Surgical group is like a football team.

Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv




The patient was a product of premature delivery of 25 week gestation and was put in ventilator with grade IV IVH. The patient had stricture of the small intestine with fistula in the right upper quadrant of the abdomen, which was repaired surgically. The patient was operated for progressing hydrocephalus 11-July-2006, which was complicated and exposed for external drain later. The shunt was inserted from the right side. Revision of the shunt was performed 07-August-2006  and the infection was treated with vancomycin for 2 weeks and reinsertion of the VPS was done 10-September-2006.

The patient was brought to the clinic 30-September-2006 with another attack of VPS malfunction. The fontanel was bulging and the HC was 40 cm with the dimensions of the anterior fontanel 6cm X4 cm. The patient could move all limbs and had no convulsions with normal defecation and micturition and he was able to stand. Neurologically, the patient showed no considerable deficits.

The patient was sent for brain and abdominal CT-scan, chest and skull X-ray. The patient came 03-October-2006 with further deterioration with engorged veins of the scalp.

Right ventriculo-atrial shunt was inserted. The right IJV was hypoplastic and with difficulty the distal part was passed only for 3 cm after what it was impossible to push it further, despite the dissection down to the retrosternal area.  PS Medical 1-level performance delta small VPS was used. Check for function was positive. Considering that the IJV was hypoplastic and four slits in the distal end of the shunt were not convincing for future function, it was decided to explore the old shunt which was in the left side.

The old abdominal incision was refreshed in the left upper quadrant and the shunt was identified and the distal wall was kept under control. After removing the abdominal part exteriorly, the shunt start to function properly. The distal part was put to its old canal and it went easy, but the last 10 cm showed resistance, from which a conclusion was achieved, that scars were present at the last 10 cm of the canal around the shunt. From the same incision, another point of peritoneal entry lateral to the previous one was done and inspection of the peritoneal cavity was done. The scars were mainly in the right side of the abdominal cavity, for what the catheter was inserted parallel to the descending colon.

Routine closure.


1.  This case is one of difficult, and challenging cases and require special attention and hold several considerations.

2. The presence of hypoplastic IJV make the judgment for future functioning of the recently available shunts in the market  under question. The one way flow must be reconstructed not in the lateral wall of the distal end, but at the tip of catheter. This needs a new concept in constructing the VAS, so that their one flow mechanism must be devised at the tip of the catheter.

3. Hemorrhage and infection are among the most common causes of malfunction. Strict observation and constant attention must be paid to the reservoir to be kept clean with clear CSF during insertion, otherwise the device will be exposed to malfunction.

4. In these circumstances, it is preferable to use low-pressure valves or 1-level performance of delta type, to keep the flow in higher rates.



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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved