Home | About Us | Current Issue | Ahead of print | Archives | Search | Instructions | Subscription | Feedback | Editorial Board | e-Alerts | Login 
Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
 Users Online:241 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size


 
Table of Contents   
LETTERS TO THE EDITOR
Year : 2020  |  Volume : 25  |  Issue : 6  |  Page : 414-416
 

Scrotal migration of two ventriculoperitoneal shunts presenting as hydrocele


Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission05-Nov-2019
Date of Decision30-Nov-2019
Date of Acceptance01-Feb-2020
Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Rahul Gupta
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_195_19

Rights and Permissions

 



How to cite this article:
Gupta R, Gupta AK. Scrotal migration of two ventriculoperitoneal shunts presenting as hydrocele. J Indian Assoc Pediatr Surg 2020;25:414-6

How to cite this URL:
Gupta R, Gupta AK. Scrotal migration of two ventriculoperitoneal shunts presenting as hydrocele. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2020 Nov 26];25:414-6. Available from: https://www.jiaps.com/text.asp?2020/25/6/414/299198




Sir,

Ventriculoperitoneal (VP) shunt is a common procedure performed for treating hydrocephalus.[1] There is a higher rate of inguinal hernia and hydrocele in pediatric patients who undergo VP shunt procedure.[2],[3] Migration of peritoneal end of the VP shunt into the scrotum is uncommon.[4],[5] Herein, we present an extremely rare case of the right-sided hydrocele with migration of peritoneal ends of two VP shunts (both right and left) into ipsilateral (right side) hemiscrotum through patent processus vaginalis. To the best of our knowledge, there is only a single case of scrotal migration of two VP shunts presenting as hydrocele reported in the literature.[4],[5]

An 11-month-old male infant presented to the pediatric surgery department with swelling in the right inguino-scrotal region for the past 2 months. He had undergone medium pressure VP shunt procedures (Chhabra shunt) twice for congenital hydrocephalus at the age of 1 month and then at 8 months (nonfunctioning/blocked) evident by bilateral subcostal scars [Figure 1]. He was doing apparently well after the second surgery. The swelling was not associated with redness, pain, or fever or features of intestinal obstruction. On examination, a swelling was noted in the right scrotal region, especially on straining and crying; shunt tubing could be rolled between the fingers on palpation [Figure 1]. Cough impulse was present; transillumination test was also present [Figure 1]. There were no features of shunt malfunction. An X-ray of the abdomen and pelvis showed that the peritoneal end of the VP shunt was extending into the right hemiscrotum [Figure 1]. Laboratory investigations were normal. The patient was operated, and a reduction in the hernial sac containing peritoneal ends of both the right and left VP shunts was done by means of a right inguinal herniotomy [Figure 2]. The patient is currently asymptomatic and doing well at follow-up.
Figure 1: Clinical photograph (left image) showing right-sided hydrocele with transillumination test confirming the presence of shunt tubing in the scrotum (arrow); inset image showing bilateral subcostal scars (yellow and red arrows). Abdominal X.ray (right image) showing both the right (yellow arrow) and left (red arrow) ventriculoperitoneal shunt in situ; peritoneal end of ventriculoperitoneal shunt extending into the right inguino-scrotal region is evident

Click here to view
Figure 2: Intraoperative images of the right inguinal herniotomy (after opening the hernial sac) showing peritoneal ends of both the right and left ventriculoperitoneal shunts as contents of the sac and entering into the scrotum (left image); catheters being repositioned into the peritoneal cavity (right image)

Click here to view


Introduced in 1908, VP shunt is one of the most common neurosurgical procedures performed for patients with hydrocephalus.[1] VP shunt complications include shunt infection, over drainage, and shunt malfunction. Peritoneal complications involve pseudocyst formation, intestinal obstruction or volvulus, perforations of a hollow viscus, and protrusion outside the body; other shunt complications are disconnection and migration.[1] There is a higher rate of inguinal hernia and hydrocele in pediatric patients who undergo a VP shunt procedure.[2],[3] The reported incidence of inguinoscrotal complications may be as high as 10%–20%.[2],[3] Most of them being unilateral, developing within a few weeks to months.[2],[3]

Migration of peritoneal end of the VP shunt into the scrotum is uncommon.[4],[5] Migration of the shunt into the scrotum tends to occur in younger children due to higher incidence of an unobliterated processus vaginalis and smaller volume of the peritoneal cavity in these patients.[6] The processus vaginalis normally remains patent in 50%–60% of infants at age 1 year.[2] Development of scrotal swelling or hydrocele in a pediatric patient with a VP shunt should raise the possibility of a shunt complication.[6]

It was proposed that with continuous cerebrospinal fluid (CSF) drainage into the peritoneal cavity, a point is reached when CSF inflow exceeds absorption. The raised fluid in the peritoneal cavity and increased intra-abdominal pressure may prevent obliteration or forces open the patent processus vaginalis, producing a clinical hydrocele or hernia.[4] Furthermore, chronic catheter irritation and fluid flow from the tubing may result in hydrocele.[6]

Scrotal migration of VP shunt catheter was hypothesized to be due to (i) trough effect of CSF into the patent processes vaginalis which tends to draw mobile objects (shunts) into the center of the trough,[4] (ii) the inguinal canal contributes to the “guttering and funnelling” mechanism.[4] In our infant, migration of two peritoneal catheters (both right and left) into the right side hemiscrotum through the ipsilateral conduit produced this unusual complication.

Early surgical repair of the inguinal hernia and repositioning of the peritoneal end of the shunt tubing is suggested due to the increased risk of incarceration in children.[6] Contralateral inguinal exploration or diagnostic laparoscopy has been proposed in infants with VP shunt because of the likelihood of patent processus vaginalis in infancy and high bilaterality rate (75%–80%).[2],[6] The lower rate of presentation with bilateral manifestation may be due to a pop-off mechanism.[2]

In conclusion, the development of hydrocele or any scrotal swelling in a pediatric patient with a VP shunt should be recognized as a possible shunt complication in the early postoperative period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are sincerely thankful to the Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India, for helping in our endeavor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gupta R, Dagla R, Agrawal LD, Sharma P. Vesical calculi formation on the slit valves of a migrated distal end of ventriculoperitoneal shunt. J Pediatr Neurosci 2015;10:368-70.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Grosfeld JL, Cooney DR. Inguinal hernia after ventriculoperitoneal shunt for hydrocephalus. J Pediatr Surg 1974;9:311-5.  Back to cited text no. 2
    
3.
Clarnette TD, Lam SK, Hutson JM. Ventriculo-peritoneal shunts in children reveal the natural history of closure of the processus vaginalis. J Pediatr Surg 1998;33:413-6.  Back to cited text no. 3
    
4.
Kwok CK, Yue CP, Wen HL. Bilateral scrotal migration of abdominal catheters: A rare complication of ventriculoperitoneal shunt. Surg Neurol 1989;31:330-1.  Back to cited text no. 4
    
5.
Ricci C, Velimirovic BM, Fitzgerald TN. Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval, diagnostic laparoscopy and hernia repair. Int J Surg Case Rep 2016;29:219-22.  Back to cited text no. 5
    
6.
Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A. Migration of the peritoneal catheter of a ventriculoperitoneal shunt into the scrotum. S Afr J CH 2012;6:93-4.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

Top
Print this article  Email this article

    

 
  Search
 
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,147 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed85    
    Printed0    
    Emailed0    
    PDF Downloaded8    
    Comments [Add]    

Recommend this journal


Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer 

  2005 - Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 

Online since 1st May '05