Page 43 - World Journal of Laparoscopic Surgery

Laparoscopic Intervention after VP Shunt
In our case, we entered the peritoneum with the pressure of more fibrotic, then it is necessary to avoid the development of
20 mm Hg. Intraoperatively there were no complications and the the emphysema. How much time exactly is needed for the tissue
patient had no complaints after the operation. Based on our case to become fibrotic is not known yet.
and the available data, we suggest that laparoscopic operations • It is recommended that the procedure is performed by an
can be safely performed with only routine anesthetic monitoring in experienced laparoscopic surgeon in order to minimize the
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patients with a VP shunt. A careful placement of the trocar should chance of spillage and contamination. 17
be considered to avoid damaging the shunt and intraoperatively a • The surgeon should be aware of the location of the catheter
careful manipulation with the peritoneal portion of the catheter is within the abdominal wall to avoid inadvertent damage to the
recommended as well. The literature did not show any benefit to catheter during the placement of the trocar.
using invasive ICP monitoring mainly because of the high possibility • It is important to ensure that the intraperitoneal portion of the
of risks like intracranial hemorrhage. Invasive perioperative ICP catheter is not twisted or obstructed prior to decompression
monitoring may be an option in very complex cases but generally of the abdomen.
a direct monitoring of the ICP during laparoscopic surgery does not • Longer laparoscopic or robotic surgeries using a steep
appear to be necessary. The risk of retrograde failure of the valve Trendelenburg position should be carried out with caution.
system was shown to be minimal, even with an intra-abdominal • An extended course of prophylactic antibiotics is recommended.
pressure of 80 mm Hg. Currently there is no evidence that • Perioperative invasive ICP monitoring may be an option in very
suggests clamping or externalization of the catheter is necessary. complex cases, but it is associated with some complications.
Manipulating with the VP shunt could potentially increase the ICP. • To identify an infection in its early stages, a prompt treatment
2
The shunt material deteriorates with time, therefore the signs of may prevent potential serious complications. Educating the
increased ICP must be always considered. We believe that a consult patients and their families about the signs and symptoms of an
with a neurosurgeon prior to the operation is advisable in order to altered VP shunt function (headaches and photophobia) that
verify the correct function of the shunt valve. The patient should may result from a postoperative infection is useful. 2
be made aware of the potential risks associated with the procedure,
including shunt obstruction, damage, and infection and should sign
a patient’s consent. 27,39 The anesthesiologist should always inform coMplIAnce wIth ethIcAl stAndArds
the surgeon about the signs of increased ICP such as bradycardia No animal research has been used.
and hypertension. 33
A pelvic operation, lasting many hours, can affect the surgeons’
27
ability to monitor the shunt, and this could potentially be the ethIcAl ApprovAl
reason why any occlusions or back-pressure problems are overseen. All procedures performed in studies involving human participants
In these cases, an intermittent release of the pneumoperitoneum, were in accordance with the ethical standards of the institutional
reduction of the Trendelenburg position, and inspection of the end and/or national research committee and with the 1964 Helsinki
of the shunt would give a possibility to avoid such complications. declaration and its later amendments or comparable ethical
Finally, an antegrade spread of malignant cells from the central standards. This article does not contain any studies with human
nervous system through VP shunts was described, 44–46 suggesting participants or animals performed by any of the authors.
that if a retrograde valve failure occurred, the central nervous
system could be inoculated with malignant cells from the pelvis.
In our case, our patient showed no signs of metastasis after the references
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World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020) 41