Laparoscopic Ventriculoperitoneal Shunts: Benefits to Resident Training and Patient Safety. PDF
Preview Laparoscopic Ventriculoperitoneal Shunts: Benefits to Resident Training and Patient Safety.
S P CIENTIFIC APER Laparoscopic Ventriculoperitoneal Shunts: Benefits to Resident Training and Patient Safety Tiffany Stoddard, MD, Stephen M. Kavic, MD ABSTRACT accomplishing both goals of improved outcomes and quality surgical education. Background and Objectives: Symptomatic hydroceph- alus is a surprisingly common clinical condition. Neuro- Key Words: Surgical education, Laparoscopy, Shunts, surgeons are expert at ventriculostomy, but minimally Hydrocephalus, Laparoscopy, Ventriculoperitoneal. invasive peritoneal access is outside the realm of their current training. We have adopted a multidisciplinary ap- proach, with general surgeons positioning the distal shunt.Ourobjectivewastoreviewthisrecentexperience. INTRODUCTION Methods: All distal shunts were placed by a single sur- Drainageofcerebrospinalfluid(CSF)iswidelyutilizedbyneu- geon with resident assistance. After ventriculostomy, the rosurgeons to treat hydrocephalus, and in the setting of most shunt tubing was tunneled onto the anterior abdominal chronicconditions,thepreferredrouteistotheperitonealcav- wall. A Veress needle was placed through the tunnel ity.Laparoscopyhasbeenusedtoaidintheabdominalplace- incision and the abdomen insufflated. A 5-mm optical ment of ventriculoperitoneal (VP) shunts since 1993.1-3 These access trocar and camera were introduced via a separate earlyseriessuggestedthatlaparoscopywassafeandeffective stabincision.Theshunttubingwasthendirectedintothe andprovideddirectvisualconfirmationofshuntpositionand abdominal cavity using a Hickman introducer kit, with function. Comparative studies of minimally invasive shunt flow confirmed visually. placement versus traditional open techniques have suggested laparoscopy is not only a reliable technique, but it has fewer Results:Studypatientswhohadbetween0and10previous complicationsaswell.4,5 abdominal operations received 111 consecutive shunts. There was one intraoperative complication, a colon injury Althoughtherearesomebarrierstowidespreadadoption, during trocar placement. In this case, the colotomy was a multidisciplinary approach to placement of catheters repaired and the shunt placed in the pleural space. There seems ideal. At our institution, the preferred approach is werenoconversionstotheopenabdominalapproach.Post- to have neurosurgeons, skilled and practiced in ventricu- operatively, there were no wound infections, no cases of lostomy, place the proximal catheter. General surgeons, shuntmalpositioning,andtherewerenodeaths. more comfortable with minimally invasive abdominal ac- cess, position the distal portion. This technique is not Conclusions: Laparoscopic placement of ventriculoperi- unique to our center, but what has not been appreciated toneal shunts is feasible, safe, and carries a low rate of to date is the utility of this procedure in the realm of complications. The value to resident education in the resident education. We have recognized the value of this practice of this procedure has not been previously em- procedure for teaching residents, including junior level phasized. In the era of increased awareness of patient residents,ratherthanaspecializedproceduretoremainin safety, laparoscopic VP shunting serves as a model for thehandsoffacultymembers.Wepresenthereourrecent experience with surgical trainees and laparoscopic- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland,USA(allauthors). assisted VP shunt placement. Presentedasanoralpresentationatthe19thSLSAnnualMeetingandEndoExpo, NewYork,NewYork,USA,September1-4,2010. MATERIALS AND METHODS Addresscorrespondenceto:StephenM.Kavic,MD,AssistantProfessor,Depart- mentofSurgery,AssociateProgramDirector,GeneralSurgeryResidency,Uni- We conducted a retrospective review of all adult patients un- versityofMarylandBaltimore,22SouthGreeneStreet,S4B09,Baltimore,MD dergoinglaparoscopicplacementofVPshuntsatasingleaca- 21201, USA. Telephone: (410) 328-7592, Fax: (410) 328-5919, E-mail: demic institution over a 2-year period. The results include all [email protected] consecutive cases from September 2007 through September DOI:10.4293/108680811X13022985131093 2009.Datacollectedincludedage,sex,diagnoses,indications ©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby theSocietyofLaparoendoscopicSurgeons,Inc. forsurgery,operativedetails,andshort-termresults. 38 JSLS(2011)15:38–40 Operative Technique The operative time for the distal placement was brief, oftenlessthan10minutes.Shuntplacementwassuccess- Each patient is placed in supine positioning after induc- ful in all patients as documented by the laparoscopic tionofgeneralanesthesia,withtheheadturnedslightly.A visualization of CSF draining from the end of the shunt scalp flap is raised, and a burr hole created in the skull. tubingatthetimeoftheoperation.Residentparticipation The ventricle is accessed, and the shunt tubing inserted. included all PGY levels (intern through chief resident). The tubing is connected via a one-way valve to the distal catheter, tunneled from a 1-cm incision on the abdominal Complications were also minimal. There were no deaths walljustbelowthecostalmargin. in the series. There were no wound complications, no intraabdominal abscess, and no malpositioned shunts. Placement is performed with standard technique, a varia- Therewerenoaccess-relatedvascularcomplications,with tion of that has been previously reported.6 Pneumoperi- no patient requiring a blood transfusion. toneumisestablishedtoapressureof10mmHgto15mm Hg using a Veress needle through the tunnel site. After In one patient, the trocar violated the right colon. Given insufflation, a 5-mm optical access camera and trocar are thatthepatienthadpriorsurgeryandadhesions,weoptedto placed through a separate stab incision approximately repairthecolotomyin2layersusingalimitedmidlinelaparot- 10cmawayfromthetunnelsite.Typically,adequateperi- omy.Theshunttubingwasplacedintothepleuralspaceonthe toneal surface is confirmed during a brief diagnostic lap- rightsiteoftheabdomen.Thepatienthadanuneventfulrecov- aroscopy. A 10-French Hickmann peel-away introducer ery,withgooddrainageofCSF,andnoabdominalsequelae. sheath is then used to place the tubing in the peritoneal cavity.Thetippositionmayneedtobealtered,andcanbe DISCUSSION repositioned through use of the camera tip itself. Flow of CSFthroughthecatheteristhenvisuallyconfirmedwhile Thetraditionalopentechniqueforplacementoftheshunt palpating the proximal valve (Figure 1). The abdomen involves creating a limited laparotomy and blindly intro- may be desufflated, and the trocar site and tunnel site ducing the catheter into the abdominal cavity. Laparos- closed with absorbable subcuticular stitch. copy has been well described for the placement of ven- triculoperitoneal shunts, using a variety of techniques. Initial reports utilized a 3-trocar technique with good re- RESULTS sults.1,2Theuseofapeel-awayintroducersheathtoinsert We performed 111 de novo ventriculoperitoneal shunt the tubing through the abdominal wall greatly facilitates placementsduringthestudyperiod.Ofourpatients,56% the procedure.4 Single trocar techniques have been de- werefemale,withanaverageageof55.2years(range,19 scribed with equal success.7 to86).Theaveragebodymassindex(BMI)was29.8,but Thecommondenominatorinthelaparoscopicapproachisthat ranged from 15 to 49.6. The indication for shunt place- itbenefitsthepatientinprovidingaguaranteeoftheadequacy mentwasalwayshydrocephalus.Themostcommoncon- oftheshunt.First,theshunttubingisconfirmedtobelocated dition requiring initial shunt placement was intracranial within the peritoneal cavity. Secondly, shunt function is con- hemorrhage, but other diagnoses included normal pres- firmedbyvisualizationofdrainageofCSFfromtheshunttub- sure hydrocephalus, intracranial tumor, syringomyelia, ing.Last,theoverallrateofwoundcomplicationsismarkedly and spina bifida, among others. decreasedovermoretraditionalincisions. For the neurosurgeon, confidence in the placement, po- sition, and flow through the catheter is also important. However, they enjoy a freedom from the procedure out- sidetheirareaofinterestandexpertise.Further,thisinter- action in the operating room builds rapport, and increases collegialityacrossthedisciplines.Someneurosurgeonsmay prefer to place their own shunts; however, we have found that an available and interested general surgery team has beenwelcomed. Figure1.Flowofcerebrospinalfluidisconfirmedvisuallyafter Mostimportantly,however,thereistheperspectiveofthegen- lumboperitonealshuntplacement. eral surgery resident. Of course, performing any procedure JSLS(2011)15:38–40 39 LaparoscopicVentriculoperitonealShunts:BenefitstoResidentTrainingandPatientSafety,StoddardTetal. addstotheoverallexperienceoftheresidency.However,there critical data inappropriately. At our institution, we have isanaspectoftrainingthathasbeenlargelyoverlooked.There foundthatbothservicestendtobemoreinvolved,perhaps areseveralcharacteristicsofanidealteachingexercise:safety, providing additional layers of thought and concern toward standard of care, rapidity, reproducibility/consistency, fre- theindividualpatient.Finally,wedidnotformallystudythe quency,applicabilitytootherprocedures. resident attitudes or aptitude in performing the shunting procedure.Itisourintenttobuildonthisinitialexperience The VP shunt meets each of these criteria as an optimal bycorrelatingthisaccessprocedurewithtasksinoursimu- learning experience. lationcenterinthefuture. Atourcenter,theprocedureissafeandsupervised.Itisa well-established, standardized procedure with an excel- CONCLUSION lent track record both in the literature as well as locally. Inthecurrentseries,wehaveconfirmedthatMIStechniques Further, it occurs frequently enough (approximately one canbeappliedtowardneurosurgicalprocedures,specifically perweek)toallowresidentstheopportunitytolearnand the placement of ventriculoperitoneal shunting. Although thenpracticetheproceduremultipletimesduringagiven thishasbeenpreviouslydemonstrated,thevaluetoresident rotation. It is also rapid, typically taking a few minutes of educationhasnotbeenemphasized.Intheeraofincreased operativetime.Thisdoesnotinterferewithschedulingof awarenessofpatientsafety,laparoscopicVPshuntingserves other operative cases, or provide a substantial drain on as a model for accomplishing both goals of improved out- resident manpower. comesandqualitysurgicaleducation. InthecaseofVPshunts,theaccessitselfistheessenceof theprocedure,makingthiscasetheclosesttotheoptimal References: training model for peritoneal access. In the example of a 1. Armbruster C, Blauensteiner J, Ammerer HP, Kriwanek S. laparoscopic colectomy, port placement and access is a Laparoscopically assisted implantation of ventriculoperitoneal necessary but very initial part of the procedure. There is shunts.JLaparoendoscSurg.1993;3:191-192. some element of impatience in the access portion, as the bulkoftheprocedureremainstooccur.Thefocusonthe 2. BausuariL,SelmanJM,LizanaC.Peritonealcatheterinsertion educational aspect of the case lies in dissection or anas- usinglaparoscopicguidance.PediatrNeurosurg.1993;19:109-110. tomosis rather than access. 3. Schievink WI, Wharen RE Jr., Reimer R, Pettit PD, Seiler JC, Shine TS. Laparoscopic placement of ventriculoperitoneal shunts: Additionally, the skills required for laparoscopic placement preliminaryreport.MayoClinicProceed.1993;68:1064-1066. of shunts translate well to other minimally invasive proce- dures. Of course, this naturally includes the laparoscopic 4. Cuatico W, Vannix D. Laparoscopically guided peritoneal managementofshuntcomplications,whichhasbeenprevi- insertion in ventriculoperitoneal shunts. J Laparoendosc Surg. ouslydescribedbyusandothers.8,9However,thisprocedure 1995;5:309-311. serves as a platform for the broader category of peritoneal 5. Schubert F, Fijen BP, Krauss JK. Laparoscopically assisted access,applicabletomosteveryabdominalprocedure.Fur- peritonealshuntinsertioninhydrocephalus:aprospectivecon- ther,thismethodofaccesstotheperitoneummaybeintro- trolledstudy.SurgEndosc.2005;19:1588-1591. duced at an early level of training, at the intern or second- 6. Roth JS, Park AE, Gerwitz R. Minilaparoscopically assisted yearlevel,suchthatitiswellpracticedbythetimeresidents placementofventriculoperitonealshunts.SurgEndosc.2000;14: approachthesenioryearsofresidency.Itisremarkablethat 461-463. this procedure provides for better resident training while 7. Fanelli RD, Mellinger DN, Crowell RM, Gersin KS. Laparo- improvingpatientoutcomesandsafety. scopic VP shunt placement: a single trocar technique. Surg The disadvantages to this procedure are few. The general Endosc.2000;14:641-643. surgery team needs to be available on a semi-urgent basis, 8. Kavic SM, Segan RD, Taylor MD, Roth JS. Laparoscopic which leads to occasional practical, logistical difficulties. managementofventriculoperitonealandlumboperitonealshunt Theseproblemscanlargelyberesolvedbyhavingboththe complications.JSLS.2007;11:14-19. neurosurgeonsandgeneralsurgeonscommittedtothepro- 9. Klee VM, Kraft RO, Zimmerman RS, Harold KL. A laparo- cedureandtheapplicationofminimallyinvasivetechniques. scopic technique for retrieval and prevention of migration of Inaddition,thereisthepotentialforlossofownershipofthe ventriculoperitonealshunttubing.JSLS.2009;13:101-103. patients,withthepotentialbetween2servicestoeachignore 40 JSLS(2011)15:38–40
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