|Year : 2018 | Volume
| Issue : 3 | Page : 397-400
Laparoscopy in the management of lumboperitoneal shunt catheter in obese patients with pseudotumor cerebri
S Ozturk1, H Cakin2, K Karabulut3, R Pasahan4, M Kaplan1
1 Department of Neurosurgery, School of Medicine, Firat University, Elazig, Turkey
2 Department of Neurosurgery, Education and Research Hospital, Antalya, Turkey
3 Department of Surgery, School of Medicine, Firat University, Elazig, Turkey
4 Department of Neurosurgery, School of Medicine, Inonu University, Malatya, Turkey
|Date of Acceptance||30-May-2017|
|Date of Web Publication||09-Mar-2018|
Dr. S Ozturk
Firat University Hospital, Neurosurgery Clinic, 6. floor, 23119, Elazig
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Lumboperitoneal shunts are widely used for the treatment of patients diagnosed with pseudotumor cerebri (PTC). Obesity is a risk factor for PTC. In particular, catheter migration out of the abdominal cavity is more commonly observed in morbidly obese patients. The aim of this study was to discuss the underlying mechanisms of catheter migration and treatment modalities in morbidly obese patients with PTC. The present study included four morbidly obese patients. All cases had undergone the previous laparotomy for insertion of a distal catheter into the abdominal cavity. In three cases, migration of the distal catheter out of the abdominal cavity was observed. Migration of the proximal tip of the catheter out of the spinal canal was observed in the fourth case. In all cases, laparoscopic revision surgeries were performed. During revision surgery, a catheter tunnel was prepared immediately over the external oblique fascia to obtain the shortest and deepest tunnel, and a distal catheter was inserted by laparoscopic guidance posterolaterally, i.e., through the postaxillary line. None of the patients developed any complications during the follow-up period of 4 years. We recommend laparoscopic insertion of distal catheters through the postaxillary line into the abdominal cavity using as short a catheter route as possible. Thus, tension and traction on the catheter due to abdominal movements can be decreased in morbidly obese patients to prevent catheter migration.
Keywords: Laparoscopy, lumboperitoneal, migration, obesity, pseudotumor cerebri, shunt
|How to cite this article:|
Ozturk S, Cakin H, Karabulut K, Pasahan R, Kaplan M. Laparoscopy in the management of lumboperitoneal shunt catheter in obese patients with pseudotumor cerebri. Niger J Clin Pract 2018;21:397-400
|How to cite this URL:|
Ozturk S, Cakin H, Karabulut K, Pasahan R, Kaplan M. Laparoscopy in the management of lumboperitoneal shunt catheter in obese patients with pseudotumor cerebri. Niger J Clin Pract [serial online] 2018 [cited 2019 Nov 12];21:397-400. Available from: http://www.njcponline.com/text.asp?2018/21/3/397/226978
| Introduction|| |
Pseudotumor cerebri (PTC) is a condition of unknown cause characterized by elevated cerebrospinal fluid (CSF) pressure and papilledema without hydrocephalus or abnormal CSF composition. Lumboperitoneal (LP) shunts are widely used in the treatment of patients diagnosed with PTC. LP shunts are preferred over ventriculoperitoneal (VP) shunts because minimally invasive application of LP shunts is easier. In addition, a low rate of complications is observed with LP shunts compared with VP shunts. Commonly observed complications include catheter obstruction, migration of the catheter out of the intra-abdominal cavity and/or spinal canal, infection, malposition of the valve, and CSF leakage.,,
Obesity is a risk factor for PTC. In particular, catheter migration out of the abdominal cavity is observed more commonly in obese patients., Accordingly, obesity is a risk factor for both conditions. In this study, we discuss the underlying mechanisms of catheter migration and treatment modalities in four morbidly obese patients with PTC.
| Case Reports|| |
A 27-year-old female presented to our outpatient clinic complaining of headache and abdominal pain. Her body mass index (BMI) was 41 kg/m2. Her medical history included LP shunt surgery using laparotomy for treatment of PTC 2 months previously. On physical examination, a right lower abdominal quadrant incision scar, hyperemia, edema, and tenderness were observed. Abdominal computed tomography (CT) demonstrated subcutaneous migration of a distal LP shunt catheter and coiling inside a subcutaneous fluid collection [Figure 1].
|Figure 1: Axial section of the abdominal computed tomography scan revealing subcutaneous migration of the distal lumboperitoneal shunt catheter and coiling inside a subcutaneous fluid collection|
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A 26-year-old female patient with a BMI of 46 kg/m2 presented with abdominal pain and bruising and swelling near a previous surgical site. She had undergone laparotomy with LP shunt catheter insertion 1 year previously for PTC. Physical examination demonstrated tenderness around a 13-cm incision in the skin. She had no complaints related to PTC. Abdominal CT revealed migration of the distal catheter out of the abdominal cavity, with an incisional hernia observed in the same area [Figure 2].
|Figure 2: Sagittal section of the abdominal computed tomography scan revealing migration of the distal catheter outside the abdominal cavity and the presence of an incisional hernia observed in the same area|
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A 31-year-old female patient who had undergone LP shunt surgery by laparotomy 2 months previously at our neurosurgery clinic. Her BMI was 45 kg/m2. CSF leakage through the abdominal incision was noted on postoperative day 6. Abdominal CT showed subcutaneous migration of the distal catheter and a subcutaneous CSF collection [Figure 3].
|Figure 3: Axial section of the abdominal computed tomography scan revealing migration of the distal catheter and subcutaneous cerebrospinal fluid collection|
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A 30-year-old female patient with a BMI of 45 kg/m2 presented with headache and progressive loss of vision. Accordingly, LP shunt dysfunction was considered. She had previously undergone laparotomy and LP shunt catheter placement for PTC. She had also undergone revision surgery using the preventive stitching method described by Nakahara et. al, because of subcutaneous migration of the distal catheter on a postoperative day 28. Abdominal CT revealed migration of the proximal catheter out of the spinal canal [Figure 4].
|Figure 4: (a) Sagittal section of the abdominal computed tomography scan revealing migration of the proximal catheter out of the spinal canal and a fibrotic tract (arrow). (b) Coronal section revealing the presence of the distal catheter in the abdominal cavity (arrow)|
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In all cases, laparoscopic revision surgeries were performed.
Surgical technique for laparoscopic revision
With the patient in the supine position, access to the intraperitoneal area was obtained using a 10-mm optical trocar and 0° telescope 10–12 cm inferior to the xiphoid process in the midline. The abdominal cavity was insufflated using CO2 to reach an intraperitoneal pressure of 10 mmHg. Then, the 0° scope was changed to a 30° scope for better visualization of the abdominal cavity. An additional 5-mm trocar was placed on the opposite side to the catheter insertion. At the level of the proximal catheter placement, a third 5-mm trocar was placed in the postaxillary line. A grasper was extended to the outside of the abdomen through the third trocar. This was used to grasp the distal tip of the catheter for manipulation into the intra-abdominal space. After lowering the intraperitoneal pressure, CSF flow from the catheter into the abdominal cavity was observed, and the function of the catheter was evaluated. After pulling the catheter into the peritoneal cavity, the tip of the catheter was placed into the pouch of Douglas. Skin incisions were closed in the usual manner.
No complication was observed during the follow-up period of 4 years.
| Discussion|| |
Ease of insertion is an important advantage of LP shunts. However, technical difficulties may be experienced in patients with morbid obesity. Placement of the distal catheter into the abdominal cavity is often difficult because of the presence of an extremely thick layer of fat tissue in morbidly obese patients. In particular, surgery is technically more difficult in the lateral decubitis position. In addition, larger and deeper incisions are required for the placement of a distal catheter into the abdominal cavity by laparotomy in such patients. Complications including wound healing problems, abdominal pain, and increased risk of an incisional hernia are also observed.
In all cases, the distal tip of shunt catheters was placed by laparotomy during previous surgeries. Two cases (cases 1 and 4) had ongoing abdominal pain, with case 4 also presenting with an incisional hernia [Figure 4]. Laparoscopic approaches are recommended for minimally invasive access through the layers of the abdominal wall and optimal visualization of the intra-abdominal cavity., Laparoscopic procedures have many advantages including the avoidance of large open wounds or incisions (thereby decreasing blood loss, pain, and discomfort); shorter operative times; decreased risk of incisional hernia; ease of surgical technique; and particularly in shunt surgeries, direct visualization of CSF flow out of the distal catheter into the abdominal cavity.
Abdominal fat layer movement is markedly increased in morbidly obese patients, particularly during changes in body position, such as sitting, standing, and rotation of the trunk. These repetitive body movements cause tension and traction on the catheter. In addition, we believe that the length of the catheter tunnel is a risk factor for migration. Longer subcutaneous catheter tunnels cause more tension and traction on the catheter because of positional changes, thereby leading to migration of the catheter. To prevent tension and traction on the catheter due to positional changes, the route of the catheter should be as short and deep as possible in morbidly obese patients [Figure 5]. Accordingly, the catheter tunnel should be prepared immediately over the external oblique fascia to facilitate the shortest and deepest tunnel, with the distal catheter inserted by laparoscopic guidance through the most posterolateral position, i.e., through the postaxillary line.
|Figure 5: Comparison of abdominal movements between lying (a and b) and standing (c and d) positions in the same patient. The X line represents the subcostal line and the Y line represents the lumber line, indicating the entrance point of the proximal catheter into the intradural area. Linear dots represent the postaxillary line (b and d) the vertical distance between the X and Y lines increases parabolically from the postaxillary line to the umbilicus during standing|
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Laparoscopic surgery allows easier and safer placement of the distal tip of the catheter into the abdominal cavity through the postaxillary line, in contrast with laparotomy, and in morbidly obese patients. None of our patients developed any complications, and the success rate of laparoscopic revision surgery in morbidly obese patients supports the importance and safety of this technique.
During LP shunt surgery, the stitching method is widely used to prevent migration of distal catheter. In case 4, revision surgery had been performed previously for migration of the distal catheter and the catheter had been stitched to the abdominal fascia firmly. However, we observed migration of the proximal (spinal) catheter out of the spinal canal in this case because of tension and traction on the catheter due to abdominal position changes. The stitching technique of the distal catheter in morbidly obese patients can be a cause of migration of the proximal catheter out of the spinal canal [Figure 4].
| Conclusion|| |
To prevent catheter migration, we strongly advise laparoscopic insertion of distal catheters into the abdominal cavity through the postaxillary line with as short as possible a catheter route. Consequently, tension and traction on the catheter caused by abdominal movements will be decreased in morbidly obese patients.
We would like to thank the Neurosurgery Clinic theater staff.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kosmorsky GS. Idiopathic intracranial hypertension: Pseudotumor cerebri. Headache 2014;54:389-93.
Wang VY, Barbaro NM, Lawton MT, Pitts L, Kunwar S, Parsa AT, et al.
Complications of lumboperitoneal shunts. Neurosurgery 2007;60:1045-8.
Matsubara T, Ishikawa E, Hirata K, Matsuda M, Akutsu H, Masumoto T, et al.
A new mechanism of cerebrospinal fluid leakage after lumboperitoneal shunt: A theory of shunt side hole – Case report. Neurol Med Chir (Tokyo) 2014;54:572-7.
Yadav YR, Parihar V, Sinha M. Lumbar peritoneal shunt. Neurol India 2010;58:179-84.
] [Full text]
Kavic MS. Obesity – An “acceptable” prejudice. JSLS 2001;5:201-2.
Nakahara K, Shimizu S, Oka H, Utsuki S, Fujii K. Preventive stitching for migration of a peritoneal catheter into the abdominal wall after ventriculoperitoneal shunting. Neurol Med Chir (Tokyo) 2010;50:614-5.
Himal HS. Minimally invasive (laparoscopic) surgery. Surg Endosc 2002;16:1647-52.
Johna S. Laparoscopic incisional hernia repair in obese patients. JSLS 2005;9:47-50.
Kubo S, Nakata H, Yoshimine T. Peritoneal shunt tube placement performed using an endoscopic threaded imaging port. Technical note. J Neurosurg 2001;94:677-9.
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