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Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 6  |  Page : 991-992

Shunt entrapment: Unusual placement of the distal end inside the falciform ligament


1 Department of Neurosurgery Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India
2 Department of MASS and Bariatric Surgery Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Anurag Gupta
Department of Neurosurgery Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.170094

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How to cite this article:
Gupta A, Singh H, Patir R, Wadhawan R. Shunt entrapment: Unusual placement of the distal end inside the falciform ligament. Neurol India 2015;63:991-2

How to cite this URL:
Gupta A, Singh H, Patir R, Wadhawan R. Shunt entrapment: Unusual placement of the distal end inside the falciform ligament. Neurol India [serial online] 2015 [cited 2019 Dec 14];63:991-2. Available from: http://www.neurologyindia.com/text.asp?2015/63/6/991/170094


Sir,

Ventriculoperitoneal (VP) shunts are one of the most common neurosurgical procedures performed. They have been associated with a long list of problems and complications. Here, we have described an unusual and a new complication, which we recently encountered.

A 60-year-old obese male patient underwent a programmable shunt insertion for normal pressure hydrocephalus (NPH). The peritoneal end was inserted via a right upper abdominal incision. The postprocedural period was uneventful, and the patient was discharged on the second postoperative day. He was doing well and sutures were removed on the tenth postoperative day in the outpatient clinic. The same evening, he developed cerebrospinal fluid (CSF) leak from the abdominal wound and came back to us the next morning. He had an active CSF leak from the suture site, and there was a diffuse bulge at the site of the abdominal wound. Plain computed tomography (CT) abdomen was done to determine the position of the peritoneal end. In the CT, the lower end appeared to be intra-peritoneal but was lying coiled up within a cystic fluid collection [Figure 1].
Figureá 1: Plain computed tomography abdomen showing the peritoneal end of the shunt coiled up inside the peritoneal cavity with surrounding fluid collection

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The general surgical team was consulted, and he was taken up for diagnostic laparoscopy the same day. On initial exploration, the peritoneal cavity looked intact with no signs of the tube or an obvious entry point in the ventral wall.

On closer examination, the falciform ligament appeared to be bulging on one side. The bulge also corresponded with the shunt entry site. The ligament was opened, and the tube was seen coiled inside along with a fluid collection. The tube was uncoiled and placed below the diaphragm [Figure 2]. The patient did well and was discharged the next day.
Figureá 2: Intra-operative pictures showing the asymmetric bulge of the falciform ligament. The peritoneal end is seen coiled up inside fatty tissue

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The falciform ligament is a fold of peritoneum containing fat and extends from the umbilicus up to the left lobe of the liver. Its superior surface lies in contact with the posterior sheath of the right rectus muscle near the midline. It can be as broad as 5 cm in some subjects.[1]

There has been no previous report of the tube being positioned inside the falciform ligament. Some recent publications have shown the usefulness of laparoscopy for treating abdominal complications of VP shunts.[2] A recent publication has also suggested using laparoscopy routinely in all cases so as to reduce distal end complications.[3]

Although some surgeons do use the trocar for abdominal end insertion, most surgeons still prefer the open method with a subcostal incision.[4] If the abdominal end shunt insertion is being done on the right side, care must be taken to make the entry site either lateral to the rectus sheath or near its lateral border so as to avoid the falciform ligament.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ╗ References Top

1.
Li XP, Xu DC, Tan HY, Li CL. Anatomical study on the morphology and blood supply of the falciform ligament and its clinical significance. Surg Radiol Anat 2004;26:106-9.  Back to cited text no. 1
    
2.
Popa F, Grigorean VT, Onose G, Popescu M, Strambu V, Sandu AM. Laparoscopic treatment of abdominal complications following ventriculoperitoneal shunt. J Med Life 2009;2:426-36.  Back to cited text no. 2
    
3.
Schucht P, Banz V, Trochsler M, Iff S, Krähenbühl AK, Reinert M, et al. Laparoscopically assisted ventriculoperitoneal shunt placement: A prospective randomized controlled trial. J Neurosurg 2015;122:1058-67.  Back to cited text no. 3
    
4.
McComb JG. Techniques of CSF diversion. In: Scott RM, editor. Hydrocephalus. Concepts in Neurosurgery. Vol. 3. Baltimore: Williams and Wilkins; 1990. p. 47-65.  Back to cited text no. 4
    


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