HPB P42 Case Report: Laparoscopic Cholecystectomies in patients with a Ventriculoperitoneal shunt: key considerations for surgeons

Abstract

Abstract Background Laparoscopic surgery has evolved to become the preferred mode of access for intraperitoneal surgery and is the gold standard approach to cholecystectomy. With the high prevalence of laparoscopic procedures to definitively treat gallstones and their associated complications, an increasing number of patients with co-morbidities are undergoing these procedures, including patients with cerebrospinal fluid (CSF) shunts in situ. These shunts pose unique challenges due to the paucity of guidelines, research and data to optimally manage these patients. Methods We report a case of a patient who underwent a successful, but technically challenging laparoscopic cholecystectomy whilst having a Ventriculoperitoneal (VP) shunt present. Important considerations are necessary, including the additional risks of: shunt failure and impaired CSF drainage, retrograde insufflation leading to increased intracranial pressure and herniation, and the risk of bile leak which could result in ascending meningitis (thereby making intra-operative cholangiogram a relative contraindication). We will discuss what unique measures were implemented pre-operatively, peri-operatively and post-operatively to prevent these complications, in consultation with both the patient and the wider multidisciplinary healthcare team. Results A 39-year-old female with gallstone pancreatitis, underwent an ERCP, and was subsequently listed for elective laparoscopic cholecystectomy. From childhood, she had a VP shunt in place for an Arnold Chiari II malformation. A literature review was conducted and a CT scan was arranged. Her case was discussed with neurosurgery, radiology, microbiology and anaesthetics, with multiple safety recommendations proposed; including US guided marking of the shunt tubing on the skin, appropriate pre-operative antibiotics, lower than normal pneumoperitoneum pressures, no attempt at intra-operative cholangiogram or bile duct exploration, avoidance of gallbladder perforation, minimal washout, neuro-observations in the post-operative period and post-operative antibiotics. Conclusions Our report shows that with thorough pre-operative planning involving communication with multidisciplinary team and with informed consent, laparoscopic cholecystectomy can be performed in this patient sub-group with relative safety without the need for shunt manipulation or peri-operative intracranial pressure monitoring. It is however, technically challenging, and should be considered by experienced laparoscopic surgeons, and perhaps reserved for those with subspecialty biliary interests.