CSF shunts in children: endoscopically-assisted placement of the distal catheter

Objectives: Ventriculoperitoneal shunting is the most common treatment for hydrocephalus. Repeated shunt revisions and other previous surgical procedures can complicate the placement of the distal catheter. Occasionally, when conventional sites like the abdominal cavity and the right atrium are used up or unavailable, a ventriculopleural shunt can be inserted. Materials and methods: Between April 2001 and August 2002, 7 children ranging in age from 5 months to 17 years underwent ten endoscopically-assisted cerebrospinal fluid shunt insertions. All patients had had previous multiple shunt revisions and other abdominal operations. In addition 4 children had suffered from severe peritonitis, 1 of them with a subsequent adhesion ileus. In 9 cases the terminal portion of the shunt was inserted with laparoscopic assistance and in 1 case with thoracoscopic assistance. The latter had previously undergone two conventional intercostal thoracotomies for shunt insertions. Placement of the shunt was performed in a suitable area under direct laparoscopic or thoracoscopic vision by a peel-off needle into the peritoneal or pleural cavity. In 2 children repeated endoscopic approaches were necessary for shunt replacement due to infections. Results: We used this procedure successfully in each case without operation-related complications. Neither new adhesions nor difficulties in laparoscopic replacement of the shunt were observed. Conclusion: Laparoscopic and thoracoscopic assistance in the placement of the distal catheter has the benefit of allowing a safe and precise insertion with visual control of shunt function, even in patients with prior surgical interventions. Additionally, this minimally invasive technique appears to prevent new adhesions arising in the peritoneal cavity.