A novel technique for placement of the shunt catheter in the pleural space: The single incision thoracoscopic approach with complete visualization: A patient series and case illustration.

Background: Long-term treatment for hydrocephalus typically involves permanent cerebrospinal fluid (CSF) diversion through shunt placement. Ventriculoperitoneal (VP) shunts are often the first-line treatment; however, they may be deferred for alternative modalities such as ventriculopleural (VPL) shunts in low-pressure hydrocephalus or cases of a hostile abdomen. Our emphasis on minimally invasive techniques led to the adoption of a single incision endoscopic approach for distal shunt placement within the pleural space. Methods: 11 patients who underwent VPL or syringopleural (SPL) shunt placement due to low-pressure hydrocephalus (LPH), syrinx, or contraindication to VP shunt were reviewed. Of the 11 patients, 8 received VPL shunts and 3 received SPL shunts. Results: Eleven patients (6 female, 5 male; mean age 56 years, range 26-79) underwent pleural-based CSF diversion, including 7 VPL and 4 SPL shunt placements. Indications included low-pressure and obstructive hydrocephalus, shunt failure, infection, and syringomyelia, with most patients having extensive prior neurosurgical histories. Clinical improvement or stabilization was achieved in the majority of cases. Hydrocephalus patients commonly experienced resolution of headache, papilledema, or altered mental status, while SPL patients demonstrated radiographic reduction in syrinx size with variable neurological recovery. Length of stay ranged from 1 to 179 days, with most patients discharged within 1 week. Complications were infrequent, with two patients requiring revision procedures and no long-term pleural complications or shunt-related infections observed. At follow-up (12-1513 days), most patients remained stable or improved, with one patient lost to follow-up. Conclusion: When VP shunting is contraindicated, techniques such as VPL, ventriculoatrial, and ventriculocholecystic shunting may be considered. Of these, VPL shunting demonstrates the most favorable rate of success and lowest rate of complications. VPL shunt placement provides a mechanistically viable solution for LPH, low-pressure syrinxes, and other forms of hydrocephalus. Our novel approach using a single thoracic incision and intrathoracic endoscopic visualization offers the maximum extent of minimal invasiveness with the greatest possible safety profile.