Ventriculoperitoneal Shunt (VP) Surgery in Delhi, India

Ventriculoperitoneal (VP) shunt surgery is a procedure to treat a condition called hydrocephalus. Hydrocephalus occurs when excess cerebrospinal fluid (CSF) collects in the brain's ventricles. CSF is a clear, watery fluid that surrounds and cushions the brain and spinal cord. It also helps remove waste products from the brain.

Normally, CSF flows through these ventricles to the base of the brain, where it is absorbed into the bloodstream. However, if there is a blockage or imbalance in production and absorption, the CSF can build up and increase pressure in the skull. This pressure can damage brain tissue and lead to serious health problems.

During a VP shunt surgery, a thin tube, known as a shunt, is inserted into one of the brain's ventricles to drain excess CSF. The other end of the shunt is placed under the skin and then threaded down into the abdominal cavity (peritoneum), where the excess CSF can be absorbed by the body or in some cases into the atrium of the heart (VA Shunt). This helps to alleviate the pressure on the brain and reduce the symptoms associated with hydrocephalus, such as headaches, nausea, vomiting, and cognitive difficulties.

Ventriculoperitoneal shunt surgery is done when there is too much cerebrospinal fluid (CSF) in the brain and thecal sac in spine, a condition called hydrocephalus. This excess fluid causes higher than normal pressure on the brain, which can lead to brain damage.

Here are some of the reasons why a doctor might recommend VP shunt surgery:

• Symptoms of hydrocephalus: If anyone experiences headaches, nausea, vomiting, vision problems, developmental delays (in children which leads to increase in the size of the head), or difficulty with balance or coordination, these could be signs of hydrocephalus.
• Hydrocephalus is causing complications: In some cases, hydrocephalus can lead to serious complications, such as seizures, intellectual disability, or even unconsciousness. If hydrocephalus is causing these problems, surgery may be necessary.
• Other treatments have not been successful: Medication or other procedures may be tried first to treat hydrocephalus. However, if these treatments are not effective, VP shunt/ ETV surgery may be the best option.

Here are different types of ventriculoperitoneal shunt surgeries:

1. Standard Ventriculoperitoneal Shunt Surgery: This is the most common type of VP shunt surgery. It involves the placement of a catheter into one of the brain's ventricles to drain excess cerebrospinal fluid (CSF), with the other end of the catheter connected to the peritoneal cavity to allow for absorption of the fluid.
2. Adjustable/ Programmable Ventriculoperitoneal Shunt: In this type of surgery, a programmable valve is used in the shunt system. This valve allows healthcare providers to adjust the rate of CSF drainage as needed, which can be externally adjusted to regulate the pressure at which CSF drains from the brain, particularly useful in managing fluctuating CSF dynamics in conditions like normal pressure hydrocephalus (NPH).
3. Neuronavigation guided placement/ deployment of shunt- with the help of navigation technique shunt tube in pulse exactly into the ventricle. Safety and cleanliness of surgery improves.
4. Lumboperitoneal Shunt Surgery: While not technically a ventriculoperitoneal shunt, lumboperitoneal shunt surgery is another option for managing hydrocephalus. In this procedure, a catheter is placed into the lumbar (lower back) region of the spine, allowing CSF to drain from the spinal subarachnoid space to the peritoneal cavity.

Each type of ventriculoperitoneal shunt surgery has its own advantages and considerations, and the choice of procedure depends on factors such as the underlying cause of hydrocephalus, the patient's overall health, and the preferences of the healthcare provider.

Preparing for Ventriculoperitoneal Shunt Surgery

Before VP shunt surgery, the doctor conducts a thorough evaluation to assess the patient’s overall health and determine if the procedure is the appropriate course of treatment. This evaluation may involve:

• Medical History: The doctor discusses the patient's medical history, including past illnesses, surgeries, and medications.
• Physical Examination: A comprehensive physical examination is performed to check vital signs, bulging fontanelle (bulge in rhomboid shape) increasing size of head in infants and newborn and neurological function.
• Imaging Tests: Imaging tests such as CT scan or MRI scan provide detailed pictures of the patient's brain to identify the cause of hydrocephalus.
• Mental Status Testing: The patient may undergo mental status testing to assess cognitive function and memory.
• Lumbar Puncture: This may be required in case of doubt to measure opening pressure or therapeutic improvement (in NPH).

The doctor also discusses the risks and benefits of VP shunt surgery with the patient and addresses any questions or concerns they may have.

During Ventriculoperitoneal Shunt Surgery

VP shunt surgery is typically performed under general anaesthesia, ensuring the patient is asleep and pain-free during the procedure. The surgery generally lasts 1-2 hours. Here's a general outline of the surgical steps:

• Incisions: The surgeon makes an incision in the patient's scalp, usually behind and above the ear, and may also create a small incision(~3 cm) in the abdomen. One small hole is made into the skull (~14mm).
• Catheter Placement: One end of a thin, flexible tube (catheter) is inserted into a ventricle in the patient's brain, while the other end is tunnelled under the skin to the abdomen.
• Valve Placement: A valve, regulating the flow of cerebrospinal fluid (CSF), is positioned under the skin, typically near the scalp incision. It may be a programmable valve.
• Closing the Incisions: The surgeon closes the incisions with stitches or staples.

Post Ventriculoperitoneal Shunt Surgery Care

After VP shunt surgery, the patient is monitored in a recovery room for several hours before being transferred to a hospital room. During this time, vital signs and neurological function are closely monitored. Here's what to expect after surgery:

• Pain Management: Medication is prescribed to manage any pain at the incision sites.
• Bandages: The incisions are covered with bandages, which are typically removed after a few days.
• Diet: The patient may start with clear liquids and gradually progress to a regular diet.
• Activity Level: Encouragement to get out of bed and move around is provided, but strenuous activity should be avoided for several weeks.
• Follow-up Appointments: The patient needs to go for follow-up appointments with their doctor to monitor the function of the shunt and ensure it's effectively managing the fluid buildup in the brain.

The main benefit of VP shunt surgery is that it alleviates the symptoms of hydrocephalus and prevents further damage to the brain. By diverting excess CSF, the shunt reduces pressure in the skull, leading to several benefits such as:

• Reduced headaches: One of the most common symptoms of hydrocephalus is headaches. A properly functioning VP shunt can significantly reduce or eliminate headaches.
• Improved cognitive function: Increased pressure from CSF buildup can impair memory, thinking, and concentration. VP shunt surgery can help improve cognitive function and overall quality of life.
• Slower progression of neurological problems: In severe cases of hydrocephalus, untreated pressure on the brain can lead to developmental delays, learning difficulties, and even vision problems. Early intervention with VP shunt surgery can help prevent these complications.
• Preserved vision: Increased intracranial pressure can affect the optic nerve, leading to vision problems. VP shunt surgery can help preserve vision and prevent further deterioration.
• Improved overall health: By alleviating the pressure and preventing further brain damage, VP shunt surgery can significantly improve a person's overall health and well-being.

While VP shunt surgery is a very effective treatment for hydrocephalus, it is important to be aware of the potential risks and complications involved. Here are some of the main concerns:

1. Infection: One of the most serious risks associated with VP shunt surgery is infection. The shunt is a foreign object in the body, and there's always a chance that bacteria can enter the shunt and cause an infection in the brain or abdomen.

• Bleeding: Bleeding in the brain can occur during surgery or shortly afterward.
• Seizures: Some people experience seizures after VP shunt surgery. The risk of seizures is higher if there was bleeding in the brain during surgery.

2. Shunt malfunction: A VP shunt is a mechanical device, and like any device, it can malfunction. The shunt can become blocked, disconnected, or improperly adjusted. A malfunctioning shunt can lead to a return of hydrocephalus symptoms. Revision surgery may be needed at times.

Long-term complications

• Shunt revisions: Over time, the shunt may need to be revised or replaced due to wear and tear, blockages, or infections.
• Shunt visibility: As children grow, the shunt may become more visible under the skin.

It's important to discuss the risks and benefits of VP shunt surgery with a doctor to make an informed decision about the treatment plan.

How do you care for a VP shunt?

Caring for a VP shunt involves regular monitoring and taking precautions to prevent complications. This includes keeping the incision site clean and dry, watching for signs of infection or shunt malfunction, and following up with your healthcare provider as scheduled for routine check-ups and adjustments.

What is the difference between fixed and programmable shunts?

Fixed shunts have a predetermined valve setting that cannot be adjusted, while programmable shunts allow for adjustments to the valve settings post-surgery to optimise CSF drainage. Programmable shunts offer more flexibility in managing CSF flow and may be preferred in certain cases.

Is a VP shunt permanent?

VP shunts are typically considered permanent implants, but they may need to be replaced or revised over time due to complications or changes in the patient's condition.

Is VP shunt surgery high risk?

VP shunt surgery carries risks like infection, bleeding, and shunt malfunction, but these risks are typically outweighed by the potential benefits for patients with conditions like hydrocephalus.

What are the 2 types of shunts?

The two main types of shunts are ventriculoperitoneal (VP) shunts, which drain CSF from the brain to the abdomen, and ventriculoatrial (VA) shunts, which drain CSF from the brain to the heart.

Can a VP shunt be removed?

In some cases, a VP shunt may be removed if it is no longer needed or if complications arise. However, this decision is made on a case-by-case basis by a healthcare provider.

What is the recommended body position after ventriculoperitoneal shunt surgery?

After VP shunt surgery, patients are often advised to keep their head elevated and avoid lying flat for extended periods to help prevent complications like overdrainage of CSF.

Who performs shunt surgery?

Shunt surgery is typically performed by a neurosurgeon, a specialised surgeon trained in treating conditions affecting the brain and nervous system.

What is the purpose of shunt surgery?

The primary purpose of shunt surgery is to alleviate symptoms caused by conditions like hydrocephalus by diverting excess cerebrospinal fluid away from the brain, thereby reducing intracranial pressure.

Is a VP shunt a neurological device?

Yes, a VP shunt is a neurological device designed to manage conditions affecting the brain's fluid dynamics, such as hydrocephalus.

What is VP shunt cost?

The cost of VP shunt surgery can vary depending on factors such as the hospital, surgeon's fees, and any additional medical expenses. It's best to consult with your healthcare provider or insurance provider for specific cost estimates.

How long is VP shunt surgery?

VP shunt surgery typically lasts 45 mins-2 hrs, but the duration may vary depending on individual factors and any complications encountered during the procedure.

Can I stay with my child during the placement of a VP shunt?

While policies may vary, many hospitals allow parents to stay with their child during the placement of a VP shunt to provide comfort and support throughout the procedure. It's best to check the hospital's guidelines and discuss any concerns with the healthcare team beforehand.

Reviewed By Dr. Hrishikesh Chakrabartty Senior Consultant Neurosciences, Neurosurgery on 17 June 2024