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Romanian Neurosurgery (2013) XX 4: 375 - 378         375 

 
 
 

Unusual complication of ventriculoperitoneal shunt 

Omotayo A. Ojo1, Olumide Elebute2, Okezie O. Kanu1,  
Olusegun Adebisi Popoola 

1Neurosurgery Unit, Department of Surgery, Lagos University Teaching Hospital, 
Idi-Araba, Lagos State. Nigeria 
2Peadiatric Surgery Unit, Department of Surgery, Lagos University Teaching 
Hospital, Idi-Araba, Lagos State. Nigeria 

 

Abstract 
Ventriculoperitoneal shunt (VPS) is the 

conventional method of managing 
hydrocephalus until recently that 
endoscopic third ventriculostomy is 
becoming popular. The major disadvantage 
of VPS is the fact that it constitutes a 
foreign body and prone to complications 
such as mechanical blockage, shunt 
infection, shunt migration and rarely shunt 
protrusion. Shunt extrusion through the 
vagina and anus are rare but have been 
documented. We present a rare case of 
shunt migrating through the external 
inguinal ring into the scrotal sac in a 
patient. 

Key words: hydrocephalus, hydroceole, 
ventriculoperitoneal shunt, shunt 
complications, processus vaginalis. 

Introduction 
Hydrocephalus is defined as an active 

distension of the ventricular system of the 
brain resulting from inadequate passage of 
cerebrospinal fluid from its point of 
production within the cerebral ventricles to 
its point of absorption into the systemic 
circulation.(Rekate, 2008) It has a 
worldwide occurrence and its incidence in 
the general population as documented in a 
Swedish study is 0.66 per 1000 life 

births.(Persson, Anderson, Wiklund, & 
Uvebrant, 2007) This rate may however be 
higher in the developing country such as 
Nigeria because the hydrocephalus of 
infective etiology is forms a large percentage 
of total hydrocephalic children.(Warf & 
East African Neurosurgical Research, 2010) 
(Warf, 2005) 

The standard treatment of 
hydrocephalus to date is 
ventriculoperitoneal shunt. In recent times, 
the advent of endoscopic third 
ventriculostomy is gaining popularity due 
to the high complication and failure rates of 
ventriculoperitonel shunt.(de Ribaupierre, 
Rilliet, Vernet, Regli, & Villemure, 2007) 

The success rate of VP shunt is in the 
range of 60 % and its failure rate in 
literature is close to 40 %.(Piatt & Garton, 
2008) Infection rate in VP shunt is close to 
20 % while complication rates is about 25.8 
% in developing countries.(Komolafe, 
Adeolu, & Komolafe, 2008) 

Failure rate of VP shunt is high because 
of the different complications seen after the 
shunt. The complications of VP shunt 
include infections, shunt malfunction, 
shunt mechanical failures include breakage 
and migration. Shunt migration is rare and 
it commonly migrates to the peritoneal 
cavity. The rarer presentations of shunt 



 
 
 
376          Ojo et al          Unusual complication of ventriculoperitoneal shunt 

 
 
 

migration include migration into virginal, 
anus and scrotal sac. We present a shunt 
migration into the scrotal sac as a result of 
pre-existing hydrocele that was not taken 
into consideration before the shunt 
procedure. 

Case report 
We present a 15 month old baby who 

was referred to Neurosurgery clinic on 
account of a swollen left hemiscrotum. He 
was a product of full term delivery and at 6 
months of life, the parents realized there 
was an occasional swelling of left 
hemiscrotum. It was only notice while the 
baby was crying and resolved 
spontaneously. 

At 9 months of age, he had an episode of 
fever following upper respiratory tract 
infection. He was treated empirically at the 
peripheral hospital with oral antibiotics. 
The fever subsided and baby became well. 
Two weeks after he was noted to have a 
gradual increase in head circumference. A 
CT scan done showed a pan ventricular 
hydrocephalus. He was otherwise well.  

The parents made an emergency 
arrangement to take him out of Nigeria for 
a ventriculoperitoneal shunt. 

Six weeks after the VP shunt and now in 
Nigeria, left hemiscrotum was gradually 
increasing in size. A diagnosis of hydrocele 
was made with possible patent processus 
vaginalis. No attempt was made to operate 
on the hydrocele. 

Two weeks before presentation to the 
Neurosurgeon in Nigeria, mother reported 
she could feel a hard tubular structure in 
the left hemiscrotum. Attempt to return to 
the center oversea where VP shunt was 
done was futile. He was then brought to us. 

At presentation, he was a playful child 
with significant craniofacial disproportion. 

There was no symptom of increasing 
intracranial pressure, anterior fontanel was 
soft and sunken, no other signs of 
hydrocephalus like distended scalp veins, 
sun set appearance of the eyes. Scars on the 
scalp and the abdomen signifying evidence 
of VP shunting. 

General examination was essentially 
normal. The abnormal findings were in the 
inguinal region. Inspection revealed a 
swollen left hemiscrotum. No differential 
warmth, no tenderness on palpation. The 
inguinal ring was comparatively wider on 
the left than on the right. It could 
conveniently accommodate the tip of the 
index finger. A coil of abdominal catheter 
part of VP shunt was palpable. Clinical 
photograph demonstration the distal 
catheter part of the VT shunt was taken. 

The only imaging done was an 
ultrasound scan of the pelvis and the 
scrotum. The distal part of the catheter was 
identified. 

 

 
Figure 1 

Baby with left scrotal hydrocele.  
Note the right sub chondrial incision- the entry 
point of the peritoneal component of VP shunt 



 
 
 

Romanian Neurosurgery (2013) XX 4: 375 - 378         377 

 
 
 

 
Figure 2 

Distal peritoneal shunt migrating through the  
Left external inguinal ring into the scrotal sac in a  

baby with pre-existing hydrocele 
 

He was prepared for surgery. While he 
was under general anesthesia, the distal end 
of the catheter in the left hemiscrotum was 
manipulated and repositioned 
intraperitoneally before cleaning and 
draping. A simple herniotomy was done 
without exposing the shunt. Patient did 
well after the surgery and swelling did not 
recall anymore. 

Discussion 
The most common complication of VP 

shunt in our setting is infection. This is not 
different from what is seen in other settings 
including the developed countries. The 
incidence of post shunt infection is a 
Nigerian tertiary center is 25.7 % as 
documented by Komolafe et al.(Komolafe 
et al., 2008) Other reported incidence 
ranges from 10-20 %. Though its been 

rarely seen in different neurosurgical 
centers, the incidence of rarer 
complications are not documented. There 
are less than ten documented cases of 
scrotal migration of distal VP shunt when a 
search was conducted on PubMed. 

A patent processus vaginalis is a potential 
route for distal migration of VP shunt due 
to increased intra-abdominal pressure. The 
intra-abdominal component of 
ventriculoperitoneal shunt wanders around 
the large peritoneal cavity and a patent 
processus vaginalis is a possible escape route 
for the distal tip of the shunt.  

Distal migration of the shunt into scrotal 
sac is potentially frightening for the parents 
/ guardians of a baby with VP shunt. Most 
parents are not sure what it might be, as 
they have probably not seen a shunt before 
and not expected to feel it in the scrotal sac. 
A proper education of all and every possible 
complication of VP shunt should be 
explained at the point of taking consent. 

A shunt in the scrotal sac potentially 
keeps the external inguinal ring opened and 
there is a likelihood of bowel herniation 
forming an inguinoscrotal hernia. The 
consequences could be grief with attending 
obstruction and strangulation. 

Although shunt migration into the 
scrotum is usually associated with 
hydrocele as in this case, its treatment is less 
frightening. Simple taxing of the distal 
shunt by serial manipulations while under 
anesthesia will ensure the catheter is in the 
peritoneum without the possibility of 
contaminating the sterile shunt system at 
surgery. It is imperative this is done under 
anesthesia to ensure relaxation just before a 
simple herniotomy is performed by the 
pediatric surgeon. With the closure of the 
external ring and without the exposure of 
the shunt system, the problem of shunt 



 
 
 
378          Ojo et al          Unusual complication of ventriculoperitoneal shunt 

 
 
 

migration is sorted at the same time that of 
hydrocele. 

Conclusion 
Shunt complications are many but 

ensuring the processus vaginalis is not 
patent before the shunt procedure is done 
can prevent some rarer ones like migration 
into the scrotal sac. By inference, all 
children should be checked for 
inguinoscrotal hernia as well as inguinal 
hydrocele before VP shunt procedure is 
done. In cases where there is hydrocele or 
inguinoscrotal hernia concomitant with 
hydrocephalus, herniotomy should be done 
at the same time of VP shunt to prevent 
migration of distal shunt to the scrotal sac. 

 
Corresponding Author: 
Dr. Omotayo A Ojo 
Neurosurgery Unit, Department of Surgery. 
Lagos University Teaching Hospital, Idi-Araba, 
Lagos State. Nigeria 
Email : tayoojo111@yahoo.com 
Tel: +2348033922181 
 
 

References 
1. de Ribaupierre, S., Rilliet, B., Vernet, O., Regli, L., & 
Villemure, J. G. (2007). Third ventriculostomy vs 
ventriculoperitoneal shunt in pediatric obstructive 
hydrocephalus: results from a Swiss series and literature 
review. Childs Nerv Syst, 23(5), 527-533. doi: 
10.1007/s00381-006-0283-4 
2. Komolafe, E. O., Adeolu, A. A., & Komolafe, M. A. 
(2008). Treatment of cerebrospinal fluid shunting 
complications in a Nigerian neurosurgery programme. 
Case illustrations and review. Pediatr Neurosurg, 44(1), 
36-42. doi: 10.1159/000110660 
3. Persson, E. K., Anderson, S., Wiklund, L. M., & 
Uvebrant, P. (2007). Hydrocephalus in children born in 
1999-2002: epidemiology, outcome and 
ophthalmological findings. Childs Nerv Syst, 23(10), 
1111-1118. doi: 10.1007/s00381-007-0324-7 
4. Piatt, J. H., Jr., & Garton, H. J. (2008). Clinical 
diagnosis of ventriculoperitoneal shunt failure among 
children with hydrocephalus. Pediatr Emerg Care, 
24(4), 201-210. doi: 10.1097/PEC.0b013e31816a8d43 
5. Rekate, H. L. (2008). The definition and classification 
of hydrocephalus: a personal recommendation to 
stimulate debate. Cerebrospinal Fluid Res, 5, 2. doi: 
10.1186/1743-8454-5-2 
6. Warf, B. C. (2005). Hydrocephalus in Uganda: the 
predominance of infectious origin and primary 
management with endoscopic third ventriculostomy. J 
Neurosurg, 102(1 Suppl), 1-15. doi: 
10.3171/ped.2005.102.1.0001 
7. Warf, B. C., & East African Neurosurgical Research, 
Collaboration. (2010). Pediatric hydrocephalus in East 
Africa: prevalence, causes, treatments, and strategies for 
the future. World Neurosurg, 73(4), 296-300. doi: 
10.1016/j.wneu.2010.02.009