Operative Planning

• Magnetic resonance imaging and computed tomography (CT) scan to review ventricular size and associated intracranial anatomy
  
• CT-guided stereotactic catheter placement may be indicated for intraventricular shunt placement in small ventricles.
  
• Site of burr hole and subsequent ventricular catheter placement is usually determined by ventricular anatomy, with preference toward side of larger ventricle or site opposite dominant hemisphere.
  
• Frontal or parietooccipital placement is determined by ventricular anatomy and surgeon preference.
  
• Site of distal peritoneal catheter is usually same side as the ventricular catheter unless previous surgeries or other contraindications favor opposite side.

Special Equipment

• Antibiotics are given within 30 minutes prior to incision

Positioning

• Frontal intraventricular catheter placement
  
  
  
  
  • Patient is supine with the head in the neutral position on a doughnut pillow or, when neuronavigation is used, in three-pin fixation
    
  • Head of bed elevated 30 degrees to prevent air entry and excessive CSF loss
  
  
• Parietal intraventricular catheter placement
  
  
  
  
  • Patient is supine with head on doughnut pillow, horseshoe, or in three-pin fixation when neuronavigation is used
    
  • Head turned 90 degrees to opposite side, with burr hole site up
    
  • Shoulder roll placed under burr hole side to slightly extend neck and allow for smoother passage of the tunneler
    
  • Eyes taped shut
    
  • Proper padding of all pressure points

Sterile Scrub and Prep

• Entire operative field should be prepped and exposed, including area over neck and chest where the tunneler will be passed.
  
• Shave is surgeon dependent; minimal shave includes area around incision. Shunt tract path is often also shaved.
  
• Betadine scrub and paint
  
• 3M drapes and/or sterile towels placed along the exposed head, neck, thorax and abdomen, and Ioban (3M) placed over draped area

Planning of Incision