OT notes · Neurosurgery

Ventriculoperitoneal shunt

Usual anaesthesia
General
Position
Supine, head on a ring and turned away from the shunt side, roll under the shoulders
Setting
elective

Operative note template for a primary ventriculoperitoneal shunt, with a filled example for an adult with obstructive hydrocephalus shunted through a right frontal burr hole under general anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • shunt infection needing removal of the whole system
  • shunt block or disconnection needing revision
  • over-drainage or under-drainage
  • intraventricular or intracerebral bleeding
  • seizures
  • bowel or other abdominal organ injury
  • abdominal CSF pseudocyst or catheter migration
  • wound breakdown over the hardware
  • need for repeat surgery during life

Pre-operative details for this operation

  1. Cause of hydrocephaluse.g. aqueductal stenosis, post-meningitic, post-haemorrhagic, tumour, NPH, congenital
  2. Imaging reviewedCT or MRI: ventricle size, which horn is larger, distance from skull to frontal horn
  3. Side and entry point plannedRight frontal (Kocher's point)Left frontalParieto-occipital (Keen's point)
  4. Abdomenprevious laparotomy scars, peritonitis, ascites, CSF pseudocyst history
  5. Recent infection screenfever, blood culture, CSF result if tapped
  6. CoagulationINR, APTT, platelets; antiplatelets or anticoagulants stopped
  7. Shunt system availablemake, valve type (fixed pressure with its range, or programmable), antibiotic-impregnated or not

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine, head on ring, turned away from shunt side, shoulder roll
  3. Skin preparationhair clipped, not shaved; antiseptic and drying time; incise drape; double gloves
  4. Image guidanceAnatomical landmarksStereotactic (image-guided) placementUltrasound

Operative findings

  1. Ventricle entered at attempt number1, 2 or 3; depth at which CSF came
  2. CSF pressureHigh, spurtingNormal flowLowopening pressure in cm H2O if a manometer was used
  3. CSF appearanceClear, colourlessXanthochromicBlood stainedTurbid
  4. Peritoneal entry confirmedbowel or liver seen, dissector passed freely
  5. Distal run-offCSF dripping from the distal end before it was placed in the peritoneum

Procedure (steps)

  1. Scalp and abdomen prepared and draped in one fieldantiseptic, incise drape, gloves changed before incision
  2. Local infiltrationdrug and strength, e.g. 1% lignocaine with adrenaline 1:100,000
  3. Scalp incisionCurvilinearLinearsite and length; incision placed so it does not lie over the valve
  4. Burr holeHigh-speed drillPerforator and burrHudson bracesite relative to midline and coronal suture
  5. Dura and pia openedbipolar coagulation, cruciate or small opening
  6. Abdominal incision and peritoneal entryRight subcostalUpper midline / subxiphoidLaparoscopicTrocarlength; layers opened; size of peritoneal opening
  7. Tunnellingpasser used, direction (abdomen to head or head to abdomen), any extra incision
  8. Ventricular catheter insertedtrajectory, depth from outer table, number of passes, stylet removed, CSF flow
  9. CSF samplesent for cell count, protein, sugar, Gram stain and culture
  10. Valve connected and testedno air in the system; connections tied with 2-0 silk
  11. Distal catheter placed in peritoneumCSF flow seen first; catheter slid in freely without coiling back; length inside
  12. Peritoneum closedabsorbable suture, tubing kept clear of the stitch

Closure, drains and dressing

  1. Scalpgalea absorbable braided; skin absorbable monofilament or nylon if skin is thin
  2. Abdomenlayers closed: peritoneum/transversalis, rectus sheath, Scarpa's fascia, skin
  3. Skin adhesive or dressing
  4. Tubing checked for kinks along the track

Specimens and implants

  1. Shunt systemmake, model, valve type and pressure (or programmable setting), antibiotic-impregnated or not
  2. Ventricular catheterlength inserted from outer table
  3. Peritoneal catheterlength placed in abdomen; any length cut off
  4. Lot / batch numbersticker pasted in the case sheet and OT implant register
  5. CSF sentYesNotests requested

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neuro observationsGCS, pupils, limb power at set intervals
  2. Positionhead end flat or raised as ordered by the surgeon
  3. Antibioticsecond prophylactic dose if ordered, within 8 hours
  4. Analgesia and anti-emeticdrug, dose, frequency
  5. Oral intakewhen to start, watch for abdominal distension
  6. Imagingpost-op CT head and shunt series X-ray as baseline
  7. Wound checkscalp and abdomen; watch for CSF leak or swelling along the track
  8. Programmable valvecheck and reset the setting after any MRI
  9. Follow-upwound review at 2 weeks, imaging at about 6 weeks; carry the shunt card

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.K., 34 years, obstructive hydrocephalus from aqueductal stenosis on MRI, with headache, vomiting and papilloedema. Elective right frontal VP shunt.

Case details

Date: 04/02/2026. Elective. Neurosurgery OT 1.

In OT 09:05. Induction 09:15. Skin incision 09:50. Skin closure 10:55.

Surgeon: Dr A. (MCh resident, 2nd year). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: obstructive hydrocephalus, aqueductal stenosis. Lateral and third ventricles dilated, fourth ventricle normal. Frontal horns symmetric.

No previous abdominal surgery. No fever. INR 1.0, platelets 2.4 lakh.

Consent: general, procedure-specific (including infection, block, revision) and anaesthesia consent taken in Hindi.

WHO checklist done. Inj cefazolin 2 g IV at induction, 09:15, 35 minutes before incision.

Shunt system checked before opening: medium-pressure fixed valve, antibiotic-impregnated ventricular catheter, peritoneal catheter.

Anaesthesia and position

Under GA, supine, head on ring turned to the left, roll under the shoulders. Pressure points padded.

Hair clipped. Scalp, neck, chest and abdomen painted with 2% chlorhexidine in 70% alcohol, left to dry for 3 minutes. Incise drape applied. Double gloves.

Procedure

Kocher's point marked 11 cm behind the nasion and 3 cm to the right of midline. Incisions infiltrated with 1% lignocaine with adrenaline 1:100,000. Gloves changed.

Curvilinear right frontal scalp incision of 4 cm, flap raised so the valve would not lie under the scar. Burr hole made with high-speed drill. Dura coagulated with bipolar and opened in a cruciate way. Pia coagulated.

Right subcostal incision of 2 cm. Anterior rectus sheath opened, muscle split, posterior sheath opened. Peritoneum held between two mosquito clamps and opened for 5 mm. Penfield dissector passed freely, bowel seen.

Shunt passer tunnelled subcutaneously from the abdominal wound to the scalp wound. Peritoneal catheter and valve pulled through.

Ventricular catheter with stylet passed perpendicular to the skull, aimed at the right inner canthus and just in front of the tragus. Ventricle entered at first pass at 5 cm. Stylet removed. Catheter inserted to 6 cm from the outer table.

Findings: CSF under high pressure, clear and colourless. 5 ml CSF sent for cell count, protein, sugar, Gram stain and culture.

Ventricular catheter connected to the valve, no air in the system, connection tied with 2-0 silk. Free drip of CSF from the distal end confirmed.

Peritoneal catheter slid into the peritoneal cavity with smooth forceps, no coiling back. About 30 cm placed inside. Peritoneum closed with absorbable suture, tubing clear of the stitch.

Closure

Wounds irrigated. Scalp: galea with absorbable braided polyglactin 910 (Vicryl), skin with subcuticular absorbable monofilament poliglecaprone (Monocryl). Abdomen: peritoneum, rectus sheath and Scarpa's fascia closed in layers with Vicryl, skin with subcuticular Monocryl.

Skin adhesive applied. Track palpated, no kink.

Specimens and implants

Implant: VP shunt system, medium-pressure fixed valve, antibiotic-impregnated ventricular catheter. Make and lot number as on sticker; sticker pasted in the case sheet and OT implant register.

Ventricular catheter 6 cm from outer table. Peritoneal catheter about 30 cm in the abdomen, not cut.

Specimen: CSF 5 ml to microbiology and biochemistry.

End of procedure

Estimated blood loss 50 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Extubated in OT. GCS 15, pupils equal and reacting. Shifted to neurosurgery HDU in stable condition.

Post-op orders

GCS, pupils and limb power hourly for 6 hours, then 4-hourly.

Inj cefazolin 2 g IV one more dose at 17:00.

Analgesia and anti-emetic as charted by the anaesthetist.

Sips after 6 hours if no vomiting, then soft diet. Watch for abdominal distension.

CT head and shunt series X-ray on POD 1.

Wound check on POD 2. Wound review in OPD at 2 weeks, MRI at 6 weeks.

Signature

Dr A., MCh resident, Neurosurgery. Reg. no. ________. 04/02/2026, 11:10.

Must document for this operation

  • Shunt make, model, valve type and pressure (or programmable setting), with the lot sticker. The next surgeon, often in another hospital at night, must know what valve is in the patient before revising or reprogramming it.
  • Side and entry point of the ventricular catheter, number of passes and depth. Several passes explain a post-op bleed, and the depth is the baseline for judging catheter position on follow-up CT.
  • CSF pressure and appearance, and which samples were sent. A turbid or blood-stained CSF changes the antibiotic plan, and the culture must be traced if the patient spikes a fever.
  • Length of the peritoneal catheter placed in the abdomen. In a growing child or a migrated catheter, the shunt series is compared against this length.
  • How peritoneal entry was confirmed. A pre-peritoneal catheter is a common reason for early distal failure, and the note shows it was checked.
  • Antibiotic, dose and time, and antiseptic used. Shunt infection rates are audited against a prophylaxis protocol.

Common mistakes in these notes

  • Writing 'VP shunt done' with no valve type or pressure.
  • Not pasting the implant sticker, or pasting it only in the OT register.
  • Not recording the CSF appearance and whether a sample was sent.
  • Leaving out the number of ventricular passes.
  • Not writing the peritoneal catheter length or how peritoneal entry was confirmed.

Indian practice and paperwork

  • The batch and serial number of every implanted device must be recorded in the patient's record, the OT master logbook and the discharge summary. This applies to the shunt valve and catheters. (NABH 5th ed., MOM.10(d))
  • The operative note must be written before the patient is moved out of recovery, and post-op care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Loftus CM, ed. Atlas of Emergency Neurosurgery. Thieme; 2015, Ch 21, Ventricular Shunt Malfunction (Abeshaus S, Browd SR, Ellenbogen RG), pp. 349-369.
  • Loftus CM, ed. Atlas of Emergency Neurosurgery. Thieme; 2015, Ch 7, Invasive Neuromonitoring Techniques (Laroche M, Huang MC, Manley GT), pp. 101-110.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 24, Neurosurgical procedures for general surgeons (burr hole, ventricular tap, Keen's point), pp. 544-556.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV adult (3 g if 120 kg or more), within 60 min before incision; cefazolin recommended for CSF-shunting procedures. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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