Laparoscopic-assisted distal ventriculoperitoneal shunt placement

ELSEVIER

Hydrocephalus

LAPAROSCOPEASSISTED VENTRICULOPERITONEAL PLACEMENT

DISTAL SHUNT

Houman Khosrovi, M.D.,* Howard H. Kaufman, M.D.,* Ellen Hrabovsky, M.D.,t Stephen M. Bloomfield, M.D.,* Vikram Prabhu, M.D.,* and Hikmat A. El-Kadi, M.D.*

Departments of *Neurosurgery and TGeneral Surgery, West Virginia University, Morgantown, West Virginia

Khosrovi H, Kaufman HH, Hrabovsky E, Bloomfield SM, Prabhu V, El-Kadi HA. Laparoscopic-assisted distal ventriculoperitoneai shunt placement. Surg Neural 1998;49:127-35. BACKGROUND

Intraperitoneal adhesions,obesity, and distorted abdominal anatomy in shunt-dependent hydrocephalic patients are patient characteristics that increase distal ventriculoperitoneal (VP) shunt failure rates. The use of laparoscopic-aided placement of the distal VP catheter as a technique to decrease the failure rate is evaluated in these patients. METHOD

Thirteen hydrocephalus patients considered to either have intra-abdominal adhesions, be obese, or have distorted abdominal anatomy underwent laparoscopicaided distal VP catheter placement or revision. Two had shunts placed for the first time and eleven had revisions. Eight patients had revisions performed by both the standard minilaparotomy and laparoscopic methods, but at different times. The average surgical times for both techniques were looked at for these eight patients. Caseillustrations are presented. RESULTS

In patients who had both types of abdominal approaches, the average surgical time was 81 min for the laparoscopic-aided technique versus 116 min for the minilaparotomy procedure. The only complication related directly to the laparoscopic procedure was one wound infection. CONCLUSION In patients with intra-abdominal adhesions, obesity, or distorted abdominal anatomy, laparoscopic-aided distal shunt insertion increases the success rate by its direct visual capability and the ability to lyse abdominal adhesions and position the distal end of the catheter in a desired place. 0 1998by Elsevier Science Inc. KEY WORDS

Hydrocephalus, laparoscopy, ventriculoperitoneal shunt, ventriculoperitoneal shunt revision. Address correspondence and reprint requests to: Dr. Howard H. Kaufman, Department of Neurosurgery, P.O. Box 9183, West Virginia University, Morgantown, WV 26506. Received July 9, 1996; accepted May 22, 1997. 0 1998 by Elsevfer Science Inc. 655 Avenue of the Americas, New York, NY 10010

I

n the 1970s because of the development of silastic catheters which, were well tolerated in the abdomen, Ames, Raimondi, and Matsumoto reintroduced ventriculoperitoneal (VP) shunting. Since then this has become the procedure of choice [5]. However, the average patient with hydrocephalus will undergo 2.1 shunt revisions every 3 years of life, with a wide range from no revision for the first decade of life to up to 21 revisions within the first year of life [ 141. Distal shunt malfunctions still cause at least 25-30% of such shunt failures. Distal shunt revisions have a higher failure rate in patients with certain characteristics. These include diffuse intraperitoneal adhesions, obesity, and distorted anatomy because of the thoracolumbar scoliosis and short stature seen in myelomeningocele patients. In such patients, the use of laparoscopy for VP shunt placement or revision has proven to be a valuable tool. We report 13 patients in whom we have used laparoscopy for placement or revision of the peritoneal catheter of a VP shunt in a 24month period from September 1993 to September 1995.

METHODS Thirteen hydrocephalic patients were selected for laparoscopic catheter placement because of suspicion of peritoneal adhesions, obesity, or distorted abdominal anatomy. Diagnostic studies and results for each patient are summarized in Table 1. Two patients had shunts placed for the first time, and eleven of the patients had revisions (Table 2). The Hakim (Cordis) shunt system was used in all patients. All patients had a complete new shunt system placed in both the minilaparotomy and laparoscopic procedures regardless of the type of malfunction. Eight of the patients had shunt revi009l%3019/93/$19.00 PII s009c-3019(97)00357-1

Surg Neurol 1998;49:127-35

128

0

Khosrovi et al

Diagnostic Studies and Results INTBA-

CASE #

SHUNT SERIFS

1 CM

5 LK 6 NA 7WT 8 HP 9 BP 10 KF

Kinking of peritoneal catheter Intact Coiling of peritoneal catheter Coiling of peritoneal catheter Intact Intact Intact Intact

11 KS 12 LM

Intact Intact

13 cc

Intact

2 KC 3KB 4MF

*Ventricular

size increased

vENTRIcuLAB SIZE ON CT

RADI~I~~T~PE STUDY

INTRACRANIAL ABDOMINAL

'IkPEOFSHUNT

PRFSSURE

PREs!wRE

t

t

-

No change t*

r

r

Distal

t*

t

t

Distal

t*

;:

Ventriculomegal Ventriculomegal +* t*

-

-

No flow distally into abdomen -

t* compared

with most recent

No flow distally into abdomen No flow distally into abdomen

-1 rt -

-r i t -

FAILURE

-

Distal Distal Proximal Proximal (Obstructed Valve) Distal Distal Distal

CT of head.

sions performed by both the standard minilaparotomy and the laparoscopy but at different times (Table 3). Two surgeons worked simultaneously, one at the cranial end and the other at the abdominal end, for both types of revisions. All but one patient were operated on by the same attending neurosurgeon. All patients in our series had the laparoscopic procedure performed by the same pe diatric surgeon. During surgery the intracranial pressure was measured by tapping the shunt reservoir and the intra-abdominal pressures were measured distal to the shunt valve using a manometer. Laparoscopy was performed by the open technique [7,10]. An incision was made in the subumbilical region where a Hasson introducer was inserted into the peritoneal cavity, through which the laparoscope camera was inserted after inflation with CO2 at 10 mm Hg. Once the peritoneal cavity was inspected for adhesions, the entrance site(s) of or the need for the other trocar(s) was determined. Up to three other entry sites were used depending on the number of instruments needed. These were introduced under direct vision. Instruments, including the grasper, scissors, and cautery, were used for lysis of adhesions and manipulation of the catheter. The catheter was introduced into the peritoneal cavity using the Seldinger technique with a needle, guide line, and finally a split sheath introducer

through an incision in the subcostal region, which is the same site of incision and catheter entrance as the standard minilaparotomy procedure. Catheter placement was visualized directly via the camera. In the standard technique, the peritoneal cavity was entered through open surgery and the catheter was placed blindly. The surgical time was compared for both techniques in the eight patients who had both procedures performed but at different times by the same surgeon. Statistical analysis was not performed because of the small number of patients.

RESULTS The time range for the eight patients who underwent the laparoscopic-aided procedure was 45-130 min, with an average time of 81 min. The total surgical time for the same eight patients who had undergone minilaparotomy for a previous shunt revision ranged from 80-145 min, with an average time of 116 min (Table 4). The duration of follow-up for the laparoscopic procedure ranged from 14 days to 24 months, with an average of 10.7 months (Table 3). The outcome of patients who underwent the laparoscopic procedure is summarized in Table 3.

Laparoscopic-Assisted

q

Age, Sex, Etiology of Hydrocephalus,

CAKE

AGE (Y) SEX

Surg Neurol 1998;49:127-35

Shunt Placement

ETIOLOGYOF HYDROCEPHALUS

Chiari 11(MM) blurred vision Aqueductal stenosis

1CM

13

F

2 KC*

35

M

3KB

18

M

4MF 5LK 6NA

14 10 12

7WT

62

M F M F

8 HP

73

M

9BP

13

F

Normal pressure hydrocephalus IVH

10 KF 11KS 12 LM

30 9 18

F M M

Chiari II (MM) IVH IVH

13 CC

13

F

Chiari II (MM)

Obstructive hydrocephalus Idiopathic confusion Chiari 11(MM) Aqueductal stenosis Normal pressure hydrocephalus

Clinical Presentation, Number, and Type of Shunt Revision USING MINI&VIsIONS @) VERWSNEW SHUNT(N)

PRIOR VP &/OR VA SHUNT -10~s

#OFVP REVISIONS USING MINILAPAROT~MY

HA.NN

R

6

6

Shunt infection and ventriculitis HA,N/V, lethargy, dysconjugate gaze HA, lethargy l-&N/V, lethargy HA,N/V, abdominal pain Ataxia, urinary incontinence, dementia Ataxia

R

1

R

4

R R R N

2 2 4 -

2 -

R R R

4

3

R

CLINICAL PRE~ENTA’I-IONS

HA,N/V, lethargy, Parinaud’s sign HAN/V Lethargy Change in mental status, school performance HA

Abbreviations: MM = Myelomeningocele. IVH = lntraventricular *This pt had ventriculo-atria1 shunt; see Case report #2.

The following laparoscopy:

cases illustrate

129

the usefulness

CASE 1 C.M. is a 13-year-old white female with a myelomeningocele that was repaired at birth, and a Chiari II malformation with shunt dependent hydrocephalus. She presented with a distal shunt malfunction. She had six previous distal shunt failures. These six revisions had been performed by the standard laparotomy, and therefore it was feared that she had intra-abdominal adhesions that were contributing to her shunt failures. In addition, her obesity and severe thoracolumbar scoliosis led to distortion of the abdominal anatomy. During the laparoscopic procedure, extensive peritoneal adhesions were noted. The peritoneal catheter was found to be trapped in scar tissue, creating a kink in the tubing that impaired the CSF drainage. Using the laparoscopic apparatus, the catheter was freed, and the peritoneal adhesions were lysed to increase cerebrospinal (CSF) circulation and the intra-abdominal absorptive surface area (Figure 1). CASE 2 K.C. is a 35-year-old white male who had a ventriculoatrial (VA) shunt to treat hydrocephalus second-

1

N R

hemorrhage.

of

2

HA = Headache.

1

1

5

5

1

1

N/V = Nausea, vomiting

ary to aqueductal stenosis. He developed acute cholecystitis and peritonitis, which led to a shunt infection and ventriculitis attributable to bacteremia. The shunt was externalized, and he was treated with intravenous antibiotics. After the infection had been cleared, the VA shunt was converted to a VP shunt. However, because of anticipated peritoneal adhesions, the procedure was performed with laparoscopy. There were significant peritoneal adhesions which were lysed prior to placement of the peritoneal catheter. He has had no further shunt problems. CASE 3 K.B. is an M-year-old white male who had obstructive hydrocephalus secondary to a hypothalamic astrocytoma that had been resected during childhood. Prior to presenting with his most recent shunt failure he had undergone three previous VP shunt revisions using the standard minilaparotomy procedure. The entire shunt system was revised again using the minilaparotomy technique, during which the surgeon noted visualization of the liver’s edge before placement of the distal catheter. Postoperatively, the shunt series showed the peritoneal catheter was tightly coiled (Figure 2). The patient

Abbreviations: DPA *See description of **Functioning shunt **“After performing **‘*Since this shunt

13 cc

12 LM

11 KS

8194

4194

7194

12194

-

12194 2195 6195

8182

7189

10186

8173

5/93

6194

3189

9193

4/94

-

4191

8195

6195

9193

4194

5194

9195

DATEOF LAPARoscoPrC PROCFLWRE

DATEOFMOSTRECENT ~SHlJNT~VISlON USING MINIhPAROTOMY LAPAROscOPIC FINDING(S)

DPA

DPA

No adhesions

DPA

DPA; catheter inside pseudocyst No adhesions No adhesions DPA

DPA; catheter inside fibrotic pocket DPA; catheter inside preperitoneal fat DPA

14 months 17 months 13 months

-

N/A*

-

-

2 months

-

9 months

24 months

-

-

17 months

-

9 months 6 months 1 month

16 months

14 days

FOLLOW-UP

-

-

COMPLICATION

Wound infection -

VP Shunt Procedure

DPA, kinked catheter DPA

and Outcome of Patients with Laparoscopic-aided

**

**

**

*x ** Proximal malfunction one month after replacement of a new system **

Infection****

**

**

**

**

OUTCOME

Ascites***

= Diffuse peritoneal adhesions; H/O = History of. Case 6 in the discussion. since laparoscopic procedure. a laparoscopic lysis of adhesions and placement of VP shunt this patient developed CSF ascites that required conversion of the VP shunt to a VA shunt. dependent patient had a history of previous spontaneous perforation, once the infection was cleared a VA shunt was placed.

Multiple minilaparotomies Previous minilaparotomy Multiple minilaparotomies Previous minilaparotomy

10 KF

2z 9 BP

6 NA

5 LK

4MF

3KEt

2 KC

Obese, multiple minilaparotomies Peritonitis, open colycystectomy Multiple minilaparotomies Obese, multiple minifaparotomies lschemic colitis, previous laparotomy Peritonitis, h/o laparotomy Obese Previous laparotomy Multiple

1 CM

INDICATION FOR LAPAROscOPIC PROCEDURE

Indication, Complication(s)

CA!SE

El

GE -lo I E

‘pz ‘Pa

SF “

%$ Laparoscopic-Assisted

q,

Surg Neural 1998:49:127-35

Shunt Placement

13 1

Total Surgical Times for Patients Having Both the Lanarosconic and MinilaDarotomv Procedures LAPAROscOPlC

CASE

CM KB MF LK BP KS LM cc Range: Average:

SURGERY TIME; MINUTES

55 120 45 130 ;z 65 115 45-130 81

MINI-LAPAROTOM~ SURGERY TIME; MINWES

140 105 125 110 120 145 80 100 80-145 116

remained symptomatic and was returned to the operating room for a laparoscopic-aided distal revision. It was noted that the catheter had actually entered the peritoneal cavity but had been placed in a fibrotic pocket where CSF had accumulated. The catheter was freed, and after most of the peri-

m

Case 3: Abdominal X-ray showing the coiling of catheter (in a fibrotic pocket) after shunt revision performed by minilaparotomy.

toneal adhesions were lysed, the tip was repositioned in the pelvis (Figure 3). CASE 4 M.F. is a 14-year-old obese white male with a VP shunt for idiopathic hydrocephalus who presented with distal shunt malfunction. The shunt was revised through a standard minilaparotomy. Intraoperatively the surgeon believed that he had entered the peritoneal cavity and had encountered omenturn. Postoperatively, the shunt series revealed coiling of the abdominal catheter (Figure 4). The patient remained symptomatic, and a second revision was performed laparoscopically. The catheter was found coiled in the preperitoneal fat and was placed in the peritoneal cavity (Figure 5).

DISCUSSION Case 1: Postoperative abdominal X-ray illustrating thoracolumbar scoliosis with distortion of abdomen and pelvis in a myelomeningocele patient. The catheter is placed in the pelvis.

EI

Neurosurgeons have begun to use the endoscope for various problems. For example, an endoscope can be used to position a ventricular catheter away

132

Surg Neurol 1998;49:127-35

Khosrovi et al

from the choroid plexus in order to lessen the chance of proximal malfunction [22] or to perform third ventriculostomy [20]. Laparoscopy has been used to retrieve a disconnected peritoneal shunt catheter [6,9,18,19]. In addition it has been used for placement of peritoneal shunt catheters [2,4,17]. We report a series of patients with specific characteristics in whom laparoscopy was used for VP shunt placement or revision. In our experience, distal revisions are particularly challenging in the face of adhesions, obesity, or distorted anatomy. Patients may have peritoneal adhesions attributable to previous intra-abdominal surgery, including multiple distal shunt revisions by the standard minilaparotomy procedure, or peritonitis. Adhesions may cause cysts or impair absorption resulting in ascites. They may scar down the peritoneal catheter, causing it to become occluded or kinked, preventing adequate CSF drainage. When laparoscopy is used, one can immediately see intraperitoneal adhesions and loculations which are not apparent during a minilaparotomy procedure because of limited exposure. If, as in Case 1, the catheter is scarred into the anterior abdominal wall or, as in

1 Case 4: Abdominal X-ray showing the coiling of cathqminilaparotomy. eter (in preperitoneal fat) after shunt revision by

El

Case 3: Abdominal X-ray after laparoscopic aided distal revision with catheter placed in the pelvis.

Case 3, positioned in a loculated space, the catheter can be freed and placed in an area of the abdominal cavity or pelvis that is free of adhesions. Patients with peritoneal adhesions may not have good anatomic planes, and during a minilaparotomy procedure, one may not be able to identify the peritoneum. In obese patients with peritoneal adhesions, the preperitoneal fat can be abundant and can be mistaken for omentum. Shunts placed in the preperitoneal fat will not have adequate absorption of CSF, leading to shunt failure. The use of laparoscopy assures that the tip of the catheter is inside the peritoneal cavity. On the other hand, adhesions tend to cause the omentum to stick to the peritoneum, and during dissection, the surgeon might wrongly believe that he/she has only entered the preperitoneal fat and continue to dissect, risking injury to the bowel. The anatomy is more obvious during laparoscopy. In addition, at the end of the shunting procedure the patency of the system can be tested with the catheter in the peritoneal cavity by observing spontaneous CSF flow or by pumping the valve.

Laparoscopic-Assisted

Shunt Placement

Case 4: Abdominal X-ray after laparoscopic-aided distal revision with catheter placed in the pelvis.

Severe lumbosacral scoliosis, often seen in patients with myelomeningocele, is associated with distortion of the abdomen. Many such patients are also short-statured and may be obese because of their sedentary lifestyle. In these circumstances, laparoscopy can greatly facilitate placement of the distal catheter. In the past, when distal shunt revisions failed because of the factors mentioned above, either the minilaparotomy would be converted into an extensive laparotomy for better visualization and lysis of adhesions, or the neurosurgeon would choose to convert the shunt into a VA or VP system. If an extensive laparotomy was performed, the patient would be subjected to increased morbidity with increased postoperative stay as well as cost. This can be avoided with laparoscopy. In addition, the laparoscopic method may minimize additional adhesions because of lesser contamination of the intra-abdominal viscera by blood and less exposure to air with subsequent drying. If laparoscopy can prevent the need for a VA shunt, it can also obviate

Surg Neurol 1998:49:127-35

133

the potentially life-threatening complications of these shunts such as septic endocarditis, pulmonary hypertension secondary to thrombotic emboli to the lungs, and nephrotic syndrome secondary to thrombotic emboli to the kidneys [15]. The average surgical time of the eight patients who underwent both the minilaparotomy and laparoscopic procedures at different times suggests that the laparoscopic procedure could shorten the surgical time; the average time for the laparoscopic group was 81 min versus 116 min for the minilaparotomy group. However, this is not a statistical analysis. There is an increase in cost with the laparoscopic procedure that comes from the added instrumentation and the need for a general surgeon. But, when one considers the risk and cost of repeated surgery for shunt failure in patients with the mentioned characteristics, the extra cost of the laparoscopic procedure is acceptable. In our 13 patients, there was one wound infection. This was treated successfully with open drainage, wet-to-dry dressing changes, and intravenous antibiotics (Case 7, Table 3). According to the laparoscopic literature, the rate of wound infection in large series is 0.2%. A majority of them occurred between the third and twentieth postoperative day. These wound infections are treated medically with intravenous antibiotics, open drainage, and dressing changes [ 131. The patient in Case 6 (Table 3) developed peritonitis from bowel perforation. This patient had a spontaneous bowel perforation 2 weeks before presenting with signs and symptoms of shunt malfunction for which he had undergone resection and primary anastomosis. Workup revealed a CSF pseudocyst. Laparoscopic procedure was performed and the catheter was freed from the cysts and externalized. The general surgeon felt that a small bowel perforation had been present, but had been sealed off at the time of the laparoscopic procedure. Spontaneous bowel perforations with pseudocyst formation have been reported in the neurosurgery literature as a complication of VP shunts [3,8,16,21] and it was thought that this was the case in this patient. Therefore, the VP shunt was converted to a VA shunt once the infection had cleared. Among the reported laparoscopic-aided VP shunt procedures [2,4,17], there have been no reported bowel-related complications. However, bowel perforation and penetration of other intraperitoneal organs is a known complication of laparoscopy, especially with the closed laparoscopic technique and the blind introduction of the Veress needle.

134

Surg Neurol 1998;49:127-35

That is why we prefer to use the open laparoscopic method [1,7,10-131. The patient in Case 5 (Table 3) presented with a VA shunt malfunction. She had her VA shunt converted to a VP shunt but, because of failure of CSF absorption by her peritoneum and development of CSF ascites, she required conversion of her VP shunt back into a VA shunt. It was not certain before surgery if the VP shunt would work, and we do not feel that this was a complication of the procedure. In summary, the laparoscopic insertion of a peritoneal catheter for a VP shunt can be performed in patients for both first time shunt placements and shunt revisions. Suspected abdominal adhesions (i.e., history of peritonitis or intra-abdominal procedures), obesity, and severe scoliosis (i.e., myelomeningocele patients) are the indications for laparoscopic-aided VP shunt procedures. The advantages of this procedure are the ability to directly visualize the location of the catheter tip within the abdominal or pelvic cavity, and to lyse adhesions in order to increase the CSF absorptive surface area. Additionally, it could be used in situations where the neurosurgeon thinks that the peritoneal cavity needs to be explored before committing the patient to a VA or VP shunt. Laparoscopy may shorten the operative time; however, an experienced laparoscopic surgeon is needed. Laparoscopy can increase the operative costs, and therefore this procedure should only be used in selected cases where its benefits may outweigh the increased cost of the procedure when compared with the cost of the traditional minilaparotomy procedure. REFERENCES 1. Al-m YW, Leach JA. A comparison of subcutaneous and preperitoneal emphysema arising from gynecologic laparoscopic procedures. J Reprod Med 1976; 17:335-7. 2. Armburster C, Blauensteiner J, Ammerer H, Kriwanek S. Laparoscopically assisted implantation of ventriculoperitoneal shunts. J Laparoendosc Surg 1993;3: 191-2. 3. Azimi F, Dinn WM, Naumann RA. Intestinal perforation: An infrequent complication of ventriculoperitoneal shunts. Radiology 1976;12:701-2. 4. Basauri L, Selman JM, Lizana C. Peritoneal catheter insertion using laparoscopic guidance. Pediatr Neurosurg 1993;19:109-10. 5. Carey CM, Tullous MW, Walker ML. Hydrocephalus: etiology, pathologic effects, diagnosis and natural history. In: Cheek WR, ed. Pediatric neurosurgery: surgery of the developing nervous system. Philadelphia: WB Saunders Company, 1994: 185-201. 6. Deinsberger W, Langhans M, Winking M, Boker DK. Retrieval of a disconnected ventriculoperitoneal shunt catheter by laparoscopy in a newborn child:

Khosrovi et al

case report. Minim Invasive Neurosurg 1995;38(3): 123-4. 7. Grimes EM. Open laparoscopy with conventional instrumentation. Obstet Gynecol 1981:57:375-f% 8. Grosfeld JL, Cooney DR, Smith J, Campbell RL. Intraabdominal complications following ventriculoperitoneal shunt procedures. Pediatrics 1974;54:791-6. 9. Guzinski GM, Meyer WJ, Loeser JD. Laparoscopic retrieval of disconnected ventriculoperitoneal shunt catheters. J Neurosurg 1982;56:587-9. 10. Hasson HM. Open laparoscopy: a report of 150 cases. J Reprod Med 1974;12:234-8. 11. Levinson CJ. Laparoscopy is easy except for the complications: a review with suggestions. J Reprod Med 1974;13:187-94. 12. Loffer F, Pent D. Indications, contradindications and complications of laparoscopy. Obstet Gynecol Surg 1975;30:407-27. 13. Peniield AJ. How to prevent complications of open laparoscopy. J Reprod Med 1985;30:660-3. 14. Raimondi AJ. Hydrocephalus. In: Raimondi AJ, ed. Pediatric neurosurgery: theoretical principles art of surgical techniques. New York: Springer-Verlag 1987: 453-91. 15. Rekate M. Treatment of hydrocephalus. In: Cheek WR, ed. Pediatric neurosurgery: surgery of the developing nervous system. Philadelphia: WB Saunders Company 1994:208-g. 16. Rubin CR, Ghatak NR, Visudhipan P. Asymptomatic perforated viscus and gram-negative ventriculitis as a complication of valve-regulated ventriculo-peritoneal shunts: report of two cases. J Neurosurg 1972;37:61618. 17. Schievink WI, Wharen RE, Reimer R, Pettit PD, Seiler JC, Shine TSJ. Laparoscopic placement of ventriculoperitoneal shunts: preliminary report. Mayo Clin Proc 1993;68:1064-6. 18. Schrenk P, Woisetschlager R, Wayand WU, Polanski P. Laparoscopic removal of dislocated ventriculoperitoneal shunts. Report of two cases. Surg Endosc 1994; 8:1113-4. 19. Tanaka J, Kikuchi K, Sasajima H, Koyama K. Laparoscopic retrieval of disconnected ventriculoperitoneal shunt catheters: report of two cases. Surg Laparosc Endosc 1995;5:263-6. 20. Walker ML, Petronio J, Carey CM. Ventriculoscopy. In: Cheek WR, ed. Pediatric neurosurgery: surgery of the developing nervous system. Philadelphia: WB Saunders Company, 1994:572-81. 21. Wilson CB, Bertan V. Perforation of the bowel complicating peritoneal shunt for hydrocephalus: report of two cases. Am Surg 1966;32:601-3. 22. Yamamoto M, Oka K, Nagasaka S, Tomonaga M. Ventriculoscope-guided ventriculoperitoneal shunt and shunt revision. Acta Neurochir (Wien) 1994;129: 85-8. COMMENTARY

The authors report the use of laparoscopic technique for the insertion of peritoneal catheters during ventriculoperitoneal shunt placement or revision. The 13 patients included in this review were selected because of suspicion of peritoneal adhesions, obesity, or distorted abdominal anatomy. A