title: Preventing Distal Catheter Obstruction in Laparoscopic Ventriculoperitoneal Shunt Placement in Adults: The "Falciform Technique".
abstract: BACKGROUND
  Distal obstruction of ventriculoperitoneal (VP) shunts is a major problem in the treatment of hydrocephalus. To avoid this complication, we describe a simple method using the falciform ligament to place and hold the distal catheter in the right subdiaphragmatic space, preventing catheter migration and distal obstruction.
  
  
  METHODS
  We retrospectively collected data of all VP shunt insertion and revision for adults with idiopathic normal-pressure hydrocephalus between November 2011 and September 2013. All of these were done using the "falciform technique," with the distal catheter portion performed laparoscopically. No exclusion criteria were applied. A neurosurgeon and a laparoscopic surgeon were involved in each case. The falciform ligament was used to tether the distal catheter above the liver, with the distal tip of the catheter reaching the hepatic flexure to allow for drainage directly into the right paracolic gutter. Baseline, operative, and postoperative data were collected and analyzed.
  
  
  RESULTS
  In total, 58 patients underwent a shunt procedure during the period of study. The majority (74%) underwent new VP shunt placement, and 26% underwent revision and replacement for catheter obstruction. The female to male ratio was 1.14:1. Mean age was 67.3±17.5 years. Revisions due to distal catheter obstruction were subsequent to previous surgery placement. Median follow-up was 329 days. Three patients (5%) had proximal catheter obstruction requiring shunt revision. None of the patients (0%) was found to have distal obstruction at the end of the study period at the most recent follow-up.
  
  
  CONCLUSIONS
  The faparoscopic falciform technique significantly reduces the rate of distal VP shunt obstruction in adults with idiopathic normal-pressure hydrocephalus. Continued follow-up is needed to confirm long-term patency of the catheter.
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Shane M
authors.initials: SM
authors.lastname: Svoboda
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Habeeba
authors.initials: H
authors.lastname: Park
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Neal
authors.initials: N
authors.lastname: Naff
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Zeena
authors.initials: Z
authors.lastname: Dorai
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Williams
authors.affiliation: Department of Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland.
authors.forename: Yassar
authors.initials: Y
authors.lastname: Youssef
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D061807:Catheter Obstruction / Q000209:etiology; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery; D010535:Laparoscopy / Q000379:methods*; D008022:Ligaments / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011322:Primary Prevention / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects* / Q000379:methods*