It is the diversion of CSF from the ventricles to the gallbladder. It was introduced by Yarzagaray in 1958 [29] and recently modified by Lyngdoh [22].

The gallbladder is the preferred distal site as it is a sterile environment; its major activity is to remove water and electrolytes. The water flux rate is about 25 ml/h, with 90 % of water being removed in this process [29]. The CSF absorption is more physiological. The valves of gallbladder prevent reflux and maintain a constant pressure for CSF drainage.

The fundus of the gallbladder is exposed via standard right subcostal incision and two purse string sutures applied around the proposed site of the puncture, an inner one around the proposed opening and the other surrounding the inner purse string. The distal end of the shunt catheter with its slit valve is cut 7 cm from the distal tip and then reconnected over a connector, this being secured by silk sutures to prevent dislodgement. A stab puncture is made on the proposed site of the fundus, just enough to pass the catheter; bile sample for checking pressure and for culture may be taken with a needle prior to this [29]. The catheter is introduced to the level of the connector. The inner purse string is tightened snugly around the connector and to the serosa of the gallbladder within the outer purse string suture. This prevents dislodgement of the lower end. Finally, the outer purse string is tied to invert the whole complex [25]. A 20 cm length of catheter tubing is left within the peritoneum for the child’s growth.

Using this shunt, CSF diversion was achieved for a 6-year follow-up [29, 31], while others, still on follow-up, have a functioning shunt [22]. Those that did require revision at a later time were diverted to the peritoneum, which had healed and regained its absorptive power [29].

Blockage due to high resistance to outflow from the cystic duct has caused failure within a few weeks in cases and with revision, infection developed. Revision to the gallbladder was thought to be impractical [25]. Retrograde flow of bile causing ventriculitis has been reported and could be fatal, some reversible with ventricular lavage. Cholangitis, infections of the biliary pathways, and cholelithiasis are not seen [29]. MR cholangiogram, at follow-up, does confirm that there is a small “hydrops” of the gallbladder (Fig. 16.2) [25, 29].

There is renewed interest in the diversion of CSF from the ventricular system to a pouch created in the subgaleal space, termed ventriculosubgaleal (VSG) shunt.

Von Mikulicz was probably the first to use this technique in 1893 [6]. The technique was improved and used since its initial description by many [5, 7, 8, 15, 16, 21, 26, 27].

It has been most beneficial for premature infants and neonates suffering intraventricular hemorrhage (IVH), meningitis with or without ventriculitis, and multiple congenital anomalies, for example, meningomyelocele with a colostomy for imperforate anus. There is a poor absorption from the peritoneum of the premature child.

Temporary diversion of CSF via a VSG shunt provides regular decompression of the ventricle system. It is a more attractive option than the other forms of temporary diversions in premature infants with hydrocephalus [18]. Other methods of temporary diversions can create more complications. The child suffers “puncture porencephaly” with repeated ventricular taps [17]. Repeated lumbar punctures are time-consuming and do not drain sufficiently; spinal osteomyelitis have been reported [3]. An external ventricular drain cannot be kept for a prolonged period of time. All these procedures have the risk of introducing infection.

The lateral ventricle is cannulated with a ventricular catheter via the standard coronal site and connected with a right-angled connector to 3 cm of shunt tubing with distal slit valves. The valves ensure unidirectional flow of fluid and debris. The connector is fixed to the dura. A subgaleal pocket is created with blunt dissection in the anterolateral and posterolateral directions from the coronal site. The catheter is then placed in the created pouch [17]. The space may get filled; this can then be tapped at intervals of a few days.

Conversion to a ventriculoperitoneal shunt could be done at 9.2 weeks; some did not require it [28]. It is the treatment of choice for neonatal hydrocephalus not suitable for a VP shunt at some centers [17].

Complications like wound leakage require the removal of the shunt. Other complications are similar to placement of a ventricular catheter such as acute hemorrhage following sudden decompression of the ventricles. This can be fatal. Dislodgement and intraventricular migration of the ventricular catheter. Many have reported no VSG shunt infection [17, 26, 27, 28]. Sklar, in 1992, reported a 10 % infection rate [30].

In the past 35 years, several reports have described the superior sagittal sinus as a physiological and easily accessible site for distal catheter placement [1, 4, 19, 33].

More recently, El-Shafei demonstrated the success of the shunts into the sinus [7]. This evolved from his theoretical conclusion [9–13] that “CSF shunts should deliver the drained excess CSF from the ventricles into the upper end of the internal jugular vein (IJV) or into a dural sinus against the direction of blood flow such as a retrograde Ventriculo jugular shunt (RVJ) and retrograde Ventriculo sinus shunt (RVS). The dynamics of flow in theses shunts depend entirely on its being a watertight connection that allows no leakage of CSF”[10].

Here we shall describe the RVS shunt.

RVS shunt can be placed in any age group, a simpler and shorter procedure, minimally invasive [12, 13]. It can be used in the treatment of hydrocephalus regardless of the cause, type, degree, or duration, provided that diversion is indicated and with great success. Cerebral mantle of less than 1.0 cm in infants suffering advance-communicating hydrocephalus is a strict contraindication [14].