Safety of Laparoscopy in Patients With Ventriculoperitoneal Shunts

INTRODUCTION: Laparoscopy allows operations to be performed with reduced blood loss, improved recovery time, decreased hospital stay, and reduced morbidity and mortality. In the past, some surgeons have considered the presence of a ventriculoperitoneal shunt (VPS) to be a contraindication to laparoscopy. Specific concerns have been raised over the use of pneumoperitoneum and intraoperative patient positioning, particularly Trendelenburg. Theoretical risks include backflow of CO2 into the CNS, dislodging the VPS intraoperatively, risk of infection, and increased intracranial pressure, particularly with Trendelenburg positioning. The safety of pneumoperitoneum with VPS has been demonstrated with several case series; however, evaluation was often limited by isolated cases. In many of these studies, the positioning of the patient was not discussed or was not Trendelenburg. Gynecologic surgery frequently uses the Trendelenburg position; thus, the gynecologic surgery candidate with a VPS may face barriers to having minimally invasive surgery as an option. OBJECTIVE: To demonstrate that laparoscopy is a safe option for patients with VPS in place, including operations performed in Trendelenburg position. METHODS: Subjects identified using ICD-10 codes for common laparoscopic procedures and for VPS. Demographic data, intraoperative heart rate, blood pressure, CO 2, and patient positioning were recorded. Intraoperative vitals were evaluated for combined significant hypertension (>20 mm Hg increase) and bradycardia (<20 bpm decrease), a proxy for the Cushing reflex indicating intracranial hypertension. Perioperative neurologic complications were recorded for 30 days post-op. These metrics were compared between operations in Trendelenburg and in non-Trendelenburg positions. Statistical analysis was performed with Fisher’s exact test for categorical data and Wilcoxon rank sum test for numeric data. RESULTS: 13 operations were performed in Trendelenburg vs 37 in non-Trendelenburg positions. No significant difference was found in group demographics. Intraoperative trends in heart rate, blood pressure, CO 2, and patient positioning were recorded as a validated proxy for the Cushing reflex, indicating worsening intracranial hypertension. These were evaluated as BP fluctuations >20 mm Hg increase and HR >20 bpm decrease. There was a significant increase in operative time for operations in Trendelenburg, 165 vs 95 minutes (p=0.0056). There was no significant difference in intraoperative data to indicate a Cushing reflex between the two groups, with no events seen in either group. Overall, perioperative complication rate was 8% (4/50 operations). There was a significant increase in perioperative complications with Trendelenburg (3/13 vs 1/37, p=0.0491). Of the Trendelenberg surgeries, 4 were gynecologic and no perioperative complications were noted. CONCLUSIONS: These results show that laparoscopy in patients with VPS appears to be generally safe and should be considered when not otherwise contraindicated. Despite a significant increase in operative time with Trendelenburg, there was no increase in intraoperative anesthetic events or evidence of Cushing reflex. There was a statistically significant increase in perioperative complications in the Trendelenburg group. It is difficult to determine the clinical significance, although this is one of the largest evaluations of laparoscopic outcomes in VPS patients to date.