Microlaparoscopic-Assisted Lumboperitoneal Shuntin the Lateral Position for Pseudotumor Cerebri in a

Morbidly Obese AdolescentNirupama Kumar, BA, Karin S. Bierbrauer, MD, Harsh Grewal, MD

ABSTRACTBackground: Pseudotumor cerebri or idiopathic intracra-nial hypertension is a known complication of morbidobesity that often requires neurosurgical intervention forworsening symptoms. Placement of a lumboperitonealshunt (LPS) is one of the treatment options, but in amorbidly obese patient it can be technically challenging.We describe the use of 3-mm instrumentation for assis-tance in placing the peritoneal end of the shunt.

Case Report: A 16-year-old morbidly obese girl with adiagnosis of pseudotumor cerebri and decreasing visualacuity and contraction of her visual fields underwent lum-boperitoneal shunt placement. Due to her body habitussecondary to her morbid obesity a microlaparoscopic-assisted approach was utilized for placement of the peri-toneal end of the lumboperitoneal shunt.

Results: No operative or postoperative problems oc-curred, and she was discharged home with resolution ofsymptoms. Her visual acuity and fields had normalized at3-month follow-up.

Conclusion: Microlaparoscopic-assisted lumboperito-neal shunt placement in the lateral position is an efficientand safe method for the treatment of pseudotumor cere-bri. It is a minimally invasive, simple, effective tool forplacing the peritoneal catheter for LPS.

Key Words: Laparoscopy, Morbid obesity, Lumboperito-neal shunt, Pseudotumor cerebri.

INTRODUCTION

Morbid obesity is a dramatically increasing problem in thepediatric population.1 Morbid obesity has numerous co-morbidities, but one rare, severe complication of morbidobesity is pseudotumor cerebri. This syndrome is charac-terized by increased intracranial pressure despite normalcerebrospinal fluid levels and normal sized ventricles.2

Untreated pseudotumor cerebri can lead to progressiveloss of vision, papilledema, persistent headaches, nausea,and cranial nerve deficits.2,3 This disorder is initiallytreated medically to decrease intracranial pressure, byusing diuretics, steroids, or repeated lumbar puncture.2,4

Pseudotumor cerebri often requires neurosurgical inter-vention for worsening symptoms, such as visual loss re-fractory to medical management. Neurosurgical treatmentoptions include ventriculoperitoneal and lumboperitonealshunting.5 We describe microlaparoscopic assistance inplacing the peritoneal end of the lumboperitoneal shuntin a morbidly obese adolescent.

CASE REPORT

A 16-year-old, morbidly obese girl presented after 1 weekof progressive dull headaches, nausea, vomiting, andworsening of visual symptoms that initially began as right-sided blurry vision. She had prior hospitalizations forsimilar complaints in which she had undergone right-sided fenestration of the optic nerve and lumbar puncturewith some improvement of symptoms and was subse-quently diagnosed with pseudotumor cerebri. Medicaltherapy with acetazolamide was started at that time butwas discontinued by the patient after 2 months because ofintolerance. She returned 2 years later with recurrence ofsymptoms. She was found on initial lumbar puncture tohave an elevated intracranial pressure. During the hospitalcourse, she was started on diuretics and steroids with littleeffect, but she did respond to lumbar punctures withdrainage of cerebrospinal fluid. She underwent fenestra-tion of the left optic nerve with minimal improvement.Repeated ophthalmic examinations showed progressivecontraction of visual fields, diplopia and blurry vision,impaired abduction of the eye, disc edema, and decreas-ing visual acuity. Following an extensive workup andbecause of deterioration in visual ability, she underwent

Section of Pediatric Surgery, Temple University School of Medicine, Philadelphia,Pennsylvania, USA (Dr Grewal).

Section of Neurosurgery, Temple University School of Medicine, Philadelphia,Pennsylvania USA (Dr Bierbrauer).

Temple University School of Medicine, Philadelphia, Pennsylvania, USA (DrsKumar, Bierbrauer, Grewal).

Temple University Children’s Medical Center, Philadelphia, Pennsylvania, USA (DrsBierbrauer, Grewal).

Address reprint requests to: Harsh Grewal, MD, FACS, FAAP, Section of PediatricSurgery, Temple University Children’s Medical Center, 3509 N Broad St, 5th East,Philadelphia, PA 19140, USA. Telephone: 215 707 6407, Fax: 215 707 6443, E-mail:harsh.grewal@temple.edu

Presented as a poster at the 14th Annual Congress for Endosurgery in Children,Venice, Italy, June 2005.

© 2006 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published bythe Society of Laparoendoscopic Surgeons, Inc.

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CASE REPORT

lumboperitoneal shunt. Due to her body habitus second-ary to morbid obesity, a laparoscopic-assisted approachwas utilized for placement of the peritoneal end of thelumboperitoneal shunt.

The procedure was performed with the patient in thelateral decubitus position with the right side up, andfluoroscopy was utilized to access the lumbar subarach-noid space (Figure 1). A radially expanding 3-mm trocarwas then placed midway between the anterior axillary lineand umbilicus. Using carbon dioxide pneumoperitoneum,a 3-mm, 30° telescope was placed to visualize the rightcolonic peritoneal attachment. The shunt tubing was tun-neled subcutaneously from the spine to the anterior axil-lary line and was inserted just anterior to the right colonperitoneal attachments by using a percutaneously placedpeel-away sheath and dilator under direct laparoscopicvisualization (Figure 2). The incisions were sealed withcyanoacrylate glue.

No operative or postoperative problems occurred, and shewas discharged home with resolution of symptoms. Hervisual acuity and fields normalized at 3-month follow-up.

DISCUSSION

Pseudotumor cerebri is also known as benign intracranialhypertension, though it can have a clinical course that isfar from benign, including the risk of loss of vision.Pseudotumor cerebri is characterized by elevated intracra-nial pressures, normal cerebrospinal fluid content, and anormal ventricular system. The incidence of pseudotumor

cerebri is 0.9 cases per 100 000.6,7 Among pediatric pa-tients with this syndrome, 30% are obese.8,9 The exactpathophysiology of pseudotumor cerebri has not beenwell described, but several different theories have beenpostulated, including elevated cerebrospinal fluid produc-tion, cerebral edema, decreased cerebrospinal fluid ab-sorption, and elevated central venous pressure.5,6,10–12

Studies have shown bilateral sinovenous stenosis or ob-struction in the venous transverse sinuses may be devel-opmental in nature.13,14 Pseudotumor cerebri often pre-sents with pulsatile headache, and on examination,papilledema, Abducens nerve palsy, and loss of vision.

Initial treatment of pseudotumor cerebri is medical man-agement. In morbidly obese patients, weight loss can bean effective therapy.15,16 However, attempts at weight losswith a medically supervised program are not consistentlysuccessful in loss of excess weight; in addition, theseusually require months of therapy. Although surgical pro-cedures for weight loss are very successful, the applica-tion to children is still very controversial. Diuresis withacetazolamide can also be used because of its action todecrease cerebrospinal fluid production. Corticosteroidsmay also be used but are not useful for long-term therapybecause of significant side effects. Another available ther-apy is repeated lumbar punctures until intracranial pres-sure returns to baseline.

Surgical treatment options are reserved for those patientsrefractory to medical management and with progressivevisual loss because they can rapidly reduce intracranialhypertension. Neurosurgical interventions include ven-triculoperitoneal and lumboperitoneal shunting. Lumbo-

Figure 2. Lumboperitoneal shunt catheter entering the perito-neal cavity under laparoscopic visualization.

Figure 1. The patient is positioned in a lateral position with theright side up; the table is rotated in the opposite direction forinitial trocar placement.

Microlaparoscopic-Assisted Lumboperitoneal Shunt in the Lateral Position for Pseudotumor Cerebri in a Morbidly Obese Adolescent,Kumar N et al.

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peritoneal shunts have some advantages over ventriculo-peritoneal shunts, such as reduced infection rate,anatomical and functional benefits, despite difficulty mea-suring intracranial pressure.17

Placement of the peritoneal end of the shunt can betechnically challenging in the morbidly obese patient be-cause the large body habitus dictates a large incision toaccess the peritoneal cavity. Microlaparoscopy is a mini-mally invasive technique that allows for accurate distalshunt placement using incisions that are 3-mm or smaller.Laparoscopic assistance allows direct visualization of theshunt tip into the peritoneum. In addition, by using alateral position during the procedure of lumboperitonealshunting one can avoid changing the position of an obesepatient while assuring the shortest possible subcutaneoustunnel for the shunt tubing. Laparoscopic placement of alumboperitoneal shunt provides many benefits while con-trolling intracranial hypertension, such as less postopera-tive pain, shorter hospital stay, earlier return to work, andcosmetic acceptability,3 as well as minimizing morbidityfrom a long subcutaneous tunnel or a large abdominalwound.18 These benefits appear to outweigh any technicalchallenges presented by taking a laparoscopic approach.Reported reasons for shunt revisions include migration,obstruction, shunt tubing fracture, and to control overd-rainage.4 Development of acquired Chiari 1 malformationfollowing lumboperitoneal placement for pseudotumorcerebri has also been reported and is usually associatedwith overdrainage.19 These complications are not specificto laparoscopically performed procedures and may occurin any lumboperitoneal shunt.

CONCLUSION

Microlaparoscopic-assisted lumboperitoneal shunt place-ment in the lateral position is a safe, efficient method forthe treatment of pseudotumor cerebri. It is a minimallyinvasive, simple, and effective tool for placing the perito-neal catheter for a lumboperitoneal shunt.

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