Turner Raymond D, Rosenblatt Steven M, Chand Bipan, Luciano Mark G
Department of Neurological Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Neurosurgery. 2007 Sep;61(3 Suppl):167-72; discussion 172-4. doi: 10.1227/01.neu.0000289730.27706.e6.
Although cerebrospinal fluid shunting remains one of the most common neurosurgical procedures, it is fraught with high infection, blockage, and reoperation rates. It has been estimated that the economic cost of ventriculoperitoneal shunting exceeds $1 billion annually. A new laparoscopic technique that eliminates abdominal incisions overlying shunt hardware was applied to 111 patients requiring ventriculoperitoneal shunts in an effort to decrease the morbidity associated with shunting.
All patients who required ventriculoperitoneal shunt insertion were eligible for this surgical technique. Patient selection was based on availability of both surgical teams (general surgery and neurological surgery) at the time of surgery. Using this technique, the distal shunt catheter is tunneled directly from the head into the peritoneal cavity under laparoscopic guidance without a skin incision directly overlying the distal catheter insertion site. Patients were followed prospectively for signs and symptoms related to shunt dysfunction, shunt infection, and incision morbidity.
One hundred eleven patients underwent 113 laparoscopic ventriculoperitoneal shunt surgeries between February 2003 and December 2004. The average follow-up period was 21.7 months (range, 12-34 mo). Nearly half of the patients (49%) were discharged the next morning and the majority (81%) was discharged within 2 days of surgery. Overall, 15 patients experienced complications requiring reoperation (13.5%) with a 1-year shunt survival rate of 91%. One patient (0.9%) acquired a new shunt infection, whereas two patients (1.8%) developed recurrence from a previous shunt infection. There were no abdominal incision-related complications.
This simplified laparoscopic shunt placement technique, which requires no overlying abdominal incisions, can be performed quickly with high shunt survivability and low infection rates. Furthermore, the laparoscopic method has the advantage of fast recovery time, elimination of preperitoneal or misplaced catheters, and decreased abdominal incision morbidity. The procedure can be performed by either a multidisciplinary team or entirely by neurosurgeons.
尽管脑脊液分流术仍是最常见的神经外科手术之一，但它存在感染率高、堵塞率高和再次手术率高的问题。据估计，每年脑室腹腔分流术的经济成本超过10亿美元。一种新的腹腔镜技术被应用于111例需要进行脑室腹腔分流术的患者，该技术消除了分流装置上方的腹部切口，以降低与分流相关的发病率。
所有需要插入脑室腹腔分流管的患者都符合这种手术技术的条件。患者的选择基于手术时两个手术团队（普通外科和神经外科）的可用性。使用这种技术，远端分流导管在腹腔镜引导下直接从头部隧道至腹腔，而无需在远端导管插入部位上方做皮肤切口。对患者进行前瞻性随访，观察与分流功能障碍、分流感染和切口发病率相关的体征和症状。
2003年2月至2004年12月期间，111例患者接受了113例腹腔镜脑室腹腔分流手术。平均随访期为21.7个月（范围12 - 34个月）。近一半的患者（49%）在第二天早上出院，大多数患者（81%）在手术后2天内出院。总体而言，15例患者出现需要再次手术的并发症（13.5%），1年分流生存率为91%。1例患者（0.9%）发生了新的分流感染，而2例患者（1.8%）出现了先前分流感染的复发。没有与腹部切口相关的并发症。
这种简化的腹腔镜分流管置入技术无需上方的腹部切口，手术速度快，分流生存率高且感染率低。此外，腹腔镜方法具有恢复时间快、消除腹膜前或位置不当的导管以及降低腹部切口发病率的优点。该手术可由多学科团队进行，也可完全由神经外科医生完成。
