Practice patterns of Canadian neurosurgeons for initial placement of ventriculoperitoneal shunts – a Delphi study on the benefits and challenges of implementing laparoscopic approaches

Practice patterns of Canadian neurosurgeons for initial placement of ventriculoperitoneal shunts

U of A ethics approval: Pro00128728

Second round of the study


Principal Investigator(s) (Supervisor(s)) (Primary Contact:
Dr. Kim
Assistant Professor
Faculty of Medicine and Dentistry
University of Alberta
Edmonton, AB
(780) 407-1165
mjkim@ualberta.ca


Co-investigator(s) (Student(s)): Dr. Chow
Clinical Associate Professor
Faculty of Medicine and Dentistry
University of Alberta
Edmonton, AB
(780) 407-1428

Dr. Heppner
Resident
Faculty of Medicine and Dentistry
University of Alberta
Edmonton, AB
(306) 717-3141
jmheppne@ualberta.ca



Invitation to Participate:
Our sincere thanks to those who have participated in the first round of the Delphi survey! You will find that there is a summary of the results from the first round included in some of the questions here. This is the second round wherein we have included ideas and issues not present in the first round, and we aim to close in on consensus through refined versions of the prior questions. It is expected that at least one more subsequent survey will be needed after this one to identify consensus on the issues of discussion.


Please note that in addition, we will be asking for the center at which you practice so that we can assess the extent to which we are capturing the overall Canadian Neurosurgical perspective. This is very important towards our goal of obtaining consensus of opinion. Aside from this, all data entered continues to be anonymous, and no other personal information is required.

As before:
You are again invited to participate in this research study about utilization of laparoscopy in the placement of primary ventriculoperitoneal (VP) shunts in Canada, because as a practicing Neurosurgeon you may have experience in placement of VP shunts. You are receiving this invitation through the Canadian Neurosurgical Society database of members. Eligibility entails anyone who is currently a practicing neurosurgeon in Canada.


Purpose of the Study: From this research we wish to learn what current experience, opinion, and practice exists in the Canadian Neurosurgical community regarding utilization of laparoscopy for the placement of the abdominal catheter in VP shunt procedures. While there is evidence in the literature supporting the possible benefits of this approach, there have been no definitive evidence-based position statements made either in favor or against this alternative to the classic mini-laparotomy. Furthermore, none of the published trials comparing laparoscopic to the mini-laparotomy approach have included Canada.


Thank you in advance for your ongoing time and participation in our research.
1.Most respondents in the initial survey have experience with laparoscopic assistance (65.5%), very few use it exclusively for de novo shunts.

IF you do not have experience with laparoscopic placement, what is the limiting factor(s) or barriers at your center that may limit this? Please choose all that apply.
2.Most participants in the previous survey felt that there is no bias for or against laparoscopic assistance at their center (72.4%). Only 3.45% feel their center has a negative opinion about laparoscopic assistance.

Have you ever felt pressure from your center or colleagues to utilize laparoscopic assistance when you might not have otherwise wanted to do so?
3.IF there are barriers to utilization of laparoscopic assistance at your center, what you believe is the major barrier?
4.If you were to estimate the frequency of complications following a de novo VP shunt for all comers, what number would you quote a patient based on local practice? Please keep in mind that we recognize this is a subjective assessment for each respondent. We aim to identify differences in institutional experiences that may differ nationally and from the literature values. We acknowledge that the numbers you provide are purely a ballpark estimate which should represent the relative likelihood of each complication.
0-5%
6-10%
11-15%
16-20%
>20%
Infection
Distal catheter obstruction
Proximal catheter obstruction
Post-operative pain that cannot be adequately managed
Misplacement of the distal catheter
Intra-abdominal adhesion creation
Incisional hernia
Intra-abdominal pseudocyst
Visceral injury
Over-shunting
Under-shunting
CSF leak
Intracerebral hemorrhage
Intraventricular hemorrhage
Scalp complication including infection and hematoma
Catheter fracture
5.A consensus emerged in the previous survey that in patients undergoing revision of VP shunt, infection was the most important complication (29.1%). This was followed by roughly equivalent importance of issues with proximal or distal catheter, and misplacement of the distal catheter.

In your opinion, is laparoscopic assistance likely superior in revision surgeries for a VP shunt where both the proximal and distal catheters are possibly in need of revision?
6.No one in the previous survey felt that laparoscopic assistance would help prevent proximal catheter misplacement. Otherwise for all other complications there were respondents who disagreed to some degree whether laparoscopic assistance could reduce specific complication incidence.

93% felt that laparoscopic assistance WOULD reduce distal catheter misplacement.

73% felt that laparoscopic assistance WOULD reduce incisional hernia.

64% felt that laparoscopic assistance WOULD reduce post-operative pain.

75% felt that laparoscopic assistance would NOT reduce the chance of infection.

67.8% felt that laparoscopic assistance would NOT reduce the chance of intra-abdominal pseudocyst.

60.7% felt that laparoscopic assistance would NOT reduce the chance of intra-abdominal adhesions.

What is the expected likelihood of laparoscopic assistance to REDUCE the incidence of the following complications? We acknowledge that the numbers you provide are purely a ballpark estimate which should represent the relative likelihood with respect to each complication in your experience and at your center.
0%
1-9%
10-19%
20-29%
30-50%
>50%
Distal catheter misplacement
Incisional hernia
Infection
Post-operative pain
Intra-abdominal pseudocyst
Intra-abdominal adhesions
Visceral injury
Distal catheter obstruction
Over-shunting
Under-shunting
CSF leak
Intracerebral hemorrhage
Intraventricular hemorrhage
Scalp complication not including infection or hematoma
Catheter fracture
7.Would you expect that operative times for laparoscopic VP shunt placement would eventually decrease or be similar to open shunt placement as experience and protocols develop and are refined?
8.Most in the previous survey felt that length of hospital stay following VP shunt would be about the same with or without laparoscopic assistance (79.3%). 13.8% felt laparoscopic assistance could reduce length of stay.

What is the most frequent cause of increased length of stay for patient receiving a de novo VP shunt?
9.Please specify the center at which you primarily currently perform shunt surgeries.