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Technical note
Modification of shunt introducer
Aleksander M. Vitali, Andries A. le Roux
Inkosi Albert Luthuli Central Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Mayville, Durban,
4058, KwaZulu-Natal, South Africa

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Address for Correspondence: Aleksander M. Vitali, Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, Nelson R.
Mandela School of Medicine, University of KwaZulu-Natal, 800 Bellair Avenue, P. Bag X03, Mayville, Durban, 4058, KwaZulu-Natal,
South Africa. E-mail: alex.vitali@excite.com

ABSTRACT

The insertion of a ventriculoperitoneal shunt is one of the most common pediatric neurosurgical procedures.
A majority of these operations are efficient by junior doctors. Any modification to the technique that makes
the procedure easier may decrease the number of complications. The authors describe a quick modification
to the ventriculoperitoneal shunt introducer. This enables the easy and fast tunneling for catheter insertion,
even in the patient with a massive head due to neglected hydrocephalus, thereby decreasing the operative
time and possibly the risk of infection.
Key words: Ventriculoperitoneal shunt, CSF shunt, hydrocephalus, surgical technique, technical note,
macrocephaly

Technique

The insertion of a ventriculoperitoneal (VP) shunt remains

one of the commonest neurosurgical procedures. The majority
of these operations are performed in pediatric patients. On
the completion of the training, most neurosurgeons have
their own technique of introducer modification and shunt
insertion. These techniques will work well for the vast
majority of hydrocephalic patients. However, in situations
where the hydrocephalus has been neglected and there is an
exceptional disproportion between the size of the head and
the body, the usual technique of shunt placement may not
be that effective. Such cases of neglected hydrocephalus are
most common in less-developed countries, where prenatal
screening is suboptimal, abortion is either not practiced (for
religious or cultural reasons) or not available and resources
for treatment and diagnosis may not be readily accessible.
In the authors unit in Durban, South Africa, children with
neglected hydrocephalus present usually with massively
enlarged heads, thin necks, with very thin and fragile skin
[Figure 1]. Over the years, the authors have introduced a
slight and quick modification to the commonly used shunt
introducers (Codman, NMT, etc.), which has facilitated the
passage of the peritoneal catheter subcutaneously between
the scalp and the abdomen during VP shunt insertion.

In a supine position, the head of the patient is turned to the

opposite side and a rolled towel is placed under his/her neck.
The incisions are marked and the skin in between the planned
incisions is prepped and covered with a sterile drape. The
abdominal cavity and cranium are opened in a routine way.
The standard straight introducer [Figure 2] is bent in the
hands of the surgeon in an S shaped manner just prior to
tunneling [Figure 3]. The curvature is vaguely proportional
to the size of the head. The tunneling is started at the cranial
incision. Initially, the introducer tip follows the curvature of
the skull. As soon as the introducer reaches the craniocervical
junction, it is turned 180 with the tip facing upwards. The
tunneling follows over the neck. After negotiating the clavicle
and the upper chest, the introducer is being turned 180
again, making it easier to travel the remaining distance to
the abdominal incision [Figure 4]. The rest of the procedure
is performed as discussed elsewhere.[1,2]

Th

Introduction

Online full text at

http://www.pediatricneurosciences.com

Discussion
Ventriculoperitoneal shunt insertion is still one of the most
common neurosurgical procedures. It has been documented
that the duration of surgery and the surgical technique are
related to the rate/risk of infection.[3-5] The tunneling for the
insertion of the catheter can be one of the most difficult,
time-consuming and traumatic parts of the operation. Patients
with neglected hydrocephalus present with exceptionally
2007 / Jul-Dec / Volume 2 / J Pediatr Neurosci / 67

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Vitali
et al.: Modification of shunt introducer
forthisjournal

to position them ideally with a straight line between cranial

and abdominal incisions, as recommended in the booklets of
the shunt companies.[1]

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To accommodate the different body contour of pediatric

patients with large heads, we modified the shunt introducer.
The bending of the shunt introducer can be done easily in
the hands of the surgeon and it takes a few seconds. The
tunneling with an S-shaped introducer with two 180 turns
so that the curvature of the introducer matches the shape
of the head and chest takes seconds . More importantly, the
pulling and pressure damage of the surrounding tissue is kept
to the minimum. This technique also eliminates the need for
a third incision, which was often placed over the neck, where
there is thin and poor quality skin and it is difficult to access
for cleaning and operating, which increases the chance of
wound infection. The abovementioned factors and the shorter
operative time reduces the risk of shunt infection.

Figure 1: Child with massive head illustrating head and neck disproportion

We recognize that this is only one of many variations of

shunt placement. Most decisions regarding the direction
of tunneling can be made on the basis of the individual
characteristics of the patient. However, it should be noted
that the described introducer modification can be employed
also in abdomen-to-head tunneling.

Figure 2: Standard shunt introducer

This technique was employed by the authors in over 200

pediatric VP shunt insertions over the last 8 years. There were
no complications related to the modification of the instrument
or the direction of the tunneling. The average time of shunt
insertion was between 20 and 30 min. In our opinion, this
quick and easy modification to the insertion of the VP shunt
is beneficial and can be used by any neurosurgeon.

Acknowledgement

Th

Figure 3: Modified shunt introducer

The authors are extremely grateful to Mrs. S. Govender from the

Department of Neurosurgery, Durban, South Africa for providing
secretarial assistance and to Dr. Paul Steinbok, Division of Pediatric
Neurosurgery, British Columbias Childrens Hospital, Vancouver,
British Columbia, Canada for guidance, help and review of the
manuscript. The authors of this manuscript do not have financial
association with any of the mentioned products.

References
1.
Figure 4: Modified shunt introducer during the procedure. Note the shape of
the introducer that follows the body contour

large heads, thin necks, very thin skin (particulary over the
neck), soft cranial bones and scaphoid abdomens. These
factors make tunneling for the passage of the peritoneal
catheter more treacherous and these children are prone to too
deep or too superficial shunt placement under the skin and
perforation of the skull, skin or lung. Proper positioning will
decrease the difficulty and risks of the procedure; however,
in young children with massive heads, it is often impossible
68 / J Pediatr Neurosci / Volume 2 / Jul-Dec / 2007

2.
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Shurtleff, Inc: 2003.
Greenberg MS. Handbook of Neurosurgery Greenberg Graphics, Inc:
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Source of Support: Nil, Conflict of Interest: None declared.