Case Report Two-port laparoscopic management of a giant pseudocyst complicating ventriculoperitoneal shunt Sandesh V. Parelkar, Beejal V. Sanghvi, Devdas S. Samala, Bhupesh A. Paradkar, Shalil H. Patil, Sanjay N. Oak Department of Pediatric Surgery, King Edward Memorial Hospital, Parel, Mumbai, Maharashtra, India Address for correspondence: Dr. Sandesh V. Parelkar, Department of Pediatric Surgery, King Edward Memorial Hospital, Acharya Dhonde Marg Parel, Mumbai - 400 012, Maharashtra, India. E-mail: [email protected]
ABSTRACT
Access this article online
Insertion of a ventriculo-peritoneal (VP) shunt is the most common operative procedure for the treatment of hydrocephalus in children. Of the several causes of shunt malfunction, cerebrospinal fluid (CSF) pseudocyst is relatively uncommon. There are several modalities to treat a CSF pseudocyst. Laparotomy is required, at times, more than once. We managed a patient of CSF pseudocyst with two-port laparoscopy, by deroofing the psuedocyst and repositioning of the shunt. This minimally invasive technique avoids morbidity associated with laparotomy and aids in early recovery.
Website: www.jiaps.com DOI: 10.4103/0971-9261.136483 Quick Response Code:
KEY WORDS: Hydrocephalus, pseudocyst, ventriculo-peritoneal shunt
INTRODUCTION
CASE REPORT
Ventriculo-peritoneal (VP) shunting is the preferred and most successful method for managing congenital hydrocephalus.[1] Abdominal complications include peritonitis, ascites, bowel obstruction, bowel and abdominal wall perforation, and inguinal herniae.[2] An uncommon but recognized complication is formation of an abdominal pseudocyst, with cerebrospinal fluid (CSF) collecting and being poorly absorbed or not absorbed across the serosa.[2] The continuous flow of CSF within a confined space leads to increased pressure within the abdominal cavity, reducing forward pressure gradient and, eventually, shunt malfunction.[2] These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion. [3] Exploratory laparotomy with a partial excision pseudocyst and placement of a catheter in a quadrant of abdomen is also an option.[4]
We report a 20-month-old female child with a VP shunt and a gradual distension of abdomen since three months, respiratory distress, and bilious vomiting for two days. She was previously operated for lumbar meningomyelocele with associated hydrocephalus. Right-sided VP shunt insertion was done on the seventh day of life and meningomyelocele repair on the 15th day of life. At the age of three months, there was shunt malfunction for which the right-sided VP shunt was removed and a VP shunt was inserted on the left side. At the time of index admission, she presented with a history of gradual distension of abdomen for 3 months and respiratory distress and bilious vomiting for 2 days. There was no history of fever or abdominal pain. The shunt chamber was compressible. On examination, there was a large, 15 cm × 12 cm, nontender, cystic intraperitoneal lump with a smooth surface and
Cite this article as: Parelkar SV, Sanghvi BV, Samala DS, Paradkar BA, Patil SH, Oak SN. Two-port laparoscopic management of a giant pseudocyst complicating ventriculoperitoneal shunt. J Indian Assoc Pediatr Surg 2014;19:181-3. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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Parelkar, et al.: Two port laparoscopic management of CSF pseudocyst
ill-defined margins, occupying almost the entire abdomen; moreover, fingers could be insinuated between the costal margins and the lump. X-ray of the abdomen showed VP shunt in the left side of the abdominal cavity having ground glass opacity around the shunt, with the displacement of bowel loops to the periphery of the opacity [Figure 1]. Abdominal ultrasonography (USG) revealed a large multiseptate pseudocyst with the presence of the shunt within. As the baby had considerable respiratory distress, an ultrasound-guided aspiration of 200 ml of a straw-colored fluid was done. The bacteriologic study of the collected CSF showed normal results. However the fluid recollected immediately with increasing abdominal distension and the symptoms persisted; hence, we decided to operate on the child. We went ahead with two-port laparoscopy; one 5-mm primary epigastric camera port above the cyst placed under vision and one 5-mm port in the right iliac fossa. The placement of the second port was difficult, as there was a large CSF pseudocyst predominantly on the left side of the abdomen, with multiple adhesions of bowel loops around the pseudocyst. Gentle maneuvering and dissection with the scope itself helped identify a window in the right iliac fossa where the second port could be placed. A grasper was used to gently free all adhesions of the cyst wall to parietes. The cyst was incised with a hook cautery and 1,100 ml of the CSF fluid was drained. The incision in the cyst wall was extended carefully so as to avoid injury to the adherent bowel loops, and the cyst was then deroofed. The shunt was repositioned in the right subdiaphragmatic space over the liver after confirming the patency of shunt with a free flow of the CSF. The postoperative period was uneventful. On sixmonth follow-up, the child is recovering well and is asymptomatic.
Figure 1: X-ray abdomen showing a giant psuedocyst on the left lower abdomen with a shunt in situ 182
DISCUSSION Insertion of a VP shunt is the preferred and most successful method for the management of congenital hydrocephalus. In the setting of a VP shunt, the frequency of abdominal CSF pseudocyst formation is approximately 3.2%.[5] The time from the last shunt procedure to the development of the abdominal CSF pseudocyst ranges from 3 weeks to 5 years.[6] A chest and abdominal X-ray visualizes the position of the thoracoabdominal part of the VP shunt. A provisional diagnosis can be made by plain abdominal X-ray.[4] Pathi reported that ultrasound and computerized tomography features of the VP shunt floating in the thickened sac wall would allow early recognition of this complication.[5] Different treatment modalities for the abdominal CSF pseudocyst are available. These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion.[3] Moreover, exploratory laparotomy with partial excision and marsupialisation of pseudocyst and placement of catheter in a quadrant of abdomen has been done.[4] An extensive review revealed increasing use of laparoscopic management of this complication. Using the technique of laparoscopy, Kim et al. excised a portion of the CSF pseudocyst, removed the shunt catheter from the residual cavity, and repositioned it within the peritoneal cavity in a 12-year-old boy. There was no recurrence after 12 months of follow-up.[7] Oak et al. (2003) found that the laparoscopic management of CSF pseudocyst, accomplished through 3-mm to 5-mm ports with the help of delicate laparoscopic instruments, minimizes the risk of a laparotomy, and the formation of intraperitoneal adhesions.[8] Furthermore, laparoscopy allows visual confirmation of the adequate flow of the CSF from the end of the catheter after it is repositioned. However, the greatest advantage of laparoscopy lies in its ability to assess the entire abdominal cavity for the presence of adhesions and undertake adhesiolysis when necessary. This allows placement of the catheter in the quadrant of the abdomen with the maximum absorptive surface. Martin et al. performed laparoscopy in ventriculoperitoneal shunt revision for pseudocyst in two cases and reported the use of extensive adhesiolysis for decreasing the risk of future adhesive obstruction and extending shunt life and thus, recommended laparoscopy for VP shunt revisions.[9] Brunori et al. performed the laparoscopic drainage of a pseudocyst containing 2 liters of fluid and retrieved the catheter from the peritoneal cavity.[10] Esposito et al. recommended that laparoscopy is a safe procedure in patients with abdominal complications of VP shunts, especially in adhesions and pseudocyst formation.[3]
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
Parelkar, et al.: Two port laparoscopic management of CSF pseudocyst
On extensive search and review of literature, we found that minimally invasive technique is a useful modality for the treatment of this complication. However, the management of this complication is generally done using three ports (one camera port and two working ports). We recommend that even giant pseudocysts can be managed by the two-port laparoscopic technique as done in another child with giant CSF pseudocyst as well.
CONCLUSION To summarize, laparoscopy is a useful modality for the treatment of intra-abdominal complications of VP shunt such as adhesions and pseudocyst. It is effective, avoids multiple laparotomies, and its attendant complications and future adhesions. It is feasible to manage this complication by using only the two-port laparoscopic technique.
REFERENCES 1. Guice KS, Kosloske AM. Recurrent pseudocyst from a ventriculoperitoneal shunt. An unusual abdominal mass. Am J Dis Child 1978;132:285-6.
2. Bryant MS, Bremer AM, Tepas JJ 3rd, Mollitt DL, Nquyen TQ, Talbert JL. Abdominal complications of ventriculoperitoneal shunts. Case reports and review of the literature. Am Surg 1988;54:50-5. 3. Esposito C, Colella G, Settimi A, Centonze A, Signorelli F, Ascione G, et al. One-trocar laparoscopy: A valid procedure to treat abdominal complications in children with peritoneal shunt for hydrocephalus. Surg Endosc 2003;17:828-30. 4. Theerawood G. Large lower abdominal cerebrospinal fluid pseudocyst 6 years after a ventriculoperitoneal shunt: Clinical features and surgical management. Chiang Mai Med Bull 2004;43:169-73. 5. Pathi R, Sage M, Slavotinek J, Hanieh A. Abdominal cerebrospinal fluid pseudocyst. Australas Radiol 2004;48:61-3. 6. Erşahin Y, Mutluer S, Tekeli G. Abdominal cerebrospinal fluid pseudocysts. Childs Nerv Syst 1996;12:755-8. 7. Kim HB, Raghavendran K, Kleinhaus S. Management of an abdominal fluid pseudocyst using laparoscopic techniques. Surg Laparosc Endosc 1995;5:151-4. 8. Oak SN, Parelkar SV, Agrawal P. Laparoscopic management of pseudocyst and adhesions as a complication of ventriculopritoneal shunt placement. J Ped Endosurg Innov Tech 2003;7:51-4. 9. Martin K, Baird R, Farmer J, Emil S, Laberge JM, Shaw K, et al. The use of laparoscopy in ventriculoperitoneal shunt revisions. J Pediatr Surg 2011;46:2146-50. 10. Brunori A, Massari A, Mascarone-Palmieri R, Benini B, Chiappetta F. Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt. Minim Invasive Neurosurg 1998;41:38-9.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
183
Copyright of Journal of Indian Association of Pediatric Surgeons is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ABSTRACT
Access this article online
Insertion of a ventriculo-peritoneal (VP) shunt is the most common operative procedure for the treatment of hydrocephalus in children. Of the several causes of shunt malfunction, cerebrospinal fluid (CSF) pseudocyst is relatively uncommon. There are several modalities to treat a CSF pseudocyst. Laparotomy is required, at times, more than once. We managed a patient of CSF pseudocyst with two-port laparoscopy, by deroofing the psuedocyst and repositioning of the shunt. This minimally invasive technique avoids morbidity associated with laparotomy and aids in early recovery.
Website: www.jiaps.com DOI: 10.4103/0971-9261.136483 Quick Response Code:
KEY WORDS: Hydrocephalus, pseudocyst, ventriculo-peritoneal shunt
INTRODUCTION
CASE REPORT
Ventriculo-peritoneal (VP) shunting is the preferred and most successful method for managing congenital hydrocephalus.[1] Abdominal complications include peritonitis, ascites, bowel obstruction, bowel and abdominal wall perforation, and inguinal herniae.[2] An uncommon but recognized complication is formation of an abdominal pseudocyst, with cerebrospinal fluid (CSF) collecting and being poorly absorbed or not absorbed across the serosa.[2] The continuous flow of CSF within a confined space leads to increased pressure within the abdominal cavity, reducing forward pressure gradient and, eventually, shunt malfunction.[2] These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion. [3] Exploratory laparotomy with a partial excision pseudocyst and placement of a catheter in a quadrant of abdomen is also an option.[4]
We report a 20-month-old female child with a VP shunt and a gradual distension of abdomen since three months, respiratory distress, and bilious vomiting for two days. She was previously operated for lumbar meningomyelocele with associated hydrocephalus. Right-sided VP shunt insertion was done on the seventh day of life and meningomyelocele repair on the 15th day of life. At the age of three months, there was shunt malfunction for which the right-sided VP shunt was removed and a VP shunt was inserted on the left side. At the time of index admission, she presented with a history of gradual distension of abdomen for 3 months and respiratory distress and bilious vomiting for 2 days. There was no history of fever or abdominal pain. The shunt chamber was compressible. On examination, there was a large, 15 cm × 12 cm, nontender, cystic intraperitoneal lump with a smooth surface and
Cite this article as: Parelkar SV, Sanghvi BV, Samala DS, Paradkar BA, Patil SH, Oak SN. Two-port laparoscopic management of a giant pseudocyst complicating ventriculoperitoneal shunt. J Indian Assoc Pediatr Surg 2014;19:181-3. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
181
Parelkar, et al.: Two port laparoscopic management of CSF pseudocyst
ill-defined margins, occupying almost the entire abdomen; moreover, fingers could be insinuated between the costal margins and the lump. X-ray of the abdomen showed VP shunt in the left side of the abdominal cavity having ground glass opacity around the shunt, with the displacement of bowel loops to the periphery of the opacity [Figure 1]. Abdominal ultrasonography (USG) revealed a large multiseptate pseudocyst with the presence of the shunt within. As the baby had considerable respiratory distress, an ultrasound-guided aspiration of 200 ml of a straw-colored fluid was done. The bacteriologic study of the collected CSF showed normal results. However the fluid recollected immediately with increasing abdominal distension and the symptoms persisted; hence, we decided to operate on the child. We went ahead with two-port laparoscopy; one 5-mm primary epigastric camera port above the cyst placed under vision and one 5-mm port in the right iliac fossa. The placement of the second port was difficult, as there was a large CSF pseudocyst predominantly on the left side of the abdomen, with multiple adhesions of bowel loops around the pseudocyst. Gentle maneuvering and dissection with the scope itself helped identify a window in the right iliac fossa where the second port could be placed. A grasper was used to gently free all adhesions of the cyst wall to parietes. The cyst was incised with a hook cautery and 1,100 ml of the CSF fluid was drained. The incision in the cyst wall was extended carefully so as to avoid injury to the adherent bowel loops, and the cyst was then deroofed. The shunt was repositioned in the right subdiaphragmatic space over the liver after confirming the patency of shunt with a free flow of the CSF. The postoperative period was uneventful. On sixmonth follow-up, the child is recovering well and is asymptomatic.
Figure 1: X-ray abdomen showing a giant psuedocyst on the left lower abdomen with a shunt in situ 182
DISCUSSION Insertion of a VP shunt is the preferred and most successful method for the management of congenital hydrocephalus. In the setting of a VP shunt, the frequency of abdominal CSF pseudocyst formation is approximately 3.2%.[5] The time from the last shunt procedure to the development of the abdominal CSF pseudocyst ranges from 3 weeks to 5 years.[6] A chest and abdominal X-ray visualizes the position of the thoracoabdominal part of the VP shunt. A provisional diagnosis can be made by plain abdominal X-ray.[4] Pathi reported that ultrasound and computerized tomography features of the VP shunt floating in the thickened sac wall would allow early recognition of this complication.[5] Different treatment modalities for the abdominal CSF pseudocyst are available. These pseudocysts have traditionally been treated with surgical shunt externalization, antibiotics, and a second surgical procedure for shunt reinsertion.[3] Moreover, exploratory laparotomy with partial excision and marsupialisation of pseudocyst and placement of catheter in a quadrant of abdomen has been done.[4] An extensive review revealed increasing use of laparoscopic management of this complication. Using the technique of laparoscopy, Kim et al. excised a portion of the CSF pseudocyst, removed the shunt catheter from the residual cavity, and repositioned it within the peritoneal cavity in a 12-year-old boy. There was no recurrence after 12 months of follow-up.[7] Oak et al. (2003) found that the laparoscopic management of CSF pseudocyst, accomplished through 3-mm to 5-mm ports with the help of delicate laparoscopic instruments, minimizes the risk of a laparotomy, and the formation of intraperitoneal adhesions.[8] Furthermore, laparoscopy allows visual confirmation of the adequate flow of the CSF from the end of the catheter after it is repositioned. However, the greatest advantage of laparoscopy lies in its ability to assess the entire abdominal cavity for the presence of adhesions and undertake adhesiolysis when necessary. This allows placement of the catheter in the quadrant of the abdomen with the maximum absorptive surface. Martin et al. performed laparoscopy in ventriculoperitoneal shunt revision for pseudocyst in two cases and reported the use of extensive adhesiolysis for decreasing the risk of future adhesive obstruction and extending shunt life and thus, recommended laparoscopy for VP shunt revisions.[9] Brunori et al. performed the laparoscopic drainage of a pseudocyst containing 2 liters of fluid and retrieved the catheter from the peritoneal cavity.[10] Esposito et al. recommended that laparoscopy is a safe procedure in patients with abdominal complications of VP shunts, especially in adhesions and pseudocyst formation.[3]
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
Parelkar, et al.: Two port laparoscopic management of CSF pseudocyst
On extensive search and review of literature, we found that minimally invasive technique is a useful modality for the treatment of this complication. However, the management of this complication is generally done using three ports (one camera port and two working ports). We recommend that even giant pseudocysts can be managed by the two-port laparoscopic technique as done in another child with giant CSF pseudocyst as well.
CONCLUSION To summarize, laparoscopy is a useful modality for the treatment of intra-abdominal complications of VP shunt such as adhesions and pseudocyst. It is effective, avoids multiple laparotomies, and its attendant complications and future adhesions. It is feasible to manage this complication by using only the two-port laparoscopic technique.
REFERENCES 1. Guice KS, Kosloske AM. Recurrent pseudocyst from a ventriculoperitoneal shunt. An unusual abdominal mass. Am J Dis Child 1978;132:285-6.
2. Bryant MS, Bremer AM, Tepas JJ 3rd, Mollitt DL, Nquyen TQ, Talbert JL. Abdominal complications of ventriculoperitoneal shunts. Case reports and review of the literature. Am Surg 1988;54:50-5. 3. Esposito C, Colella G, Settimi A, Centonze A, Signorelli F, Ascione G, et al. One-trocar laparoscopy: A valid procedure to treat abdominal complications in children with peritoneal shunt for hydrocephalus. Surg Endosc 2003;17:828-30. 4. Theerawood G. Large lower abdominal cerebrospinal fluid pseudocyst 6 years after a ventriculoperitoneal shunt: Clinical features and surgical management. Chiang Mai Med Bull 2004;43:169-73. 5. Pathi R, Sage M, Slavotinek J, Hanieh A. Abdominal cerebrospinal fluid pseudocyst. Australas Radiol 2004;48:61-3. 6. Erşahin Y, Mutluer S, Tekeli G. Abdominal cerebrospinal fluid pseudocysts. Childs Nerv Syst 1996;12:755-8. 7. Kim HB, Raghavendran K, Kleinhaus S. Management of an abdominal fluid pseudocyst using laparoscopic techniques. Surg Laparosc Endosc 1995;5:151-4. 8. Oak SN, Parelkar SV, Agrawal P. Laparoscopic management of pseudocyst and adhesions as a complication of ventriculopritoneal shunt placement. J Ped Endosurg Innov Tech 2003;7:51-4. 9. Martin K, Baird R, Farmer J, Emil S, Laberge JM, Shaw K, et al. The use of laparoscopy in ventriculoperitoneal shunt revisions. J Pediatr Surg 2011;46:2146-50. 10. Brunori A, Massari A, Mascarone-Palmieri R, Benini B, Chiappetta F. Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt. Minim Invasive Neurosurg 1998;41:38-9.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
183
Copyright of Journal of Indian Association of Pediatric Surgeons is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
