Indian J Pediatr DOI 10.1007/s12098-013-1316-0

SCIENTIFIC LETTER

Inguinal Hernia—A Rare Complication of Ventricuoloperitoneal Shunt Kanwaljeet Garg & Hitesh Kumar Gurjar & Guru Dutta Satyarthee & Raghav Singla & Bhawani Shankar Sharma

Received: 7 September 2013 / Accepted: 2 December 2013 # Dr. K C Chaudhuri Foundation 2013

To the Editor: A 6-mo-old male child presented to us with a swelling over his lower back since birth and weakness of both lower limbs (Power 3/5). MRI revealed open dysraphic spine defect in lumbar region with herniation of spinal cord, suggestive of myelomenigocele, hydrocephalous and chiari type 2 malformation. He underwent right ventriculoperitoneal Fig. 1 a Clinical photograph of patient showing swelling in the left inguinoscrotal region (star), b Hernia fully reduced (star), c Abdominal X-ray of the patient showing the extension of the shunt tubing into the scrotum (arrow)

K. Garg : H. K. Gurjar (*) : G. D. Satyarthee : R. Singla : B. S. Sharma Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 110029, India e-mail: [email protected]

shunt (VPS) and repair of myelomeningocele. A week after the surgery, patient started having reducible swelling of left scrotum, which used to increase on coughing (Fig. 1a). He didn’t have any scrotal abnormality prior to the surgery. Clinical examination revealed hydrocele with completely reducible indirect hernia (Fig. 1b). Scrotal ultrasonogram revealed

Indian J Pediatr

inguinoscrotal hernia with fluid and bowel loops in the scrotum. Abdominal X-ray revealed the abdominal end of the shunt to be in the scrotum (Fig. 1c). CSF diversion in the form of VPS is the most common pediatric neurosurgical procedure. It seems to be a relatively simple procedure, however, it may be associated with varied complications. Some studies have reported the complication rate with VPS to range from 24 to 74 % [1]. Various intraabdominal complications associated with VPS include shunt ascites, pseudocyst formation and migration. However, VPS leading to hydrocele and hernia is a rare complication. Many reports of scrotal migration of shunt tubing presenting as scrotal mass has been reported in literature but VPS leading to hydrocele and hernia is rare [2,3]. Hydrocoele formation following VPS is thought to result from fluid tracking from the peritoneal cavity into the scrotum via a patent processus vaginalis. The rate of absorption of CSF may not be adequate in children due to less absorptive surface area of peritoneum. The excess CSF can track down into scrotum through the patent processus vaginalis and may push the bowel loops into scrotum as well. Other putative factors include the tendency to use long shunt tubing in children to accommodate the growth

of the child and the vertical relationship of the superficial and deep inguinal rings in children, which may favor the passing of the shunt tubing into the scrotum. Management of this unique complication includes herniotomy and replacement of the abdominal end. Contributions All the authors have drafted and reviewed the manuscript. BSS will act as guarantor. Conflict of Interest None. Role of Funding Source None.

References 1. Celik A, Ergun O, Arda MS, Yurtseven T, Ersahin Y, Balik E. The incidence of inguinal complications after ventriculoperitoneal shunt for hydrocephalus. Childs Nerv Syst. 2005;21:44–7. 2. Ho CC, Jamaludin WJ, Goh EH, Singam P, Zainuddin ZM. Scrotal mass: A rare complication of ventriculoperitoneal shunt. Acta Med (Hradec Kralove). 2011;54:81–2. 3. Walsh AR, Kombogiorgas D. Coiled ventricular-peritoneal shunt within the scrotum. Pediatr Neurosurg. 2004;40:257–8.

Inguinal hernia--a rare complication of ventricuoloperitoneal shunt.

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