Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease. Its advantages include smaller incisions, less postoperative pain, faster recovery, and reduced hospital stay compared to open surgery. However, in certain patient populations, such as those with a ventriculoperitoneal (VP) shunt, performing laparoscopic surgery poses unique challenges. The presence of intra-abdominal adhesions adds further complexity, demanding advanced surgical skills and careful planning.

Background

A ventriculoperitoneal shunt is a device used to treat hydrocephalus by diverting cerebrospinal fluid (CSF) from the cerebral ventricles to the peritoneal cavity. While effective, its presence raises concerns when laparoscopic surgery is indicated:

Risk of shunt infection due to intra-abdominal contamination.

Altered anatomy from adhesions around the catheter tip.

Concerns about pneumoperitoneum, which may affect intracranial pressure (ICP).

When patients with VP shunts also present with gallstone disease, the surgeon must balance these risks with the benefits of laparoscopy.

Challenges in Laparoscopic Cholecystectomy with VP Shunt

Adhesions:
Many patients with VP shunts develop adhesions around the catheter site in the peritoneum. These adhesions can make access difficult and distort biliary anatomy. Adhesiolysis increases the risk of bowel injury.

Pneumoperitoneum and Intracranial Pressure:
Carbon dioxide insufflation may theoretically increase ICP, though most studies show that VP shunts with unidirectional valves prevent retrograde transmission of pressure. Still, careful monitoring is essential.

Shunt Safety:
The catheter may be damaged during port placement or dissection. Identifying and protecting the shunt during the procedure is mandatory.

Infection Risk:
Any contamination of the peritoneal cavity during gallbladder removal could predispose to shunt infection and subsequent meningitis.

Preoperative Considerations

Neurosurgical consultation is advised to assess shunt function and valve type.

Prophylactic antibiotics covering both biliary flora and skin organisms are recommended.

Imaging studies such as ultrasound or CT scan may help locate the distal shunt catheter and identify adhesion patterns.

Patients and relatives should be counseled about the higher technical difficulty and potential need to convert to open surgery.

Surgical Technique
Patient Positioning

The patient is placed supine in reverse Trendelenburg with the right side elevated, similar to standard laparoscopic cholecystectomy.

Port Placement

Careful planning is essential to avoid injuring the shunt catheter. Ports are placed under direct vision when possible.

An open (Hasson) technique for initial trocar placement is often safer, especially in patients with adhesions.

Adhesiolysis

Adhesions around the catheter and upper abdomen are dissected meticulously with blunt and sharp techniques. Energy devices may be used but should be applied cautiously to avoid thermal injury to the bowel or shunt.

Gallbladder Dissection

The gallbladder is grasped and retracted to expose Calot’s triangle.

Dense adhesions may obscure anatomy; a “fundus-first” approach is sometimes safer.

Critical View of Safety (CVS) must be achieved to identify the cystic duct and artery.

Protection of Shunt Catheter

The shunt tube is visualized and kept away from the operative field. If the catheter is embedded in adhesions near the gallbladder, it should be gently freed without compromising its function.

Extraction of Gallbladder

The gallbladder is removed in a retrieval bag to prevent bile spillage and contamination of the shunt.

If spillage occurs, thorough irrigation and suction are mandatory.

Completion

Hemostasis is ensured, ports are closed, and the patient is monitored postoperatively for both abdominal and neurological complications.

Postoperative Care

Antibiotics are continued to minimize infection risk.

Patients are observed for signs of shunt malfunction such as headache, vomiting, or altered consciousness.

Routine postoperative monitoring of liver function and recovery follows the standard cholecystectomy protocol.

Outcomes

Several case reports and small series indicate that laparoscopic cholecystectomy can be performed safely in patients with VP shunts, even with adhesions, provided that careful technique is followed. The recurrence of neurological complications is rare, and most patients benefit from the minimally invasive approach with faster recovery compared to open surgery.

Conclusion

Laparoscopic cholecystectomy in patients with ventriculoperitoneal shunt and adhesions is a technically demanding but feasible procedure. The main concerns are shunt safety, adhesion management, and infection prevention. With thorough preoperative evaluation, judicious port placement, meticulous adhesiolysis, and protective measures against contamination, excellent outcomes can be achieved. Collaboration between neurosurgeons and laparoscopic surgeons enhances patient safety and minimizes risks. Ultimately, laparoscopic surgery offers these patients the same benefits of minimally invasive techniques as the general population, provided it is performed by experienced hands.