ventriculoperitoneal ( vp ) shunting is commonly utilized as a diversion procedure for patients with hydrocephalus .
multiple techniques for initial placement of the catheters have been described , including conventional minilaparotomy , peel - away introducer sheaths , as well as full laparoscopic approaches .
vp shunts fail for a variety of reasons , including failure secondary to disconnection of abdominal tubing with migration of the tubing , most commonly further into the peritoneal cavity ; this occurs in 2.5% to 4% of shunts placed according to current published series .
initial shunt failure rates continue to be high , with a reported failure rate of 31% at 6 months and an infection rate of 7% .
common presenting features of shunt failure include headache , mental status changes , and vomiting .
laparoscopy avoids laparotomy and may provide improved confirmation of shunt functionality and placement at the time of revision .
a 31-year - old obese female was initially treated for pseudotumor cerebri with placement of a lumbar peritoneal shunt in 2003 .
after 5 failed revisions for nonfunction , a ventriculoperitoneal shunt was placed in september 2007 .
the patient subsequently presented 11 days postoperatively with headaches , dizziness , and formation of a seroma in her right upper quadrant .
ct scan revealed the vp catheter tubing coiled in the subcutaneous tissue of the right upper quadrant .
four 5-mm titanium clips were placed on the catheter in an attempt to prevent repeated migration of the tubing .
one month later , the patient presented with recurrence of headaches , nausea , and right upper quadrant abdominal pain .
ct scan was again obtained , revealing that the shunt tubing had migrated back into the subcutaneous tissue ( figure 1 ) .
a laparoscopic approach was again utilitzed for retrieval and attempted improved fixation of the vp shunt .
adhesions were taken down at the original entry site of the shunt , revealing a 2-cm fascial defect in the abdominal wall with the shunt tubing coiled within it ( figure 2 ) .
the tubing was brought down through the defect out of the subcutaneous space and into the peritoneal cavity ( figure 3 ) .
one port was upsized to 10 mm , and the tubing was externalized through the port and secured to a 3-cm x 10-cm piece of ptfe mesh with 30 prolene sutures ( figure 4 ) .
csf flow was confirmed , and the tubing attached to the mesh was reintroduced into the peritoneal cavity .
the mesh was secured to the abdominal wall by using spiral tacks and 0 gore - tex sutures ( figure 5 ) .
the separate 2-cm fascial defect was repaired with a 10-cm x 10-cm piece of ptfe mesh placed as an onlay with the vp shunt exiting from its inferior border .
it was secured with spiral tacks and 0 gore - tex sutures for transabdominal fixation ( figure 6 ) .
the patient was seen in follow - up 7 months postprocedure and reported no recurrence of her symptoms .
traditionally , laparotomy was necessary for both peritoneal shunt placement as well as subsequent shunt revisions .
the advent of laparoscopy has afforded a minimally invasive approach that has resulted in decreased patient morbidity related to shunt placement .
retrieval and repositioning of a displaced vp shunt in the peritoneal cavity using laparoscopic techniques has been previously described . in the present case ,
our subsequent laparoscopic approach utilized ptfe mesh , well described in the use of laparoscopic ventral hernia repair , to fixate the tubing to the abdominal wall to prevent further tubing migration .
this approach also allowed us to simultaneously repair the fascial defect associated with the shunt entry site into the peritoneal cavity , allowing us to reap the benefits of decreased recurrence and decreased patient morbidity associated with this technique .
the technique described was well tolerated without complication and resulted in improvement of clinical symptoms .
 a 31-year - old female with a history of pseudotumor cerebri presented with headache and abdominal discomfort after placement of a ventriculoperitoneal ( vp ) shunt . 
 the vp shunt was placed after prior failure and revision of a lumbar peritoneal shunt . 
 computed tomography demonstrated shunt migration into the subcutaneous tissue . 
 laparoscopy was used to reposition the vp shunt , directing the shunt toward the pelvis . 
 the patient presented for further evaluation one month later , at which point the shunt was shown to have migrated into the subcutaneous tissue once again . 
 laparoscopy was again used to reposition the shunt and affix it to the abdominal wall by using polytetrafluoroethylene ( ptfe ) mesh . 
INTRODUCTION
CASE REPORT
DISCUSSION