DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Communicating hydrocephalus.
POSTOPERATIVE DIAGNOSIS: Communicating hydrocephalus.
OPERATION PERFORMED: Right frontal ventriculoperitoneal shunt using a Codman Hakim programmable valve set at 120 mm of water.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: None.
BLOOD LOSS: Minimal.
COUNTS: Sponge and needle counts were correct.
POSTOP CONDITION: Stable.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic gentleman, who was recently worked up by us for possible normal pressure hydrocephalus. According to him and his family, the patient has had a slow shuffling gait for four to five years. Over that period of time, he has also had trouble with short-term memory and general fatigue. He had urinary frequency due to prostate problems for at least nine years but has had a few episodes of urinary incontinence over the last month or so. However, his primary problem was his gait. He had suffered a subarachnoid hemorrhage in the remote past, for which no surgery was required. The risks and benefits of shunting, as well as alternative methods of management were discussed with him and his family. They all accepted the potential risks of surgery, including hemorrhage, infection, paralysis, shunt malfunction, need for additional surgery, and even death among others. After considering the options, they decided to proceed with the shunt at this time.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, and general endotracheal anesthesia was induced. He received 1 g of Ancef for infection prophylaxis. He was placed in the supine position with the head turned to the left. The right side of the head, neck, chest, and abdomen were prepped and draped with alcohol as well as DuraPrep.
A C-shaped incision was made in the right frontal region in the mid axillary line. A bur hole was created and the dura was cauterized. An incision was then made in the right paramedian region, and the layers were dissected through the outer and inner rectus sheath to identify the peritoneum. This was opened and the peritoneal contents were identified. A catheter was then tunneled from the abdominal to the cervical region, and an intermediate cut was made behind the right ear. The catheter was tunneled up into the cranial wound. A Codman Hakim programmable valve that had been previously set to drain at 120 mm of water and without an anti-syphon device was connected to the catheter. All connections were double tied.
A ventricular catheter was then inserted into the right lateral ventricle in a single pass without difficulty. Excellent outflow of CSF was obtained. The catheter was cut short and connected to the valve. This connection was also double tied. Excellent outflow of CSF was seen from the distal catheter, which was then dropped into the peritoneal cavity.
All wounds and tracks were irrigated with antibiotic solution. The incisions were then closed with 2-0 and 3-0 Vicryl and staples on the skin.
