Laparoscopy-assisted Ventriculoperitoneal Shunt Surgery By Modified Falciform Technique

Background:Laparoscopy-assisted insertion of the distal catheter of the Ventriculoperitoneal shunt(VPS)in the abdomen is performed universally and many maneuvers have been executed for placement of the distal end of VPS in the peritoneal cavity.Most recently a falciform ligament of the liver has been utilized as a support for the distal shunt,without clipping or ligation of the catheter.Despite the improvements in shunt procedures,abdominal complication like infection,migration,obstruction/blockage,perforation and pseudocyst still attribute a major part in revision surgeries.We have brought modification in previously described "falciform technique" to overcome the manifestation related to the distal shunt.Methods:Between June 2013 and March 2017,total 55 patients underwent VPS,32 with the modified falciform technique and 23 with open technique.Open technique was the conventional blunt insertion procedure for distal catheter in peritoneal cavity,whereas,in modified falciform technique a threaded strap was formed around the catheter before insertion into the abdominal cavity.A hole was made in a falciform ligament and the distal catheter was clamped with the falciform ligament in supra-hepatic space,using the threaded strap as a holder.Modified falciform technique and open technique were compared in aspect of pre-operative characteristics and post-operative complications like age,gender,type of hydrocephalus,etiology of hydrocephalus,infection,obstruction,CSF drainage and occurrence of revision surgeries.Results:Pre-operatively no statistical difference between modified falciform technique and open technique was noted in age,gender,type of hydrocephalus etiology of hydrocephalus and operative time.But,post-operatively CSF over or under-drainage shown statistical significance(P=0.036),over-drainage(9%)and under-drainage(4%)has been recorded in open technique.In contrary,modified falciform technique had 0%CSF over or under-drainage cases.Other post-operative complications like infection(6%),obstruction(9%),occurrence of VPS revision surgeries(9%)and re-hospitalization(9%)were reduced in modified falciform technique compared with infection(22%)obstruction(9%),occurrence of VPS revision surgeries(17%)and re-hospitalization(26%)in open technique,but couldn't reached statistical significance.Conclusion:The modified falciform technique for emplacement of the distal catheter in supra-hepatic space significantly reduces the rates of postoperative complications such as infection,obstruction,under or over-drainage of CSF and revisions of VPS for a longer period of time but improvements are required to avoid upper quadrant abdominal discomfort.Modified falciform technique is a suitable procedure in emplacement of the distal end in supra-hepatic space,therefore,suggesting this technique as a better way in the management of hydrocephalus.