In the treatment of pediatric hydrocephalus, cerebrospinal fluid (CSF) diversion can become problematic in shunt-dependent patients when the conventional sites for diversion, such as the peritoneal cavity and the right atrium, are unavailable. Ventriculopleural shunting is infrequently used [2, 3, 4, 5]. The pediatric applications of minimally invasive surgical procedures such as thoracoscopy continue to increase due to advances in endoscopic equipment. We report the case of a thoracoscopically assisted placement of the pleural catheter in a boy with a history of repeated shunt revisions.

Case report

A 16-year-old boy with spastic tetraparesis, epilepsy, and psychomotoric retardation was admitted emergently with a progressive alteration of conciousness due to shunt malfunction. After a premature birth, he developed posthemorrhagic hydrocephalus, and in subsequent years the patient required numerous shunt procedures to treat complications related to infections, decubitus, disconnection, migration, and blockage of the catheter. In total, he underwent nine ventriculoperitoneal shunts and five ventriculoatrial shunts, until, at the age of 6 years, a ventriculopleural shunt (VPLS) was inserted by intercostal thoracotomy. Four years later, a replacement of the distal catheter was necessary. Six years after that, he presented again and a computed tomographic scan showed significantly dilated ventricles (Fig. 1). A shunt series revealed that the shunt malfunction was due to dislocation of the pleural catheter (Fig. 2). Revision was immediately performed, and at surgery both ventricular catheters and the valve worked well. For thoracoscopic assistance, the patient was placed in the lateral position. Through a 5-mm skin incision in the area of the former thoracotomy, the thoracoscope was introduced into the thoracic cavity. Despite two previous thoracotomies, the pleural cavity was unscarred. After effortless removal of the dislocated shunt, a new distal catheter was tunneled to a second 5-mm skin incision overlying the rib at the same level. Under thoracoscopic vision, the new distal catheter was placed by a peel-off needle (Fig. 3) into the pleural cavity. After positioning the tubing in the pleural cavity (Fig. 4), the needle was sectioned and removed. Function of the VPLS was assessed visually. The thoracoscope was removed with positive pressure ventilation at the end, and suture closure of the shunt entry site and the thoracoscope site completed the procedure. The postoperative course was uneventful. A postoperative chest radiograph showed the catheter in a correct position. Chest films and clinical follow-up examination 1 year later revealed an optimally functioning shunt.

Figure 1
figure 1

CT scan at admission shows significantly dilated ventricles.

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Figure 2
figure 2

Chest radiograph showing the cause of the shunt malfunction—dislocation of the pleural catheter in the subcutaneous space.

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Figure 3
figure 3

The peel-off needle for introduction of the pleural catheter.

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Figure 4
figure 4

Endoscopic view after placement of the pleural catheter.

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Discussion

In general, VPLS is considered an alternative route for draining CSF in selected patients when conventional sites, such as the peritoneal cavity and the right atrium, are used up or not available due to adhesions, infection, thrombosis, or obliteration. Several series suggest that VPLS is a suitable alternative for CSF drainage in children as in adults [2, 3, 4, 5].

During the past few years, thoracoscopic surgery has become a standard procedure and its applications to a variety of surgical indications has increased. In contrast to open thoracotomy, the endoscopic-assisted placement of the distal end of the catheter in the pleural cavity has several advantages [1], including a reduction in operating time; the ability to inspect the thoracic, particularly in cases of prior conventional surgery; visual control of the desired intrapleural length and location of the drain; and the ability to visualize shunt function while compressing the valve. This procedure is associated with reduced trauma to the pleural wall, and in our case there were no operation-related complications, such as the often reported symptomatic tension hydrothorax, pneumothorax, or pleural empyema.

Thoracoscopic guidance allows precision in the positioning of the distal catheter and reduces the risk by visual assessment [1]. Therefore, the endoscopic approach may be particularly beneficial when there is a suitable area in which to place the shunt in patients with prior surgical interventions. The pleural portion of the shunt is delivered through a peel-off needle, which is sectioned and removed after placement. This method is less invasive than using a minithoracotomy for access to the thoracic cavity, and this technique appears to be associated with low morbidity. When performed by a skilled endoscopic surgeon, it is a safe and efficient technique that ensures precise insertion and provides definite patient benefit.