Operative Report (Ventriculoperitoneal Shunt Placement/Revision)

Document Header

Date of Procedure: [Date]

Start Time / End Time: [Start time] / [End time]

Facility / OR: [Facility name] / [OR number]

Primary Surgeon: [Name, credentials]

Assistant(s): [Names and roles] (If none, state "None")

Anesthesia: [Type and airway]

Pre-operative Diagnosis: [Diagnosis]

Post-operative Diagnosis: [Diagnosis] (State if unchanged from pre-operative)

Procedure(s) Performed: [Procedure description with laterality and components] (Include laterality; specify placement vs revision; specify components addressed; include distal approach if applicable)

Brief Operative Summary

[3–6 sentence summary including: indication, shunt configuration (side, entry site, valve type, valve setting as-left, distal destination), notable techniques (navigation/endoscopy/laparoscopy if used), key intraoperative findings (CSF appearance, abdominal findings if applicable), complications or "no complications," and patient disposition]

Indication and Consent

[Clinical indication including hydrocephalus etiology or shunt malfunction/infection context] [Key pre-operative findings including relevant imaging and ventricular size] [Confirmation that risks, benefits, and alternatives were discussed and informed consent obtained]

Antibiotic Prophylaxis

• Prophylactic antibiotic(s): [Name(s) and dose(s)]
• Timing: [Time relative to incision] (Include redosing and timing if performed)
• Therapeutic antibiotics: [Name(s), dose(s), indication] (Include only if treating suspected/confirmed infection)

Implanted Components

As-Left Configuration

[Final construct in one statement: laterality, cranial entry site (frontal/occipital), valve type (programmable vs fixed; anti-siphon/gravitational components if present), valve setting as-left, and distal terminus]

Ventricular Catheter

• Manufacturer/Model: [Manufacturer, model]
• Catheter type: [standard / antibiotic-impregnated / other]
• Length inserted: [cm] (If not measured, state "not recorded")
• Target: [Ventricular target and trajectory]

Valve/Reservoir

• Manufacturer/Model: [Manufacturer, model]
• Valve type: [programmable / fixed]
• Valve setting (as-left): [Exact setting] (If unknown at close, state "not recorded" and address in Postoperative Plan)
• Setting confirmation: [programmer interrogation / radiographic confirmation / not confirmed]
• Add-on device(s): [Anti-siphon device and/or gravitational unit with manufacturer/model] (If none, state "None")

Peritoneal Catheter

• Manufacturer/Model: [Manufacturer, model]
• Catheter type: [standard / antibiotic-impregnated / other]
• Placement approach: [open / laparoscopic]

Device Identifiers

• Ventricular catheter: UDI: [UDI]; Lot: [Lot]; Serial: [Serial]
• Valve/Reservoir: UDI: [UDI]; Lot: [Lot]; Serial: [Serial]
• Add-on device(s): UDI: [UDI]; Lot: [Lot]; Serial: [Serial] (Omit if no add-on device)
• Peritoneal catheter: UDI: [UDI]; Lot: [Lot]; Serial: [Serial]

(For any identifier not available, state "not recorded")

Intraoperative Findings

• CSF return: [immediate / delayed / none]; [description of flow quality]
• CSF appearance: [clear / xanthochromic / bloody / turbid]
• Opening pressure/ICP: [Value in mmHg or cm H2O] (If not measured, state "not measured")
• Ventricular cannulation: [Number of passes] (Note any difficulty or use of guidance)
• Abdominal findings: [adhesions / pseudocyst / ascites / contamination / normal] (If peritoneum not entered, state "peritoneum not entered")
• Revision assessment: [Findings on shunt system evaluation including occlusion location and mechanical testing results] (Include only for revision cases)
• CSF sampling: [obtained / not obtained] (If obtained, specify source)

Operative Technique

Positioning and Preparation

[Patient position] [Sites prepped and draped] [Planned incision locations]

Proximal/Cranial Technique

[Incision location and burr hole creation] [Dural opening and cortical entry method] [Ventricular catheter placement: trajectory, number of passes, method of confirming ventricular entry (CSF flow/ultrasound/navigation/endoscopy)] [Catheter securing method] (Document number of passes explicitly; if unknown, state "not recorded")

Valve Placement and Connection

[Valve pocket location and creation] [Connection of proximal catheter to valve and valve orientation] [Confirmation of programmable valve setting]

Tunneling

[Tunneling route from cranial to abdominal site] [Intermediate incisions if any] [Confirmation of smooth catheter passage without kinking]

Distal/Peritoneal Technique

[Incision location and peritoneal entry method: open mini-laparotomy vs laparoscopic] [Confirmation of peritoneal entry and catheter position] [Fascial and skin closure for abdominal site]

Revision-Specific Elements

(Include only applicable subsections; omit this section entirely for new placements)

Proximal revision: [Removal technique, tract assessment, CSF sampling]

Valve revision: [Old valve findings, exchange technique, new valve setting and confirmation method]

Distal revision: [Abdominal exploration findings, pseudocyst management, catheter repositioning]

Externalization/EVD conversion: [Rationale and EVD configuration including drainage parameters]

Specimens and Cultures

• CSF studies: [Culture, cell count, chemistry] with source: [ventricle / reservoir / distal catheter] (If none sent, state "None")
• Hardware sent for culture: [Catheter tip / valve / other] (If none sent, state "None")

Closure and Hemostasis

[Hemostasis method and hemostatic agents if used] [Irrigation if performed] [Layered closure by site] [Dressings applied]

Estimated Blood Loss and Counts

Estimated Blood Loss: [mL]

Counts: [correct / discrepancy with resolution]

Complications

[None] or [Description of event, timing of recognition, corrective action, and outcome]

Disposition

[Extubation status], [immediate neurologic condition], [destination: PACU / ICU]

Postoperative Plan

• Imaging: [CT head timing and/or shunt series plan] (If deferred, state rationale)
• Valve Setting Follow-up: [Intended maintenance setting, who will verify, plan to re-check/reprogram after any MRI]
• Antibiotics: [Stop time or duration plan] (Distinguish therapeutic vs prophylactic if both given)
• Wound Care and Activity: [Restrictions, dressing changes, head-of-bed instructions]
• Follow-up: [Clinic timing, suture/staple removal plan, interval imaging if indicated]