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Laparoscopic Treatment of Ventriculoperitoneal Shunt Complication Caused by Distal Catheter Isolation Inside the Falciform Ligament
Case Report
Laparoscopic Treatment of Ventriculoperitoneal Shunt Complication Caused by Distal Catheter Isolation Inside the Falciform Ligament Jong-Hoon Kim, Young-Jin Jung, Chul-Hoon Chang
Key words Falciform ligament - Laparoscopy - Shunt malfunction - Ventriculoperitoneal shunt -
Abbreviations and Acronyms CSF: Cerebrospinal fluid VPS: Ventriculoperitoneal shunt Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Korea To whom correspondence should be addressed: Chul-Hoon Chang, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2016) 90:707.e1-707.e4. http://dx.doi.org/10.1016/j.wneu.2016.03.023 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.
INTRODUCTION The preferred modality to treat hydrocephalus is the ventriculoperitoneal shunt (VPS), which connects the lateral ventricles and the peritoneal cavity.1 Although shunt placement is a common procedure and is considered safe, several complications may occur. Up to 80% of shunts implanted for the treatment of hydrocephalus may fail at some point during the patient’s life, with approximately 30% failing within the first year.2 According to the literature, the percentage of abdominal complications related to VPSs ranges from 5% to 47%.3 Many cases of catheter-related complications involve a problem with the distal catheter near the abdominal cavity. In this case, the distal catheter entered the falciform ligament of the peritoneal cavity. As the catheter entered into the falciform ligament and expanded because of the accumulation of cerebrospinal fluid (CSF), a cyst formed. The aim of this study was to understand how the distal catheter entered the falciform ligament in the abdominal cavity and to prevent complications associated with this event.
- BACKGROUND:
A ventriculoperitoneal shunt is a widely recognized treatment that we use to treat hydrocephalus. In one’s lifetime, there is a high possibility of being diagnosed with shunt dysfunction. Occasionally, complications caused by the distal catheter located in the intra-abdominal cavity may occur.
- CASE
DESCRIPTION: In this case, after undergoing shunt surgery, the patient’s distal catheter had not moved and was fixed in 1 place. Therefore, we used abdominal computed tomography and discovered the presence of a pseudocyst where the distal catheter was located. Through laparoscopicassisted surgery performed by the department of general surgery, we discovered that the distal catheter entered into the falciform ligament and caused it to expand, creating a cyst. The fascia of the falciform ligament was dissected using a harmonic scalpel. Cerebrospinal fluid and the distal catheter were noted. Afterwards, the distal catheter was placed into the peritoneal cavity. After surgery, the patient was discharged without any complications.
- CONCLUSIONS:
Although this is an unusual circumstance, there have been reports of some cases in which the ventriculoperitoneal shunt distal catheter entered the falciform ligament. Therefore, one must pay close attention during the operation. In addition, when treatment is necessary, laparoscopicassisted surgery might serve as an effective diagnostic and therapeutic modality.
CASE REPORT A 76-year-old female patient in the emergency room with a subarachnoid hemorrhage underwent an emergency craniectomy and clipping of the ruptured aneurysm at the left posterior communicating artery. After surgery, the patient showed signs of improvement to a stuporous conscious level and had continuous hydrocephalus. Therefore, VPS and cranioplasty were performed 8 months after subarachnoid hemorrhage surgery. First, the whole scalp, chest, and abdomen were prepared and draped using aseptic surgical manners. After the insertion of the proximal shunt catheter at the Kocher point, a catheter passer was passed through the subcutaneous tunnel from the retromastoid area to the abdomen. The shunt catheter was subsequently passed through the catheter
WORLD NEUROSURGERY 90: 707.e1-707.e4, JUNE 2016
passer. Afterwards, the rectus abdominis muscle was retracted in the lateral direction based on the midline, the peritoneum at the midline was incised, and the catheter was inserted. When the distal catheter was inserted, there was no resistance or abnormal findings. Examination of the abdomen plain film immediately after surgery showed that the distal catheter was fixed in 1 location and tangled in a circular formation (Figure 1). The followup plain film showed that the location and shape of the distal catheter had not changed. The shunt valve was functioning properly. On the fifth day of VPS surgery, the location of the catheter had still not changed; thus, an abdominal computed tomography scan was performed. The distal catheter was isolated beneath the liver in a cyst-shaped capsule formation (Figure 2).
www.WORLDNEUROSURGERY.org
707.E1
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
Figure 1. The simple abdomen plain film shows the circular entangled formation of the distal catheter fixed in one location.
After consultation, laparoscopicassisted surgery was performed by the department of general surgery. During surgery, the distal catheter expanding the falciform ligament was confirmed by surgical video materials (Figure 3). The fascia from the falciform ligament was dissected using a harmonic scalpel. CSF and the distal catheter were noted. Afterwards, the distal catheter was placed into the peritoneal cavity. In the abdomen plain film examined after laparoscopic surgery, we confirmed that the distal catheter was appropriately located in the abdominal cavity. Liver function tests were normal. After surgery, the patient was discharged without any complications. DISCUSSION VPS is a widely accepted technique for the treatment of hydrocephalus. VPS systems
707.E2
www.SCIENCEDIRECT.com
are foreign bodies that may cause intraabdominal complications.4 Abdominal complications of VPS are not rare, and the common mechanism involves epithelial responses to the presence of the catheter, which cause peritoneal retraction, intra-abdominal CSF collection, and adhesions.2 Usually, complications are found from the presence of the patient’s symptoms, but because our patient was in a conscious but stuporous state, it was not possible to check the patient’s symptoms. However, after the shunt surgery was completed, the patient’s distal catheter had not moved and was fixed in 1 place. Therefore, we took an abdominal computed tomography scan and discovered the presence of a pseudocyst. Through laparoscopic-assisted surgery, we discovered that the distal catheter had entered into the falciform ligament.
The falciform ligament is the embryologic remnant of the ventral mesentery, and it marks the separation of the most caudal part of the left lobe of the liver into medial and lateral segments. The ligament is composed of 2 mesothelial layers, within which lie the ligamentum teres hepatic (obliterated left umbilical vein), the paraumbilical veins, the muscular fibers, and a variable amount of adipose tissue. The ligament extends from the anterior abdominal wall to the liver, where the 2 layers separate and become continuous with the peritoneum over the surface of the liver.5 Anatomically, the falciform ligament consists of a double layer of peritoneum arising from the anterior abdominal wall and extending into the midline above the umbilicus to the tendinous part of the inferior diaphragmatic surface (Figure 4).6 With the advent of minimally invasive techniques, these complications are diagnosed and managed laparoscopically.7,8 Laparoscopic-assisted surgery has become a useful option, because it allows for abdominal exploration with shorter surgical time and fewer complications. In 1995, Kim et al.9 first described the laparoscopic management of an abdominal complication.10 The advantages of the laparoscopic approach include a shorter hospital stay because of a minimally invasive operation and less postoperative pain. The catheter is positioned under direct vision with less bowel manipulation, thus reducing the risk of bowel injury and the development of adhesions.11 For these reasons, when dealing with distal catheter-related abdominal complications that occur after VPS, laparoscopic-assisted surgery has often been performed recently. In our case, several points are relevant to this complication. First, the site of the skin incision was at a higher location than usual. It is general practice for the incision site to be 2 fingers above the umbilicus. However, in this patient, the incision was located slightly higher. Second, in general, the position of the falciform ligament is located above the incision site. However, there is a possibility that this patient’s falciform ligament was descended more than usual. Because of the location of the
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.03.023
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
Figure 2. Computed tomography of the abdomen shows the isolated distal catheter that forms capsules in the shape of cysts beneath the liver.
falciform ligament, if these 2 conditions were met, the distal catheter could enter the falciform ligament.
Third, usually, after the skin is incised and the rectus abdominis muscle is dissected, the peritoneum is opened.
However, we did not dissect the rectus abdominis muscle. Instead, to avoid rectus abdominis muscle injury caused by the dissection, the muscle was retracted in the lateral direction based on the midline; then, the peritoneum at the midline was incised and the catheter was inserted. As mentioned earlier, it is considered that our method caused the location of the falciform ligament, which is usually at the midline and might possibly be the cause of entry of the distal catheter. After VPS surgery, when abdominal complications are expected, an accurate diagnosis of the patient through these various examinations is necessary and, when treatment is necessary after examination, laparoscopic-assisted surgery might serve as an effective diagnostic and therapeutic modality. In addition, as a way of preventing this complication, the incision site near the umbilicus and the use of the rectus abdominal muscle splitting method might be helpful. Confirmation of the identification of bowel loops or the use of intraoperative ultrasonography could be used to confirm peritoneal placement, and the primary use of the laparoscope to place the distal catheter might be helpful.
CONCLUSIONS Although VPS surgery is relatively simple and is a widely used treatment option, complications from VPS are not rare. Although the entry of the distal catheter into the falciform ligament is rare, one must pay careful attention during surgery. When complications are suspected, an accurate diagnosis should be made, and, if treatment is necessary, safe and effective diagnoses and treatments might be possible through laparoscopic-assisted surgery.
ACKNOWLEDGMENTS Figure 3. A captured picture of the laparoscopic-assisted surgery video; the expanded falciform ligament is shown.
WORLD NEUROSURGERY 90: 707.e1-707.e4, JUNE 2016
This work was supported by the 2013 Yeungnam University Research Grant.
www.WORLDNEUROSURGERY.org
707.E3
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
4. Kaplan M, Ozel SK, Akgun B, Kazez A, Kaplan S. Hepatic pseudocyst as a result of ventriculoperitoneal shunts: case report and review of the literature. Pediatr Neurosurg. 2007;43:501-503. 5. Enterline DS, Rauch RE, Silverman PM, Korobkin M, Akwari OE. Cyst of the falciform ligament of the liver. AJR Am J Roentgenol. 1984;142: 327-328. 6. Bills D, Moore S. The falciform ligament and the ligamentum teres: friend or foe. ANZ J Surg. 2009; 79:678-680. 7. Kusano T, Miyazato H, Shimoji H, Hirayasu S, Isa T, Shiraishi M, et al. Revision of ventriculoperitoneal shunt under laparoscopic guidance in patients with hydrocephalus. Surg Laparosc Endosc. 1998;8:474-476. 8. Paddon AJ, Horton D. Knotting of distal ventriculoperitoneal shunt tubing. Clin Radiol. 2000; 55:570-571. 9. Kim HB, Raghavendran K, Kleinhaus S. Management of an abdominal cerebrospinal fluid pseudocyst using laparoscopic techniques. Surg Laparosc Endosc. 1995;5:151-154. 10. Basauri L, Selman JM, Lizana C. Peritoneal catheter insertion using laparoscopic guidance. Pediatr Neurosurg. 1993;19:109-110.
Figure 4. The anatomy of the falciform ligament.
11. Esposito C, Porreca A, Gangemi M, Garipoli V, De Pasquale M. The use of laparoscopy in the diagnosis and treatment of abdominal complications of ventriculo-peritoneal shunts in children. Pediatr Surg Int. 1998;13:352-354.
Conflict of interest statement: This work was supported by the 2013 Yeungnam University Research Grant. revision surgery. World J Gastrointest Endosc. 2014; 6:415-418.
REFERENCES 1. Browd SR, Ragel BT, Gottfried ON, Kestle JR. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol. 2006;34:83-92. 2. Pinto FC, de Oliveira MF. Laparoscopy for ventriculoperitoneal shunt implantation and
707.E4
www.SCIENCEDIRECT.com
Received 10 November 2015; accepted 10 March 2016 Citation: World Neurosurg. (2016) 90:707.e1-707.e4. http://dx.doi.org/10.1016/j.wneu.2016.03.023 Journal homepage: www.WORLDNEUROSURGERY.org
3. Nfonsam V, Chand B, Rosenblatt S, Turner R, Luciano M. Laparoscopic management of distal ventriculoperitoneal shunt complications. Surg Endosc. 2008;22:1866-1870.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.03.023
Laparoscopic Treatment of Ventriculoperitoneal Shunt Complication Caused by Distal Catheter Isolation Inside the Falciform Ligament Jong-Hoon Kim, Young-Jin Jung, Chul-Hoon Chang
Key words Falciform ligament - Laparoscopy - Shunt malfunction - Ventriculoperitoneal shunt -
Abbreviations and Acronyms CSF: Cerebrospinal fluid VPS: Ventriculoperitoneal shunt Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Korea To whom correspondence should be addressed: Chul-Hoon Chang, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2016) 90:707.e1-707.e4. http://dx.doi.org/10.1016/j.wneu.2016.03.023 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.
INTRODUCTION The preferred modality to treat hydrocephalus is the ventriculoperitoneal shunt (VPS), which connects the lateral ventricles and the peritoneal cavity.1 Although shunt placement is a common procedure and is considered safe, several complications may occur. Up to 80% of shunts implanted for the treatment of hydrocephalus may fail at some point during the patient’s life, with approximately 30% failing within the first year.2 According to the literature, the percentage of abdominal complications related to VPSs ranges from 5% to 47%.3 Many cases of catheter-related complications involve a problem with the distal catheter near the abdominal cavity. In this case, the distal catheter entered the falciform ligament of the peritoneal cavity. As the catheter entered into the falciform ligament and expanded because of the accumulation of cerebrospinal fluid (CSF), a cyst formed. The aim of this study was to understand how the distal catheter entered the falciform ligament in the abdominal cavity and to prevent complications associated with this event.
- BACKGROUND:
A ventriculoperitoneal shunt is a widely recognized treatment that we use to treat hydrocephalus. In one’s lifetime, there is a high possibility of being diagnosed with shunt dysfunction. Occasionally, complications caused by the distal catheter located in the intra-abdominal cavity may occur.
- CASE
DESCRIPTION: In this case, after undergoing shunt surgery, the patient’s distal catheter had not moved and was fixed in 1 place. Therefore, we used abdominal computed tomography and discovered the presence of a pseudocyst where the distal catheter was located. Through laparoscopicassisted surgery performed by the department of general surgery, we discovered that the distal catheter entered into the falciform ligament and caused it to expand, creating a cyst. The fascia of the falciform ligament was dissected using a harmonic scalpel. Cerebrospinal fluid and the distal catheter were noted. Afterwards, the distal catheter was placed into the peritoneal cavity. After surgery, the patient was discharged without any complications.
- CONCLUSIONS:
Although this is an unusual circumstance, there have been reports of some cases in which the ventriculoperitoneal shunt distal catheter entered the falciform ligament. Therefore, one must pay close attention during the operation. In addition, when treatment is necessary, laparoscopicassisted surgery might serve as an effective diagnostic and therapeutic modality.
CASE REPORT A 76-year-old female patient in the emergency room with a subarachnoid hemorrhage underwent an emergency craniectomy and clipping of the ruptured aneurysm at the left posterior communicating artery. After surgery, the patient showed signs of improvement to a stuporous conscious level and had continuous hydrocephalus. Therefore, VPS and cranioplasty were performed 8 months after subarachnoid hemorrhage surgery. First, the whole scalp, chest, and abdomen were prepared and draped using aseptic surgical manners. After the insertion of the proximal shunt catheter at the Kocher point, a catheter passer was passed through the subcutaneous tunnel from the retromastoid area to the abdomen. The shunt catheter was subsequently passed through the catheter
WORLD NEUROSURGERY 90: 707.e1-707.e4, JUNE 2016
passer. Afterwards, the rectus abdominis muscle was retracted in the lateral direction based on the midline, the peritoneum at the midline was incised, and the catheter was inserted. When the distal catheter was inserted, there was no resistance or abnormal findings. Examination of the abdomen plain film immediately after surgery showed that the distal catheter was fixed in 1 location and tangled in a circular formation (Figure 1). The followup plain film showed that the location and shape of the distal catheter had not changed. The shunt valve was functioning properly. On the fifth day of VPS surgery, the location of the catheter had still not changed; thus, an abdominal computed tomography scan was performed. The distal catheter was isolated beneath the liver in a cyst-shaped capsule formation (Figure 2).
www.WORLDNEUROSURGERY.org
707.E1
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
Figure 1. The simple abdomen plain film shows the circular entangled formation of the distal catheter fixed in one location.
After consultation, laparoscopicassisted surgery was performed by the department of general surgery. During surgery, the distal catheter expanding the falciform ligament was confirmed by surgical video materials (Figure 3). The fascia from the falciform ligament was dissected using a harmonic scalpel. CSF and the distal catheter were noted. Afterwards, the distal catheter was placed into the peritoneal cavity. In the abdomen plain film examined after laparoscopic surgery, we confirmed that the distal catheter was appropriately located in the abdominal cavity. Liver function tests were normal. After surgery, the patient was discharged without any complications. DISCUSSION VPS is a widely accepted technique for the treatment of hydrocephalus. VPS systems
707.E2
www.SCIENCEDIRECT.com
are foreign bodies that may cause intraabdominal complications.4 Abdominal complications of VPS are not rare, and the common mechanism involves epithelial responses to the presence of the catheter, which cause peritoneal retraction, intra-abdominal CSF collection, and adhesions.2 Usually, complications are found from the presence of the patient’s symptoms, but because our patient was in a conscious but stuporous state, it was not possible to check the patient’s symptoms. However, after the shunt surgery was completed, the patient’s distal catheter had not moved and was fixed in 1 place. Therefore, we took an abdominal computed tomography scan and discovered the presence of a pseudocyst. Through laparoscopic-assisted surgery, we discovered that the distal catheter had entered into the falciform ligament.
The falciform ligament is the embryologic remnant of the ventral mesentery, and it marks the separation of the most caudal part of the left lobe of the liver into medial and lateral segments. The ligament is composed of 2 mesothelial layers, within which lie the ligamentum teres hepatic (obliterated left umbilical vein), the paraumbilical veins, the muscular fibers, and a variable amount of adipose tissue. The ligament extends from the anterior abdominal wall to the liver, where the 2 layers separate and become continuous with the peritoneum over the surface of the liver.5 Anatomically, the falciform ligament consists of a double layer of peritoneum arising from the anterior abdominal wall and extending into the midline above the umbilicus to the tendinous part of the inferior diaphragmatic surface (Figure 4).6 With the advent of minimally invasive techniques, these complications are diagnosed and managed laparoscopically.7,8 Laparoscopic-assisted surgery has become a useful option, because it allows for abdominal exploration with shorter surgical time and fewer complications. In 1995, Kim et al.9 first described the laparoscopic management of an abdominal complication.10 The advantages of the laparoscopic approach include a shorter hospital stay because of a minimally invasive operation and less postoperative pain. The catheter is positioned under direct vision with less bowel manipulation, thus reducing the risk of bowel injury and the development of adhesions.11 For these reasons, when dealing with distal catheter-related abdominal complications that occur after VPS, laparoscopic-assisted surgery has often been performed recently. In our case, several points are relevant to this complication. First, the site of the skin incision was at a higher location than usual. It is general practice for the incision site to be 2 fingers above the umbilicus. However, in this patient, the incision was located slightly higher. Second, in general, the position of the falciform ligament is located above the incision site. However, there is a possibility that this patient’s falciform ligament was descended more than usual. Because of the location of the
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.03.023
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
Figure 2. Computed tomography of the abdomen shows the isolated distal catheter that forms capsules in the shape of cysts beneath the liver.
falciform ligament, if these 2 conditions were met, the distal catheter could enter the falciform ligament.
Third, usually, after the skin is incised and the rectus abdominis muscle is dissected, the peritoneum is opened.
However, we did not dissect the rectus abdominis muscle. Instead, to avoid rectus abdominis muscle injury caused by the dissection, the muscle was retracted in the lateral direction based on the midline; then, the peritoneum at the midline was incised and the catheter was inserted. As mentioned earlier, it is considered that our method caused the location of the falciform ligament, which is usually at the midline and might possibly be the cause of entry of the distal catheter. After VPS surgery, when abdominal complications are expected, an accurate diagnosis of the patient through these various examinations is necessary and, when treatment is necessary after examination, laparoscopic-assisted surgery might serve as an effective diagnostic and therapeutic modality. In addition, as a way of preventing this complication, the incision site near the umbilicus and the use of the rectus abdominal muscle splitting method might be helpful. Confirmation of the identification of bowel loops or the use of intraoperative ultrasonography could be used to confirm peritoneal placement, and the primary use of the laparoscope to place the distal catheter might be helpful.
CONCLUSIONS Although VPS surgery is relatively simple and is a widely used treatment option, complications from VPS are not rare. Although the entry of the distal catheter into the falciform ligament is rare, one must pay careful attention during surgery. When complications are suspected, an accurate diagnosis should be made, and, if treatment is necessary, safe and effective diagnoses and treatments might be possible through laparoscopic-assisted surgery.
ACKNOWLEDGMENTS Figure 3. A captured picture of the laparoscopic-assisted surgery video; the expanded falciform ligament is shown.
WORLD NEUROSURGERY 90: 707.e1-707.e4, JUNE 2016
This work was supported by the 2013 Yeungnam University Research Grant.
www.WORLDNEUROSURGERY.org
707.E3
CASE REPORT JONG-HOON KIM ET AL.
SHUNT CATHETER INSIDE FALCIFORM LIGAMENT
4. Kaplan M, Ozel SK, Akgun B, Kazez A, Kaplan S. Hepatic pseudocyst as a result of ventriculoperitoneal shunts: case report and review of the literature. Pediatr Neurosurg. 2007;43:501-503. 5. Enterline DS, Rauch RE, Silverman PM, Korobkin M, Akwari OE. Cyst of the falciform ligament of the liver. AJR Am J Roentgenol. 1984;142: 327-328. 6. Bills D, Moore S. The falciform ligament and the ligamentum teres: friend or foe. ANZ J Surg. 2009; 79:678-680. 7. Kusano T, Miyazato H, Shimoji H, Hirayasu S, Isa T, Shiraishi M, et al. Revision of ventriculoperitoneal shunt under laparoscopic guidance in patients with hydrocephalus. Surg Laparosc Endosc. 1998;8:474-476. 8. Paddon AJ, Horton D. Knotting of distal ventriculoperitoneal shunt tubing. Clin Radiol. 2000; 55:570-571. 9. Kim HB, Raghavendran K, Kleinhaus S. Management of an abdominal cerebrospinal fluid pseudocyst using laparoscopic techniques. Surg Laparosc Endosc. 1995;5:151-154. 10. Basauri L, Selman JM, Lizana C. Peritoneal catheter insertion using laparoscopic guidance. Pediatr Neurosurg. 1993;19:109-110.
Figure 4. The anatomy of the falciform ligament.
11. Esposito C, Porreca A, Gangemi M, Garipoli V, De Pasquale M. The use of laparoscopy in the diagnosis and treatment of abdominal complications of ventriculo-peritoneal shunts in children. Pediatr Surg Int. 1998;13:352-354.
Conflict of interest statement: This work was supported by the 2013 Yeungnam University Research Grant. revision surgery. World J Gastrointest Endosc. 2014; 6:415-418.
REFERENCES 1. Browd SR, Ragel BT, Gottfried ON, Kestle JR. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol. 2006;34:83-92. 2. Pinto FC, de Oliveira MF. Laparoscopy for ventriculoperitoneal shunt implantation and
707.E4
www.SCIENCEDIRECT.com
Received 10 November 2015; accepted 10 March 2016 Citation: World Neurosurg. (2016) 90:707.e1-707.e4. http://dx.doi.org/10.1016/j.wneu.2016.03.023 Journal homepage: www.WORLDNEUROSURGERY.org
3. Nfonsam V, Chand B, Rosenblatt S, Turner R, Luciano M. Laparoscopic management of distal ventriculoperitoneal shunt complications. Surg Endosc. 2008;22:1866-1870.
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.03.023