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Published on: October 14, 2022
Management of the ventriculo-peritoneal shunt in pediatric patients during robot-assisted laparoscopic urologic
Pablo Marchetti1, Aria Razmaria, Greg P Zagaja
1Pediatric Urology Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Medical Center and Pritzker School of Medicine, Chicago, Illinois, USA. pemarchetti@yahoo.com
Insights
A novel technique using an Endopouch bag protected ventriculo-peritoneal (VP) shunts during robot-assisted laparoscopic urologic surgery. This method effectively prevented shunt-related complications in preliminary patient studies.
Area of Science:
- Urology
- Minimally Invasive Surgery
- Neurosurgery
Background:
- Ventriculo-peritoneal (VP) shunts are susceptible to infection or malfunction during laparoscopic gastrointestinal or urinary tract surgery.
- Strategies like shunt externalization or conversion to ventriculo-atrial shunts have been proposed to mitigate these risks.
- Robot-assisted laparoscopic (RAL) procedures introduce unique challenges for VP shunt management.
Purpose of the Study:
- To present and evaluate a novel technique for managing VP shunts during RAL urologic procedures.
- To assess the efficacy of an intracorporeal Endopouch bag in protecting VP shunts.
- To determine the incidence of perioperative shunt-related complications using this technique.
Main Methods:
- The technique involves placing the distal VP shunt end within an Endopouch bag inside the peritoneal cavity.
- The Endopouch is secured around the shunt and positioned in the subhepatic space.
- Controlled pneumoperitoneal pressure (12 mm Hg) and antibiotic prophylaxis were maintained throughout the procedure.
Main Results:
- The technique was applied in four patients undergoing RAL cystoplasty and related procedures.
- One patient required conversion to open surgery due to adhesions, with temporary shunt externalization.
- No shunt-related complications were observed at a mean follow-up of 13 months.
Conclusions:
- The intracorporeal Endopouch technique with controlled pneumoperitoneal pressure appears to be a safe and effective method for VP shunt protection during RAL urologic surgery.
- This approach offers a potential alternative to prevent shunt complications in procedures involving the GI or urinary tracts.
- Further research is warranted to validate these preliminary findings in larger cohorts.
Introduction:
Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures.
Materials And Methods:
After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications.
Results:
We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen.
Conclusions:
In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results.
