Lumboperitoneal (LP) shunts are used in patients with communicating hydrocephalus or small slit ventricles (due to overdrainage caused by other extrathecal shunts like ventriculoperitoneal and ventriculoatrial shunts) and patients who have had multiple ventricular shunt malfunctions. These shunts have the advantage of avoiding injury by the ventricular catheter, maintaining the patency of ventricles (unlike ventricular shunts where the ventricles tend to collapse leading to shunt malfunction), and have lower risk of obstruction and infection. However, LP shunts are more prone to malfunction from mechanical failures like migration out of the spine or peritoneum and carry a definite risk of development of hindbrain herniation over a period of time especially in children. The assessment of function of a lumbar shunt is more difficult as compared to ventricular shunt [4].

Ventriculoatrial (VA) shunts are provided to divert cerebrospinal fluid from the cerebral ventricle into the right atrium. These are not chosen as the first-line method to redirect the CSF rather when there have been multiple failure of the VP shunt (Table 4.1). The intraoperative appropriate vein selection and exact shunt placement are important to reduce complications such as obstruction [5].

Ventriculopleural shunts were introduced as a management option for hydrocephalus by Ransohoff in 1954. Ventriculopleural shunts have been used infrequently in the management of hydrocephalus and have become the “next preferred procedure” in case if the ventriculoperitoneal shunt fails. It has low complication rates and is easy to perform, but involvement and collaboration of the thoracic surgery team is required. The risk of pleural effusion is highest among the infants which seemed to be reduced with the introduction of antisiphon device [6].

Ventriculoureteric shunt (VUS) is rarely used nowadays in neurosurgical practice owing to much better techniques that are available. It is technically demanding – exposure of the renal pelvis and ureter requires the help of an urologist. As previously thought, it no more requires nephrectomy and reimplantation of the ureter, but to prevent expulsion, flanged at the distal catheter must be used. Hyponatremia is a known metabolic complication immediately following the VUS [7].

Ventriculo-gallbladder shunts (VGS) are used because of the ability of the biliary tree to adequately control intracranial pressure, low risk of infection due to the sterility of bile, and also the prospect for electrolyte reabsorption from the small intestine (Table 4.1). But it is not the first line of treatment. Indications described are multiple shunt revisions, abdominal pseudocysts, and ascites secondary to shunts in optic chiasmal hypothalamic astrocytomas. Bile calculus causing a distal obstruction in the VG shunt catheter is a frequently reported complication. There are also chances of cholecystitis causing retrograde and descending shunt infections [8].

It is widely accepted that ventriculoperitoneal shunts represent the most common extracranial CSF diversion choice, given that the peritoneal cavity is the most efficient and reliable location for CSF absorption. The peritoneal cavity is the preferred drainage site in children because it enables the implantation of drainage catheter of sufficient length to allow for the growth and predisposes to less severe complications than does the right atrium and ease of shunt revision. The first ventriculoperitoneal shunt is probably attributed to Kaush. In 1908 he reported a patient in whom he connected a lateral ventricle to the peritoneum using a rubber tube, but the patient died because of overdrainage.