Chaudhari, et al.

: Laparoscopic Cholecystectomy in ventriculoperitoneal shunt

National Journal of Medical and Allied Sciences

[eISSN: 2319 – 6335 |Case report |Open Access]

Website:-www.njmsonline.org

SAFETY OF LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH

VENTRICULOPERITONEAL SHUNT
Namita Chaudhari, Suman Khopde, Bhushan Thombare, HK Shah

Department of General Surgery, ESIPGIMSR, Andheri (East), Mumbai - 400 093, Maharashtra, India

Abstract
Advancements in Laparoscopy and Anaesthesia techniques has greatly minimised the list of
contraindications for Laparoscopic surgery. Presence of a Ventriculoperitoneal shunt in patients of
Hydrocephalus was considered a contraindication for Laparoscopic surgery as pnuemoperitoneum is
described as a cause of raised intracranial pressure that could potentially lead to shunt malfunction. Herein,
we discuss elective Laparoscopic Cholecystectomy for Chronic Calculous Cholecystitis in a patient of
Hydrocephalus with a V P shunt; without any shunt manipulation or intra-cranial pressure monitoring and a
review of the literature pertaining to Laparoscopic cholecystectomy in patients with hydrocephalus having
V P shunt.
Key words: Hydrocephalus, Ventriculoperitoneal Shunt, Laparoscopy, Cholecystectomy

Author for correspondence: Dr. Namita Chaudhari, ESIPGIMSR, Andheri (East), Mumbai - 400 093,
Maharashtra, India. E mail: [email protected]

Introduction: manipulation. The authors discuss elective

Consequent to the advancements in Surgical and Laparoscopic Cholecystectomy in a patient with a
Anaesthesia techniques, the feasibility of VP shunt and a brief review of literature
Laparoscopy in any patient, is not limited by the Case report:
presence of associated medical comorbidities. A 65 year old male patient presented in the surgery
Laparoscopic procedures were previously department of ESI PGIMSR and Model Hospital (
contraindicated in patients of Hydrocephalus having Andheri , Mumbai ) with a 3 month history of right
a Ventriculoperitoneal (VP) shunt. A routine upper quadrant pain associated with dyspepsia and
laparoscopic procedure like cholecystectomy for sour eructation. Written Informed Consent was
Gallstone disease was fraught with potential risks obtained from the patient for the Laparoscopic
like shunt malfunction or blockage and infection. procedure and the subsequent publication of this
Shunt blockage follows the elevation of the intra- case report. Clearance from the Institutional Ethical
cranial pressure resulting from pnuemoperitoneum committee was obtained. His past medical history
induced raised intra-abdominal pressure 1, 2. included subarachnoid haemorrhage (SAH) from
However, the literature now has conclusive anterior communicating artery aneurysm 6 years
evidence indicating that it is safe to perform ago for which he had aneurismal coils and a VP
laparoscopic surgery on these patients using routine shunt for subsequent chronically elevated
anaesthetic monitoring and without any shunt Intracranial pressure (ICP). SAH had left him with a

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 Chaudhari, et al.: Laparoscopic Cholecystectomy in ventriculoperitoneal shunt

residual right Hemiparesis. On examination, the The patient’s post-operative recovery was
patient was afebrile, anicteric and had only a mild uneventful and was discharged on the 4th post
discomfort in the right upper quadrant. Laboratory operative day with the Neurophysician and
data showed normal Haemogram, White blood cell Neurosurgeon certifying fitness for discharge. Upon
count, liver function test, Serum Lipase and follow-up, 3 months post discharge, the patient had
Amylase. An Abdominal Ultrasonography revealed recuperated well with no neurological deficit or
a distended gall bladder with multiple calculi and a signs of increased ICP.
normal Common Bile duct with the rest of the scan Discussion:
being normal. Laparoscopic surgery in the presence of a VP shunt
A Neurosurgeon and a Neurophysician were has been reported and discussed in literature;
consulted and a shunt series was obtained. This however the safety of Laparoscopy in such patients
included plain radiographs of the head, chest, and has been controversial 1. A Ventriculo-peritoneal
abdomen to evaluate the subcutaneous and intra shunt comprises of a silicone catheter stationed in
abdominal path of the shunt catheter. The imaging the lateral cerebral ventricle, a reservoir, a
demonstrated an intact VP shunt with the tip of the unidirectional valve and a tube ending with a
catheter seen within the abdomen. The patency of catheter lying freely in the peritoneal cavity. From
the shunt and its proper functioning of were the lateral ventricle the catheter is tunnelled through
preoperatively verified by the Neurosurgeon and the the subcutaneous tissue into the free peritoneal
patient was planned for Elective Laparoscopic space in order to drain off the surplus cerebrospinal
Cholecystectomy after a thorough assessment by the fluid. A patent and functional shunt relieves the
Anaesthesiologist. An informed consent for the raised ICP resulting from hydrocephalus by virtue
Laparoscopic cholecystectomy was obtained from of continuous drainage of the cerebrospinal fluid
the Patient. into the abdomen. The unidirectional valve is
Laparoscopic Cholecystectomy was carried instrumental in preventing the reflux of
out using a standard 4-port technique.( Fig 1 )The cerebrospinal and intra-abdominal fluids 2, 3. The
first port access was achieved using Hasson's shunt valve is capable of withstanding a pressure of
technique and the other ports were placed by up to 300 mg Hg. Hence an intra abdominal
inserting trocars under vision away from the shunt. pressure of 12–15 mmHg which is used to insufflate
The abdomen was insufflated with CO2 to a the abdomen during Laparoscopic Cholecystectomy
pressure of 12–15 mmHg. Intra-operative findings is very unlikely to produce pneumocephalus 4.
included flimsy adhesions between the omentum Especially worrisome is the potential rise in the
and the fundus of the gallbladder, a thick Intra cranial pressures following pnuemoperitoneum
gallbladder wall and a long narrow cystic duct. The which may lead to shunt malfunction.
shunt was seen lying free in the abdomen without Uzzo et al have reported transient increases in the
any adhesions (Fig 2). intracranial pressure during Laparoscopic
Routine anaesthetic monitoring took place procedures on two children with VP shunts 5. Thus
all through the operation without the need for ICP ideally patients with VP shunt, undergoing
monitoring or special precautions. The surgery was laparoscopy merit a routine intra-operative
completed laparoscopically. The shunt was seen monitoring of ICP 6. Besides this, the technical
lying free and intact at the end of the procedure. difficulties during gall bladder dissection, extensive
Complete haemostasis was achieved. No drains adhesions due to the presence of the shunt, bile
were left in situ. The patient tolerated the spillage, haemorrhagic collection and the use of
pnuemoperitoneum and the entire procedure with no irrigation fluid during dissection may lead to
hemodynamic instability to suggest increased blockage and infection of the shunt. Several factors
intracranial pressure. contribute to the elevation of intracranial pressure
during Laparoscopy. Hypercapnea caused due to

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 Chaudhari, et al.: Laparoscopic Cholecystectomy in ventriculoperitoneal shunt

absorption of CO2 from the peritoneal cavity visualization and proper placement of the
10
following CO2 insufflation and the effect of catheter .
insufflation on ventilation, leads to intracranial The authors, following the standard
arterial dilation and increased cerebral perfusion. operative steps and routine anaesthetic monitoring
CO2 insufflation leads to venecaval compression completed the elective Laparoscopic
causing engorgement of the cerebral veins. Cholecystectomy uneventfully without any shunt
An incompetent shunt valve may facilitate a manipulation or intra-operative ICP monitoring.
retrograde insufflation of CSF. Distal obstruction of
the shunt catheter by soft tissues can occur during
creation of pnuemoperitoneum 7. Several measures
have been suggested to decrease the risks of raised
intra-cranial pressure during the procedure
including intra operative ICP monitoring, lowering
the intra abdominal pressure during CO2
Insufflation, ventricular drainage , clamping or
clipping the distal Intraperitoneal end of the shunt
catheter and shunt externalization and clamping the
subcutaneous portion of the catheter for the entire
duration of the procedure 7,8 . However, invasive
ICP monitoring may precipitate intracranial
haemorrhage and the clamping or clipping of the
intraperitoneal end of the shunt catheter may
aggravate the intracranial hypertension, hence these
methods have not been used routinely. Besides
there are reports of Laparoscopic Cholecystectomy
being performed successfully without the need for Fig 1: Laparoscopic Cholecystectomy carried out
any modification in intra-abdominal pressure or using a standard 4-port technique
shunt manipulation 9. There are two studies with a
large series of patients namely Jackman et al
published an 18 patient series in 20006 and Collure
et al published data in 1995 on a series of four
patients4 ,that have soundly concluded that
Laparoscopy is safe in patients with V P
Shunts. The main concern while undertaking
Laparoscopy in such patients is a clinically
significant rise in the intracranial pressure and
retrograde shunt failure resulting in
pnuemoencephalus and any inadvertent damage to
the intra peritoneal portion of the shunt catheter
during placement of trocars and the dissection of the
gall bladder11. The greatest advantage laparoscopy
, in such cases is that Laparoscopy permits
panoramic visualization of the abdominal cavity,
effective adhesiolysis in view of previous Shunt
Insertion and also ensures the complete Fig 2: VP shunt lying free in the abdomen without
any adhesions

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 Chaudhari, et al.: Laparoscopic Cholecystectomy in ventriculoperitoneal shunt

Conclusion: ventriculoperitoneal shunts. Surg Laparosc

In adult patients with established VP shunts, a Endosc Percutan Tech. 2005;15(1):28–29.
standard Laparoscopic Cholecystectomy can be 8. Kimura T, Nakajima K, Wasa M, Yagi M,
safely performed using routine Anaesthesia Kawahara H, Soh H. Successful
monitoring. A preoperative neurosurgical laparoscopic fundoplication in children
with ventriculoperitoneal shunts. Surg
evaluation asserting a properly functioning shunt is
Endosc. 2002;16(1):215.
mandatory. Charting the path of the catheter within 9. Damrah O, Naik P, Fusai G, Sharma D. Is
the abdominal wall helps the surgeon to judiciously laparoscopic cholecystectomy safe for
avoid damage to the catheter during Trocar acute cholecystitis in the presence of
placement and Gall Bladder dissection. Knowledge ventriculo-peritoneal shunt? International
of the position of the shunt reservoir is of Journal of Surgery Case Reports
importance to the anaesthesiologist and surgeon, so 2011;2(6):157–158.
that the reservoir can be pumped if required. The 10. Jain S, Bhandarkar D, Shah R, Vengsarkar
concluding step of the surgeon before U. Laparoscopic management of
decompressing the abdomen should be a thorough complicated ventriculoperitoneal shunts.
inspection of the catheter to ensure that the catheter Neurol India 2003;51:269-270
11. Roth J, Sagie B, Szold A, Elran H.
is not twisted, obstructed or damaged.
Laparoscopic versus non–laparoscopic-
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Conflicts of Interest: None
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