Unusual complication of ventriculoperitoneal shunt surgery.

Ventricular shunts are commonly employed in the management of hydrocephalus, and numerous complications such as dissection or migration have been reported in the literature besides shunt malfunction. We present a case of the migration of the peritoneal catheter into the scrotum who attended at our institute. He was managed successfully, but subsequently developed intraabdominal cystic swelling for which he was reoperated.

Introduction

A number of complications may occur after ventriculo peritoneal shunt insertion for management of hydrocephalus. These include infection, blockage, malfunction or migration of the shunt. Migration may occur into the lateral ventricle, mediastinum, chest, gastrointestinal tract, abdominal wall, bladder, vagina, and scrotum.[126-8101214] We present a case which presented various complications at intervals during the whole course.

Case Report

A 14-month-old boy presented with erythema along the tract of his ventriculoperitoneal. shunt 6 months after its insertion. It was not associated with any shunt malfunction. The patient was given antibiotics and he responded. Three months later, he presented with recurrent vomiting and signs of lower end of shunt obstruction. Revision of shunt was done. Seven months later, the patient presented with right-sided scrotal swelling with some hard tube-like structure within. Cough impulse was present. An X-ray of the abdomen was done which showed the coiled end of shunt in the scrotum [Figure 1]. The patient was operated, and a reduction in the hernial sac containing a ventriculoperitoneal shunt with herniotomy was done. Six months later, the patient presented with pain in the abdomen, lump in the abdomen around umbilicus for six months. Exploratory laparotomy with decompression of the pseudocyst around the peritoneal end of the ventriculoperitoneal shunt with a repositioning of peritoneal catheter was done. Presently, the patient is asymptomatic and still in follow-up.

Figure 1

X-ray of the abdomen A-P erect showing shunt migration into the scrotum

Discussion

There are many complications listed which may be seen after v-p shunt insertion.[34913] Most of these patients present with abdominal signs and/or intracranial sepsis.[9] Inguinal hernia and/or hydrocele may follow the insertion of a ventriculoperitoneal shunt with a frequency ranging from a minimum of 3.8% to a maximum of 16.8%.[413] Grosfeld was the first to report this.[8] The complication may occur at a variable length of time after operation (from 1 day to 1 year).[2] Yamasaki et al. reported two cases of spontaneous dissection of a Raimondi catheter among 23 cases, and several similar cases were reported.[1121365] Oktem et al.[10] have reported migration of the peritoneal catheter into the scrotum through the unobliterated processus vaginalis; however, the tube was not dissected in all of those cases. Peritoneal CSF pseudocysts are an infrequent but important complication in patients with ventriculoperitoneal shunts. Their incidence is regarded as ranging between 1 and 4.5%.[411] In our case, we encountered multiple complications, at intervals, i.e., shunt infection followed by transcrotal migration and finally peritoneal CSF pseudocysts formation.