Ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).
This article primarily discusses shunt placement in children.
See also: Intracranial pressure
Description
This procedure is done in the operating room under general anesthesia. It takes about 1 1/2 hours.
The child's hair behind the ear is shaved off. A surgical cut in the shape of a horseshoe (U-shape) is made behind the ear. Another small surgical cut is made in the child's belly.
A small hole is drilled in the skull. A small thin tube called a catheter is passed into a ventricle of the brain.
Another catheter is placed under the skin behind the ear and moved down the neck and chest, and usually into the abdominal (peritoneal) cavity. Sometimes, it goes to the chest area. The doctor may make a small cut in the neck to help position the catheter.
A valve (fluid pump) is placed underneath the skin behind the ear. The valve is attached to both catheters. When extra pressure builds up around the brain, the valve opens, and excess fluid drains out of it into the belly or chest area. This helps decrease intracranial pressure.
The valves in newer shunts can be programmed to drain more or less fluid from the brain.
Why the Procedure Is Performed
In hydrocephalus, there is a buildup of fluid of the brain and spinal cord (cerebrospinal fluid or CSF). This buildup of fluid causes higher than normal pressure on the brain. Too much pressure, or pressure that is present too long, will damage the brain tissue.
A shunt helps to drain the excess fluid and relieve the pressure in the brain. A shunt should be placed as soon as hydrocephalus is diagnosed.
Risks
Risks for any anesthesia are:
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Reactions to medications
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Problems breathing
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Changes in blood pressure or breathing rate
Risks for any surgery are:
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Bleeding
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Infection
Possible risks of ventriculoperitoneal shunt placement are:
Blood clot or bleeding in the brain
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Brain swelling
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The shunt may stop working and fluid will begin to build up in the brain again.
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The shunt may become infected.
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Infection in the brain
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Damage to brain tissue
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Seizures
Before the Procedure
If the procedure is not an emergency (planned surgery):
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Tell your doctor or nurse what drugs, supplements, vitamins, or herbs your child takes.
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Give any drugs the doctor told you to give your child. It is okay if they take them with a small sip of water.
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The doctor or nurse will tell you when to arrive at the hospital.
Ask your doctor or nurse about eating and drinking before the surgery. The general guidelines are:
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Older children should not eat any food or drink any milk for 6 hours before surgery, but they can have clear fluids (juice or water) up until 4 hours before the operation.
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Infants younger than 12 months can usually eat formula, cereal, or baby food until about 6 hours before surgery. They may have clear fluids up until 4 hours before the operation.
Your doctor may ask you to wash your child with a special soap on the morning of the surgery. Rinse well after using this soap.
After the Procedure
Your child will need to lie flat for 24 hours the first time a shunt placed. After that your child will be helped to sit up.
The usual stay in the hospital is 3 to 4 days.The doctor will check vital signs and neurological status often. Your child may get medication for pain. Intravenous fluids and antibiotics are given. The shunt will be checked to make sure it is working properly.
Outlook (Prognosis)
Shunt placement is usually successful in reducing pressure in the brain. But if hydrocephalus is related to other conditions, such as spina bifida, brain tumor, meningitis, encephalitis, or hemorrhage, these conditions could affect the prognosis. The severity of hydrocephalus present before surgery will also affect the outcome.
Support groups for families of children with hydrocephalus or spina bifida are available in most areas.
The major complications to watch for are an infected shunt and a blocked shunt.
References
- Etiological categories of neurological disease. In: Goetz CG, ed. Textbook of Clinical Neurology. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 28.
- Kinsman SL, Johnston MV. Congential anomalies of the central nervous system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 592.
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Review Date: 11/22/2010.
Reviewed by: Kevin Sheth, MD, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
Copyright © 2011, A.D.A.M., Inc
Alisons Story
I was 37 when, as a woman with spina bifida I became pregnant for the first time. Although it was a lovely surprise I have to admit it was also quite a shock having been told at the age of 20 I was infertile. Hence the pregnancy was unplanned as I had come to a point of acceptance years before that I wouldn't ever be a mum.
So there I was, standing in my bathroom in a state of disbelief staring at my pregnancy test as the word "pregnant" flashed up. I dropped the test stick in the sink and rushed in to my living room pacing the room. It was a mixture of elation and fear flooding through me all at once. Elation that once again the medical profession had got it wrong just like they told my mum I would probably never walk when I was two years old (I walked at 3 1/2). The realisation that I would in fact be a mum after so many years of believing I wouldn't. Then of course the fear. Fear for the baby as I hadn't been taking folic acid and fear for me. How would the pregnancy affect me and how could I physically cope with being a mum.
My pregnancy was full of professionals who although monitored me as a high risk "mum to be" appeared to have no specialist knowledge of spina bifida. Thank God for ASBAH and the medical advisers who I was really able to talk to and discuss and prepare myself for the way ahead.
My pregnancy wasn't easy. I went from walking without aids to being on crutches and barely able to dress myself at the end and other problems related to my disability worsened. Having said that I look back on the experience fondly and still remember the first time my unborn baby kicked me. It was Boxing Day and it was the best Christmas present I could ever have.
At 20 weeks pregnancy came a bit of a blow. My scan showed that my baby had talipes. They had been looking for spina bifida and had ruled it out up to then but since I too have talipes (clubfoot) and it can be associated with spina bifida I was told that they had to suspect that the baby could have some form of spina bifida even though they couldn't see it. Again I was fearful. Having a baby was going to be physically demanding enough for me but having a baby who also had physical problems to deal with seemed overwhelming. From then on I was scanned regularly until 30 weeks.
On 11th June 2008 I gave birth to my beautiful son Jack. He was born by emergency caesarean nearly 2 weeks overdue after I had been induced and he had gone into distress during labour. I have to say that one of the positive aspects of being a spina bifida mum in labour was that pain didn't scare me nor did medical intervention. The big disappointment was that my spina bifida meant that my caesarean had to be performed under general anaesthetic rather than a spinal anaesthetic so I wasn't awake to see him come into the world.
When I woke up I peered across the room to see my partner Michael holding this bundle in his arms. He brought him over to me and the midwife put him straight to my breast. It was love at first sight. I soon discovered why my labour hadn't progressed so well. He weighed in at 8 pound 14 oz and I'm only 4 ft 9 inches tall! My advice to other mums to be in my position is to push for a 36-week scan to estimate the baby’s size. I was offered one but was told it was optional and therefore didn’t have one as I’d had so many during my pregnancy. I think if I'd had one at that point they wouldn't have let me go overdue and the birth would have been a lot less traumatic for all of us whether it had been a planned Caesarean or a pre term vaginal delivery.
Jack started treatment for his clubfoot at 13 days old when he was put in plaster. His foot was gradually straightened using a series of weekly plasters, a small op and the boots and bars. He will have to wear them at night until he is 4 years old.
Jack doesn't have spina bifida. He was 10 weeks old before they finally ruled it out. I was relieved because even though I've achieved everything I have wanted to in life I'm glad he won't have to go through the operations and pain I had to put up with. And when he is 4 years old his foot will be completely corrected.
Caring for Jack through his treatment has been emotionally hard for me. Going to Great Ormond Street, albeit a fantastic hospital, bought back memories of my childhood that I would have rather left behind me. It's also been physically very challenging for me, as Jack is very tall and heavy for his age. My initial reservations about asking for help have subsided and I have managed to get some good support from occupational therapy in looking for equipment that will help me and strategies in helping me to get Jack be a bit more cooperative during change times so he doesn't fight and run away from me but gets rewarded for sitting still. I think though that asking for help has been the hardest aspect of being a new mum as I've fought all my life for maximum independence. You have to remember though that all new mums need help and not feel as though it's the disability getting the better of you.
A positive aspect of being a disabled mum is that I feel I am so much more used to assessing the risks that could be present for Jack. When you have a disability you have to plan ahead when you are going out and know your limitations. These become a way of life for a physically disabled person and they are excellent attributes to have as a mum. Also I've noticed how much of a shock it is to new able-bodied mums: having to think about ramps and access for buggies. Even though I walk independently I'm used to looking for lifts, handrails and ramps so a new pram didn't feel like a new obstacle; in fact it helped me get back on my feet by offering me something to hold on to... The best walking aid ever.... a pram with your new baby in it.
There are days when Jack is having tantrums that he makes me feel very physically inadequate. If he decides to run off and lie down on the ground in a temper there is nothing I can do to stop him. But I think every mum goes through these feelings so I try not to let it get to me. I know that all Jack really needs is love and affection. My disability is as insignificant to him as his foot problems are to me. They are just part of who we are and if anything add to the bond we have with each other.
Alison has spina bifida and is mum to Jack who is 2 years old.
