Technology Lumbar Peritoneal Shunting with Video-Laparoscopic Assistance: A Useful Technique for the Management of Refractory Postoperative Lumbar CSF Leaks H. Gordon Deen, M.D.,* Paul D. Pettit, M.D.,† Bernd U. Sevin, M.D.,† Robert E. Wharen, M.D.,* and Ronald Reimer, M.D.* Departments of *Neurosurgery and †Gynecologic Surgery, Mayo Clinic Jacksonville, Jacksonville, Florida Deen HG,Pettit PD, Sevin BU, Wharen RE,Reimer R. Lumbar peritoneal shunting with video-laparoscopic assistance: a useful technique for the management of refractory postoperative lum- bar CSF leaks. Surg Neurol 2003;59:473– 8. BACKGROUND Cerebrospinal fistulas and pseudomeningoceles can occur after lumbar spinal surgery, and are sometimes refractory to direct repair, external drainage, and blood patches. The authors report a technique for cerebrospinal fluid (CSF) diversion from the lumbar spine to the peritoneum to assist with the management of these difficult situations. METHODS Using video-laparoscopicassistance, two shunts are placed from the lumbar region into the peritoneal cavity: first, a lumbar subarachnoid space to peritoneum shunt; and second,a meningocele cavity to peritoneum shunt. Patients are ambulated immediately after the procedure. External drains are not used. RESULTS Four patients with refractory CSF leaks were successfully managed with this technique. Complications associated with prolonged bedrest and external drains were avoided. Ancillary procedures were minimized, and hos- pital stay was shortened. Laparoscopic assistance offered verification of accurate placement of the peritoneal cath- eter and shortened operative times. CONCLUSIONS Dual lumbar peritoneal shunts (intrathecal–peritoneal and meningocele cavity–peritoneal), placed with laparo- scopic assistance, proved effective in the management of four patients with postoperative lumbar CSF leaks, who had failed to respond to conventional treatment. © 2003 Elsevier Inc. All rights reserved. KEY WORDS Laparoscopic surgery, lumbar peritoneal shunt, CSF leak C erebrospinal fluid fistulas and pseudomenin- goceles can occur after lumbar spinalsur- gery. Many cases can be managed with direct re- pair, external cerebrospinal fluid (CSF) drainage, or blood patches. However, a few cases fail to respond to these treatment measures and can become quite problematic for the patient and the surgeon. The authors describe a CSF diversion procedure to as- sist with the management of these difficult situations. Methods PATIENT DEMOGRAPHICS The procedure was used in four patients, including two men and two women, age range 67-77 years. All four patients had undergone at least one previous lumbar surgicalprocedure before receiving treat- ment at our institution. In three patients, the oper- ation that led to the CSF leak was a redo lumbar decompression and fusion with instrumentation for degenerative lumbar spondylosis. In one patient, the operation that precipitated the leak was a re- section of lumbar intraduraltumor at the site of previous extradural lumbar surgery. SURGICAL TECHNIQUE With the patient under general anesthesia and in the prone position, the lumbar wound is reopened. The dural opening is identified, and direct repair is attempted if feasible. Using a Medtronic lumboperi- toneal catheter system, a catheter with an internal diameter of 0.7 mm is introduced through a 14- gauge Tuohy needle placed in the subarachnoid Address reprint requests to: H. Gordon Deen, M.D., Departmentof Neurosurgery,Mayo Clinic Jacksonville,4500 San Pablo Road, Jackson- ville, FL 32224 Received May 22, 2002; accepted December 11, 2002. © 2003 Elsevier Inc. All rights reserved. 0090-3019/03/$–see front matter 360 Park Avenue South, New York, NY 10010 –1710 doi:10.1016/S0090-3019(03)00165-4