OPERATIVE TECHNIQUE

Modern Paradigm for Peritoneal Catheter

Insertion: Single Port Optical Access Laparoscopic
Shunt Insertion
Jacob Cherian, MD
Jared S. Fridley, MD
Edward A.M. Duckworth, MD
Department of Neurosurgery, Baylor
College of Medicine, Houston, Texas
Correspondence:
Edward A.M. Duckworth, MD,
Neurosurgery,
Baylor College of Medicine,
6501 Fannin St, Suite NC100,
Houston, TX 77030.
E-mail: edward.duckworth@bcm.edu
Received, September 27, 2014.
Accepted, December 28, 2014.
Published Online, February 14, 2015.
Copyright © 2015 by the
Congress of Neurological Surgeons.
BACKGROUND: Ventriculoperitoneal shunting is one of the most commonly per-
formed neurosurgical procedures. Typically, for insertion of the peritoneal catheter,
a mini-laparotomy technique is used. Although generally safe, it can be cosmetically
undesirable and time consuming. Complications include malpositioning, bowel injury,
and delayed hernias. Laparoscopic techniques have been advocated to address these
issues, but have been slow to gain traction with neurosurgeons.
OBJECTIVE: To describe our experience with single port optical access laparoscopy for
placement of ventriculoperitoneal shunts. Our technique simplifies adoption of a lapa-
roscopic technique for neurosurgeons looking to incorporate its benefits.
METHODS: All ventriculoperitoneal shunts placed by the senior author since April 2011
were retrospectively reviewed. Surgical and perioperative complications, length of
postoperative stay, and need for revisions were analyzed.
RESULTS: Fifty-six patients were included in the study. There were no cases of peri-
toneal catheter misplacement. One intraoperative complication occurred early in the
series, in which there was an injury to the gallbladder necessitating cholecystectomy.
There were 7 cases followed by shunt revision inclusive of the abdomen. In 3 cases,
pseudocysts were noted.
CONCLUSION: Single port optical access laparoscopy is a fast and minimally invasive
technique that allows direct visualization of the layers of the abdominal wall as they are
traversed and visualization of the peritoneal catheter during placement. It uses a small
cosmetic incision and obviates the need for postoperative abdominal radiographic
studies. The procedure has a modest learning curve, but can be safely used without the
assistance of an assist surgeon after the skills are acquired.
KEY WORDS: Laparoscopy, Optical access, Shunt insertion

Operative Neurosurgery 11:205–212, 2015 DOI: 10.1227/NEU.0000000000000678

C
erebrospinal fluid shunting to the perito-
neum is one of the most commonly per-
formed neurosurgical procedures. When
performed by neurosurgeons, the distal peritoneal
catheter is generally placed using either the open
laparotomy approach or a blind percutaneous
trocar technique.1
During the past decade, laparoscopy has
WHAT IS THIS BOX? become widely accepted—if not standard of
A QR Code is a matrix care—for most intraperitoneal surgeries. Modern
barcode readable by QR
scanners, mobile phones
with cameras, and
smartphones. The QR Supplemental digital content is available for this article.
Code above links to Direct URL citations appear in the printed text and are
Supplemental Digital provided in the HTML and PDF versions of this article on
Content from this the journal’s Web site (www.neurosurgery-online.com).
article.
techniques and technology have allowed for
smaller incisions, as well as faster and safer
operations, with superior visualization. One
significant advance has been the way in which
the peritoneal cavity is first entered. New devices
have emerged that allow for dissection through
the abdominal wall under direct visualization with
the laparoscope peering through a clear trocar.
This process is referred to as optical access.2-7
Despite significant uptake in numerous other
specialties, these techniques have seen slow
adoption by neurosurgeons for shunt surgery.
Here we describe our experience using single port
optical access for laparoscopic peritoneal catheter
placement, and we review the current literature with
particular emphasis on operative techniques.

OPERATIVE NEUROSURGERY VOLUME 11 | NUMBER 2 | JUNE 2015 | 205

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CHERIAN ET AL

METHODS
All ventriculoperitoneal shunts placed by the senior author from April
2011 (when this technique was adopted) to March 2014 were retrospec-
tively reviewed through electronic chart review. Parameters including
surgical and perioperative complications, length of postoperative stay, and
the need for shunt revision were analyzed.
Surgical Technique
The proximal catheter, ventricular or lumbar, is placed in the usual
fashion. A shunt passer is then used to pass the distal catheter to a small
abdominal wall stab incision, usually in the right upper quadrant of the
abdomen. A 5-mm optical access trocar is then inserted and used to traverse
the layers of the abdominal wall under direct visualization (Figure and
Video, Supplemental Digital Content, http://links.lww.com/NEU/
A721). The trocar is rotated and advanced, primarily with the weight
of the camera and scope, until the peritoneum is visualized and traversed.
Pneumoperitoneum is established, and intraabdominal visualization is
used to choose a suitable area for placement of the shunt (typically the
pelvis). A split abdominal trocar is then inserted parallel to the optical
access trocar through the same incision under laparoscopic visualization.
Finally, the distal shunt catheter is inserted through this split trocar, again
under direct visualization, and directed towards a suitable region of the
peritoneal cavity. Cerebrospinal fluid flow through the catheter end is
confirmed by visualization via the laparoscope. The abdominal incision,
measuring 8 mm, is then closed using 1 or 2 buried absorbable sutures and
dressed with a simple bandage.

FIGURE. Stages of optical access into peritoneum and laparoscopic shunt placement. A, subcutaneous fat. B, superficial rectus fascia. C, rectus muscle coming into view. D,
deep rectus fascia and peritoneum being broached. E, omental fat entered. F, pneumoperitoneum induced with camera now in insufflated peritoneal space. G, split trocar placed
coaxially through the same skin incision under visualization. H, shunt catheter passed through split trocar under visualization. Cerebrospinal fluid flow through the shunt is
confirmed.

206 | VOLUME 11 | NUMBER 2 | JUNE 2015 www.neurosurgery-online.com

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RESULTS
Fifty-six patients undergoing this technique were included in
our study, in which 60 procedures using laparoscopic technique
were performed. The 2 most common indications for shunt
placement were posthemorrhagic hydrocephalus and normal
pressure hydrocephalus. The mean age in our cohort was 58, with
a range of 25 to 85 years old. Table 1 lists additional clinical details
for patients in the series. There were no cases of peritoneal
catheter misplacement using our technique. There was 1 case of
initial entry into a loculated peritoneal pocket that necessitated
a second entry through a separate skin incision. Excluding cases
using navigation and those combined with other procedures,
both average and median operative times were 44 minutes.
Operative time ranged from 19 to 72 minutes. In cases where
only shunt placement was performed, estimated blood loss was
,5 mL in almost 90% of cases. Median postoperative length of
stay was 6 days (range, 1-23 days). For elective shunt procedures,
median postoperative length of stay was 2 days. Follow-up for
evaluation of shunt failure ranged from 2 to 53 months, with
a median of 23 months.
Complications and Revisions
One intraoperative complication occurred early in the series, in
which there was an injury to the gallbladder necessitating general
surgery consultation and laparoscopic cholecystectomy. The
laparoscopically placed distal catheter was not repositioned.
Six patients developed severe abdominal pain after laparoscopic
shunt placement necessitating revision. In 3 cases, there were no
organized collections and no evidence of infection. These patients
were all converted to ventriculoatrial shunts. In the remaining 3
cases, organized peritubal fluid collections (pseudocysts) were
noted by imaging. These were treated with shunt externalization
followed by a course of antibiotics directed by infectious disease
TABLE 1. Demographic Summary of Series
Patients
Cases
Age at operation
20-40 y
41-60 y
.60 y
Sex
Male
Female
Cause
Posthemorrhagic
Normal pressure hydrocephalus
Pseudotumor cerebrii
Cerebrospinal fluid leak
Obstructive tumor
Leptomeningial disease
Other
OPERATIVE NEUROSURGERY
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SINGLE PORT OPTICAL ACCESS SHUNT INSERTION
consultants. In 2 of these 3 cases of pseudocyst development,
cultures returned negative and abdominal reimplantation was
avoided with conversion to a ventriculoatrial shunt. In the remaining
case of pseudocyst, cultures returned positive and the shunt was
reimplanted to the peritoneal space using a laparoscopic technique
after completion of microbiology-specific antibiotic therapy. Of 60
procedures, this was the only case of culture-confirmed infection
involving the shunt system. In 1 additional patient, infection was
reportedly identified at an outside facility before shunt system
explantation. Records from the outside facility are unavailable, and it
is unknown if there was an associated pseudocyst. Taken together,
there were 4 cases of presumed or confirmed shunt infection for
a postoperative infection rate of 6.67%.
In total, roughly 23% (14/60) of cases were followed by
subsequent shunt revisions. All revisions involving the abdominal
catheter system occurred on a delayed basis with a median time to
revision of 152 days (range, 43-420 days). In contrast, revisions
isolated to the proximal shunt system occurred more acutely with
a median time to revision of 31 days (range, 13-196 days). Refer to
Table 2 for a breakdown of revisions after laparoscopic shunt
placements.
DISCUSSION
Numerous benefits for laparoscopic shunt surgery have been
advanced in the literature (Table 3). Such benefits include smaller
and more cosmetic incisions, and reduced adhesion formation.8
Additionally, distal catheter placement can be directly visualized.
Prospective work by Schubert et al9 indicated a lower risk of distal
shunt malfunction with laparoscopic placement of the peritoneal
catheter. Indeed, laparoscopic techniques have become standard
in intraperitoneal surgery for numerous specialties including
general surgery, urology, and gynecology.
Despite these clear benefits, neurosurgeons have been slow to
directly adopt laparoscopy to shunt surgery. When laparoscopy is
used, it is generally in the context of an assist surgeon. The failure
of widespread acceptance may be partly attributable to the
complexity of previous descriptions of laparoscopy for shunt
placement. Previous authors have reported use of multiple ports
56
60 and incisions, the need for an assist surgeon, and unfamiliar entry
techniques. A simpler approach may improve accessibility to
11 neurosurgeons looking to incorporate the benefits of this now-
23 standard approach to abdominal surgery.
26
Single Port Optical Access and Laparoscopy
20
36 Our approach combines 2 key advances from the abdominal
surgery literature: optical access and single port laparoscopic
24 technique. Many of the basic elements of these techniques are
10 already familiar to neurosurgeons and offer significant advantages
7
compared with traditional methods. Initial access to the perito-
4
5
neum is done under visualization through the same layers familiar
2 to those using the mini-laparotomy technique. Access is achieved
4 quickly, usually within 1 minute.2 The final peritoneal defect is
small and limits the risk of hernia. Navigation of the laparoscope
VOLUME 11 | NUMBER 2 | JUNE 2015 | 207
CHERIAN ET AL

TABLE 2. Revisions After Laparoscopic Shunt Placement

Days to
Case No. Age Sex Revision Reason for Revision Comments
Revisions involving distal
catheter
19 46 F 62 Abdominal pain No collections identified. Normal infectious
markers. Revised to ventriculoatrial shunt
21 52 M 275 Abdominal pain Converted to a ventriculoatrial shunt at an outside
facility
39 47 F 420 Abdominal pain; malabsorption Diagnostic laparoscopy revealed cloudy peritoneal
fluid without organized collection. Cultures
negative. Antibiotics not given. Converted to
ventriculoatrial shunt
42 34 F 43 Abdominal pain; pseudocyst Shunt externalized. Antibiotics given. Cultures
negative. Converted to ventriculoatrial shunt
51 32 F 80 Abdominal pain; pseudocyst Shunt externalized. Antibiotics given. Cultures
negative. Converted to ventriculoatrial shunt
42 58 M 152 Abdominal pain; pseudocyst Shunt externalized. Cultures positive for coagulase-
negative staphylococcus and Propionibacterium
acnes. Shunt reimplanted laparoscopically after
microbiology specific antibiotic course
52 60 F 172 Presumed infection Reported shunt infection at outside hospital.
Microbiology unavailable, but complete shunt
explanted
Revisions involving
proximal system only
10 72 M 15 Subdural hemorrhage Subdural hemorrhage evacuated. Converted to
lumboperitoneal shunt
33 60 M 31 Subdural hemorrhage Subdural evacuated and valve revised
20 36 M 15 Epidural hematoma Epidural hematoma evacuated. Valve
reprogrammed
36 54 M 13 Proximal obstruction Proximal catheter exchanged
37 60 F 183 Proximal obstruction Proximal catheter exchanged
50 65 F 196 Shunt not helping Shunt removed after patient was without relief in
gait and mentation difficulties
52 58 M 84 Insufficient drainage Fixed valve converted to programmable valve

is similar to manipulation of a rigid endoscope during trans-
sphenoidal or ventriculoscopic cases, such as endoscopic third
ventriculostomy. No imaging is required postoperatively and
distal catheter placement can be optimally directed into the pelvis
under direct visualization. Furthermore, flow of cerebrospinal
fluid from the distal catheter can be confirmed within the
peritoneal space.
Our series differs from previous ones describing laparoscopic
shunt placement in a few major respects. First, peritoneal entry is
achieved under direct visualization through optical access.2-7 With
the exception of work from Kubo et al,10 Turner et al,11 and
Tormenti et al12 all previous work has used either open dissection
or a blind percutaneous puncture to initially access the peritoneal
space. Second, the technique described uses only 1 small
abdominal incision with a single port. Most authors rely on at
least 2 abdominal skin incisions (Table 3). Third, in this work all
peritoneal catheters were placed by a neurosurgeon rather than by
a specialized laparoscopist, as described in most other series.
While the assistance of a laparoscopic surgeon in difficult cases
can be helpful, routine use of an assist surgeon complicates
surgical planning, particularly in urgent cases. Furthermore, it
adds to the number of people in the operating room, increasing
the risk of shunt infection.13 We think that for routine cases,
neurosurgeons can be just as comfortable with laparoscopy as
they are with traditional methods of entering the abdomen.
Previous authors have highlighted possible training path-
ways.11,14 Based on our experience, for established neurosurgeons
in practice, 10 to 20 cases under the supervision of a laparoscopist
should be sufficient to gain proficiency for the techniques
described herein. Neurosurgery trainees may be able to achieve

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 SINGLE PORT OPTICAL ACCESS SHUNT INSERTION

TABLE 3. Summary of Peritoneal Access Literature for Placement of Ventricular and Lumbar Shuntsa
Initial Peritoneal Abd Incisions Abdominal
Reference Cases (No.) Entry (No.) Surgeon Pneumoperitoneum
22
Armbruster et al, J Laparoendosc Surg, 1993 3 Hasson 3 Laparoscopist Yes
Basauri et al, Pediatr Neurosurg, 199323 7 Not specified 2 Not specified Yes
Schievink et al, Mayo Clin Proc, 199324 10 Veress and Hasson 3 Laparoscopist Yes
Cuatico and Vannix, J Laparoendosc Surg, 199525 11 Veress 2 Laparoscopist Yes
Box et al, Surg Endosc, 199626 6 Veress and Hasson 2-4 Laparoscopist Yes
Reimer et al, J Am Coll Surg, 199827 70 Hasson 1-3 Laparoscopist Yes
Khosrovi et al, Surg Neurol, 199828 13 Hasson 2-4 Laparoscopist Yes
Khaitan and Brennan, Surg Endosc, 199929 10 Veress and Hasson 2 Neurosurgeon Yes
Fanelli et al, Surg Endosc, 200030 5 Hasson 2 Laparoscopist Yes
Reardon et al, Surg Endosc, 200031 8 Veress 3-4 Laparoscopist Yes
Roth et al, Surg Endosc, 200032 27 Veress and optical 2 Laparoscopist Yes
access
Kubo et al, J Neurosurg, 200110 8 Optical access 1 Neurosurgeon No
Kubo et al, J Neurosurg, 200333 6 Retroperitoneal 1 Neurosurgeon Yes
endoscopic
Kirshtein et al, Surg Laparosc Endosc Percutan Tech, 28 Veress and Hasson 2 Laparoscopist Yes
20048
Kurschel et al, Childs Nerv Syst, 200534 10 Hasson 2 Laparoscopist Yes
Schubert et al, Surg Endosc, 20059 50 Veress 2 Laparoscopist Yes
Bani and Hassler, Pediatr Neurosurg, 200635 39 Hasson 2 Laparoscopist Yes
Bani et al, 200636 151 Veress 2 Laparoscopist Yes
Goitein et al, J Laparoendosc Adv Surg Tech A, 10 Veress 2-3 Laparoscopist Yes
200637
Tepetes et al, Clin Neurol Neurosurg, 200638 15 Hasson 2 Laparoscopist Yes
Jea et al, J Neurosurg, 200739 11 Hasson 3 Laparoscopist Yes
Konstantinidis et al, Minim Invasive Neurosurg, 12 Hasson 2 Laparoscopist Yes
200740
Roth et al, Surg Neurol, 200741 59 Veress 2-3 Laparoscopist Yes
Turner et al, Neurosurgery, 200711 113 Optical access 2 Laparoscopist Yes
Handler and Callahan, J Neurosurg Pediatr, 200814 137 Veress and Hasson 2-3 Both Yes
Argo et al, Surg Endosc, 200919 258 Veress 1-3 Laparoscopist Yes
Sekula et al, Br J Neurosurg, 200942 76 Veress and Hasson 2 Not specified Yes
Naftel et al, J Neurosurg, 201118 475 Veress 1-3 Laparoscopist Yes
Raysi Dehcordi et al, Neurosurg Rev, 201143 30 Hasson 1-3 Laparoscopist Yes
Stoddard and Kavic, JSLS, 201144 111 Veress 2 Laparoscopist Yes
Tormenti et al, J Neurosurg Pediatr, 201112 6 Optical access 1 Laparoscopist Yes
Aoki et al, No Shinkei Geka, 201245 10 Not specified 2 Laparoscopist Yes
Present Series, 2014 58 Optical access 1 Neurosurgeon Yes
a
Abd, abdominal.

sufficient laparoscopy training through required general surgery
rotations if optical access techniques are used.
Kubo et al10 describe optical access for initial entry into the
peritoneal space in a small series of 8 patients. They used a single
abdominal incision, but they did not induce pneumoperitoneum
and did not place the catheter under active laparoscopic guidance.
Similarly, Tormenti et al12 report single port optical access and
a single incision in a small series of 6 patients. Their technique
avoids contact of the distal catheter with the abdominal skin by
using the shunt passer to puncture into the peritoneal space, with
laparoscopic visualization from the umbilical port. The technique
as described is relatively complicated, requiring a grasper to assist
with passer puncture and final positioning of the catheter. We
have used this technique once, for a patient not in this series who
had Ehlers-Danlos syndrome and severe wound healing prob-
lems. The technique, although more involved, allows catheter
entry into the peritoneal space to be disassociated from any skin
incision, which was paramount in her situation.
Difficulties and Lessons
Despite the inherent advantages of optical access, complications
such as bowel and vascular injury can occur.3,4,15,16 We had 1
serious intraabdominal injury early in this series. This was
attributed to overly aggressive technique in passing the optical

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CHERIAN ET AL
trocar through the deepest layers of the abdominal wall. Since
that early case, our technique has been modified. Our experience
has shown that much of the dissection can be accomplished with
only the weight of the trocar and laparoscope, which, in
combination with rotational left and right movement, results
in predictable forward progression. Additionally, when planning
the abdominal incision and aiming the access trocar we attempt
to deliberately avoid the liver and gallbladder. In their published
comments to Danan et al,15 Braslow and Zager summarize the
laparoscopic literature across different surgical specialties to argue
that the available evidence does not support the use of any single
fail-safe initial entry technique. All approaches including optical
access “have a small, but real, associated complication rate.”
In many ways, the method described herein is no more difficult in
the obese patient than the nonobese patient (as opposed to the mini-
laparotomy approach). There is simply more adipose tissue to
traverse prior to getting to the rectus sheath (a recognizable
landmark). From there, the layers are not significantly different,
although there is occasionally a more robust layer of preperitoneal
fat, which can obscure the final stages of dissection. Based on our
significant experience with pseudotumor cerebri patients, this
technique is perfectly suited for even the morbidly obese.
Though incisions are smaller, abdominal pain after laparoscopy
is not uncommon, and can occur due to pneumoperitoneum.17
Our rate of isolated abdominal pain without associated pseudo-
cyst prompting revision was 5% (3/60). This rate is larger than
retrospective data reported in the large laparoscopic cohorts of
Naftel et al18 (1.9%), Argo et al19 (1.6%), and Handler and
Callahan14 (1.5%). It is unclear as to why this is the case and the
differences are not statistically significant. It may reflect our
learning curve with a laparoscopic technique or simply the smaller
number of patients in this series. Additionally, some authors have
reported that the induction of pneumoperitoneum may increase
intracranial pressure.20,21 Fortunately, the technique described
here uses pneumoperitoneum for only a short period, typically
,5 minutes, and is done only after ventriculostomy has been
achieved. In this way significant intracranial pressures are lowered
prior to the establishment of pneumoperitoneum.
The overall rate of infection in this series was 6.67%. This rate
compares similarly to the retrospective reporting from the large
laparoscopic cohorts of Naftel et al18 (8.2%), Argo et al19 (9.3%), and
Handler and Callahan14 (6.6%). Interestingly, Handler and Call-
ahan noted a trend toward a lower rate of infection when laparoscopy
was performed by neurosurgeons rather than by general surgeons
(5.4% vs 8.8%). Our rate of infection lies in between these rates.
Previous authors have demonstrated decreased time in the
operating theater and decreased length of hospital stay after surgery
in patients undergoing laparoscopic as opposed to open placement
of the distal peritoneal catheter.18,19 Our mean operative time of
44 minutes follows data reported by Naftel et al18 (43.5 minutes),
Argo et al19 (41 minutes), and Handler and Callahan14
(50.75 minutes). Length of hospital stay is difficult to compare
among different hospital cohorts due to differences in shunting
techniques and different requirements of patient management
210 | VOLUME 11 | NUMBER 2 | JUNE 2015
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
outside of perioperative shunt care. Nonetheless, in cases deemed
elective, patients were discharged in less than 48 hours in roughly
60% of cases. In comparison, Turner et al11 noted that about
three-fourths of their patients were discharged within 48 hours.
However, 80% of their patients had normal pressure hydro-
cephalus as the cause of hydrocephalus compared to roughly 50%
of patients in this series undergoing elective surgery.
Future Directions
Our technique uses a separate split trocar placed through the
same skin incision into the peritoneum once access and pneumo-
peritoneum is achieved. We have designed and are currently
developing an all-in-one trocar to obviate the need for 2 devices,
which would allow an even smaller skin incision, decrease the risk
of the procedure, and shorten operative times.
CONCLUSION
With appropriate experience, single port optical access laparos-
copy can be a safe, fast, and minimally invasive technique for
peritoneal catheter placement during ventriculoperitoneal shunting.
It allows direct visualization of the layers of the abdominal wall as
they are being dissected, as well as placement of the shunt catheter in
the peritoneal cavity. It uses a small cosmetic incision (on the scale of
8 mm), and eliminates the need for radiographic studies to verify
catheter placement. The procedure nonetheless has a modest
learning curve and difficulties can be encountered. With careful
application and commitment to thoughtful refinement, however,
this technique can be used without the assistance of an assist surgeon
in routine cases and even more complex cases, after the skills are
acquired. As laparoscopy has become widely received in other
specialties, the technique described here presents an opportunity for
neurosurgeons to translate its benefits to shunt surgery.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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COMMENTS
I
n the general surgery community, laparoscopic entry has become the
gold standard for intraperitoneal access where it is available. Laparos-
copy affords smaller incisions, reduced incidence of healing complications
such as hernias, and has a well-established safety record with a rate of bowel
and vascular injury on entry under 1 in 1000.1 However, this technique
has not been widely adopted by the neurosurgical community due to
perceived technical challenges and likely because few practicing neuro-
surgeons have experience with laparoscopy. Furthermore, due to changes
in neurosurgical training paradigms, many residents now have little to no
exposure to abdominal surgery during residency. Within this article, the
authors present their initial experience with a single port access technique
for insertion of peritoneal shunt catheters. Although 7 out of 60 patients
(12%) subsequently required revision of the distal catheter, none were
associated directly with the entry technique and only 1 patient had
a technical complication, and that occurred early in the authors’ expe-
rience. As a whole, while the described technique is not quite ready for
generalized adoption, the authors as well as the readers should be
encouraged by the results. This article suggests a refinement that can
improve patient care in a common neurosurgical procedure. As a field,
neurosurgery stands out as being innovative, adaptable, and progressive.
This study continues that tradition by updating the paradigms of our
surgical technique to match the progress made in other fields. There will
naturally be a learning curve and a need for additional refinements,
which we anticipate to see as further experience is attained by the authors
and others. Neurosurgical training needs to be updated to obtain the
better results that general surgery already has attained with laparoscopy.
VOLUME 11 | NUMBER 2 | JUNE 2015 | 211
CHERIAN ET AL
The added cost of this technique should be assessed against the potential
savings in revision surgeries it may offer.
David Xu
Peter Nakaji
Phoenix, Arizona
1. Ahmad G, O’Flynn H, Duffy JM, Phillips K, Watson A. Laparoscopic entry
techniques. Cochrane Database Syst Rev. 2012;(2):CD006583.
V entriculoperitoneal shunts represent an imperfect, yet prevalent
treatment option in neurosurgery. Innovative techniques to reduce
operative time, decrease morbidity, and increase successful shunt place-
ment are necessary for our field. The particular technique of single port
optical access placement of the abdominal catheter adds another option for
placement. However, as this article demonstrates, any innovative tech-
nique must be thoroughly explored, both in reference to the learning curve
of technique adoption as well as long-term patient outcomes. The authors
present their experience with this new technique. The authors report
a complication rate of 12% in 60 surgeries on 56 patients, demonstrating
the learning curve associated with this technique. Given the limited
exposure to laparoscopy in neurosurgical training, initial use of this
technique should be carried forth with appropriate guidance and super-
vision by a well-trained surgeon familiar with the technique.
Krystal Lynne Tomei
Cleveland, Ohio
212 | VOLUME 11 | NUMBER 2 | JUNE 2015
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
T his article describes a series of 56 patients and 60 operations in
which an optical access laparoscopic port was placed, and a ven-
triculoperitoneal shunt catheter was brought in coaxially through the
same incision. This is in contrast to most other descriptions of lap-
aroscopic shunt placement, which typically involve 2, or in some
series 3 small port and trocar incisions. Fewer incisions is the theo-
retical advantage of this technique and has its attraction. The authors
report 1 serious complication: a gall bladder perforation which
required calling a general surgeon and an emergent, an unplanned
cholecystectomy. They note that this occurred relatively early in their
series, therefore attributing it to the (neurosurgical) operator’s
inexperience with the technique. Their complication underscores
what I think is an important consideration for any neurosurgeon
who wishes to undertake laparoscopic placement of shunts, namely,
the support of their general surgical colleagues. One needs their
good collaboration, and they must be willing to back up the neu-
rosurgeon who enters the abdomen by whatever laparoscopic
technique, as they will be called upon to handle any complication.
Neurosurgeons certainly can, and I think should be trained in basic
laparoscopic techniques, well enough to perform a straightforward
insertion in a patient with no abdominal scarring. If only from
a credentialing point of view, one should have some form of vetting
by the general surgeons to do it. It would behove the neurosurgeon
to use whichever techniques his or her colleagues are most com-
fortable with, if one undertakes this alone.
Michael H. Handler
Aurora, Colorado
www.neurosurgery-online.com