ventriculo-peritoneal shunt

In any case, in the case of suspected traumatic hydrocephalus, early imaging diagnosis should be performed in time to confirm the diagnosis, and shunt surgery should be performed as soon as possible to alleviate the progressive brain tissue atrophy caused by hydrocephalus. The more common ventriculo-peritoneal shunt. Treatment of diseases: normal intracranial pressure hydrocephalus hydrocephalus Indication Applicable to obstructive hydrocephalus, traffic hydrocephalus and normal intracranial pressure hydrocephalus. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation 1. Regular examination before surgery. 2. Head CT and MRI to understand the extent of ventricular enlargement. CT showed a low-density area around the ventricle. The T2-weighted image of MRI showed a high signal area around the ventricle and the frontal angle was blunt. 3. If there is bleeding or infection of the ventricles, routine and biochemical examination of the cerebrospinal fluid is required. 4. If there is extraventricular drainage, it is recommended to clamp the drainage tube 6-12h before surgery to facilitate the placement of the diversion tube. 5. Give broad-spectrum antibiotics 1 day before surgery. 6. Selection of the shunt tube. There are many types of shunts depending on the application. The main ones are: 1 anti-siphon device: to prevent the patient from siphoning when standing upright. 2 Tumor filter: used to prevent tumors from being transferred to the abdominal cavity or blood vessels through the cerebrospinal fluid. 3 can regulate the pressure of the flap in vitro, and regulate the cerebrospinal fluid discharge velocity shunt tube. High, medium and low pressure tubes are selected according to the specific conditions of the patient's intracranial pressure. Surgical procedure 1. Endotracheal intubation, general anesthesia. Broad-spectrum antibiotics were given intravenously 30 minutes before the incision. 2. The patient is supine, the right shoulder is padded under the pillow, and the head is turned to the left side (usually the right ventricle puncture is selected) 90°. 3. Puncture site (1) Pillow drilling: 3~4cm beside the midline and 6~7cm above the occipital protuberance (if the positioning of the occipital bulge is not accurate, the placement position may be unsatisfactory). (2) Forehead drilling: The puncture point is 2~3cm beside the midline, which is about the center line of the pupil at the front of the eyeball and 1cm before the coronal suture. (3) After the top hole: the tube is placed in the triangle area, 2.5~3cm on the ear and 2.5~3cm on the back. 4. Select the puncture hole and make a straight or small horseshoe-shaped incision in the head. The skull is drilled and the diameter of the skull hole is determined by the volume of the reservoir of the shunt. 5. Puncture pathway and ventricular tube. The dura mater was cut and the avascular zone was selected as the puncture site. (1) Pillow hole drilling: For patients without giant cranial disease, the length of adult penetration is usually 10~11cm, and the length of puncture of children's hydrocephalus is usually 10cm. The tip end of the shunt tube is preferably 2 to 3 cm in front of the forehead and the inter-chamber hole. Puncture with a ventricle catheter with a metal lead, the direction of the needle is first directed to the center of the forehead of the ventricle, 2 cm above the eyebrow. After 5~6cm with a guided core needle, the metal core is pulled out, and the cerebrospinal fluid flows out, confirming that the catheter is in the ventricle and then continuing to feed the remaining length. The ventricular catheter should be prevented from entering the ridge of the choroid plexus, avoiding the end of the shunt tube placed near the posterior choroid plexus of the interventricular septum, increasing the risk of clogging of the shunt. It can be accurately placed with nerve endoscopy. Cut the appropriate length of the ventricle tube and connect it to the connector of the reservoir. It is indeed ligated and fixed. Place the reservoir holder into the skull hole and suture it with the periosteum with a non-absorbent line. The proximal end of the valve is then attached to the conduit connector at the outlet of the reservoir. Note that the upper and lower parts of the valve cannot be reversed. The direction of the arrow marked on the small pump chamber of the valve indicates the direction of cerebrospinal fluid shunt. At this point, the catheter can be temporarily blocked, so that the cerebrospinal fluid is not lost too much, but the catheter and valve cannot be damaged. (2) Forehead access: The shunt tube is inserted vertically into the brain surface. It points to the ipsilateral medial condyle in the coronal plane and points to the external auditory canal in the anteroposterior direction. Penetration depth: with a needle core piercing until the cerebrospinal fluid outflow (depth should be <7cm), the ventricles are obviously enlarged, the depth is 3~4cm. Note: If the needle is too deep (8cm) to reach the cerebrospinal fluid, the needle tip is likely to enter the arachnoid pool (such as the bridge front pool) and need to be avoided. 6. Separate the subcutaneous tunnel. The abdominal catheter reaches the upper abdomen from the head incision through the back of the ear, neck, and chest. The subcutaneous tunnel is long. If it is difficult to punch through, it can be divided into 2~3 times. The first incision is under the mastoid, the second incision is under the clavicle, and the third incision is under the right upper abdomen. Using a blunt metal guide, the subcutaneous deep separation is performed subcutaneously to form a subcutaneous tunnel. 7. Install the abdominal catheter. The proximal end of the catheter is connected to the outlet of the valve, and the distal end is passed through the subcutaneous tunnel into the incision of the right upper abdomen. Preferably, the catheter is curved in the neck to ensure that the neck is stretched during movement. 8. Placement of the end of the abdominal catheter (1) The abdominal cavity catheter is placed on the surface of the liver. Under the xiphoid process of the abdomen, a mid-median incision or a median incision is made, which is about 5 cm long. The abdominal wall and retroperitoneal tissue were cut according to the layer, and the left lobe of the liver was exposed. The end of the abdominal catheter was placed on the surface of the liver, which is currently less used. The catheter is about 10 cm in length in the abdominal cavity, and it is preferable to use a catheter with a slit at the distal end wall to reduce the chance of lumen occlusion. Sew the catheter on the round ligament of the liver to prevent it from falling off. Once the catheter is detached, it leaves the liver and is in the abdominal cavity. It is easily covered by the omentum and blocked. (2) The abdominal catheter is placed in the free abdominal cavity. The abdominal incision can be in the midline or the midline of the upper abdomen or lower abdomen, about 3 cm long, preferably avoiding the surgical incision of appendicitis. After entering the abdominal cavity, the end of the catheter is sent to the abdominal cavity. The end of the catheter preferably has a plurality of small round openings, as far as possible from the abdominal wall incision, and can not be twisted near the peritoneal incision, and is generally placed in the right (or left) side axilla. The free length of the catheter in the abdominal cavity is generally 30 to 40 cm.

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