Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results.
OBJECTIVE
In spite of the recent interest in endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt is still the gold standard in treating non-obstructive hydrocephalus in children. The peritoneal cavity remains the optimal site for cerebrospinal fluid (CSF) diversion. Shunt insertion and re-interventions carry a high risk of inaesthetic abdominal scars and long-term morbidity. We report a technique of transumbilical shunt insertion, which provides better cosmetic results and without many more complications. This approach has been performed for a long period in a wide variety of intra-abdominal conditions by pediatric surgeons.


METHODS
Between March and October 2003, we inserted 12 VP shunts in children. For eight consecutively treated children the follow-up is more than 3 months. All the shunts were inserted through the umbilicus. These eight children are the subjects of this study. Indications for shunting were: communicating hydrocephalus (6 cases), subdural hematoma (1 case), and hygroma associated with an arachnoid cyst (1 case). The population consisted of 7 boys and 1 girl, ranging in age between 6 weeks and 47 months (mean age: 15 months), and their body weights varied between 2,110 g and 18,000 g (mean weight: 8,470 g). All children were examined twice a day for 3 days, and wounds were examined daily to check for the absence of sepsis or dehiscence. Clinical controls were performed 1 month after discharge. The operating surgeon was invited to comment on any difficulties encountered in making or closing this incision afterwards.


RESULTS
The average length of clinical follow-up was 6 months (range 4-7 months). One infection of the VP shunt occurred. It was treated with external drainage and antibiotics. After 1 week, a second VP shunt was inserted using the same technique without particular difficulty and with a nice cosmetic result. Concerning the seven other children, the cosmetic results were optimal, with no puckered abdominal scars or wound dehiscence, and with no perioperative or long-term complications related to the umbilical approach.


CONCLUSIONS
At this early follow-up, umbilical incision for shunt insertion is a safe and easy technique. It provides an optimal cosmetic result, even in cases of re-intervention. This minimally invasive surgery does not require long specialized training. We have not shown an increase in complications associated with a "learning curve." Longer follow-up is needed to evaluate the risk of infection.
Scavarda
Didier
D
Department of Pediatric Neurosurgery, Hôpital des Enfants La Timone, 13385 Marseille, France. didier.scavarda@ap-hm.fr
Breaud
J
J
Khalil
M
M
Paredes
A Paz
AP
Takahashi
M
M
Fouquet
V
V
Louis-Borrione
C
C
Lena
G
G
D002557:Cerebrospinal Fluid Shunts / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006849:Hydrocephalus / Q000145:classification / Q000601:surgery*; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome; D014470:Umbilical Cord / Q000601:surgery*