Robot-guided Ventriculoperitoneal Shunt in Slit-like Ventricles.

Background: Ventriculoperitoneal shunt (VPS) is the most common procedure used in the management of hydrocephalus regardless of the etiology. The standard free-hand technique is used for the placement of VPS in patients with enlarged ventricles. In patients with very small ventricles, CSF access through ventriculostomy becomes challenging and free-hand technique may be associated with high failure rates. In these situations, stereotactic-guided VPS becomes very useful.

Objective: To validate and describe the technique of robotic-guided VPS in cases with very small ventricles.

Methods: Three patients underwent VPS with robotic guidance between 2016 and 2019. One patient with a diagnosis of occipital meningocele, who later developed recalcitrant CSF leak from the operative site, and two other patients were diagnosed with idiopathic intracranial hypertension (IIH). Plain CT brain with 1-mm slice thickness acquired prior to the surgery was uploaded into the ROSA machine (Zimmer Biomet Warsaw, Indiana). The trajectory for the VPS is created on the robotic software presurgery. The patient is placed in the supine position with head turned to the side contralateral to VPS insertion and fixed with Mayfield clamp. Registration of the patient is done with the robot. The placement of the VPS is commenced with the robotic arm in the predetermined trajectory.

Results: Ventricle was hit in a single attempt in all the cases. CSF leak stopped in the case with meningocele; headache, and visual acuity improved in both the cases of IIH.

Conclusion: Robotic-guidance provides a safe and accurate method of VPS placement even in the presence of slit-like ventricles.