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Management of inguinal cerebrospinal fluid leak after communicating hydrocele repair in a child with spina bifida
CASE REPORT
MANAGEMENT OF INGUINAL CEREBROSPINAL FLUID LEAK AFTER COMMUNICATING HYDROCELE REPAIR IN A CHILD WITH SPINA BIFIDA BENJAMIN T. SHURTLEFF, AARON B. GROTAS, MURALI K. ANKEM,
AND
JOSEPH G. BARONE
ABSTRACT Children with ventriculoperitoneal shunts undergoing communicating hydrocele repair are at increased risk of postoperative complications, including hydrocele recurrence, shunt injury, infection, and meningitis. This is the first case report of a child with a ventriculoperitoneal shunt who developed a cerebrospinal fluid leak through the inguinal incision after hydrocele repair. Management included placing the child in the Trendelenburg position and sealing the leak with cyanoacrylate tissue adhesive. UROLOGY 59: 296iv–296vi, 2002. © 2002, Elsevier Science Inc.
C
hildren with spina bifida and ventriculoperitoneal (VP) shunts are at increased risk of inguinal hernia or hydrocele formation because of the increased intra-abdominal pressure.1 It is believed that the cerebrospinal fluid shunted to the abdomen results in increased intra-abdominal fluid volume and pressure that can predispose a child to the development of an inguinal hernia or hydrocele. This is the first case report of a child with a VP shunt who developed a cerebrospinal fluid leak through the inguinal incision after hydrocele repair. The management of this problem is also discussed. CASE REPORT A 3-year-old boy with spina bifida presented with a recurrent right communicating hydrocele. The patient had undergone right inguinal hydrocelectomy 2 years before at another institution. No complications had been reported during the original surgery. The hydrocele was uncomfortable and had been increasing in size since the original surgery. The patient had had a VP shunt placed as an From the Division of Urology, Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey Address for correspondence: Joseph G. Barone, M.D., Section of Pediatric Urology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, MEB 588, New Brunswick, NJ 08903-0091 Submitted: July 23, 2001, accepted (with revisions): October 5, 2001
296iv
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
infant because of hydrocephalus and was allergic to latex. On physical examination, a 3-cm right inguinal incision and 10-cm right hydrocele that extended into the groin up to the level of the external ring were noted. The latter was nontender and transilluminated. The fluid within the hydrocele sac was reducible, which suggested that the hydrocele was communicating with the abdominal cavity. A plain film of the abdomen demonstrated the VP shunt tubing in the abdomen, not in the hydrocele sac. Right inguinal hydrocelectomy was recommended, because the hydrocele was enlarging and appeared to be in communication with the abdominal cavity. At surgery, a typical right communicating hydrocele was discovered and was repaired through the prior incision. The hydrocele sac was divided and ligated with 3-0 polyglactin sutures. Dissection and closure of the sac at the level of the internal ring was difficult because of adhesions secondary to the prior surgery. After ligation of the sac, the distal sac was opened down to the level of the testis, and a bottleneck hydrocelectomy was performed to prevent future noncommunicating hydrocele formation. The external oblique fascia was closed with 3-0 polyglactin sutures, Scarpa’s fascia was closed with 4-0 polyglactin sutures, and the skin was approximated with 5-0 polyglecaprone sutures. The patient was discharged home later that morning. On postoperative day 2, the patient presented to the emergency room with a 2-day history of clear 0090-4295/02/$22.00 PII S0090-4295(01)01531-X
fluid draining from a pinpoint opening on the medial aspect of the inguinal incision. On physical examination, the patient was afebrile and no sign of wound infection such as erythema, tenderness, or purulence was found. There was no evidence of a seroma or localized fluid collection beneath the incision. The laboratory evaluation, including a complete blood count, serum chemistry, and urinalysis, was normal. A plain film of the abdomen and a cystogram were normal, demonstrating an intra-abdominal shunt tip and no evidence of bladder injury, respectively. The draining fluid did not demonstrate elevated creatinine and was consistent with an inguinal leak of cerebrospinal fluid. The patient was started on intravenous cefazolin (20 mg/kg) to prevent wound infection and was hospitalized for observation. The pediatric surgery department was consulted and agreed that a repeated operation might actually increase the size of the peritoneal defect and recommended conservative management of the fluid leak. On postoperative day 3, the leakage had not decreased in amount, but the patient remained stable clinically. In an attempt to decrease the amount of fluid drainage, a 24 to 48-hour trial of placing the patient at bed rest in the Trendelenburg position was attempted before possible repeated operation. We believed that the Trendelenburg position would direct fluid away from the inguinal area by gravity and might slow down the fluid leak. The inguinal area was manually compressed for several minutes, and then several layers of cyanoacrylate tissue adhesive were applied directly to the wound. No allergic skin or systemic reactions were noted. On postoperative days 3 and 4, the wound was observed at least three times daily for evidence of subcutaneous expansion due to concealment of the leak, and none was noted. By the end of the third postoperative day, only a small amount of drainage was noted without any localized collection. By postoperative day 5, all leakage had ceased. At 5 months of follow-up, no evidence of recurrent hydrocele or fluid collection in the inguinal area was noted. COMMENT Complications after communicating hydrocele or hernia repair in children with a VP shunt include recurrence, shunt injury, infection, and meningitis.2,3 Hydrocele recurrence is the most common complication and is thought to be due to the higher intra-abdominal pressure. If the amount of fluid draining into the peritoneal cavity is excessive, it is occasionally necessary to redirect the shunt to a pleural or intravenous location.1 UROLOGY 59 (2), 2002
In some instances, the shunt tip can migrate through the patent processus vaginalis and result in a large hydrocele.4,5 Shunt injury can occur in this situation if the tubing is inadvertently divided and ligated during communicating hydrocele repair. To reduce the risk of this complication, a preoperative plain film of the abdomen can localize the position of the shunt tip. Infection can be a potentially serious complication after herniorrhaphy or hydrocelectomy in patients with a VP shunt. Bacteria can spread retrograde along the course of the shunt tubing, resulting in meningitis. Although prophylactic antibiotics are usually given to children with VP shunts undergoing abdominal surgery unrelated to their shunts, few data support their use.3 The development of a cerebrospinal fluid leak after communicating hydrocele repair has not been reported, indicating the rarity of the event. Such a leak indicates that the peritoneal closure was not watertight, but it does not suggest the size of the peritoneal defect. In our case, we believed that adequate peritoneal closure was achieved and that the defect causing this leak was small. For this reason, a repeated operation was not done immediately, because there were no clinical signs of infection. In fact, we believed that repeated surgery might actually increase the size of the defect owing to postoperative inflammation and the high intraabdominal pressure associated with the VP shunt. Conservative management consisted of prophylactic intravenous antibiotics. Coverage of grampositive cocci was most important to prevent a wound infection from developing that could potentially lead to meningitis. In addition, the patient was placed in the Trendelenburg position to minimize the amount of cerebrospinal fluid in contact with the inguinal defect. A dressing composed of several layers of cyanoacrylate tissue adhesive was used to prevent further leakage of cerebrospinal fluid. This tissue adhesive forms a water-resistant barrier that can also be used for tissue approximation. Within 24 hours of treatment, the fluid leakage ceased. No evidence of recurrent hydrocele formation at 5 months of follow-up was noted. In conclusion, inguinal leakage of cerebrospinal fluid following hydrocelectomy in a child with a VP shunt can be managed nonoperatively. If infection develops or the leakage does not subside within 24 to 48 hours of Trendelenburg positioning, a repeated operation with possible repositioning of the shunt may be necessary. REFERENCES 1. Blount JP, Campbell JA, and Haines SJ: Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin North Am 4: 633– 656, 1993. 296v
2. Pittman T, Williams D, Weber TR, et al: The risk of abdominal operations in children with ventriculoperitoneal shunts. J Pediatr Surg 27: 1051–1053, 1992. 3. Grosfeld JL, Minnick K, Shedd F, et al: Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatr Surg 26: 283–287, 1991.
296vi
4. Magee JF, Barker NE, Blair GK, et al: Inguinal herniation with glial implants: possible complication of ventriculoperitoneal shunting. Pediatr Pathol Lab Med 16: 591–596, 1996. 5. Oktem IS, Akdemir H, Koc K, et al: Migration of abdominal catheter of ventriculoperitoneal shunt into the scrotum. Acta Neurochir 140: 167–701, 1998.
UROLOGY 59 (2), 2002
MANAGEMENT OF INGUINAL CEREBROSPINAL FLUID LEAK AFTER COMMUNICATING HYDROCELE REPAIR IN A CHILD WITH SPINA BIFIDA BENJAMIN T. SHURTLEFF, AARON B. GROTAS, MURALI K. ANKEM,
AND
JOSEPH G. BARONE
ABSTRACT Children with ventriculoperitoneal shunts undergoing communicating hydrocele repair are at increased risk of postoperative complications, including hydrocele recurrence, shunt injury, infection, and meningitis. This is the first case report of a child with a ventriculoperitoneal shunt who developed a cerebrospinal fluid leak through the inguinal incision after hydrocele repair. Management included placing the child in the Trendelenburg position and sealing the leak with cyanoacrylate tissue adhesive. UROLOGY 59: 296iv–296vi, 2002. © 2002, Elsevier Science Inc.
C
hildren with spina bifida and ventriculoperitoneal (VP) shunts are at increased risk of inguinal hernia or hydrocele formation because of the increased intra-abdominal pressure.1 It is believed that the cerebrospinal fluid shunted to the abdomen results in increased intra-abdominal fluid volume and pressure that can predispose a child to the development of an inguinal hernia or hydrocele. This is the first case report of a child with a VP shunt who developed a cerebrospinal fluid leak through the inguinal incision after hydrocele repair. The management of this problem is also discussed. CASE REPORT A 3-year-old boy with spina bifida presented with a recurrent right communicating hydrocele. The patient had undergone right inguinal hydrocelectomy 2 years before at another institution. No complications had been reported during the original surgery. The hydrocele was uncomfortable and had been increasing in size since the original surgery. The patient had had a VP shunt placed as an From the Division of Urology, Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey Address for correspondence: Joseph G. Barone, M.D., Section of Pediatric Urology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, MEB 588, New Brunswick, NJ 08903-0091 Submitted: July 23, 2001, accepted (with revisions): October 5, 2001
296iv
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
infant because of hydrocephalus and was allergic to latex. On physical examination, a 3-cm right inguinal incision and 10-cm right hydrocele that extended into the groin up to the level of the external ring were noted. The latter was nontender and transilluminated. The fluid within the hydrocele sac was reducible, which suggested that the hydrocele was communicating with the abdominal cavity. A plain film of the abdomen demonstrated the VP shunt tubing in the abdomen, not in the hydrocele sac. Right inguinal hydrocelectomy was recommended, because the hydrocele was enlarging and appeared to be in communication with the abdominal cavity. At surgery, a typical right communicating hydrocele was discovered and was repaired through the prior incision. The hydrocele sac was divided and ligated with 3-0 polyglactin sutures. Dissection and closure of the sac at the level of the internal ring was difficult because of adhesions secondary to the prior surgery. After ligation of the sac, the distal sac was opened down to the level of the testis, and a bottleneck hydrocelectomy was performed to prevent future noncommunicating hydrocele formation. The external oblique fascia was closed with 3-0 polyglactin sutures, Scarpa’s fascia was closed with 4-0 polyglactin sutures, and the skin was approximated with 5-0 polyglecaprone sutures. The patient was discharged home later that morning. On postoperative day 2, the patient presented to the emergency room with a 2-day history of clear 0090-4295/02/$22.00 PII S0090-4295(01)01531-X
fluid draining from a pinpoint opening on the medial aspect of the inguinal incision. On physical examination, the patient was afebrile and no sign of wound infection such as erythema, tenderness, or purulence was found. There was no evidence of a seroma or localized fluid collection beneath the incision. The laboratory evaluation, including a complete blood count, serum chemistry, and urinalysis, was normal. A plain film of the abdomen and a cystogram were normal, demonstrating an intra-abdominal shunt tip and no evidence of bladder injury, respectively. The draining fluid did not demonstrate elevated creatinine and was consistent with an inguinal leak of cerebrospinal fluid. The patient was started on intravenous cefazolin (20 mg/kg) to prevent wound infection and was hospitalized for observation. The pediatric surgery department was consulted and agreed that a repeated operation might actually increase the size of the peritoneal defect and recommended conservative management of the fluid leak. On postoperative day 3, the leakage had not decreased in amount, but the patient remained stable clinically. In an attempt to decrease the amount of fluid drainage, a 24 to 48-hour trial of placing the patient at bed rest in the Trendelenburg position was attempted before possible repeated operation. We believed that the Trendelenburg position would direct fluid away from the inguinal area by gravity and might slow down the fluid leak. The inguinal area was manually compressed for several minutes, and then several layers of cyanoacrylate tissue adhesive were applied directly to the wound. No allergic skin or systemic reactions were noted. On postoperative days 3 and 4, the wound was observed at least three times daily for evidence of subcutaneous expansion due to concealment of the leak, and none was noted. By the end of the third postoperative day, only a small amount of drainage was noted without any localized collection. By postoperative day 5, all leakage had ceased. At 5 months of follow-up, no evidence of recurrent hydrocele or fluid collection in the inguinal area was noted. COMMENT Complications after communicating hydrocele or hernia repair in children with a VP shunt include recurrence, shunt injury, infection, and meningitis.2,3 Hydrocele recurrence is the most common complication and is thought to be due to the higher intra-abdominal pressure. If the amount of fluid draining into the peritoneal cavity is excessive, it is occasionally necessary to redirect the shunt to a pleural or intravenous location.1 UROLOGY 59 (2), 2002
In some instances, the shunt tip can migrate through the patent processus vaginalis and result in a large hydrocele.4,5 Shunt injury can occur in this situation if the tubing is inadvertently divided and ligated during communicating hydrocele repair. To reduce the risk of this complication, a preoperative plain film of the abdomen can localize the position of the shunt tip. Infection can be a potentially serious complication after herniorrhaphy or hydrocelectomy in patients with a VP shunt. Bacteria can spread retrograde along the course of the shunt tubing, resulting in meningitis. Although prophylactic antibiotics are usually given to children with VP shunts undergoing abdominal surgery unrelated to their shunts, few data support their use.3 The development of a cerebrospinal fluid leak after communicating hydrocele repair has not been reported, indicating the rarity of the event. Such a leak indicates that the peritoneal closure was not watertight, but it does not suggest the size of the peritoneal defect. In our case, we believed that adequate peritoneal closure was achieved and that the defect causing this leak was small. For this reason, a repeated operation was not done immediately, because there were no clinical signs of infection. In fact, we believed that repeated surgery might actually increase the size of the defect owing to postoperative inflammation and the high intraabdominal pressure associated with the VP shunt. Conservative management consisted of prophylactic intravenous antibiotics. Coverage of grampositive cocci was most important to prevent a wound infection from developing that could potentially lead to meningitis. In addition, the patient was placed in the Trendelenburg position to minimize the amount of cerebrospinal fluid in contact with the inguinal defect. A dressing composed of several layers of cyanoacrylate tissue adhesive was used to prevent further leakage of cerebrospinal fluid. This tissue adhesive forms a water-resistant barrier that can also be used for tissue approximation. Within 24 hours of treatment, the fluid leakage ceased. No evidence of recurrent hydrocele formation at 5 months of follow-up was noted. In conclusion, inguinal leakage of cerebrospinal fluid following hydrocelectomy in a child with a VP shunt can be managed nonoperatively. If infection develops or the leakage does not subside within 24 to 48 hours of Trendelenburg positioning, a repeated operation with possible repositioning of the shunt may be necessary. REFERENCES 1. Blount JP, Campbell JA, and Haines SJ: Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin North Am 4: 633– 656, 1993. 296v
2. Pittman T, Williams D, Weber TR, et al: The risk of abdominal operations in children with ventriculoperitoneal shunts. J Pediatr Surg 27: 1051–1053, 1992. 3. Grosfeld JL, Minnick K, Shedd F, et al: Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatr Surg 26: 283–287, 1991.
296vi
4. Magee JF, Barker NE, Blair GK, et al: Inguinal herniation with glial implants: possible complication of ventriculoperitoneal shunting. Pediatr Pathol Lab Med 16: 591–596, 1996. 5. Oktem IS, Akdemir H, Koc K, et al: Migration of abdominal catheter of ventriculoperitoneal shunt into the scrotum. Acta Neurochir 140: 167–701, 1998.
UROLOGY 59 (2), 2002