The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results

Clinical article

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Object

The aim of this study was to examine the feasibility and safety of ventriculoperitoneal (VP) shunt placement using a periumbilical approach for distal peritoneal access. By using this minimally invasive approach, the authors hypothesized that the cosmetic outcomes would be better than could be achieved by using a traditional minilaparotomy and that clinical results would be comparable.

Methods

A periumbilical approach was used for distal catheter insertion during a first-time VP shunt placement in 20 patients (8 males and 12 females). Median age at time of surgery was 3.0 months (range 7 days–11.9 years) and mean follow-up time was 17.8 months (range 1.2–28.0 months). The median weight of the patients was 3.99 kg (range 1.95–57.0 kg). A single incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1-mm incision made while the patient was temporarily held in a Valsalva maneuver. A peritoneal trocar was then inserted through the fascial incision and the distal catheter was passed into the peritoneal space.

Results

The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients' families. Mean operative time was 35 minutes. Eight patients required revision surgery. One distal failure occurred when the distal shunt tubing retracted and became coiled in the neck; this was repaired by conversion to a minilaparotomy for distal replacement. There was 1 shunt infection (5%) requiring shunt removal and replacement. One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system, and another patient underwent a conversion to a ventriculoatrial shunt due to poor peritoneal absorption. In the remaining 4 patients who required operative revision, the peritoneal portion of the shunt was not involved.

Conclusions

The periumbilical approach for peritoneal access during VP shunt placement is technically feasible, has low infection rates, and has cosmetically appealing results. It may be considered as an alternative option to standard VP shunt placement techniques.

Abbreviation used in this paper:VP = ventriculoperitoneal.

Article Information

Address correspondence to: Violette Renard Recinos, M.D., Pediatric Neurosurgical Oncology, Cleveland Clinic Foundation, 9500 Euclid Avenue, S-60, Cleveland, Ohio 44195. email: recinov@ccf.org.

Please include this information when citing this paper: published online February 22, 2013; DOI: 10.3171/2013.1.PEDS1254.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraoperative photos demonstrating the distal shunt insertion technique using a periumbilical approach. After a 1-mm incision is made into midline fascia, a peritoneal trocar is inserted using gentle downward pressure (A). The stylet is removed and the distal catheter is passed using bayonet forceps (B). The catheter should glide easily during the entire passage of the entire length of tubing (C). If resistance is met, the trocar should be repositioned until the tubing passes easily. The trocar sleeve is removed as the final portion of tubing is inserted into the peritoneum (D). Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011–2012. All Rights Reserved.

  • View in gallery

    Illustration depicting the distal shunt tubing insertion into the peritoneum. The trocar is passed gently so that the fascia is completely penetrated (A) and the trocar sleeve lies in the peritoneum (B). The trocar sleeve serves as a channel to pass the shunt tubing into the peritoneum (C). The tubing should pass easily so that a significant length of redundant catheter is placed in the peritoneum (D). Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011–2012. All Rights Reserved.

  • View in gallery

    Preoperative (left) and postoperative (right) photographs depicting the oblique view of the periumbilical incision used in an infant. Placement of the incision in the infraumbilical crease results in excellent cosmetic outcomes. In infants, a periumbilical approach avoids dissection of the remnant umbilical vessels, which is necessary for transumbilical approaches. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011–2012. All Rights Reserved.

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