**3. Ventriculoperitoneal shunt: challenges**

With time, the frequent revision rates and complications have provoked multiple changes and advancements in both VP shunt equipment, including the catheters and valve mechanisms [9, 13], as well as the surgical procedure itself [9]. Traditionally, VP shunts have been inserted using mini-laparotomy, although recently, a neuronavigated laparoscopically assisted approach has become a more commonly accepted surgical technique [9, 14]. Multiple studies have demonstrated that relative to the mini-laparotomy technique, a laparoscopically assisted approach has a shorter operative time and length of stay in the hospital, a decreased distal shunt failure rate [4, 9, 14], and a decreased risk of visceral injury [10]. Laparoscopy has also been shown to offer favorable outcomes with smaller incisions leading to reduced post-operative pain [11], faster mobilization and a preferred cosmetic appearance [5]. Many of the proposed benefits associated with laparoscopicassisted VP shunts are a direct result of the increased visualization offered by laparoscopy. Laparoscopy allows for the verification of accurate peritoneal placement of the distal catheter as well as the proper functioning of the shunt by observing CSF outflow [5]. Laparoscopy can also be used to perform adhesiolysis, useful in the presence of excess adhesions, often found in patients who have undergone previous

**69**

*Neuronavigated and Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement*

requiring that both surgeons be available at given times [17].

abdominal surgeries [11]. As shunt obstruction can commonly result from the distal catheter becoming lodged in a collection of adhesions, adhesiolysis offers a potential solution to prevent this from occurring, reducing complications and future shunts failures. Additionally, the mini-laparotomy approach has been associated with increased risks of post-operative hernia formation and adhesion formation [4]. Neuronavigation has also been shown to increase the accuracy of ventricular placement of the proximal catheter resulting in a decrease in proximal shunt revisions [15, 16]. However, as most neurosurgeons do not possess the necessary laparoscopy skill, collaboration with a general surgeon is required for the laparoscopic-assisted approach [4]. Incorporating a second surgeon may elicit difficulties in scheduling,

Due to the high revision rates for VP shunts as well as the personal and medical burden of the complications and associated revisions, current practices must be assessed for alterations to improve these outcomes. Neuronavigated laparoscopicassisted VP shunt placement is being regarded as a minimally invasive alternative to

The procedure is done under general anesthesia, in the supine position with the head turned 30–45° toward the left, as right trigone is favored for the insertion of the ventricular catheter. The left upper limb is in abduction with the shoulder at 90°, and the right upper limb is tucked against the body. First generation cephalosporin is administered 30–60 minutes before incision. The neuronavigation magnetic system (Axiem, on Stealth by Medtronic) is used with 3D reconstruction of preoperative brain CT scan. Entry point, trajectory and length of insertion are defined on the navigation system. A Foley catheter is not used, as the risk of bladder injury is lowered by laparoscopic approach, which in turn reduces the post-operative UTI risk. A retro-auricular shaving for horizontal 2 cm incision or question mark incision is done. Scrubbing with chlorhexedine 2% is done at the cranial level and over the neck, chest and abdomen. Draping from the scalp to the pubic level is done in sterile fashion.

Starting at the scalp, an incision is made, dissection of the galea until reaching the entry point. Dissection of the subcutaneous cranio-cervical tissue is done.

A 60–90 cm passer is used from the scalp to the right upper quadrant (RUQ ). The peritoneal catheter is tunneled through the passer and 5 mm incision is done at the RUQ. An anti-siphon programmable or pre-fixed pressure valve is con-

The ventricular catheter is inserted using the navigation stylet until reaching the body of the right lateral ventricle. CSF is drained and a sample for culture is routinely sent. Ventricular catheter is connected to the valve and CSF flow through the valve to

Laparoscopic approach to the peritoneum is done by the general surgeon. A supra-umbilical, longitudinal incision is incised through skin with the scalpel blade.

the peritoneal catheter is observed before peritoneal insertion of the catheter.

an open technique to improve surgical complications and patient outcomes.

*DOI: http://dx.doi.org/10.5772/intechopen.89252*

**4. Surgical technique**

**4.1 Tunneling of the peritoneal catheter**

nected to the peritoneal catheter.

**4.2 Placement of ventricular catheter**

**4.3 Placement of abdominal catheter**

*Neuronavigated and Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement DOI: http://dx.doi.org/10.5772/intechopen.89252*

abdominal surgeries [11]. As shunt obstruction can commonly result from the distal catheter becoming lodged in a collection of adhesions, adhesiolysis offers a potential solution to prevent this from occurring, reducing complications and future shunts failures. Additionally, the mini-laparotomy approach has been associated with increased risks of post-operative hernia formation and adhesion formation [4]. Neuronavigation has also been shown to increase the accuracy of ventricular placement of the proximal catheter resulting in a decrease in proximal shunt revisions [15, 16]. However, as most neurosurgeons do not possess the necessary laparoscopy skill, collaboration with a general surgeon is required for the laparoscopic-assisted approach [4]. Incorporating a second surgeon may elicit difficulties in scheduling, requiring that both surgeons be available at given times [17].

Due to the high revision rates for VP shunts as well as the personal and medical burden of the complications and associated revisions, current practices must be assessed for alterations to improve these outcomes. Neuronavigated laparoscopicassisted VP shunt placement is being regarded as a minimally invasive alternative to an open technique to improve surgical complications and patient outcomes.
