**6. Results**

There were 14 patients in total who received a ventriculoperitoneal shunt placement using a neuronavigated laparoscopic-assisted approach. The mean age of patients at the time of surgery was 56.8 years, although ranged from 31 to 78. There were 11 females and three males in the group. Eleven patients received a new VP shunt placement, whereas three patients were undergoing shunt revision. All patients except for one had undergone at least one previous abdominal surgery, with many of the patients having experienced multiple abdominal surgeries. Of note is the average BMI of the group being 31.2. Only one patient was within the normal range with a BMI of 24.6, one patient was classified as underweight at 14.6, four patients were considered overweight, and the remaining eight patients were obese with a BMI above 30.

Patients required a VP shunt for a variety of indications, with idiopathic normal pressure hydrocephalus (NPH) being the most common, occurring in half of the patients. Other indications included obstructive hydrocephalus secondary to a ventricular tumor, NPH secondary to subarachnoid hemorrhage (SAH), idiopathic intracranial hypertension, and a revision of the shunt for subependymal hemorrhage at birth. Average operative time for the VP shunt placements was approximately 45 minutes but ranged from 35 to 90 minutes. Patients on average stayed in the hospital for 2.25 days after the surgery, however, over 40% of patients were discharged after a single day in the hospital, 2/3 had left by 2 days, and all but one patient had left the hospital at 3 days. Two patients were not discharged from the hospital due to other medical conditions unrelated to the VP shunt placement and were therefore excluded from this calculation. There were no intraoperative complications that occurred, however it is worth noting that there were many patients with extensive abdominal adhesions due to previous abdominal surgeries, as well as the extra difficulty presented by the increased rate of obesity in the patient group.

Three patients experienced post-operative complications. One patient's shunt became infected with *Staph epidermis*, another patient experienced a functional complication of overdrainage with symptomatic bilateral subdural hematomas, requiring the removal of the shunt and drainage of the subdural hematomas. The remaining patient experienced mechanical dysfunction of the shunt. Each patient with a post-operative complication led to a shunt failure necessitating a shunt revision. The latter patient first underwent a proximal revision to replace both the ventricular catheter and the valve, due to valve malfunction. This same patient eventually experienced peritoneal complications requiring two distal shunt revisions on separate occasions. Following the second peritoneal complication, the patient decided to obtain a VA shunt insertion, which continues to offer successful treatment.

## **7. Discussion**

VP shunts are one of the most common neurosurgical procedures performed [3]. Despite its widespread use and successes in the treatment of hydrocephalus, there are often complications and failures. This has encouraged the ongoing development of alternative procedural techniques producing better outcomes [5]. The cost associated with VP shunts produces a significant medical burden, which is only furthered by the numerous complications and shunts revisions following the initial surgery. Shunt revisions account for approximately 50% of all shunt-related costs and admissions [5, 12]. By decreasing the amount of shunt revisions and complications, both the medical and personal burden of VP shunts will greatly improve. The

**73**

*Neuronavigated and Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement*

neuronavigated laparoscopic-assisted VP shunt placement performed in this study offers a safe and effective technique, bringing numerous benefits not seen with the

The length of stay in the hospital followed a similar trend to other studies with most patients being discharged in the first 24 hours [18]. The more minimally invasive technique decreases the length of stay in the hospital as well as prompts a faster recovery rate [9, 14]. This allows for less resource use by individual patients and increased patient satisfaction by leaving the hospital soon after surgery and returning to regular activities faster than with the mini-laparotomy technique [9, 11, 14]. Of the most noteworthy benefits of a laparoscopic-assisted neuronavigated technique is the decreased proximal and distal revision rates. The decreased revision rates are largely due to the avoidance of catheter malposition during placement. The accuracy of ventricular [16, 17] and peritoneal [4, 14, 17] catheter placement has increased as a result of clear visualization of the placement in the proper anatomical locations. Once properly positioned, the laparoscopic approach helps prevent migration of the distal catheter because of the fewer abdominal incisions and the smaller peritoneal wall defect [10]. The decreased revision rates can be seen in our patient population, as only a single patient required a distal revision for shunt malposition as a result of peritoneal adhesions, as well as a ventricular repositioning due to a valve dysfunction. Additionally, the increased visualization offered by this technique can be used to confirm CSF outflow through the VP shunt, indicating a

This technique should also be heavily considered for obese individuals as well as those who have undergone previous abdominal surgeries [12], the two patient populations demonstrating the highest number of distal complications with VP shunt placements [5]. Both obesity and peritoneal adhesions resulting from abdominal surgeries pose difficulties with visualization during surgery, which leads to improper placement of shunts and increased complications and shunt failures. Further advantages come with adhesiolysis that can be performed during laparoscopy, creating a clearer visualization for those with previous abdominal surgeries as well as preventing obstruction of the distal catheter by placing it within the perito-

There have been concerns over the laparoscopic-assisted approach to VP shunts in that they require two surgical teams and specific instrumentation, increasing the cost of the surgery [5, 9] as well as the difficulty of scheduling, especially for emergent cases [17]. However, with the countless benefits being demonstrated by laparoscopy and neuronavigation, it should be considered that the mentioned

Our study has limitations, specifically in the small sample size and the surgeries all being performed by the same surgeons. It is possible that results could differ based on the level of expertise of a surgeon. General surgeons performing laparoscopy often will have more experience with adhesions and distorted anatomy as well as neurosurgeons using neuronavigation more often will gain more expertise. It has been suggested that neurosurgeons should be trained on laparoscopy in the future to both avoid the influence of the general surgeon's expertise and to prevent poten-

Advancements are continuing to be made in VP shunts technology and procedures. All advancements are aimed at continuing the improvement of patient outcomes and lifting the imposed medical and personal burden of VP shunts. Recently, there have been some new advancements in techniques including a percutaneous minimal access insertion without the use of laparoscopy, as well as a single-port laparoscopic surgery that show further promise in optimizing patient care and

tial scheduling conflicts when organizing two surgical teams [9].

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

traditional mini-laparotomy method.

properly functioning shunt, before finishing surgery.

neal adhesions [4, 9].

concerns are outweighed.

routine practices [19, 20].

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

neuronavigated laparoscopic-assisted VP shunt placement performed in this study offers a safe and effective technique, bringing numerous benefits not seen with the traditional mini-laparotomy method.

The length of stay in the hospital followed a similar trend to other studies with most patients being discharged in the first 24 hours [18]. The more minimally invasive technique decreases the length of stay in the hospital as well as prompts a faster recovery rate [9, 14]. This allows for less resource use by individual patients and increased patient satisfaction by leaving the hospital soon after surgery and returning to regular activities faster than with the mini-laparotomy technique [9, 11, 14].

Of the most noteworthy benefits of a laparoscopic-assisted neuronavigated technique is the decreased proximal and distal revision rates. The decreased revision rates are largely due to the avoidance of catheter malposition during placement. The accuracy of ventricular [16, 17] and peritoneal [4, 14, 17] catheter placement has increased as a result of clear visualization of the placement in the proper anatomical locations. Once properly positioned, the laparoscopic approach helps prevent migration of the distal catheter because of the fewer abdominal incisions and the smaller peritoneal wall defect [10]. The decreased revision rates can be seen in our patient population, as only a single patient required a distal revision for shunt malposition as a result of peritoneal adhesions, as well as a ventricular repositioning due to a valve dysfunction. Additionally, the increased visualization offered by this technique can be used to confirm CSF outflow through the VP shunt, indicating a properly functioning shunt, before finishing surgery.

This technique should also be heavily considered for obese individuals as well as those who have undergone previous abdominal surgeries [12], the two patient populations demonstrating the highest number of distal complications with VP shunt placements [5]. Both obesity and peritoneal adhesions resulting from abdominal surgeries pose difficulties with visualization during surgery, which leads to improper placement of shunts and increased complications and shunt failures. Further advantages come with adhesiolysis that can be performed during laparoscopy, creating a clearer visualization for those with previous abdominal surgeries as well as preventing obstruction of the distal catheter by placing it within the peritoneal adhesions [4, 9].

There have been concerns over the laparoscopic-assisted approach to VP shunts in that they require two surgical teams and specific instrumentation, increasing the cost of the surgery [5, 9] as well as the difficulty of scheduling, especially for emergent cases [17]. However, with the countless benefits being demonstrated by laparoscopy and neuronavigation, it should be considered that the mentioned concerns are outweighed.

Our study has limitations, specifically in the small sample size and the surgeries all being performed by the same surgeons. It is possible that results could differ based on the level of expertise of a surgeon. General surgeons performing laparoscopy often will have more experience with adhesions and distorted anatomy as well as neurosurgeons using neuronavigation more often will gain more expertise. It has been suggested that neurosurgeons should be trained on laparoscopy in the future to both avoid the influence of the general surgeon's expertise and to prevent potential scheduling conflicts when organizing two surgical teams [9].

Advancements are continuing to be made in VP shunts technology and procedures. All advancements are aimed at continuing the improvement of patient outcomes and lifting the imposed medical and personal burden of VP shunts. Recently, there have been some new advancements in techniques including a percutaneous minimal access insertion without the use of laparoscopy, as well as a single-port laparoscopic surgery that show further promise in optimizing patient care and routine practices [19, 20].

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

There were 14 patients in total who received a ventriculoperitoneal shunt placement using a neuronavigated laparoscopic-assisted approach. The mean age of patients at the time of surgery was 56.8 years, although ranged from 31 to 78. There were 11 females and three males in the group. Eleven patients received a new VP shunt placement, whereas three patients were undergoing shunt revision. All patients except for one had undergone at least one previous abdominal surgery, with many of the patients having experienced multiple abdominal surgeries. Of note is the average BMI of the group being 31.2. Only one patient was within the normal range with a BMI of 24.6, one patient was classified as underweight at 14.6, four patients were considered overweight, and the remaining eight patients were

Patients required a VP shunt for a variety of indications, with idiopathic normal pressure hydrocephalus (NPH) being the most common, occurring in half of the patients. Other indications included obstructive hydrocephalus secondary to a ventricular tumor, NPH secondary to subarachnoid hemorrhage (SAH), idiopathic intracranial hypertension, and a revision of the shunt for subependymal hemorrhage at birth. Average operative time for the VP shunt placements was approximately 45 minutes but ranged from 35 to 90 minutes. Patients on average stayed in the hospital for 2.25 days after the surgery, however, over 40% of patients were discharged after a single day in the hospital, 2/3 had left by 2 days, and all but one patient had left the hospital at 3 days. Two patients were not discharged from the hospital due to other medical conditions unrelated to the VP shunt placement and were therefore excluded from this calculation. There were no intraoperative complications that occurred, however it is worth noting that there were many patients with extensive abdominal adhesions due to previous abdominal surgeries, as well as the extra difficulty presented by the increased rate of obesity in the patient group. Three patients experienced post-operative complications. One patient's shunt became infected with *Staph epidermis*, another patient experienced a functional complication of overdrainage with symptomatic bilateral subdural hematomas, requiring the removal of the shunt and drainage of the subdural hematomas. The remaining patient experienced mechanical dysfunction of the shunt. Each patient with a post-operative complication led to a shunt failure necessitating a shunt revision. The latter patient first underwent a proximal revision to replace both the ventricular catheter and the valve, due to valve malfunction. This same patient eventually experienced peritoneal complications requiring two distal shunt revisions on separate occasions. Following the second peritoneal complication, the patient decided to obtain a VA shunt insertion, which continues to offer successful

VP shunts are one of the most common neurosurgical procedures performed [3]. Despite its widespread use and successes in the treatment of hydrocephalus, there are often complications and failures. This has encouraged the ongoing development of alternative procedural techniques producing better outcomes [5]. The cost associated with VP shunts produces a significant medical burden, which is only furthered by the numerous complications and shunts revisions following the initial surgery. Shunt revisions account for approximately 50% of all shunt-related costs and admissions [5, 12]. By decreasing the amount of shunt revisions and complications, both the medical and personal burden of VP shunts will greatly improve. The

**6. Results**

obese with a BMI above 30.

**72**

treatment.

**7. Discussion**
