Technical Note

Laparoscopic Implantation of Distal Peritoneal Ventriculoperitoneal Shunt Catheter: A Comparative Study Or Cohen-Inbar1

Michael Krausz2

Menashe Zaaroor1

1 Department of Neurosurgery, Rambam Health Care Campus, Haifa,

Israel 2 Department of General Surgery, Rambam Health Care Campus, Haifa, Israel

Ahmad Mahajna2

Address for correspondence Or Cohen-Inbar, MD, Department of Neurosurgery, Rambam Health Care Campus, Haifa 31096, Israel (e-mail: [email protected]).

J Neurol Surg A 2014;75:392–397.

Abstract

Keywords

► single-trocar technique ► laparoscopic aided neurosurgery ► ventriculo-abdominal shunt

Objective Ventriculoperitoneal shunts (VPS) are a common treatment for hydrocephalus. Placement of the distal abdominal catheter can be difficult in the setting of advanced age, previous abdominal surgeries, obesity, or chronic illnesses. At our institute, complex patients are treated using a multidisciplinary team of a neurosurgeon and a laparoscopic surgeon. We evaluated the influence on prognosis of a laparoscopically assisted VPS placement using a single-port technique as compared with the conventional mini-laparotomy approach. Methods Between 2006 and 2010, 302 patients were operated for hydrocephalus or shunt dysfunction. Among these, a total of 48 patients were operated on using the single-trocar laparoscopy. Neurosurgeons and laparoscopic surgeons logged the presenting symptoms, past medical history, chronic diseases, past surgical procedures, the actual surgical procedure and intraoperative findings. Outcome data were collected at several time points, using several independent outcome parameters. Results The laparoscopic group was significantly older, had more chronic diseases, and had more prior abdominal and shunt operations. However, this group had the same outcome as the minilaparotomy group.. Conclusions The outcome of elderly patients, patients with chronic diseases and obesity, and patients who underwent previous abdominal or shunt operations equals the outcome of young, otherwise healthy patients, if the laparoscopic single-port technique for distal catheter placement during VPS procedure is used. The laparoscopic technique reduces surgical complications.

Introduction Hydrocephalus, be it congenital or acquired, is caused by the accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain that may cause symptoms of increased intracranial pressure, neurologic deficits, and, in pediatric patients, increased cranial size. The prevalence of hydro-

received June 22, 2013 accepted after revision January 13, 2014 published online June 27, 2014

cephalus is 1 to 1.5%.1,2 The prevalence of shunts for hydrocephalus of any type in the United States is estimated at no less than 125.000. The etiologies for the obstructive type include congenital malformations, Arnold-Chiari malformation, aqueductal stenosis, or tumors. The main etiology for the communicating type is inflammation and fibrosis of the arachnoid granulations that follows

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DOI http://dx.doi.org/ 10.1055/s-0034-1371516. ISSN 2193-6315.

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392

meningitis or subarachnoid hemorrhage (so named postinfectious and posthemorrhagic fibrosis).1,2 The standard treatment for hydrocephalus is the shunting of the CSF to alternative body spaces capable of handling the excess volume, which are the pleura, the atrium and the peritoneal cavity. In most cases, the peritoneal cavity provides the optimal risk-benefit balance.1,2 The operation usually is done by having a neurosurgeon pass the distal catheter subcutaneously from the valve to the right abdominal quadrant where a mini-laparotomy is performed. The distal end of the catheter is then placed in the peritoneal cavity. Common operative complications include shunt infections, obstruction at both the ventricular and peritoneal sites, and local surgical site complications. Intracranial complications include cerebral parenchymal hemorrhage, intracranial hypotension syndrome (overdrainage), or underdrainage. Abdominal site complications include intestinal perforation, hemorrhage, and damage to vessels and viscera.1,2 More recently, laparoscopic procedures have become adopted in selected cases for insertion of the distal catheter. The laparoscopic approach requires a stab incision overlying the rectus muscle just lateral to the umbilicus. A trocar is inserted, and then the stylet is removed and a pneumoperitoneum created. Typically, a second trocar is introduced in different locations (according to the indication). Once the distal catheter of the shunt is placed, the trocar is removed.1 In the single-trocar technique, while the neurosurgeon places the ventricular catheter and valve, a 5-mm umbilical trocar is placed utilizing the open Hasson technique. A 5-mm

Cohen-Inbar et al.

laparoscope is then used to inspect the abdomen and identify the ventriculoperitoneal shunt (VPS) entry site. Under laparoscopic visualization, the abdominal wall is penetrated by a 5-mm trocar, and the tube is inserted by forceps through this to the pelvis (►Fig. 1). The function of the VPS is assessed visually while compressing the valve. The laparoscopic approach has advantages in that it is minimally invasive and allows for better visualizing of the entire peritoneal cavity for concurrent conditions and for localizing the best site for the distal catheter. The recovery time is usually less than for the mini-laparotomy approach. Disadvantages of the laparoscopic approach are minor and include irritation to the peritoneum from inflation, hemodynamic compromise from increased abdominal pressures, and a slow learning curve. The laparoscopic approach has been documented in case reports and uncontrolled trials to have a better outcome; however, this applies only for the conventional laparoscopic technique and not the single-trocar technique. In this study our aim was to evaluate the effect this new technique will have on complications incidence and patient’s prognosis.2,3

Patients and Methods Inclusion and Exclusion Criteria All patients admitted to and operated on at the Department of Neurosurgery at Rambam Maimondes health care campus for hydrocephalus or shunt dysfunction (be it VPS or lumboperitoneal shunts [LPS]) between 2006 and 2010 were

Fig. 1 The single-trocar technique for insertion of the distal ventriculoperitoneal shunt catheter. (A) Obstacles in positioning such as adhesions and fibrous bands. (B–D) Using endoscopic tools, the catheter is navigated and positioned within the peritoneal cavity. Journal of Neurological Surgery—Part A

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Laparoscopic-Assisted VPS Placement

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Table 1 Patients related parameters logged and evaluated Admission data

Prior shunt operations, prior abdominal operations Chronic diseases (diabetes mellitus, essential hypertension, pulmonary disease) and adequacy of their treatment Obesity, known cancer, other chronic conditions

Surgical findings

Surgical approach to the peritoneal cavity, no. of ports/length and position of skin incision, presence of peritoneal adhesions, operating time

Outcome data

Length of hospital stay (general, neurosurgical intensive care unit )

Surgical complications (intestinal perforations, bleeding) After 3 months

Surgical wound infection, bacterial meningitis, distal catheter obstruction, proximal catheter obstruction, need for reoperation, mortality

After 12 months

Need for reoperation

logged. Patients with either reduced general medical condition or prior abdominal surgeries, were randomly assigned to the open mini-laparotomy approach or the laparoscopic single-trocar approach for the insertion of the distal peritoneal catheter.Patients treated conservatively or not operated on for any other reason during the study period were excluded.

Clinical Presentation Board-certified neurosurgeons and general laparoscopic surgeons logged the presenting symptoms and their time course, past medical history, chronic diseases and their treatment, the type of shunt system, and past surgical procedures (►Table 1). It was also recorded, if an elective or emergency operation was performed.

Surgical Data Board-certified neurosurgeons and general laparoscopic surgeons logged the surgical approach, the number of ports used in laparoscopic cases, the length and position of the laparatomy incision in relevant cases, the presence of intraperitoneal adhesions, and immediate surgical complications (►Table 1).

Outcome Outcome data were collected at several time points after the surgical intervention, namely during the admission, within 3 months, and within 12 months after the surgical intervention. Outcome parameters were assessed by two independent

observers blinded to patient data. The outpatient clinic charts and medical records from further hospitalizations were used for long-term follow-up (►Table 1).

Statistical Analysis Statistical tests were performed using SPSS software (SPSS Inc., Chicago, Illinois, United States). For univariate analysis, the Pearson correlation, chi-square test, and Fisher exact test were used for comparison of nonparametric data. Comparison of quantitative parameters such as age or length of hospitalization was performed using a t test in case of normal distribution and the Mann-Whitney U test in nonnormal distribution. For multivariate analysis, logistic regression or a general linear model of analysis of variance was used.

Results Cohort Overview A cohort of 302 patients were operated on at our institute during the years 2006 to 2010 for acute hydrocephalus or shunt dysfunction, . The mean age was 39.3  27.3 years with a median of 37.5 years. There were 54.8% (n ¼ 166) men. The mean length of hospitalization was 13.7  20.7 days with a median of 5.00 days. Overall, 5%of the cohort (n ¼ 15) underwent the insertion of an LPS, 95% (n ¼ 288) underwent an insertion or revision of a VPS. For statistical reasons, only the VPS patients were analyzed (►Table 2).

Table 2 Demographic data Surgical technique Laparoscopy

Overall

Mini-laparotomy

No. of patients

40

248

302

Age (mean  SD), y

54.28  22.23

37.04  27.71

39.3  27.3

Age (median), y

62.5

34.0

37.5

Males, %

55

54

54.8

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►Table 3 summarizes the results of the univariate analysis.

Admission Parameters A total of 14% of the patients (n ¼ 40) underwent a laparoscopic single-trocar insertion of the distal catheter; 86% (n ¼ 248) an mini-laparotomy insertion of the distal catheter. The mean age for the laparoscopy group was 54.28  22.23 years and 37.04  27.71 years for the mini-laparotomy group. Fifty-five percent of the laparoscopy group and 54% of the mini-laparotomy group were men. A higher incidence of chronic disease was present in the laparoscopy group, and the diseases were less successfully controlled medically. Diabetes mellitus was present in 27.5% of the laparoscopy group and in 17% of the mini-laparotomy group. Essential hypertension was present in 37.5% of the laparoscopy group and in 28% of the mini-laparotomy group. Obesity (body mass index [BMI] > 31) was present in 35% of the laparoscopy group and in 17.7% of the mini-laparotomy group. Overall, 60.1% of the patients (n ¼ 173) had a single prior abdominal

surgery; 26% (n ¼ 75) had two prior abdominal surgeries and 10.1% (n ¼ 29) three prior abdominal surgeries. This distribution was roughly the same in the laparoscopy and the minilaparotomy group, with no statistically significant difference. Still, 3.2% of the patients of the mini-laparotomy group (n ¼ 8) and 7.5% of the patients of the laparoscopy group (n ¼ 3) had four or more prior abdominal surgeries.

Surgical Parameters A single-trocar approach was realizable in 92% (n ¼ 35) of the operations in the laparoscopy group. The length of skin incision for the mini-laparotomy approach was 5 cm in 96% of the patients. Intraperitoneal adhesions were found in 12.5% of the patients of the laparoscopy group (n ¼ 5), and in 3.6% (n ¼ 9) of the mini-laparotomy group. Mean surgical time was 45.7  22.9 minutes for the laparoscopic approach (median: 40 minutes) and 59.24  32.2 minutes for the mini-laparotomy approach (median: 55 minutes). Surgical complications were rare with both techniques, with no statistically significant difference between the

Table 3 Univariate analysis: laparoscopic versus open mini-laparotomy approaches p

Surgical technique Laparoscopy

Mini-laparotomy

54.28

37.04

< 0.001

DM

27.5

17

0.12

Essential HTN

37.5

28

0.26

Admission parameters Age, y Chronic diseases (% within group),

Obesity

35

17.7

0.018

1

62.5

59.7

NS

2

20.0

27.0

NS

3

10.0

10.1

NS

4

7.5

3.2

0.001

1

57.5

46.0

0.065

2

10.0

30.2

NS

3

20.0

13.7

NS

4

12.5

10.1

NS

Presence of peritoneal adhesions,% within group

12.5

3.6

0.031

Length of surgery

45.75

59.24

0.001

12.37

14.1

0.44

Length of hospital stay, median, d

5

5

Surgical wound infection, within 3 mo. after initial surgery, % within group

15.0

13.3

0.8

Bacterial meningitis, within 3 mo. after initial surgery, % within group

10.0

11.3

1.00

Distal catheter obstruction, within 3 mo. after initial surgery, % within group

15.0

12.9

0.8

Reoperation, within 3 mo. after initial surgery, % within group

27.5

26.2

0.85

Reoperation, within 12 mo. after initial surgery, % within group

42.5

33.9

0.29

Prior abdominal surgeries (% within group)

Prior VPS operations, % within group

Outcome parameters Length of hospital stay, mean, d

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Abbreviations: DM, diabetes mellitus; HTN, hypertension; NS, not statistically significant; VPS, ventriculoperitoneal shunt. Journal of Neurological Surgery—Part A

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Univariate Analysis

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populations (for intestinal perforation and severe operative bleeding).

Outcome Parameters The mean length of hospital stay was 12.37  20.475 days for the laparoscopygroup and 14.1  21.20 days for the minilaparotomy group. With 5.0 days, the median length of hospital stay was identical for both groups. Surgical wound infection within 3 months after surgery was noted in 15% of the patients of the laparoscopic group (n ¼ 6) and in 13.3% (n ¼ 33) of the open mini-laparotomy group (p ¼ 0.8). Bacterial meningitis within 3 months after surgery was noted in 10% of the patients of the laparoscopy group (n ¼ 4) and in 11.3% (n ¼ 28) of the minilaparotomy group (p ¼ 1.0). Distal shunt obstruction within 3 months after surgery occurred in 15% of the patients of the laparoscopy group (n ¼ 6) and in 12.9% (n ¼ 32) of the minilaparotomy group (p ¼ 0.8). There was an indication for reoperation within 3 months after surgery in 27.5% of the patients of the laparoscopy group (n ¼ 11) and in 26.2% (n ¼ 65) of the mini-laparotomy group (p ¼ 0.85). There was an indication for reoperation within 12 months after surgery in 42.5% of the patients of the laparoscopy group (n ¼ 17) and in 33.9% (n ¼ 84) of the mini-laparotomy group (p ¼ 0.29). The postoperative mortality was 10.0% (n ¼ 4) in the laparoscopy group and 8.1% (n ¼ 20) in the mini-laparotomy group (p ¼ 0.76).

Multivariate Prediction Model Analysis Based on the univariate analysis, following parameters were analyzed as independent predictors of outcome: age, chronic disease (namely diabetes mellitus, essential hypertension, obesity), prior abdominal surgeries, prior shunt operations, length of stay, presence of intraperitoneal adhesions, and surgical approach into the peritoneal cavity.

Surgical Wound Infection The number of shunt operations and revisions has a direct influence on the likelihood of developing a surgical wound infection. In patients who underwent two prior operations, the risk of infection is increased by the factor of 4.61. This factor increases to 5.668, if three prior operations had been performed. The length of stay was also found to directly increase the relative risk for surgical wound infections by a factor of 1.017 (1.002–1.032) for every additional day.

Distal Shunt Obstruction Single prior abdominal surgery increases the risk for obstruction by a factor of 10.3. This factor increases to 18.9, if two prior abdominal surgeries had been performed, and to 43.7, if three prior abdominal surgeries had been performed. The presence of intraperitoneal adhesions was found to increase the risk for distal shunt obstruction by a factor of 4.575.

Bacterial Meningitis In patients who underwent more than three shunt revisions, the risk for meningitis increases by a factor of 6.22, as compared with those who underwent a single operation. The length of hospital stay also increases the risk for meningitis by a factor of 1.037 per additional day. Journal of Neurological Surgery—Part A

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Reoperation within Three Months after Surgery The number of prior shunt operations is a direct linear risk factor for reoperation, with an odds ratio of 3.686 for two, 11.869 for three, and 41.739 for four prior operations.

Discussion This study compares the laparoscopic and mini-laparotomy approach for distal catheter placement during VPS operation. Argo et al4 described a series of 535 consecutive patients who underwent 579 VPS operations (258 by laparoscopy, 321 by mini-laparotomy). Median age (52.0 years) and American Society of Anesthesiologists score were similar in both groups. BMI was comparable, whereas previous operations, estimated blood loss, operative time, and length of hospital stay were statistically different between the mini-laparotomy and the laparoscopy groups. The authors concluded, that there was no statistical difference in complication rates between groups.2 This conclusion is consistent with a previous reports by Roth et al5,6 and Naftel et al.7 Schubert et al and Turner et al reported a significantly higher rate of abdominal complications in the mini-laparotomy group.8,9 Hong et al presented a small series of 31 patients who underwent a single-incision laparoscopic surgery for VPS showing to be a safe and effective technique.10 In our study, the cohort was roughly segregated into two patient populations, differing in many demographic, clinical, and presenting features (►Table 3). The mean age in the laparoscopy group was significantly higher than in the minilaparotomy group (54.28  22.23 versus 37.04  27.71 years) . Chronic diseases were more frequent in the laparoscopy group, and less successfully controlled medically (for diabetes mellitus, essential hypertension, and obesity). Significantly more patients in the laparoscopy group had four or more prior abdominal surgeries (7.5% versus 3.2%). Intraperitoneal adhesions were more frequently found in the laparoscopy than in the min-laparotomy group (12.5% versus 3.6%, [p ¼ 0.03]). Thus, patients who underwent a single-trocar laparoscopic insertion of the distal catheters are worse surgical candidates, which is also supported by the fact, that patients in the laparoscopy group experienced more medical and surgical complications, as indicated by an overall greater number of shunt-related and shunt-unrelated reoperations. Despite the very different patients groups, the analysis of multiple unrelated outcome parameters give clear results (►Table 3). With 5.0 days, the median length of hospital stay was similar for both groups. Surgical wound infection, bacterial meningitis, distal catheter obstruction within 3 months, need for reoperation 3 and 12 months after initial operation were comparable. Our mean operative time was 45.7  22.9 minutes for the laparoscopic approach (median: 40 minutes) and 59.24  32.2 minutes for the mini-laparotomy approach (median: 55 minutes), which is in line with other series.1,2,5–14 In multivariate analysis (►Table 4), surgical wound infection was found to be most significantly related to prior shunt operations and the length of hospital stay (risk per day). Distal

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Table 4 Multivariant prediction model analysis

Surgical wound infection

Prior shunt operations

2

4.61

0.009

3

5.66

0.005

1.017

0.025

1

10.36

0.001

2

18.91

< 0.0001

3

43.74

< 0.0001

4.57

0.04

2

6.22

0.008

3

5.62

0.017

1.037

< 0.0001

3.68

0.024

Length of hospital stay, risk per day Distal shunt obstruction

Prior abdominal operation

Presence of intraperitoneal adhesions Bacterial meningitis

Prior shunt operations Length of hopsital stay, risk per day

Reoperation within 3 mo. after initial surgery

Prior shunt operations

shunt obstruction was found to be most significantly related to prior abdominal operation and the presence of intraperitoneal adhesions. Postoperative meningitis was most significantly related to prior shunt operations and the length of hospital stay (risk per day). The relative risk for reoperation within 3 months after initial surgery was found to be directly influenced by the number of prior shunt operations. These findings suggest that in poor surgical candidates, the laparoscopic technique allows to obtain results which are comparable with those of good surgical candidates. This technique should thus be considered for patients of older age, in a poorer medical condition with multiple prior abdominal and shunt operations. Our study has several limitations, among which are the learning curves for mini-laparotomy and laparoscopy with potential influence on outcome parameters.

Conclusion Elderly patients, patients with poorly controlled chronic diseases and obesity, and patients with previous abdominal or shunt operations may benefit from the laparoscopic singletrocar technique for distal catheter placement during the VPS procedure. Although the laparoscopic single-trocar technique requires a multidisciplinary team, coordination, effort, and is more costy, we showed that it reduces the surgical complications and allows to obtain outcomes similar to that of good surgical candidates.

4

5

6

7

8

9

10

11

12

13 1 Kaye A. Essential Neurosurgery. Oxford, UK: Wiley-Blackwell;

2005:27–40 book of Neurosurgery. New York, NY: Thieme; 2006:180–207

3

11.86

< 0.0001

4

41.73

< 0.0001

3 Fanelli RD, Mellinger DN, Crowell RM, Gersin KS. Laparoscopic

References

2 Mark S. Greenberg. Hydrocephalus. In: Greenberg MS, ed. Hand-

2

14

ventriculoperitoneal shunt placement: a single-trocar technique. Surg Endosc 2000;14(7):641–643 Argo JL, Yellumahanthi DK, Ballem N, et al. Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement. Surg Endosc 2009;23(7): 1449–1455 Roth JS, Park AE, Gewirtz R. Minilaparoscopically assisted placement of ventriculoperitoneal shunts. Surg Endosc 2000;14(5): 461–463 Roth J, Sagie B, Szold A, Elran H. Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis. Surg Neurol 2007;68(2):177–184; discussion 184 Naftel RP, Argo JL, Shannon CN, et al. Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. J Neurosurg 2011; 115(1):151–158 Schubert F, Fijen BP, Krauss JK. Laparoscopically assisted peritoneal shunt insertion in hydrocephalus: a prospective controlled study. Surg Endosc 2005;19(12):1588–1591 Turner RD, Rosenblatt SM, Chand B, et al. Laparoscopic peritoneal catheter placement: results of a new method in 111 patients. Neurosurgery 2007;61(3 Suppl):167–172 Hong WC, Lai PS, Chien YH, Tu YK, Tsai JC. Single-incision laparoscopic surgery (SILS) for ventriculoperitoneal shunt placement. J Neurol Surg A Cent Eur Neurosurg 2013;74(6):351–356 Khaitan L, Brennan EJ Jr. A laparoscopic approach to ventriculoperitoneal shunt placement in adults. Surg Endosc 1999;13(10): 1007–1009 Khosrovi H, Kaufman HH, Hrabovsky E, Bloomfield SM, Prabhu V, el-Kadi HA. Laparoscopic-assisted distal ventriculoperitoneal shunt placement. Surg Neurol 1998;49(2):127–134; discussion 134–135 Reardon PR, Scarborough TK, Matthews BD, Marti JL, Preciado A. Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation. Surg Endosc 2000;14(6):585–586 Reimer R, Wharen RE Jr, Pettit PD. Ventriculoperitoneal shunt placement with video-laparoscopic guidance. J Am Coll Surg 1998; 187(6):637–639

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Relative risk increase

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Laparoscopic implantation of distal peritoneal ventriculoperitoneal shunt catheter: a comparative study.

Ventriculoperitoneal shunts (VPS) are a common treatment for hydrocephalus. Placement of the distal abdominal catheter can be difficult in the setting...
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