title: Management of the ventriculo-peritoneal shunt in pediatric patients during robot-assisted laparoscopic urologic procedures.
abstract: BACKGROUND
  Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures.
  
  
  METHODS
  After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications.
  
  
  RESULTS
  We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen.
  
  
  CONCLUSIONS
  In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results.
authors.affiliation: Pediatric Urology Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Medical Center and Pritzker School of Medicine, Chicago, Illinois, USA. pemarchetti@yahoo.com
authors.forename: Pablo
authors.initials: P
authors.lastname: Marchetti
authors.forename: Aria
authors.initials: A
authors.lastname: Razmaria
authors.forename: Greg P
authors.initials: GP
authors.lastname: Zagaja
authors.forename: Mohan S
authors.initials: MS
authors.lastname: Gundeti
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D010535:Laparoscopy; D008297:Male; D012371:Robotics / Q000379:methods*; D013520:Urologic Surgical Procedures / Q000379:methods*; D017287:Ventriculoperitoneal Shunt / Q000379:methods*