Where do you place the incision for the distal end (abdominal end) of a Ventriculoperitoneal (VP) shunt?

VP Shunt Distal (Abdominal) Incision Placement

The distal catheter incision for VP shunt placement should be made in the right upper quadrant of the abdomen, typically lateral to the rectus muscle, allowing for direct peritoneal access while avoiding previous surgical scars and areas of potential adhesions.

Standard Abdominal Incision Approach

Primary Incision Location

• The right upper quadrant is the preferred site for the abdominal incision, positioned lateral to the rectus abdominis muscle 1, 2
• A small 5-mm skin incision at the right upper quadrant allows for catheter insertion after laparoscopic visualization confirms an adhesion-free entry site 1
• The incision should be placed to avoid previous surgical scars and areas where adhesions are likely to interfere with catheter placement 2, 3

Technical Considerations for Incision Placement

• Under laparoscopic guidance, identify the optimal VPS entry site free of adhesions before making the skin incision 1
• The catheter is tunneled subcutaneously from the abdominal insertion point to the postauricular region where it connects to the valve 1
• Position the incision to allow the catheter tip to reach the pelvis or lower abdomen where CSF absorption is optimal 2

Alternative Approaches for Special Populations

Transumbilical Approach in Infants and Small Children

• An umbilical incision provides superior cosmetic results in infants and children under 5 years of age, with a 0% infection rate and only 4% complication rate in one series 4
• This approach is quicker, nearly bloodless, and leaves no visible scar as the umbilicus heals without noticeable scarring 4
• The age range for this technique is 6 days to 5 years, with mean follow-up of 3.2 years showing excellent outcomes 4

Laparoscopic-Assisted Placement

• An infraumbilical trocar is placed using the Hasson open technique for laparoscope insertion 1, 2
• A 10-12 mm laparoscope allows inspection of the abdomen to identify the best entry site for the distal catheter 1
• The actual catheter entry incision is then made at the identified optimal location, typically in the right upper quadrant 1, 2

Critical Pitfalls to Avoid

Incision Site Selection Errors

• Avoid placing incisions through areas of previous abdominal surgery where adhesions increase the risk of catheter malfunction and pseudocyst formation 2, 3
• Do not blindly insert the catheter without visualizing the peritoneal cavity, especially in obese patients or those with prior abdominal operations 2, 3
• Ensure the incision is not too close to the costal margin, which can cause catheter kinking or breakage at the entry point 3

Hardware-Related Complications

• Five cases of catheter breakage occurred at the abdominal entry site due to shearing by the trocar, emphasizing the need for smooth catheter passage 3
• Position the catheter to avoid tension or acute angulation at the abdominal wall entry point 3

Verification of Proper Placement

Intraoperative Confirmation

• Visually confirm CSF flow from the distal catheter under laparoscopic visualization before completing the procedure 1, 2
• Compress the valve while observing the catheter tip to verify appropriate function 2
• Direct the catheter to the pelvis or paracolic gutter using laparoscopic graspers for optimal positioning 2, 3

Postoperative Monitoring

• Monitor for signs of shunt malfunction including headache, nausea, vomiting, and visual disturbances in the immediate postoperative period 5, 6
• Assess surgical sites for CSF leakage or signs of infection 6
• Watch for abdominal complications including pseudocyst formation (rare but important complication requiring revision) 7