title: The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results.
abstract: OBJECTIVE
  The aim of this study was to examine the feasibility and safety of ventriculoperitoneal (VP) shunt placement using a periumbilical approach for distal peritoneal access. By using this minimally invasive approach, the authors hypothesized that the cosmetic outcomes would be better than could be achieved by using a traditional minilaparotomy and that clinical results would be comparable.
  
  
  METHODS
  A periumbilical approach was used for distal catheter insertion during a first-time VP shunt placement in 20 patients (8 males and 12 females). Median age at time of surgery was 3.0 months (range 7 days-11.9 years) and mean follow-up time was 17.8 months (range 1.2-28.0 months). The median weight of the patients was 3.99 kg (range 1.95-57.0 kg). A single incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1-mm incision made while the patient was temporarily held in a Valsalva maneuver. A peritoneal trocar was then inserted through the fascial incision and the distal catheter was passed into the peritoneal space.
  
  
  RESULTS
  The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients' families. Mean operative time was 35 minutes. Eight patients required revision surgery. One distal failure occurred when the distal shunt tubing retracted and became coiled in the neck; this was repaired by conversion to a minilaparotomy for distal replacement. There was 1 shunt infection (5%) requiring shunt removal and replacement. One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system, and another patient underwent a conversion to a ventriculoatrial shunt due to poor peritoneal absorption. In the remaining 4 patients who required operative revision, the peritoneal portion of the shunt was not involved.
  
  
  CONCLUSIONS
  The periumbilical approach for peritoneal access during VP shunt placement is technically feasible, has low infection rates, and has cosmetically appealing results. It may be considered as an alternative option to standard VP shunt placement techniques.
authors: Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors: Pablo F
authors: PF
authors: Recinos
authors: Jonathan A
authors: JA
authors: Pindrik
authors: Mazen I
authors: MI
authors: Bedri
authors: Edward S
authors: ES
authors: Ahn
authors: George I
authors: GI
authors: Jallo
authors: Violette Renard
authors: VR
authors: Recinos
mesh_terms: D002648:Child; D002675:Child, Preschool; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D010535:Laparoscopy / Q000379:methods; D007813:Laparotomy / Q000009:adverse effects; D008297:Male; D010537:Peritoneum / Q000601:surgery; D011446:Prospective Studies; D012086:Reoperation; D016896:Treatment Outcome; D014472:Umbilicus / Q000601:surgery; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects / Q000379:methods*