Vol. 31, pp , cm. 4 cm 3, 4) 5 ) 2 0 % V e n t r i c u l o - peritoneal shunt :V-P 1, 2) V - P

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1 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF Vol. 31, pp , 2003 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF cm cm 3, 4) 5 ) 2 0 % V e n t r i c u l o - peritoneal shunt :V-P 1, 2) V - P 1 2 9

2 BMI (body mass index) V-P BMI % V - P 28 Table Table

3 Fig.1 Planning for laparoscopic port sites. Three- to 5-mm open laparotomies were performed in the supraumbilical region for the insertion of the laparoscope, and in the upper right and lower right quadrants for the insertion of trocars. Fig.2 Ventriculo-peritoneal shunt under laparoscopic guidance. The laparoscope and two trocars have been inserted into the abdominal cavity through the three open laparotomies. V-P 3-5 mm ( F i g. 1 ) 3-5 mm (Fig.1 ) 7 m m H g m m H g 11

4 Fig.3 Under laparoscopic observation, the abdominal shunt tube is placed surely into the Douglas pouch. Fig.4 The two small skin incisions are sutured, and the other is fixed using surgical tape at the end of the surgery. 3 mm ( F i g. 1 ) B M I ( F i g. 1 ) p= (Fig.3) / % 1-2 p= (Fig.4) 7) 4 cm M a n n - W h i t n e y C T ( F i g. 5 a ) Fisher Fisher's exact probability test StatView Version C T 4.5J SAS Institute Inc.,USA V-P ( F i g. 5 b ) 12

5 a c b d Fig.5 Compared with the size of the lateral ventricles on postoperative CT scan (a), size of the ventricles remains unchanged on the CT scan 1 month after surgery (b). The abdominal shunt tube is visible around the hepatic region on both abdominal radiographs, taken postoperatively (c) and 1 month after the operation (d). ( F i g. 5 c ) 1 ( F i g. 5 d ) C T ( F i g. 6 a ) V-P ( F i g. 6 c ) 1 CT (Fig.6b) 13

6 a c b Fig.6 Compared with the size of the lateral ventricles on preoperative CT scan (a), shrinkage of the ventricles is visible on the postoperative CT scan (b). An abdominal shunt tube has been inserted into the Douglas pouch under laparoscopic guidance on the postoperative abdominal radiograph (c) V-P 3, 4) 2) 3 ) V-P 14

7 8, 9) % 10 ) V-P ( 7. 9% ) a) b) c ) d) e) f) % 57.1 % % 11) p = ) 5), 10), 14) Davison 1 5 ) Khosrovi 13 ) V-P d i s t o r t e d abdominal anatomy 13 V-P Khosrovi 13 ) 15

8 ) Fitzgibbons, Jr RJ, Salerno GM and Filipi CJ..,,, ,, 1993: ) Ignelzi RJ and KirschWM. Follow up analysis of ventriculo-peritoneal and ventriculo-atrial shunts for 2 hydrocephalus. J Neurosurg 1975; 42: ),, ; 6: ) Cuatico W and Vannix D. Laparoscopically guided peritoneal insertion in ventriculoperitoneal shunts. J Laparoendosc Surg 1995; 5: ),,,, 1),.. 12) Fanelli RD, Mellinger DN, Crowell RM and Gersin,, 8,,, 2000: ) Vale FL, Bradley EL and Fisher WS 3rd. The relationship of subarachnoid hemorrhage and the need 13) Khosrovi H, Kauhuman HH, Hrabovsky EH, for postoperative shunting. J Neurosurg 1977; 86 : Bloomfield SM, Prabhu V and El-Kadi HA Laparoscopic-assisted distal ventriculoperitoneal shunt 3)..,. placement. Surg Neurol 1998; 49: ,,, 1, 14) Reimer R, Wharen Jr RE and Pettit PDM.,, 1992: Ventriculoperitoneal shunt placement with videolaparoscopic guidance. J Am Coll Surg 1998; 187: 4)..,,,,,, II, 1,,, 1990: 15) Davison MJ, van Daren RM and MacFarlane MR Laparoscopic removal of a detached peritoneal shunt 5) Kusano T, Miyazato H, Shimoji H, Hirayasu S, Isa T, ShiraishiM, Muto Y and Furukawa M. Revision of ventriculo-peritoneal shunt under laparoscopic guidance in patients with hydrocephalus. Surgical Laparoscope & Endoscopy 1998; 8: )..,,, 2002,,, 2002:,,, ; 9: KS. Laparoscopic ventriculoperitoneal shunt placememt. A single-trocar technique. Surg Endosc 2000; 14: catheter with revision ventriculo-peritoneal shunt. Aust N Z J Surg 1992; 62:

9 Abstract Ventriculo-Peritoneal Shunt under Laparoscopic Guidance in Patients with Adult Hydrocephalus Yoshio Hazama 1, Hiroaki Sekino 1, Takashi Sakurai 1, and Naosi Suda 2 Ventriculoperitoneal shunt (VPS) placement is an important therapeutic technique for patients with hydrocephalus. However, placement of the abdominal shunt catheter in VPS can be difficult in cases of previous abdominal surgery, prior failure of VPS or obesity. Even under ideal circumstances, standard minilaparotomy does not allow precise placement of the abdominal shunt catheter into the abdominal cavity. Therefore, we report a technique for inserting the abdominal shunt catheter into the abdominal cavity under laparoscopic guidance. Clinical material and methods: Among the 28 cases we treated, 25 were due to subarachnoid hemorrhage, and one each caused by traumatic subarachnoid hemorrhage, intracerebral hemorrhage, and brain tumor. Among the 28 cases, 15 suffered from obesity and 6 had undergone intraabdominal surgery. A laparoscopic port site is prepared using a 3 to 5 mm open laparotomy over the supraumbilical region, and a 3-mm trocar is inserted and fixed. After inducing pneumoperitoneum, a 3-mm laparoscope is inserted and adhesions in the abdominal cavity are identified. Then, two other 3 to 5 mm open laparotomies are performed in the upper right and lower right quadrants, and two 3-mm trocars are inserted. Through the lower trocar, long, narrow forceps are inserted into the abdominal cavity, where they are inserted into the upper trocar. When the forceps appear outside the abdomen through the upper trocar, they are used to pull the lower end of the abdominal shunt catheter back into the abdominal cavity. Under laparoscopic observation, the abdominal shunt catheter is finally placed surely into the Douglas' pouch. Results Under laparoscopic guidance, placement of the abdominal shunt catheter was completed safely in all patients, even in patients with previous intraabdominal surgery. There have been no intra or postoperative complications or postoperative infections to date. Conclusion Laparoscopic-aided abdominal shunt catheter insertion increases the success rate of abdominal shunt placement for hydrocephalus patients. It not only improves direct visualization and facilitates lysis of abdominal adhesions, especially in cases of obesity and/or prior intraabdominal surgery, but also allows precise placement of the distal end of the abdominal shunt catheter in the desired place. 1 Department of Neurosurgery, St. Marianna University School of Medicine 2 Department of Gastroenterological Surgery, St. Marianna University School of Medicine 17

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