Modern paradigm for peritoneal catheter insertion: single port optical access laparoscopic shunt insertion.

OPERATIVE TECHNIQUE

Modern Paradigm for Peritoneal Catheter Insertion: Single Port Optical Access Laparoscopic Shunt Insertion BACKGROUND: Ventriculoperitoneal shunting is one of the most commonly performed 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 laparoscopic 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 peritoneal 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.

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: [email protected] Received, September 27, 2014. Accepted, December 28, 2014. Published Online, February 14, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.

KEY WORDS: Laparoscopy, Optical access, Shunt insertion Operative Neurosurgery 11:205–212, 2015

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erebrospinal fluid shunting to the peritoneum is one of the most commonly performed 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 become widely accepted—if not standard of care—for most intraperitoneal surgeries. Modern

OPERATIVE NEUROSURGERY

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DOI: 10.1227/NEU.0000000000000678

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.

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 retrospectively 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.

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SINGLE PORT OPTICAL ACCESS SHUNT INSERTION

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


56 60 11 23 26 20 36 24 10 7 4 5 2 4

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 and incisions, the need for an assist surgeon, and unfamiliar entry techniques. A simpler approach may improve accessibility to neurosurgeons looking to incorporate the benefits of this nowstandard approach to abdominal surgery. Single Port Optical Access and Laparoscopy Our approach combines 2 key advances from the abdominal surgery literature: optical access and single port laparoscopic technique. Many of the basic elements of these techniques are already familiar to neurosurgeons and offer significant advantages compared with traditional methods. Initial access to the peritoneum is done under visualization through the same layers familiar to those using the mini-laparotomy technique. Access is achieved quickly, usually within 1 minute.2 The final peritoneal defect is small and limits the risk of hernia. Navigation of the laparoscope



CHERIAN ET AL

TABLE 2. Revisions After Laparoscopic Shunt Placement Age

Sex

Days to Revision

46

F

62

Abdominal pain

21

52

M

275

Abdominal pain

39

47

F

420

42

34

F

43

Abdominal pain; malabsorption Diagnostic laparoscopy revealed cloudy peritoneal fluid without organized collection. Cultures negative. Antibiotics not given. Converted to ventriculoatrial shunt Abdominal pain; pseudocyst Shunt externalized. Antibiotics given. Cultures negative. Converted to ventriculoatrial shunt

51

32

F

80

Abdominal pain; pseudocyst

42

58

M

152

Abdominal pain; pseudocyst

52

60

F

172

Presumed infection

Reported shunt infection at outside hospital. Microbiology unavailable, but complete shunt explanted

72

M

15

Subdural hemorrhage

33 20

60 36

M M

31 15

Subdural hemorrhage Epidural hematoma

36 37 50

54 60 65

M F F

13 183 196

Proximal obstruction Proximal obstruction Shunt not helping

Subdural hemorrhage evacuated. Converted to lumboperitoneal shunt Subdural evacuated and valve revised Epidural hematoma evacuated. Valve reprogrammed Proximal catheter exchanged Proximal catheter exchanged Shunt removed after patient was without relief in gait and mentation difficulties

52

58

M

84

Insufficient drainage

Case No. Revisions involving distal catheter 19

Revisions involving proximal system only 10

Reason for Revision

is similar to manipulation of a rigid endoscope during transsphenoidal 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


Comments

No collections identified. Normal infectious markers. Revised to ventriculoatrial shunt Converted to a ventriculoatrial shunt at an outside facility

Shunt externalized. Antibiotics given. Cultures negative. Converted to ventriculoatrial shunt Shunt externalized. Cultures positive for coagulasenegative staphylococcus and Propionibacterium acnes. Shunt reimplanted laparoscopically after microbiology specific antibiotic course

Fixed valve converted to programmable valve

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 pathways.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




TABLE 3. Summary of Peritoneal Access Literature for Placement of Ventricular and Lumbar Shuntsa Reference 22

a

Initial Peritoneal Entry

Cases (No.)

Armbruster et al, J Laparoendosc Surg, 1993 Basauri et al, Pediatr Neurosurg, 199323 Schievink et al, Mayo Clin Proc, 199324 Cuatico and Vannix, J Laparoendosc Surg, 199525 Box et al, Surg Endosc, 199626 Reimer et al, J Am Coll Surg, 199827 Khosrovi et al, Surg Neurol, 199828 Khaitan and Brennan, Surg Endosc, 199929 Fanelli et al, Surg Endosc, 200030 Reardon et al, Surg Endosc, 200031 Roth et al, Surg Endosc, 200032

3 7 10 11 6 70 13 10 5 8 27

Kubo et al, J Neurosurg, 200110 Kubo et al, J Neurosurg, 200333

8 6

Kirshtein et al, Surg Laparosc Endosc Percutan Tech, 20048 Kurschel et al, Childs Nerv Syst, 200534 Schubert et al, Surg Endosc, 20059 Bani and Hassler, Pediatr Neurosurg, 200635 Bani et al, 200636 Goitein et al, J Laparoendosc Adv Surg Tech A, 200637 Tepetes et al, Clin Neurol Neurosurg, 200638 Jea et al, J Neurosurg, 200739 Konstantinidis et al, Minim Invasive Neurosurg, 200740 Roth et al, Surg Neurol, 200741 Turner et al, Neurosurgery, 200711 Handler and Callahan, J Neurosurg Pediatr, 200814 Argo et al, Surg Endosc, 200919 Sekula et al, Br J Neurosurg, 200942 Naftel et al, J Neurosurg, 201118 Raysi Dehcordi et al, Neurosurg Rev, 201143 Stoddard and Kavic, JSLS, 201144 Tormenti et al, J Neurosurg Pediatr, 201112 Aoki et al, No Shinkei Geka, 201245 Present Series, 2014

Abd Incisions (No.)

Abdominal Surgeon

Pneumoperitoneum

3 2 3 2 2-4 1-3 2-4 2 2 3-4 2

Laparoscopist Not specified Laparoscopist Laparoscopist Laparoscopist Laparoscopist Laparoscopist Neurosurgeon Laparoscopist Laparoscopist Laparoscopist

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1 1

Neurosurgeon Neurosurgeon

No Yes

28

Hasson Not specified Veress and Hasson Veress Veress and Hasson Hasson Hasson Veress and Hasson Hasson Veress Veress and optical access Optical access Retroperitoneal endoscopic Veress and Hasson

2

Laparoscopist

Yes

10 50 39 151 10

Hasson Veress Hasson Veress Veress

2 2 2 2 2-3

Laparoscopist Laparoscopist Laparoscopist Laparoscopist Laparoscopist

Yes Yes Yes Yes Yes

15 11 12

Hasson Hasson Hasson

2 3 2

Laparoscopist Laparoscopist Laparoscopist

Yes Yes Yes

59 113 137 258 76 475 30 111 6 10 58

Veress Optical access Veress and Hasson Veress Veress and Hasson Veress Hasson Veress Optical access Not specified Optical access

2-3 2 2-3 1-3 2 1-3 1-3 2 1 2 1

Laparoscopist Laparoscopist Both Laparoscopist Not specified Laparoscopist Laparoscopist Laparoscopist Laparoscopist Laparoscopist Neurosurgeon

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

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 problems. 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



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 minilaparotomy 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 pseudocyst 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 Callahan 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


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 hydrocephalus 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 pneumoperitoneum 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 laparoscopy 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. Laparoscopy 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 neurosurgeons 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’ experience. 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.



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.

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entriculoperitoneal shunts represent an imperfect, yet prevalent treatment option in neurosurgery. Innovative techniques to reduce operative time, decrease morbidity, and increase successful shunt placement 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 technique 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 supervision by a well-trained surgeon familiar with the technique. Krystal Lynne Tomei Cleveland, Ohio


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his article describes a series of 56 patients and 60 operations in which an optical access laparoscopic port was placed, and a ventriculoperitoneal shunt catheter was brought in coaxially through the same incision. This is in contrast to most other descriptions of laparoscopic shunt placement, which typically involve 2, or in some series 3 small port and trocar incisions. Fewer incisions is the theoretical 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 neurosurgeon 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 comfortable with, if one undertakes this alone. Michael H. Handler Aurora, Colorado



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