Patel Aneek, Golub Danielle, Guerrero Zuniga Adler, Kaufman Brian
Department of Neurosurgery, New York University School of Medicine, NYU Langone Health, New York, NY, USA.
Departments of Medicine, Anaesthesiology and Neurology, New York University School of Medicine, NYU Langone Health, New York, NY, USA.
Br J Neurosurg. 2023 Oct;37(5):1285-1288. doi: 10.1080/02688697.2020.1858025. Epub 2020 Dec 11.
Cerebrospinal fluid (CSF) diversion for hydrocephalus via ventriculoperitoneal (VP) shunting is one of the most commonly performed neurosurgical procedures. Unfortunately, VP shunting also carries a high complication rate. While long-term complications of VP shunting are generally well-described, the literature on more acute, iatrogenic injury during shunt placement is essentially limited to easily identifiable intracranial bleeds. Herein is presented the first reported case of iatrogenic abdominal wall vessel injury as a consequence of blind distal VP shunt catheter placement causing a critical haemoperitoneum that necessitated multiple transfusions. Presentation and recognition of this bleed was delayed as it occurred over a number of days. Injury to the inferior epigastric artery, or potentially a distal branch of the superficial epigastric artery, is suspected to have occurred during either blind subcutaneous tunnelling of the shunt catheter passage or during penetration of the peritoneum. Haemoperitoneum as a potential complication of procedures involving manipulation or penetration of the abdominal wall (i.e. paracentesis) is well-described in the medical and general surgical literature, and ultrasound-guidance has been widely adopted to mitigate bleeding in these cases. Familiarity with intra-abdominal haemorrhage as a potential complication of VP shunting and an understanding of its presentation is critical for timely identification of this phenomenon. Furthermore, the use of real-time ultrasound-guidance for tunnelling and distal shunt catheter placement may decrease the incidence of intrabdominal complications after shunt placement more generally and should be considered an area of future study.
通过脑室腹腔（VP）分流术进行脑脊液（CSF）分流治疗脑积水是最常见的神经外科手术之一。不幸的是，VP分流术的并发症发生率也很高。虽然VP分流术的长期并发症通常已有详细描述，但关于分流器置入过程中更急性的医源性损伤的文献基本上仅限于容易识别的颅内出血。本文报道了首例因盲目放置VP分流管远端导致医源性腹壁血管损伤，进而引发严重腹腔积血并需要多次输血的病例。由于出血持续了数天，其表现和识别被延迟。怀疑在盲目进行分流管皮下隧道置入或穿透腹膜过程中发生了腹壁下动脉损伤，也可能是腹壁浅动脉的远端分支损伤。腹腔积血作为涉及腹壁操作或穿透的手术（如腹腔穿刺术）的潜在并发症，在医学和普通外科文献中已有充分描述，超声引导已被广泛应用于减少这些情况下的出血。熟悉腹腔内出血作为VP分流术的潜在并发症及其表现对于及时识别这一现象至关重要。此外，在隧道置入和分流管远端放置过程中使用实时超声引导可能会更普遍地降低分流术后腹腔内并发症的发生率，应被视为未来研究的一个领域。
