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Ventriculoperitoneal Shunt

Procedure description

A ventriculoperitoneal shunt is used to take excess fluid from the ventricles (fluid filled cavities) within the brain, and "shunt" or divert it to the abdomen for absorption.  Normally, the brain produces about 500 cc (half a liter) of cerebrospinal fluid (CSF) per day, and it is absorbed back into the blood by filtration into the superior sagittal sinus and other veins in the brain.  At times, the filtration process may become partially obstructed, and the fluid may build up, causing pressure on the brain.  This is known as hydrocephalus.  There may be a number of causes of the build up of fluid.  Hemorrhage in the CSF, or meningitis (an infection of the CSF) may cause the drainage channels into the superior sagittal sinus to become "clogged," and the fluid which is produced cannot be easily reabsorbed into the blood.  A tumor or other mass lesion may be obstructing the normal circulation patterns of CSF within the brain, and this may lead to hydrocephalus.  Or, sometimes in the elderly, CSF builds up in the ventricles within the brain, and the patient may suffer from a condition known as normal pressure hydrocephalus (NPH).  Regardless of the reason for the hydrocephalus, a ventriculoperitoneal shunt allows the excess CSF to be channeled into the abdomen, from where it is absorbed back into the blood.

During a ventriculoperitoneal (VP) shunt procedure, a small hole is made in the skull, and a tube is passed into the ventricle within the brain.  The tube (known as a ventricular catheter) is connected to a valve, which in turn is connected to another tube which is tunneled beneath the skin, and the end is placed within the abdomen.  The valve regulates the pressure at which the shunt will divert fluid from the brain.  The valve may be either fixed in its opening pressure (the pressure above which fluid will drain from the brain into the abdomen), or it may be programmable.  A programmable valve will give the surgeon the ability to postoperatively adjust the pressure for which fluid will be shunted.  Often, a general surgeon will perform the abdominal portion of the procedure.  The tube is passed from the head to the abdomen, beneath the skin.  There may be one or more incisions along the path of the shunt, to help pass it to the abdomen.

 

Procedure Risks

Ventriculoperitoneal shunts are placed relatively frequently. Yet, there certainly are risks to the procedure. Risks can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure:  The patient is placed in a supine position (on their back).      In this position, there can be pressure sores and pressure injuries to nerves.  A hole is made in the skull and a catheter inserted into the brain.  There can be bleeding in the area of the tube, in the brain and drill hole, potentially requiring emergent surgery to make a larger opeining in the skull for clot removal.  There may be difficulty getting the catheter into the ventricle, and several "passes" of the tube may be needed.  If the catheter "irritates" the brain, seizures may occur.  The distal (bottom portion) of the catheter is placed within the abdomen.  There could be injury to the bowel, and infection may occur.  The wounds could have difficulty with proper healing.

General Risks:  These include  general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions in  the scalp and abdomen generally heal well, but there may be tenderness and numbness, or the wounds may heal in an unpleasant manner.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed.  The problem for which the surgery was performed may recur, requiring additional surgery in the future.  If the shunt drains too much CSF, if is possible that the brain could "collapse" around the shunt tube, with fluid or blood developing around the brain.  This may require an operation to remove the fluid or blood around the brain.  The abdominal portion of tubing could pull out of the abdomen, or could become walled off in a cystic area, requiring surgery for repositioning.  The tubing may deteriorate and break over time.  The valve and tubing may malfunction or become clogged, requiring a revision of the shunt.   In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia
Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if  given. 

 

Post-operative care:

There shall be no bending, twisting, or heavy lifting for several weeks after surgery.    Your doctor will gradually ease your work restrictions, depending on your progress. 

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

The following is a list of suggestions that should help speed your recovery and give you every possible chance for the best results from your surgery.

  1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been made.
  2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incisions a chance to heal.
  3. No jogging or running.
  4. No driving until OK with your physician. 
  5. You may shower after you go home unless otherwise instructed.  Cover the incisions with plastic wrap before the shower and remove it afterward.  Change dressing immediately.  Tub baths are not advisable.  You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tape strips, stitches or staples.  Your surgeon or nurse clinician will explain the techniques used in the closure of your incision.
  6. Sexual activities are permitted.
  7. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call if greater than 101 degrees Fahrenheit.
  8. If you have any questions, call our office, and for after hours emergencies, call the after hours number.
  9. Take your medications prescribed on discharge, as directed.

 

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