2007 / Jul-Dec / Volume 2 / J Pediatr Neurosci / 67

This PDF is

avail

able

for free

download fr

om

a site

hosted by M

edkn

ow Publicati

ons

(www.m

edkn

ow.com).

Modification of shunt introducerAleksander M. Vitali, Andries A. le RouxInkosi Albert Luthuli Central Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Mayville, Durban, 4058, KwaZulu-Natal, South Africa

Address for Correspondence: Aleksander M. Vitali, Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 800 Bellair Avenue, P. Bag X03, Mayville, Durban, 4058, KwaZulu-Natal, South Africa. E-mail: alex.vitali@excite.com

ABSTRACT

The insertion of a ventriculoperitoneal shunt is one of the most common pediatric neurosurgical procedures. A majority of these operations are efficient by junior doctors. Any modification to the technique that makes the procedure easier may decrease the number of complications. The authors describe a quick modification to the ventriculoperitoneal shunt introducer. This enables the easy and fast tunneling for catheter insertion, even in the patient with a massive head due to neglected hydrocephalus, thereby decreasing the operative time and possibly the risk of infection.

Key words:Key words: Ventriculoperitoneal shunt, CSF shunt, hydrocephalus, surgical technique, technical note, macrocephaly

Technical note

Online full text at http://www.pediatricneurosciences.com

Introduction

The insertion of a ventriculoperitoneal (VP) shunt remains one of the commonest neurosurgical procedures. The majority of these operations are performed in pediatric patients. On the completion of the training, most neurosurgeons have their own technique of introducer modification and shunt insertion. These techniques will work well for the vast majority of hydrocephalic patients. However, in situations where the hydrocephalus has been neglected and there is an exceptional disproportion between the size of the head and the body, the usual technique of shunt placement may not be that effective. Such cases of neglected hydrocephalus are most common in less-developed countries, where prenatal screening is suboptimal, abortion is either not practiced (for religious or cultural reasons) or not available and resources for treatment and diagnosis may not be readily accessible. In the author�s unit in Durban, South Africa, children with neglected hydrocephalus present usually with massively enlarged heads, thin necks, with very thin and fragile skin [Figure 1]. Over the years, the authors have introduced a slight and quick modification to the commonly used shunt introducers (Codman, NMT, etc.), which has facilitated the passage of the peritoneal catheter subcutaneously between the scalp and the abdomen during VP shunt insertion.

Technique

In a supine position, the head of the patient is turned to the opposite side and a rolled towel is placed under his/her neck. The incisions are marked and the skin in between the planned incisions is prepped and covered with a sterile drape. The abdominal cavity and cranium are opened in a routine way. The standard straight introducer [Figure 2] is bent in the hands of the surgeon in an �S� shaped manner just prior to tunneling [Figure 3]. The curvature is vaguely proportional to the size of the head. The tunneling is started at the cranial incision. Initially, the introducer tip follows the curvature of the skull. As soon as the introducer reaches the craniocervical junction, it is turned 180° with the tip facing upwards. The tunneling follows over the neck. After negotiating the clavicle and the upper chest, the introducer is being turned 180° again, making it easier to travel the remaining distance to the abdominal incision [Figure 4]. The rest of the procedure is performed as discussed elsewhere.[1,2]

Discussion

Ventriculoperitoneal shunt insertion is still one of the most common neurosurgical procedures. It has been documented that the duration of surgery and the surgical technique are related to the rate/risk of infection.[3-5] The tunneling for the insertion of the catheter can be one of the most difficult, time-consuming and traumatic parts of the operation. Patients with neglected hydrocephalus present with exceptionally

[Downloaded free from http://www.pediatricneurosciences.com on Thursday, December 06, 2012, IP: 180.149.7.11]  ||  Click here to download free Android applicationfor this journal

68 / J Pediatr Neurosci / Volume 2 / Jul-Dec / 2007

This PDF is

avail

able

for free

download fr

om

a site

hosted by M

edkn

ow Publicati

ons

(www.m

edkn

ow.com).

large heads, thin necks, very thin skin (particulary over the neck), soft cranial bones and scaphoid abdomens. These factors make tunneling for the passage of the peritoneal catheter more treacherous and these children are prone to too deep or too superficial shunt placement under the skin and perforation of the skull, skin or lung. Proper positioning will decrease the difficulty and risks of the procedure; however, in young children with massive heads, it is often impossible

to position them ideally with a straight line between cranial and abdominal incisions, as recommended in the booklets of the shunt companies�.[1]

To accommodate the different body contour of pediatric patients with large heads, we modified the shunt introducer. The bending of the shunt introducer can be done easily in the hands of the surgeon and it takes a few seconds. The tunneling with an �S�-shaped introducer with two 180° turns so that the curvature of the introducer matches the shape of the head and chest takes seconds . More importantly, the pulling and pressure damage of the surrounding tissue is kept to the minimum. This technique also eliminates the need for a third incision, which was often placed over the neck, where there is thin and poor quality skin and it is difficult to access for cleaning and operating, which increases the chance of wound infection. The abovementioned factors and the shorter operative time reduces the risk of shunt infection.

We recognize that this is only one of many variations of shunt placement. Most decisions regarding the direction of tunneling can be made on the basis of the individual characteristics of the patient. However, it should be noted that the described introducer modification can be employed also in abdomen-to-head tunneling.

This technique was employed by the authors in over 200 pediatric VP shunt insertions over the last 8 years. There were no complications related to the modification of the instrument or the direction of the tunneling. The average time of shunt insertion was between 20 and 30 min. In our opinion, this quick and easy modification to the insertion of the VP shunt is beneficial and can be used by any neurosurgeon.

Acknowledgement

The authors are extremely grateful to Mrs. S. Govender from the Department of Neurosurgery, Durban, South Africa for providing secretarial assistance and to Dr. Paul Steinbok, Division of Pediatric Neurosurgery, British Columbia�s Children�s Hospital, Vancouver, British Columbia, Canada for guidance, help and review of the manuscript. The authors of this manuscript do not have financial association with any of the mentioned products.

References

1. Codman. Leaflet to UNI-SHUNT with Reservoir Kit, Codman and Shurtleff, Inc: 2003.

2. Greenberg MS. Handbook of Neurosurgery Greenberg Graphics, Inc: Lakeland, Florida; 1997. p. 408.

3. Choux M, Genitori L, Lang D, Lena G. Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 1992;77:875-80.

4. George R, Leibrock I, Epstein M. Long-term analysis of cerebrospinal fluid shunt infections. J Neurosurg 1979;51:804-11.

5. Kang JK, Lee IW. Long-term follow-up of shunting therapy. Childs Nerv Syst 1999;15:711-7.

Figure 1: Child with massive head illustrating head and neck disproportion

Figure 2: Standard shunt introducer

Figure 3: Modifi ed shunt introducer

Figure 4: Modifi ed shunt introducer during the procedure. Note the shape of the introducer that follows the body contour

Source of Support: Nil, Confl ict of Interest: None declared.

Vitali et al.: Modifi cation of shunt introducer[Downloaded free from http://www.pediatricneurosciences.com on Thursday, December 06, 2012, IP: 180.149.7.11]  ||  Click here to download free Android applicationfor this journal