inguinal hernia—a rare complication of ventricuoloperitoneal shunt

SCIENTIFIC LETTER

Inguinal Hernia—A Rare Complicationof Ventricuoloperitoneal Shunt

Kanwaljeet Garg & Hitesh Kumar Gurjar &

Guru Dutta Satyarthee & Raghav Singla &

Bhawani Shankar Sharma

Received: 7 September 2013 /Accepted: 2 December 2013# Dr. K C Chaudhuri Foundation 2013

To the Editor : A 6-mo-old male child presented to us with aswelling over his lower back since birth and weakness of bothlower limbs (Power 3/5). MRI revealed open dysraphic spinedefect in lumbar region with herniation of spinal cord, sug-gestive of myelomenigocele, hydrocephalous and chiari type2 malformation. He underwent right ventriculoperitoneal

shunt (VPS) and repair of myelomeningocele. A week afterthe surgery, patient started having reducible swelling of leftscrotum, which used to increase on coughing (Fig. 1a). Hedidn’t have any scrotal abnormality prior to the surgery. Clin-ical examination revealed hydrocele with completely reduc-ible indirect hernia (Fig. 1b). Scrotal ultrasonogram revealed

Fig. 1 a Clinical photograph ofpatient showing swelling in theleft inguinoscrotal region (star),b Hernia fully reduced (star),c Abdominal X-ray of the patientshowing the extension of theshunt tubing into the scrotum(arrow)

K. Garg :H. K. Gurjar (*) :G. D. Satyarthee : R. Singla :B. S. SharmaDepartment of Neurosurgery, All India Institute of Medical Sciences,New Delhi 110029, Indiae-mail: hiteshgurjar@gmail.com

Indian J PediatrDOI 10.1007/s12098-013-1316-0

inguinoscrotal hernia with fluid and bowel loops in the scro-tum. Abdominal X-ray revealed the abdominal end of theshunt to be in the scrotum (Fig. 1c).

CSF diversion in the form of VPS is the most commonpediatric neurosurgical procedure. It seems to be a relativelysimple procedure, however, it may be associated with variedcomplications. Some studies have reported the complicationrate with VPS to range from 24 to 74 % [1].

Various intraabdominal complications associated with VPSinclude shunt ascites, pseudocyst formation and migration.However, VPS leading to hydrocele and hernia is a rarecomplication. Many reports of scrotal migration of shunttubing presenting as scrotal mass has been reported in litera-ture but VPS leading to hydrocele and hernia is rare [2,3].

Hydrocoele formation following VPS is thought to resultfrom fluid tracking from the peritoneal cavity into the scrotumvia a patent processus vaginalis.

The rate of absorption of CSF may not be adequate inchildren due to less absorptive surface area of peritoneum.The excess CSF can track down into scrotum through thepatent processus vaginalis and may push the bowel loops intoscrotum as well. Other putative factors include the tendency touse long shunt tubing in children to accommodate the growth

of the child and the vertical relationship of the superficial anddeep inguinal rings in children, which may favor the passingof the shunt tubing into the scrotum. Management of thisunique complication includes herniotomy and replacementof the abdominal end.

Contributions All the authors have drafted and reviewed the manu-script. BSS will act as guarantor.

Conflict of Interest None.

Role of Funding Source None.

References

1. Celik A, Ergun O, Arda MS, Yurtseven T, Ersahin Y, Balik E. Theincidence of inguinal complications after ventriculoperitoneal shuntfor hydrocephalus. Childs Nerv Syst. 2005;21:44–7.

2. Ho CC, Jamaludin WJ, Goh EH, Singam P, Zainuddin ZM. Scrotalmass: A rare complication of ventriculoperitoneal shunt. Acta Med(Hradec Kralove). 2011;54:81–2.

3. Walsh AR, Kombogiorgas D. Coiled ventricular-peritoneal shuntwithin the scrotum. Pediatr Neurosurg. 2004;40:257–8.

Indian J Pediatr