Ventriculoperitoneal Shunt (VPS) Placement

Intervention for congenital hydrocephalus.

Congenital hydrocephalus is characterized by an abnormal accumulation of cerebrospinal fluid (CSF) in the brain's ventricles. For long term management of the condition, a shunt may be placed in the ventricle to allow for drainage into an alternate location—often a ventriculoperitoneal shunt (VPS; from the ventricle to the peritoneal region) is utilized.

Positioning

The patient is positioned supine, with the head rotated 45-60 degrees laterally. The head is tilted slightly posteriorly. For safe drain tunneling, there should be a straight line from the mastoid process to the clavicle.

Preparation of Materials

The patency (condition) of the Chubbra shunt system should be tested by irrigation with gentamicin saline. This ensures that the shunt system is working properly for when it is inserted later in the procedure.

Location of Burr Hole Surgical Sites

The location of the burr hole will depend on the surgery. Commonly, Keen’s point will be utilized for catheter insertion. Keen’s point is located ~3 cm superior and posterior to the pinna.

Alternate locations for burr holes include Kocher’s point (1 cm anterior to coronal suture, and 3 cm lateral to midline) and Frazier’s point (6 cm lateral and superior to inon).

Accessing the Proximal Site

Create a curvilinear incision (pediatric) or linear incision (adult), keeping the galea attached to the skin. This is the only layer that will hold deep stitches in infants.

A burr hole is created using the Hudson brace hand drill.

Accessing the Distal Site

An incision is made to ensure that there is safe room for passage of the metal catheter guide. In the paraumbilical region of the ipsilateral side of the proximal incision, create a horizontal incision. The incision should cut through all layers superior to the parietal peritoneum (the Camper's fascia, Scarpa's fascia, external oblique mm., internal oblique mm., transversus abdominus mm., and extraperitoneal fat).

Accessing the Distal Site Continued

Grab the exposed peritoneum with 2 sets of hemostats, cut a small opening using scissors, and move the hemostats to have one tyne in the intraperitoneal space and one outside the peritoneal layer. Use the Mcdonald or Penfield 3 dissectors to confirm the space and remove necessary adhesions.

Entering Ventricle

Move back to the cranial portion. Pass the catheter into the desired ventricle. The trajectory of the catheter should pass through the least amount of brain tissue possible while avoiding important structures.

Ensure CSF Flow

Confirm CSF flow through the catheter, then clamp the catheter with padded forceps to avoid crushing the end. If the end of the catheter is crushed, ensure that there is enough remaining material that the crushed portion can be cut off without displacing the catheter within the ventricle.

Subcutaneous Tunneling

The metal shunt passer is tunneled from the abdomen to the head. Important considerations to make while tunneling include:

Stay above the clavicle in order to avoid lung injury.
Tunneling should be deep enough to avoid accidental skin penetration.
In female children, care should be taken to avoid the breast tissue.
When nearing the proximal incision, stay above the mastoid process.

Passing the Catheter

Pass the distal portion of the catheter to the abdomen through the tunneled space. Leave slack at the proximal portion of the catheter. The metal passer can be removed, leaving the catheter in position.

Connection the System

Use arterial forceps to grab the catheter and pull it anteriorly, towards the burr hole. Do not pull the intraventricular catheter—as it may become displaced. If necessary, cut off the portion of the catheter that is crushed from being held.

Connecting the System Continued

Once the distal and proximal catheters are in place, connect the frontal portion to the peritoneal portion using the connector piece. Confirm CSF flow by pressing on the valve.

Securing the System

To secure the shunt system, feed the distal end of the valve and the proximal end of the catheter into the connecting bit. Tag and tie off one end of the bit. Tag the other end of the bit, leaving a tail. Continue the stitch by tagging some of the periosteum with the continued stitch and secure to the first tag. This will help ensure that the shunt system stays connected and fixed to the area.

Testing and Closure

Return to the abdominal incision and pull the shunt system to confirm that there is no kinking in its final place.

With the shunt system in its final place under the skin, test flow through the valve again.

Close cranial incisions and check flow through the valve again.

Close abdominal incisions.

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