which is not possible with our periumbilical approach. It is our opinion that complications from trocar insertion can be minimized by 1) emptying the bladder preoperatively, 2) making a small incision in the midline raphe prior to trocar insertion to decrease insertion resistance, 3) aiming the trocar away from the midline during initial insertion, and 4) having the patient in a Valsalva maneuver to provide counter resistance during trocar insertion. We do not advocate the periumbilical approach during VP 561

5 P. F. Recinos et al. TABLE 2: Summary of patients requiring shunt-revision surgery Case No. Time to Subsequent Revision(s) After 1st Op Revision Type Peritoneal Portion Removed Infection mos proximal no no 9.2 mos proximal no no 10.2 mos whole system yes* no 4 20 days distal no no mos proximal no no mos distal yes no mos proximal no no mos distal no no days whole system yes yes mos proximal no no 14.1 mos distal yes no * The entire system was replaced due to significant skin thinning around valve. A periumbilical incision was reused for peritoneal access. A left inguinal hernia developed requiring transumbilical laparoscopic repair of the hernia and mobilization of the distal shunt tip from the scrotum to the peritoneum. Conversion to ventriculoatrial shunt secondary to poor peritoneal absorption. shunt placement in patients with a history of peritonitis or open abdominal surgery given the increased likelihood of adhesions. Those patients are best treated using a traditional laparotomy or a laparoscopic procedure. In addition, we have limited experience using this technique in adult patients with a normal body habitus. Given the need to visualize the linea alba prior to trochar insertion, a larger incision would need to be made in obese patients, possibly negating the benefits of this technique. Conclusions The periumbilical approach for peritoneal access during VP shunt placement is feasible and provides excellent cosmetic results. It may be considered as an alternate technique to the traditional minilaparotomy for distal catheter placement in pediatric patients undergoing initial VP shunt placement. In our pediatric series, the periumbilical approach had comparable morbidity and cosmetic Fig. 3. Preoperative (left) and postoperative (right) photographs depicting the oblique view of the periumbilical incision used in an infant. Placement of the incision in the infraumbilical crease results in excellent cosmetic outcomes. In infants, a periumbilical approach avoids dissection of the remnant umbilical vessels, which is necessary for transumbilical approaches. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography All Rights Reserved. results to those associated with laparoscopy without the need for additional resources. Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: Renard Recinos, Recinos, Jallo. Acquisition of data: Renard Recinos, Recinos, Pindrik, Ahn, Jallo. Analysis and interpretation of data: Renard Recinos, Recinos, Bedri, Jallo. Drafting the article: Recinos. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Renard Recinos. Administrative/technical/ material support: Renard Recinos, Jallo. Study supervision: Renard Recinos, Jallo. Acknowledgments The authors are grateful to Joseph Kanasz (medical illustrator from the Cleveland Clinic) for providing the illustrations for this manuscript, and to Christine Moore for assistance with manuscript preparation. References 1. Argo JL, Yellumahanthi DK, Ballem N, Harrigan MR, Fisher WS III, Wesley MM, et al: Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement. Surg Endosc 23: , Danan D, Winfree CJ, Mckhann GM: Intra-abdominal vascular injury during trocar-assisted ventriculoperitoneal shunting: case report. Neurosurgery 63:E613, Drake JM, Iantosca MR: Cerebrospinal fluid shunting and management of pediatric hydrocephalus, in Schmidek HH, Roberts DW (eds): Schmidek and Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results, ed 5. Philadelphia: Elsevier, 2005, Vol 1, pp Esposito C, Colella G, Settimi A, Centonze A, Signorelli F, Ascione G, et al: One-trocar laparoscopy: a valid procedure 562 J Neurosurg: Pediatrics / Volume 11 / May 2013

6 Periumbilical approach for shunt placement to treat abdominal complications in children with peritoneal shunt for hydrocephalus. Surg Endosc 17: , Hai A, Rab AZ, Ghani I, Huda MF, Quadir AQ: Perforation into gut by ventriculoperitoneal shunts: a report of two cases and review of the literature. J Indian Assoc Pediatr Surg 16: 31 33, Keucher TR, Mealey J Jr: Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50: , Kulkarni AV, Drake JM, Lamberti-Pasculli M: Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94: , Lin JY, Lee ZF, Chang YT: Transumbilical management for neonatal ovarian cysts. J Pediatr Surg 42: , Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, et al: Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. Clinical article. J Neurosurg 115: , Parker SL, Attenello FJ, Sciubba DM, Garces-Ambrossi GL, Ahn E, Weingart J, et al: Comparison of shunt infection incidence in high-risk subgroups receiving antibiotic-impregnated versus standard shunts. Childs Nerv Syst 25:77 83, Popa F, Grigorean VT, Onose G, Popescu M, Strambu V, Sandu AM: Laparoscopic treatment of abdominal complications following ventriculoperitoneal shunt. J Med Life 2: , Pudenz RH: The surgical treatment of hydrocephalus an historical review. Surg Neurol 15:15 26, Scavarda D, Breaud J, Khalil M, Paredes AP, Takahashi M, Fouquet V, et al: Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results. Childs Nerv Syst 21:39 43, Sciubba DM, Noggle JC, Carson BS, Jallo GI: Antibiotic-impregnated shunt catheters for the treatment of infantile hydrocephalus. Pediatr Neurosurg 44:91 96, Simon TD, Hall M, Riva-Cambrin J, Albert JE, Jeffries HE, Lafleur B, et al: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4: , Soutter AD, Askew AA: Transumbilical laparotomy in infants: a novel approach for a wide variety of surgical disease. J Pediatr Surg 38: , Tan KC, Bianchi A: Circumumbilical incision for pyloromyotomy. Br J Surg 73:399, Tormenti MJ, Adamo MA, Prince JM, Kane TD, Spinks TJ: Single-incision laparoscopic transumbilical shunt placement. Technical note. J Neurosurg Pediatr 8: , Tubbs RS, Azih LC, Mortazavi MM, Chern JJ, Hankinson T, Oakes WJ, et al: Transumbilical approach for ventriculoperitoneal shunt placement in infants and small children: a 6-year experience. Childs Nerv Syst 28: , Turner RD, Rosenblatt SM, Chand B, Luciano MG: Laparoscopic peritoneal catheter placement: results of a new method in 111 patients. Neurosurgery 61 (3 Suppl): , van der Voort M, Heijnsdijk EAM, Gouma DJ: Bowel injury as a complication of laparoscopy. Br J Surg 91: , Vinchon M, Lemaitre MP, Vallée L, Dhellemmes P: Late shunt infection: incidence, pathogenesis, and therapeutic implications. Neuropediatrics 33: , 2002 Manuscript submitted January 30, Accepted January 21, Please include this information when citing this paper: published online February 22, 2013; DOI: / PEDS1254. Address correspondence to: Violette Renard Recinos, M.D., Pediatric Neurosurgical Oncology, Cleveland Clinic Foundation, 9500 Euclid Avenue, S-60, Cleveland, Ohio recinov@ ccf.org. J Neurosurg: Pediatrics / Volume 11 / May