Letter: Laparoscopic-Assisted Versus Mini-Open Laparotomy for Ventriculoperitoneal Shunt Placement in the Medicare Population

To the Editor: Since the use of laparoscopic-assisted ventriculoperitoneal shunts (VPS) by Basauri et al in 1993,1 they have been of ongoing interest to neurosurgeons because of their minimally invasive and visibility qualities, but the benefit of laparoscopic-assisted VPS has been controversial.2-4 Khalid et al5 reported the largest retrospective study up to date on the effectiveness of laparoscopic-assisted VPS compared with classically mini-open VPS, and the results of the article concluded promisingly that laparoscopic-assisted VPS can reduce the rate of distal revision in specific populations. However, there are some limitations to the study that cannot be ignored, and blindness to these flaws is enough to overshadow the encouraging findings. First, the time span reviewed in this study5 is large, and the time distribution of the 2 groups of patients is not presented. Considering the more recent emergence of laparoscopic-assisted VPS compared with classical VPS, it is reasonable to suspect that patients with laparoscopic-assisted VPS are more distributed among the more recently performed operations. However, such differences in population distribution may lead to biased study results because of improvements in anti-infection concepts and surgical techniques. Second, as summarized in Table 1 in the supplementary material provided by the authors,5 laparoscopic VPS in the subgroup analysis seemed to increase infections at 6 and 12 months by 1.63 and 1.66 times, respectively, for patients with a BMI of >30 Kg/M2, and by 3.57 and 1.99 times, respectively, for patients with a history of laparoscopic abdominal surgery. The authors only highlighted the advantages of laparoscopic-assisted VPS to reduce distal revision, without providing an explanation for these results. However, postoperative infection is also one of the common complications after VPS, which is also crucial for the safety application and promotion of laparoscopic-assisted VPS. Of course, in addition to these factors, cost factors should have been the focus of this study (based on Medicare patients), and unfortunately, the authors did not cover them. As mentioned by the authors in the article, there has been recognition of the advantages of laparoscopic-assisted VPS, and this study clarifies and highlights its benefits in distal revision for well-selected patients. It is expected that better designed and more comprehensive prospective studies will be available at a later stage.