Page 39 - World Journal of Laparoscopic Surgery

Laparoscopic Intervention after VP Shunt

cAse descrIptIon antibiotics (cefuroxime and metronidazole) intraoperatively as well
A 74-year-old female had been referred to the department of as postoperatively for 5 days.
In the postoperative phase, the patient presented no
gynecology with ascites. She came to the hospital 3 weeks prior complications and was discharged 24 hours after the operation.
for dyspnea and tachycardia. She was initially admitted to the There were no neurological symptoms. A neurosurgical consultation
cardiology department with increased levels of d-dimer, troponin, had taken place, and no intervention was recommended. The patient
and pleural effusion. The medical history of the patient revealed demonstrated an uneventful recovery. The histopathological
a head trauma followed by an epileptic seizure. In 2004, she had results showed papillary serous carcinoma of the fallopian tube.
undergone several cranial operations resulting in a VP shunt. The patient underwent an ovarian cancer typical laparotomy.
As reported by colleagues from the cardiology department, In the 8-month follow-up, the patient showed no neurological
at the time of admission the patient was conscious, alert, and complications.
oriented. She presented with tachycardia (heart rate 144/minute),
and the electrocardiography (ECG) showed atrial fibrillation and
high blood pressure of 155/95 mm Hg. The laboratory results MAterIAls And Methods
were normal: white cell count, 8.8 trillion cells/L, hemoglobin 15 Search Strategy, Study Selection, and Data Extraction
g/dL, normal serum electrolytes, and coagulation profile. A blood We searched PubMed, EMBASE, and Google Scholar for all
gas analysis showed the following values: pH: 7.47, pO : 70 mm publications between January 1975 and December 2018 with
2
Hg, pCO : 29 mm Hg, HCO : 23 mmol/L, lactate: 15 mg/dL, and the search terms “ventriculoperitoneal shunt,” “laparoscopy,”
2
3
O saturation 96%. Chest X-rays revealed pleural effusion and “complications,” “management,” “cerebral monitoring,” and
2
lung infiltration. An ultrasound was performed, which showed “intracranial pressure”.
cholecystolithiasis and ascites. A paracentesis of approximately 6 l The preliminary search results and article titles have been
of ascites was carried out and a sample of the fluid was sent to the reviewed. All studies published with an abstract in English which
pathology. The atrial fibrillation was treated with beta-blockers, reported at least one case of laparoscopic operation after VP shunts
and the patient was started on anticoagulation therapy. The were potentially eligible for inclusion and have been screened
transthoracic echocardiogram had presented a mild mitral and to assess whether a full text was possible to acquire. Then all
tricuspid insufficiency and an ejection fraction of 40%. abstracts and full texts for all potentially eligible studies were
The pathology findings showed non-small cell adenocarcinoma reviewed and data were extracted. The relevant abstracts have been
and the patient was referred to the department of internal selected of this initial pool. A reference list of retrieved relevant
medicine to rule out lung, pancreas, and gastrointestinal articles was screened for other studies. Any disagreement during
malignancies. There were no tumor or suspicion lesions in study selection and the data extraction process was resolved by
the endoscopic ultrasound, esophagogastroduodenoscopy, discussion with the senior author (Sv.B). We excluded studies that
and colonoscopy. The computed tomography (CT) scan of the were written and published in languages other than English or
thorax and abdomen pointed out only suspicious abdominal provided insufficient data.
retroperitoneal lymph nodes, and there were no other relevant A total of 136 publications were initially identified as eligible
findings. The patient was referred to the department of using the mentioned search terms. The inclusion criteria were met
gynecology to rule out gynecological malignancy. in 26 publications which came to 19.11%. A systematic review was
During the examination in our department, she had normal performed according to Preferred Reporting Items for Systematic
vital parameters. The abdominal examination showed a distended Reviews and Meta-Analysis guidelines (Liberati 2009). Flowchart 1
18
abdomen. No lesions or tumors were found in vaginal examination. summarizes the article’s search strategy.
The Pap smear was normal. The vaginal ultrasound revealed small
ovaries and an endometrium thickness of 8 mm. To rule out a results
gynecological malignancy, we proceeded with hysteroscopy,
dilatation, curettage, and laparoscopy with biopsies. Population of Reported Patients
In the operating room, the patient was placed in a supine According to our research, 128 cases of laparoscopic operations
position. After the induction of general anesthesia, an orogastric and after VP shunt were reported between 1992 and 2018 (Table 1). The
a Foley catheter were placed with the patient in the low lithotomy collected data included the gender and the age of the patients, the
position. A 1-cm umbilical incision was carried out, followed by the kind of laparoscopic intervention, time from the shunt insertion to
placement of the Veress needle and insufflation of the abdomen the laparoscopic operation, the pressure of pneumoperitoneum,
up to 20 mm Hg (high flow technique). After establishing a 20-mm manipulation with the VP shunt during the operation, and the
Hg pneumoperitoneum, a 10-mm port and camera were inserted complications. In our analysis, we specifically focused on different
in the abdominal cavity. The peritoneal contents were visualized, approaches and managements in patients with VP shunts needing
confirming no injury or abnormality. The distal VP shunt tube was laparoscopic intervention. 1,2,8,10,17,19–39
lying across a small bowel in the left peritoneum and appeared to The age of the patients ranged from 1 to 79 years. The
be intact without signs of abnormalities. The pneumoperitoneum operations were performed by the departments of general surgery,
was reduced and maintained at 14 mm Hg. Three liters of ascites gynecology, and urology. The time from the shunt operation to
were excreted. Because of adhesions in the left part of the pelvis, we laparoscopy ranged from 5 days to 28 years. The year the shunt
could not see the left ovary properly. After removing the adhesions, was manufactured ranged from 1975 to 2013.
there appeared to be suspicious lesions on the left fallopian tube In different articles, 1,2,8,10,17,19–37,39,40 four important points
and the left ovary. We took several biopsies and removed all of them are considered and discussed: the risk of a shunt infection or
in an EnDo-Bag. The surgical field was examined and there was complication, technical difficulties carrying out laparoscopy in
no bleeding. No drain was inserted. The patient was administered patients with a VP shunt, the necessity of routine monitoring of

World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020) 37