LAPAROSCOPIC SURGERY IN CHILDREN WITH VENTRICULOPERITONEAL SHUNTS - EFFECT OF PNEUMOPERITONEUM ON INTRACRANIAL-PRESSURE - PRELIMINARY EXPERIENCE

Objectives. We monitored changes in intracranial pressure (ICP) in 2 c hildren with myelodysplasia undergoing laparoscopic bladder autoaugmen tation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II). Methods. ICP was monitored t hrough a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean art erial pressure, end-tidal CO2 (ETCO2), ICP, abdominal pressure, and ce rebral perfusion pressures were all monitored. Results. Both children demonstrated rapid onset and sustained increases in ICP of greater tha n 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The avera ge cerebrospinal fluid removed from each patient was 30 cc, thereby lo wering ICP with no adverse neurologic sequela. The pCO(2) remained con stant throughout the procedures, as measured by ETCO2. Conclusions. We believe that intracranial hypertension (IH) results from a ''Valsalva -like'' phenomenon, which causes cerebral vascular engorgement. in add ition, the pneumoperitoneum may increase the resistance to outflow thr ough the distal peritoneal catheter, causing a partial or complete shu nt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perf orm intraoperative ICP monitoring in this subgroup of patients undergo ing laparoscopic surgery and that IH should be treated by ventricular drainage. (C) 1997, Elsevier Science Inc.