MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Ventriculoperitoneal shunt malfunction.
POSTOPERATIVE DIAGNOSIS:
Ventriculoperitoneal shunt malfunction.
OPERATION PERFORMED:
Proximal left frontal ventriculoperitoneal shunt revision.
SURGEON:
John Doe, MD
ANESTHESIA:
General with endotracheal intubation.
TUBES AND DRAINS:
Ventricular catheter.
ESTIMATED BLOOD LOSS:
10 mL.
COMPLICATIONS:
None.
DESCRIPTION OF OPERATION:
The patient was brought into the operating room where he was induced under general anesthesia and intubated. He was placed in the supine position with the head in neutral position, resting on a doughnut headrest. Care was taken to ensure that all pressure points were carefully padded and that the limbs were positioned comfortably. The head was carefully marked for the midline, and the previous left frontal incision site prepped and draped in the usual sterile fashion.
After removing the skin staples, the skin was reopened using Metzenbaum scissors to cut the subgaleal sutures with left frontal curvilinear incision. The shunt catheter was identified. We noticed a small amount of bloody CSF in the reservoir. The proximal catheter was disconnected from the valve and was noted not to be draining. A syringe was hooked up to the proximal end of the valve and lightly flushed and was noted to flush very easily and was used to purge the blood and any air. The bur hole was then widened to the left to allow more lateral trajectory with a Midas Rex drill. Care was taken to cover the valve to ensure that no bone dust would be introduced. After copiously irrigating the site with lactated Ringer’s, the cover was removed from the valve. The dura was cauterized with bipolar cautery and then opened with a 15 blade.
A new ventricular catheter was then passed from this site. On our first two passes, where we attempted to stay fairly lateral, no CSF was encountered. The third pass, however, which was slightly more medial, reached CSF at 4.5 cm. It was passed without the stylet slightly further to 5.5 cm, but there, it stopped draining. We noticed that with slight withdrawal of the catheter, it would begin draining vigorously at approximately 5 cm. An elbow connector was therefore slid onto the catheter and secured at this position so that with the elbow at the outer table of the bone, the catheter continued to drain. The pressure remained low, however, and drainage had to be confirmed using a Valsalva maneuver.
The catheter was then cut to length and attached to the proximal end of the valve and secured there with a 3-0 silk tie. The skin incision was extended slightly so that we could visualize the catheter at the distal end of the valve. This was due to the fact that we had to pull the valve slightly into the field of view to manipulate it for reattachment, and we wanted to ensure that, with reseating, the distal catheter did not kink. After we repositioned the valve, it was pumped and noted to pump and refill easily suggesting that there was no distal or proximal obstruction.
At this point, we closed the galea with 2-0 Vicryl sutures. An x-ray was obtained in the operating room to ensure that the catheter was not kinked beyond the valve. The skin was then finally closed with skin staples. It was dressed with Telfa dressings, sponge and paper tape. The patient was awakened from anesthesia without difficulty and extubated. The patient was taken to the PACU in stable condition.
