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Laparoscopic surgery in patients with ventriculoperitoneal shunts: safety and monitoring
S V Jackman1, J D Weingart, S L Kinsman
1James Buchanan Brady Urological Institute, and Departments of Neurosurgery and Neurology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Insights
Patients with ventriculoperitoneal shunts undergoing laparoscopic surgery did not show increased intracranial pressure. Routine anesthetic monitoring is sufficient, avoiding risky invasive shunt monitoring.
Area of Science:
- Neurosurgery
- Anesthesiology
- Pediatric Surgery
Background:
- Ventriculoperitoneal shunts are used to treat hydrocephalus.
- Concerns exist regarding increased intracranial pressure during laparoscopic procedures in patients with shunts.
- Previous recommendations included shunt pressure monitoring and ventricular drainage.
Purpose of the Study:
- To evaluate clinical indications of increased intracranial pressure in patients with ventriculoperitoneal shunts during laparoscopic surgery.
- To assess the safety and necessity of invasive shunt monitoring during laparoscopy.
Main Methods:
- Retrospective review of anesthesia records for 18 patients (12 female, 6 male) with ventriculoperitoneal shunts undergoing 19 laparoscopic operations.
- Data collected included operative time, carbon dioxide levels, vital signs, and anesthetic events.
- Postoperative records were analyzed for neurological changes.
Main Results:
- Mean operative time was 7 hours 13 minutes; mean laparoscopic time was 2 hours 52 minutes.
- Average insufflation pressure was 16 mm Hg (range 12-20).
- No evidence of increased intracranial pressure, neurological deterioration, or adverse anesthetic events was observed. Shunt revision rate was consistent with literature.
Conclusions:
- Laparoscopic surgery in patients with ventriculoperitoneal shunts does not appear to cause clinically significant increased intracranial pressure.
- Invasive shunt monitoring methods carry risks and are not routinely indicated.
- Standard anesthetic monitoring is adequate for these patients in the absence of contrary evidence.
Purpose:
It was suggested that patients with a ventriculoperitoneal shunt are at risk for increased intracranial pressure during pneumoperitoneum. Shunt pressure monitoring and ventricular drainage to maintain normal pressure were recommended. We evaluated a series of patients with a ventriculoperitoneal shunt who underwent laparoscopic surgery to determine the clinical indications of increased intracranial pressure.
Materials And Methods:
We reviewed the anesthesia records of 12 females and 6 males with a mean age of 13.2 years who had a ventriculoperitoneal shunt and underwent a total of 19 consecutive laparoscopic operations. Data on operative time, carbon dioxide level, pulse, blood pressure and any untoward anesthetic events were obtained. Postoperative records were assessed for evidence of neurological change.
Results:
Mean operative time was 7 hours 13 minutes and estimated mean laparoscopic time was 2 hours 52 minutes. Average insufflation pressure was 16 mm. Hg (range 12 to 20). There was no evidence of a trend to combined bradycardia and hypertension or surgically related neurological deterioration and no untoward anesthetic events. Ventriculoperitoneal shunt revision was done in 3 cases, a rate consistent with that in the literature. Mean followup was 23.4 months (range 1 to 58).
Conclusions:
There was no evidence of clinically significant increased intracranial pressure in our series or in the literature in patients with a ventriculoperitoneal shunt who undergo laparoscopy. Invasive methods for shunt monitoring are not without risk. Routine anesthetic monitoring should remain the standard of care in the absence of clear evidence to the contrary.
