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Laparoscopic and thoracoscopic assistance with CSF shunts in children
Laparoscopic and Thoracoscopic Assistance Wit!h CSF Shunts in Ckldren By George
W. Holcomb
Ill and Harold
P. Smith
Nashville, Tennessee 0 Between June 1992 and June 1994, six children underwent laparoscopic or thoracoscopic assistance in the management of cerebrospinal fluid (CSF) shunts. Four children (3 to 12 years of age) required laparoscopic assistance. Two children (5 and 10 years of age) underwent thoracoscopy with insertion of syringopleural shunts for decompression of cervicothoracic hydromyelia. Most children who require CSF decompression do not need endoscopic assistance for placement of the terminal portion of the shunt. However, in selected patients who have undergone previous abdominal procedures, in patients with a persistent pseudocyst occupying an extensive portion of the abdominal cavity, and in patients requiring removal of a disconnected shunt, laparoscopy is the ideal approach. Thoracoscopy for a syringopleural shunt prevents the need for minithoracotomy. Copyright Q 1995 by W. B. Saunders Company INDEX
WORDS:
Laparoscopy,
thoracoscopy,
CSF shunts.
HE MINIMALLY invasive approach is becoming increasingly popular for surgical problems in adults and is being employed increasingly in children. Although laparoscopy has been described previo~sly,l-~ thoracoscopy for the management of children who have a cerebrospinal fluid (CSF) shunt has not been reported. We have used minimally invasive surgery (MIS) in children with special problems related to their CSF shunts beginning in 1992. Herein we review that experience.
T
CASE REPORTS
Cases 1 arzd 2 Two children, 8 and 9 years old, had large pseudocysts surrounding their indwelling shunts, Despite exteriorization of the shunt, the pseudocysts persisted, and laparoscopic assistance was indicated for lysis of the adhesions along with insertion of a new shunt. One of these patients previously underwent gastrostomy and appendectomy.
Cases 3 and 4 In two patients, the terminal end of the ventricufoperitoneal (VP) shunt had become disconnected and required removal. At the time of removal in one patient, laparoscopic assistance was used for insertion of a new shunt as well.
From the Departments of Surgery and Pediatrics, Children’s Hospital, Vanderbilt Universi~ Medical Center, Nashville, TN, and the Depanment of Neurosciences and the Neuroscience Center, Baptist Hospital, Nashville, TN. Address reprint requests to George W Holcomb III, MD, 12112lst Ave S, Suite 338, Nashville, TN 37212. Copyright 0 1995 by KB. Saunders Company 0022-3468l95l3012-0002$03.00l0 1642
Cases 5 and 6 Two children, 5 and 10 years old, underwent thoracoscopy for insertion of syringopleural shunts for decompression of cervicothoracic hydromyelia. In both patients, thoracoscopy was instrumental because a minithoracotomy incision would have been necessary for access and visualization of the thoracic cavity for insertion of the terminal end of the shunt. In one of these chiIdren, bilateral pneumothoraces had complicated his care as a newborn. TECHNIQUE
For laparoscopic assistance, access to the abdominal cavity is obtained using an umbilical cutdown technique with insertion of a 5-mm umbilical cannula and telescope. For patients undergoing either lysis of a pseudocyst or removal of a previously disconnected shunt, another 5-mm cannula is inserted through which scissors or grasping forceps are introduced for lysis of the pseudocyst or remova of the shunt. If another VP shunt is indicated, the Seldinger technique is used, employing a 1OF Cook catheter introducer set (Cook, Bloomington, IN). A needle is introduced into the abdominal cavity, followed by insertion of a guide-wire. A dilator and sheath are then placed over the guide-wire, the dilator and guidewire are removed, and the tubing is introduced through the sheath, which is then pealed away leaving the tubing in the pelvis. Its position is confirmed visually and the procedure terminated. For thoracoscopic assistance, the patient is positioned prone and, upon access to the syrinx, thoracoscopy is initiated. A 5-mm incision is made overlying the sixth rib and is carried down to the pleura. The pleural space is entered bluntly, and a 5-mm cannula is inserted at this point. After introduction of the telescope through the cannula, a site is selected for insertion of the shunt into the pleural space. The Seldinger technique also is used, and the distal end of the shunt is introduced into the thoracic cavity. The 5-mm thoracic incision is closed in layers around a 14F catheter that is removed with positive pressure ventiIation at the end of the procedure. RESULTS
There was no mortality or morbidity associated with either the neurosurgical or the minimally invasive aspects of the procedure. For patients undergoing laparoscopic assistance, the mean surgical time was 64 minutes and the mean postoperative hospitalization was 3 days. The patients were ready for JuurnatofPediatric
Surgery,
Vol30,
No 12 (December),
1995: pp 1642-1643
LAPAROSCOPY
AND
THORACOSCOPY
1643
FOR CSF SHUNTS
discharge on the first postoperative day but remained hospitalized for administration of intravenous antibiotics after insertion of the new shunt. For the two patients who underwent the thoracoscopic approach, the mean surgical time was 7.5 minutes and the postoperative hospitalization period averaged 2.5 days. These patients also were ready for discharge the day after the procedure, but required hospitalization for postoperative antibiotics. DISCUSSION
MIS is being used increasingly for common and not-so-common problems. In children it has been used for common procedures such as cholecystectomy, appendectomy, splenectomy, and fundoplication. In special circumstances, such as patients who have an extensive CSF pseudocyst documented by ultrasonography, patients with previous abdominal operations, or cases in which a previously placed shunt must be removed, laparoscopy provides ideal visualization for minimal access to the abdominal cavity. In addition, it allows preservation of the
maximal peritoneal absorptive surface, which is imperative if the VP shunt is to function effectively. It should be emphasized that this technique is not required for routine insertion of these shunts and should be used very selectively. Complications of retained indwelling shunts include pseudocyst formation, perforated viscus, infection, and bowel obstruction.4-6 Removal of such nonfunctioning material theoretically should decrease the risk of these complications. The minimally invasive approach allows removal of such catheters and insertion of new ones in a simplified manner. For patients with cervicothoracic hydromyeha who require decompression with a syringopleural shunt, thoracoscopy is a minimally invasive technique for access to the thoracic cavity for insertion of the distal end of the shunt. Rather than using a minithoracotomy technique for access to the thoracic cavity, only a 5-mm incision is required for insertion of a cannula and telescope for visualization, and the catheter is inserted into the cavity using the Seldinger technique. With this approach, postoperative discomfort should be markedly reduced.
REFERENCES 1. Rodgers BM, Vries JK, Talbert .ILz Laparoscopy in the diagnosis and treatment of malfunctioning ventriculo-peritoneal shunts in children. .I Pediatr Surg 13:247-253,1978 2. Morgan WW Jr: The use of peritoneoscopy in the diagnosis and treatment of complications of ventriculoperitoneal shunts in children. J Pediatr Surg 14:180-181, 1979 3. Grosfeld JL, Cooney DR, Smith I, et al: Intra-abdominal
complications following ventriculo-peritoneal shunt procedures. Paediatrics 54:791-796,1974 4. Ames RA Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg 27:525-529,1967 5. Nishijima M, Endoh S, Ohyama H, et al: Gastric perforation by a ventriculo-peritoneal shunt. Neurosurgery 10:754-756,1982 6. Snow RB, Lavyne MH, Fraser RAR: Colonic perforation by ventriculo-peritoneal shunts. Surg Neurol25:173-177,1986
W. Holcomb
Ill and Harold
P. Smith
Nashville, Tennessee 0 Between June 1992 and June 1994, six children underwent laparoscopic or thoracoscopic assistance in the management of cerebrospinal fluid (CSF) shunts. Four children (3 to 12 years of age) required laparoscopic assistance. Two children (5 and 10 years of age) underwent thoracoscopy with insertion of syringopleural shunts for decompression of cervicothoracic hydromyelia. Most children who require CSF decompression do not need endoscopic assistance for placement of the terminal portion of the shunt. However, in selected patients who have undergone previous abdominal procedures, in patients with a persistent pseudocyst occupying an extensive portion of the abdominal cavity, and in patients requiring removal of a disconnected shunt, laparoscopy is the ideal approach. Thoracoscopy for a syringopleural shunt prevents the need for minithoracotomy. Copyright Q 1995 by W. B. Saunders Company INDEX
WORDS:
Laparoscopy,
thoracoscopy,
CSF shunts.
HE MINIMALLY invasive approach is becoming increasingly popular for surgical problems in adults and is being employed increasingly in children. Although laparoscopy has been described previo~sly,l-~ thoracoscopy for the management of children who have a cerebrospinal fluid (CSF) shunt has not been reported. We have used minimally invasive surgery (MIS) in children with special problems related to their CSF shunts beginning in 1992. Herein we review that experience.
T
CASE REPORTS
Cases 1 arzd 2 Two children, 8 and 9 years old, had large pseudocysts surrounding their indwelling shunts, Despite exteriorization of the shunt, the pseudocysts persisted, and laparoscopic assistance was indicated for lysis of the adhesions along with insertion of a new shunt. One of these patients previously underwent gastrostomy and appendectomy.
Cases 3 and 4 In two patients, the terminal end of the ventricufoperitoneal (VP) shunt had become disconnected and required removal. At the time of removal in one patient, laparoscopic assistance was used for insertion of a new shunt as well.
From the Departments of Surgery and Pediatrics, Children’s Hospital, Vanderbilt Universi~ Medical Center, Nashville, TN, and the Depanment of Neurosciences and the Neuroscience Center, Baptist Hospital, Nashville, TN. Address reprint requests to George W Holcomb III, MD, 12112lst Ave S, Suite 338, Nashville, TN 37212. Copyright 0 1995 by KB. Saunders Company 0022-3468l95l3012-0002$03.00l0 1642
Cases 5 and 6 Two children, 5 and 10 years old, underwent thoracoscopy for insertion of syringopleural shunts for decompression of cervicothoracic hydromyelia. In both patients, thoracoscopy was instrumental because a minithoracotomy incision would have been necessary for access and visualization of the thoracic cavity for insertion of the terminal end of the shunt. In one of these chiIdren, bilateral pneumothoraces had complicated his care as a newborn. TECHNIQUE
For laparoscopic assistance, access to the abdominal cavity is obtained using an umbilical cutdown technique with insertion of a 5-mm umbilical cannula and telescope. For patients undergoing either lysis of a pseudocyst or removal of a previously disconnected shunt, another 5-mm cannula is inserted through which scissors or grasping forceps are introduced for lysis of the pseudocyst or remova of the shunt. If another VP shunt is indicated, the Seldinger technique is used, employing a 1OF Cook catheter introducer set (Cook, Bloomington, IN). A needle is introduced into the abdominal cavity, followed by insertion of a guide-wire. A dilator and sheath are then placed over the guide-wire, the dilator and guidewire are removed, and the tubing is introduced through the sheath, which is then pealed away leaving the tubing in the pelvis. Its position is confirmed visually and the procedure terminated. For thoracoscopic assistance, the patient is positioned prone and, upon access to the syrinx, thoracoscopy is initiated. A 5-mm incision is made overlying the sixth rib and is carried down to the pleura. The pleural space is entered bluntly, and a 5-mm cannula is inserted at this point. After introduction of the telescope through the cannula, a site is selected for insertion of the shunt into the pleural space. The Seldinger technique also is used, and the distal end of the shunt is introduced into the thoracic cavity. The 5-mm thoracic incision is closed in layers around a 14F catheter that is removed with positive pressure ventiIation at the end of the procedure. RESULTS
There was no mortality or morbidity associated with either the neurosurgical or the minimally invasive aspects of the procedure. For patients undergoing laparoscopic assistance, the mean surgical time was 64 minutes and the mean postoperative hospitalization was 3 days. The patients were ready for JuurnatofPediatric
Surgery,
Vol30,
No 12 (December),
1995: pp 1642-1643
LAPAROSCOPY
AND
THORACOSCOPY
1643
FOR CSF SHUNTS
discharge on the first postoperative day but remained hospitalized for administration of intravenous antibiotics after insertion of the new shunt. For the two patients who underwent the thoracoscopic approach, the mean surgical time was 7.5 minutes and the postoperative hospitalization period averaged 2.5 days. These patients also were ready for discharge the day after the procedure, but required hospitalization for postoperative antibiotics. DISCUSSION
MIS is being used increasingly for common and not-so-common problems. In children it has been used for common procedures such as cholecystectomy, appendectomy, splenectomy, and fundoplication. In special circumstances, such as patients who have an extensive CSF pseudocyst documented by ultrasonography, patients with previous abdominal operations, or cases in which a previously placed shunt must be removed, laparoscopy provides ideal visualization for minimal access to the abdominal cavity. In addition, it allows preservation of the
maximal peritoneal absorptive surface, which is imperative if the VP shunt is to function effectively. It should be emphasized that this technique is not required for routine insertion of these shunts and should be used very selectively. Complications of retained indwelling shunts include pseudocyst formation, perforated viscus, infection, and bowel obstruction.4-6 Removal of such nonfunctioning material theoretically should decrease the risk of these complications. The minimally invasive approach allows removal of such catheters and insertion of new ones in a simplified manner. For patients with cervicothoracic hydromyeha who require decompression with a syringopleural shunt, thoracoscopy is a minimally invasive technique for access to the thoracic cavity for insertion of the distal end of the shunt. Rather than using a minithoracotomy technique for access to the thoracic cavity, only a 5-mm incision is required for insertion of a cannula and telescope for visualization, and the catheter is inserted into the cavity using the Seldinger technique. With this approach, postoperative discomfort should be markedly reduced.
REFERENCES 1. Rodgers BM, Vries JK, Talbert .ILz Laparoscopy in the diagnosis and treatment of malfunctioning ventriculo-peritoneal shunts in children. .I Pediatr Surg 13:247-253,1978 2. Morgan WW Jr: The use of peritoneoscopy in the diagnosis and treatment of complications of ventriculoperitoneal shunts in children. J Pediatr Surg 14:180-181, 1979 3. Grosfeld JL, Cooney DR, Smith I, et al: Intra-abdominal
complications following ventriculo-peritoneal shunt procedures. Paediatrics 54:791-796,1974 4. Ames RA Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg 27:525-529,1967 5. Nishijima M, Endoh S, Ohyama H, et al: Gastric perforation by a ventriculo-peritoneal shunt. Neurosurgery 10:754-756,1982 6. Snow RB, Lavyne MH, Fraser RAR: Colonic perforation by ventriculo-peritoneal shunts. Surg Neurol25:173-177,1986