Operative Planning

• Review imaging: ultrasound (computed tomography/magnetic resonance imaging not necessary)
  
• Ventricular catheter placement
  
  
  
  • Right frontal placement preferred
    
  • Target largest ventricle if marked ventricular asymmetry present
    
  • Length of selected ventricular catheter should result in placement in frontal horn

Special Equipment

• Ventricular access device; for example, Medtronic CSF-ventricular reservoir with convertible outlet tube an integral right angle catheter, 20 or 30 mm

Operating Room Set-up

• Procedure can be performed in neonatal intensive care unit (NICU; preferred)

Anesthetic Issues

• Room should be warm enough to maintain normothermia (heat lamps)
  
• Intravenous antibiotics for skin flora coverage: vancomycin because of NICU contamination of resistant strains, give 1 hour before incision

Positioning

• Patient supine with head in midposition
  
• No shave

Opening of Surgical Packs

• Done after room/NICU set-up and positioning

Mark Incision

• Lateral aspect of anterior fontanelle in midpupillary line

Linear or Curved Scalp Incision

• Bipolar cautery for hemostasis
  
• Small, self retaining retractor (Hess)
  
• To avoid erosion, do not implant hardware beneath incision

Burr Hole

• Bipolar through dura

Subgaleal Pocket

• Use Metzenbaum scissors to create pocket posterolaterally
  
• Reservoir placed in pocket
  
• Suture reservoir to galea and an anchor if needed

Catheter Placement

• Confirm head to be in neutral position
  
• Pass catheter perpendicular to skull

Connection

• Pre-connected right angle device preferred
  
• From the ventricular reservoir, cut off the outlet tube plug

Closure

• Reservoir tested to insure function and remove air
  
• Wound irrigated
  
• Single-layer 4–0 nylon runner

• Reservoir can be used immediately, via 23-gauge or smaller needle