Operative Planning

• Review imaging (computed tomography [CT] or magnetic resonance imaging)
  
• Measure and record radiographic distance on chest x-ray from clavicle to the junction of superior vena cava and the right atrium
  
• Placement of ventricular catheter
  
  
  
  • We prefer occipital placement on the right side
    
  • If there is marked asymmetry of the ventricles, the left side and/or frontal placement may be used
  
  
• Distal catheter placement: consider general or pediatric surgeon assistance for complex cases

Equipment

Operating Room Set-up

• Headlight
  
• Loupes (optional)
  
• Bipolar cautery and Bovie cautery

Anesthetic Issues

• General anesthesia
  
• Normothermia shuold be ensured with warm temperature, disposable heat-controlled blankets, and/or heat lamps for infants.
  
• Intravenous antibiotics with skin flora coverage (cefazolin 2 g for adults, 30 mg/kg pediatrics) shuold be given within 30 minutes prior to skin incision.
  
• Degree of intracranial pressure elevation shuold be communicated to anesthesiologist.

Positioning

• Patient’s head turned 90 degrees to opposite side if no contraindications
  
• Neck elevated slightly with pads or shuolder roll
  
• Eyes secured shut
  
• Heels and ulnar areas padded

Planning of Shave

• Use disposable hair clippers
  
• Width is two fingerbreadths in a child, three fingerbreadths in an adult
  
• Some surgeons prefer only area around incision shaved, others include shunt tract path

Planning of Incisions

• Scalp: crescentic, 3 cm curvilinear incision with a dot 1 cm within incision line marked for burr hole placement
  
• Cervical: using ultrasound guidance the internal jugular vein shuold be located ~4 cm superior to clavicle and a 1.5 to 2 cm horizontal line marked over this location
  
• Old incisions shuold be reused when possible

• Five-minute scrub is performed using either a moistened chlorhexidine scrub brush or a Betadine detergent scrub
  
• Sterile towel completely dry
  
• Apply DuraPrep and allow 3 minutes to dry or alternatively apply a Betadine paint
  
• Apply Ioban drapes over exposed head, neck, chest, and abdomen
  
• Always prep the abdomen and chest in case an alternate distal location needs to be used

Shunt Assembly

• Shunt valve shuold be attached to distal catheter and secured with a 2–0 silk tie
  
• The catheter shuold be primed in normal saline with bibiotic solution ensuring distal flow
  
• The partially assembled system is then placed in normal saline with bibiotic solution

Scalp Incision

• A curvilinear, semilunar incision is made to create a pocket within the confines of the incision
  
  
  
  • Linear incision carries a higher risk of damage to the shunt valve or system if revision is required in the future
  
  
• Small, self retaining Weitlaner retractor is placed

Burr Hole

• Occipital approach
  
  
  
  • Three cm behind and 3 cm above ear (may be estimated with fingerbreadths)

Cervical Approach

• Incision through the skin and Bovie cautery through subcutaneous tissue
  
• Platysma divided sharply (Metzenbaum scissors or no. 10 blade)

Shunt Pass

• Advance bent passer, usually from below; we prefer metal passers because catheters are less likely to stick
  
• Single pass for occipital placement
  
• Additional retroauricular incision is usually necessary for frontal placement
  
• Pocket for valve is created by lifting shunt passer and dissecting underneath using Bovie cautery to a depth of ~5 cm from burr hole
  
• Distal tubing is tied to the end of the shunt passer using 2–0 silk ligature
  
• Passer is withdrawn to pass distal shunt tubing subcutaneously from cranial to cervical incision
  
• Ensure 1 to 2 cm distance from burr hole to shunt valve

Proximal Catheter Placement