STRANGULATED VENTRAL HERNIA CAUSING VENTRICULOPERITONEAL SHUNT OCCLUSION

Objectives: Excess cerebral spinal fluid (CSF) accumulation leading to hydrocephalus is associated with neurological decline in pediatric and adult patients. A ventriculoperitoneal shunt (VPS) is an established treatment for hydrocephalus with known complications, including mal-positioning, occlusion, and infection. We present a unique case of a strangulated ventral hernia complicated by acute VPS occlusion. The patient is a 39-year-old male with a complex history of hydrocephalus since birth, Bartter syndrome, and multiple prior abdominal surgeries, including cholecystectomy and 32 prior VPS revisions. Presenting complaints included headache, bilateral aural fullness, and abdominal pain associated with an epigastric bulge. He denied obstructive symptoms. His abdominal exam revealed multiple scars and a 5x5cm partially reducible tender right upper quadrant hernia with mild skin erythema. A head computed tomography (CT) demonstrated interval enlargement of the ventricular system compared to imaging two months prior. CT abdomen revealed a fascial defect consistent with a ventral hernia containing omental fat and the VPS. Both neurosurgery and surgery evaluated the patient and agreed on an urgent repair. In the operating room, a 2 cm fascial defect was found. Upon opening the hernia sac, strangulated omentum intimately involved the VPS. The VPS was gently separated from the omentum and placed in a wet lap pad. Once the strangulated omentum was resected, Neurosurgery ensured VPS patency and obtained CSF and VPS cultures. The VPS was then replaced in the abdomen positioned in the left lower quadrant, and the fascia was closed primarily, followed by skin closure. Post-operatively the patient was started on broad-spectrum antibiotics until cultures resulted negative. A shunt series was obtained that revealed appropriate VPS placement with the resolution of the prior hernia. The patient did well and was discharged on postoperative day four. This case of VPS occlusion is unique in its presentation with intra-operative findings of the VPS intimately entangled within the strangulated omental fat suggesting the acute on chronic nature of the hernia. Even though open primary ventral hernia repair has a higher risk of recurrence and surgical site infection, this patient’s fascial defect was small, easily approximated primarily, and tension free. The patient had an exceptional outcome with negative CSF and tip cultures. This case reassures us that open ventral repair and VPS repositioning can yield excellent outcomes in a complex surgical patient.

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