What are the considerations for performing a laparotomy on a patient with a Ventriculoperitoneal (VP) shunt?

From the Guidelines

When performing a laparotomy on a patient with a ventriculoperitoneal (VP) shunt, it is crucial to prioritize precautions to prevent shunt malfunction or infection, as these complications can lead to increased intracranial pressure or introduce pathogens directly to the central nervous system, potentially causing life-threatening complications. The surgical team should consult with neurosurgery preoperatively to evaluate shunt function and determine if temporary externalization is necessary 1.

Key Considerations

• Prophylactic antibiotics should be administered, typically cefazolin 2g IV (or vancomycin 15mg/kg if MRSA risk or beta-lactam allergy exists), within 60 minutes before incision.
• The surgical team must identify and carefully protect the distal catheter during abdominal entry and throughout the procedure to prevent damage, disconnection, or contamination.
• If the catheter must be manipulated, strict aseptic technique is essential.
• Intraoperative positioning should avoid pressure on shunt components, particularly at the valve sites behind the ear and along the neck/chest tract.
• Postoperatively, monitor for signs of shunt malfunction (headache, altered mental status, nausea/vomiting) and infection (fever, erythema along shunt tract).

Management of Shunt Malfunction or Infection

• According to the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline, patients with ventriculoperitoneal shunt malfunction should have the revision performed in a single procedure, while those with a bacterial or other superinfection should have the infected shunt removed and a replacement placed at a subsequent time as a second procedure 1.
• A rational approach in a patient who is hemodynamically stable is to perform lumbar puncture to assess for infection and measure opening pressure to indirectly assess shunt function, and consider a shunt tap to sample the CSF for infection and evaluate the patency and function of the shunt apparatus 1.

From the Research

Considerations for Laparotomy with a Patient with a VP Shunt

• The presence of a ventriculoperitoneal (VP) shunt is a significant consideration in laparotomy procedures, as it can increase the risk of complications such as shunt infection or malfunction 2.
• Studies have shown that laparoscopic procedures can be safely performed in patients with VP shunts, but careful monitoring and management are necessary to prevent complications 3, 2.
• The use of prophylactic antibiotics, such as vancomycin and gentamicin, has been shown to reduce the incidence of shunt infection in patients undergoing VP shunt placement 4, 5.
• The route of antibiotic prophylaxis, including intravenous, intrathecal, and topical administration, may also play a role in preventing shunt infections, although the evidence is not yet conclusive 6.

Risk Factors for Shunt Infection

• Prematurity, age less than one month, and duration of surgery of 90 minutes or more have been identified as significant risk factors for postoperative shunt infection 4.
• The presence of a cerebrospinal fluid (CSF) leak and young age (< 6 months) at the time of surgery have also been associated with an increased risk of shunt infection 5.

Management of Patients with VP Shunts Undergoing Laparotomy

• Careful preoperative planning and coordination with neurosurgical and anesthesiology teams are essential to ensure safe management of patients with VP shunts undergoing laparotomy 2.
• Intraoperative monitoring of intracranial pressure (ICP) and careful management of anesthesia and ventilation are also crucial to prevent complications 2.
• The use of laparoscopic techniques, such as laparoscopically assisted VP shunt placement, may help reduce the risk of distal shunt failure and other complications 3.