endoscopic third ventriculostomy and the related nursing care

1. ENDOSCOPIC THIRD
VETRICULOSTOMY (ETV)
NEUROSURGICAL
PERIOPERATIVE NURSING
TEAM
NIMHANS, BENGALURU

2. DEFINITION
oEndoscopic third ventriculostomy (ETV) is a surgical procedure for treatment
of hydrocephalus in which an opening is created in the floor of the third ventricle using
an endoscope placed within the ventricular system through a burr hole.
oThis allows the cerebrospinal fluid to flow directly to the basal cisterns, bypassing the
obstruction

3. BACKGROUND
Walter Dandy was the first to pioneer the choroid plexotomy and
open third ventriculostomy in the early 20th century.
The first endoscopic third ventriculostomy (ETV) was performed in
1923 by William Mixter.
INDICATIONS
•an alternative to a cerebral shunt mainly
 noncommunicating obstructive hydrocephalus (such
as aqueductal stenosis)
communicating obstructive hydrocephalus (e.g. post intracranial
hemorrhage or post intracranial infection)

4. PATIENT POSITION
After induction of anesthesia, the patient is placed in the supine
position on head pins or horse shoe ( based on surgeon’s preference)
with a small roll under the shoulders.
The head is elevated approximately 30 degrees to prevent excessive
CSF loss.
The endoscope monitor should be positioned directly opposite the
surgeon for unobstructed viewing during the endoscopic portion of
the procedure

5. POSITIONING AND MARKING OF
SKIN INCISION AT RIGHT KOCHER’S
POINT

6. INCISION
A small area of the scalp is shaved, skin is
prepared in standard manner and draped.
a 2- to 3-cm vertical incision is made at 11
cm posterior to the nasion at the
midpupillary line, or ~ 1 cm anterior to the
coronal suture.
The right side is typically chosen unless the
patient anatomy or the presence of
pathology requires a left-sided approach

7. PROCEDURE
Patient is positioned on head pins
Draping id done for craniotomy
On the right side (i.e., nondominant side, if not specifically
indicated), with proper aseptic measures, 2 to 3 cm vertical incision is
made bone deep
burr hole is made with Manman burr,
dura is coagulated then opened in cruciate manner with bipolar
forceps and its margins coagulated.
endoscope system with rigid (0 and 30 degrees) endoscope and Karl
Storz camera is used after adequate illumination and white balance.
Using free-hand method, 10 mm obturator sheath with blunt end
trocar is used.

8. Lateral ventricle is preferably hit at 5 to 6 cm depth; then trocar is
removed and endoscope inserted. After visualization of lateral
ventricle and identifying defined landmarks, third ventricle is reached
via foramen of Monro.
Mammillary bodies, infundibular recess, and optic chiasma are
identified followed by puncture of intermammillary membrane with
Fogarty balloon catheter.
Fogarty balloon is inflated with up to 2 to 4 cc saline to enlarge the
stoma (or controlled bipolar cautery is used with low current in
selected cases of thick floor of third ventricle).
 Endoscope is further negotiated via the stoma to inspect
interpeduncular cistern and open the Liliequist membrane.
After that as per the need on individual basis other procedures are
done together with ETV. Ringer lactate is used for intraoperative saline
wash.
After ascertaining hemostasis, obturator sheath and endoscope are
removed synchronously under vision.
Cortical opening is packed with gelfoam.
Burr hole is filled with bone dust or bone cement and skin closure is

9. ENDOSCOPIC VIEW OF THE
ANATOMICAL STRUCTURES
(a) septal vein,
(b) thalamostriate vein, and
(c) choroid plexus, which
converge on the posterior
margin of the foramen of
Monroe.
(d) The fornix forms the
medial and anterior margin of
this opening.

10. The endoscope is advanced
through the foramen of
Monro and into the third
ventricle.
Mammillary bodies are
identified and used as the
posterior landmark.
The infundibular recess is
identified as the anterior
landmark of the area of
interest.

11. CONTD.
The initial opening in the floor can be made with
neuroendoscopic instruments or monopolar
cautery.
A small Fogarty balloon is advanced through the
working channel of the endoscope and passed
through the initial fenestration
The fogarty balloon is slowly inflated with
saline(0.7ml)to dilate the opening upto 4 to 6 mm
in diameter.
A small amount of bleeding is frequently seen
and usually resolves with gentle irrigation (warm
ringer lactate)
If excessive bleeding is encountered during the
procedure, or if there is concern for elevated
intracranial pressure, a ventriculostomy catheter
should be left in place.
A Gelfoam pledget is placed in the burr hole.
The scalp is closed in anatomic fashion.

12. ENDOSCOPIC CAMERA
SCOPES TO BE ATTACHED
TO THE LENS OF CAMERA
THIS END IS TO BE GIVEN
TO TECHNICHIAN TO BE
CONNECTED TO THE
MACHINE

13. LIGHT SOURCE
THIS END IS TO BE
CONNECTED TO THE
SCOPES THIS END IS TO BE
GIVEN TO THE
TECHNICHIAN TO
BE CONNECTED
TO THE MACHINE

14. SCOPES
0 (GREEN),30 (RED) ,70 (YELLOW) DEGREE SCOPES
DIFFERENCE IN TIPS OF
SCOPES
Red colored ring
indicating 30 degree
scope
Green colored ring
indicating 0
(zero)degree scope
Yellow colored
ring indicating 70
degree scope

15. OPERATING SCOPE, TROCHAR(OR
OBTURATOR) & SHEATH(USED IN
ETV)
OPERATING SCOPE
TROCHAR/
OBTURATOR
SHEATH

16. ENDOSCOPIC BIOPSY FORCEPS
(ETV)

17. FOGARTY CATHETER (USED IN
ETV)`
Should be used with stillet

18. ENDOSCOPIC BIPOLAR (ETV)
BIPOLAR CABLE TO BE
CONNECTED TO THIS END

19. ENDOSCOPIC MONOPOLAR (ETV)
MONOPLOAR
CABLE TO BE
CONNECTED HERE

20. THINGS REQUIRED FOR AN ETV
CASE

21. PROGNOSIS
This procedure has a high success for patients with:
•Hydrocephalus in myelomeningocele.
•Hydrocephalus associated with brain tumors.
•Obstructive hydrocephalus with other causes.
Patients who have low success rate with this procedure include:
•Those with communicating hydrocephalus.
•Children under the age of 2 years with hydrocephalus.
•Patients with hydrocephalus who were previously treated with whole brain irradiation.
COMPLICATIONS
The most frequent intraoperative complications of ETV are
hemorrhage (the most severe being due to basilar rupture) and
injury of neural structures
hematomas,
infections, and
cerebrospinal fluid leaks may present.

22. JOURNAL DISCUSSION
Endoscopic Third
Ventriculostomy: Our Experience
of Consecutive 50 Cases at a
Tertiary Care Center
Ramesh Chandra Venkata Vemula
BCM Prasad
Kunal Kumar
Journal of the Neurological Surgeons’ Society of India. 2022.

23. ABSTRACT
OBJECTIVE
The aim of this study was to do a retrospective analysis of the various
neurosurgical pathologies where endoscopic third ventriculostomy (ETV) was
used and to evaluate the outcome and prognosis.
METHODS
The retrospective data collection was done for the patients who underwent ETV
with or without other adjunct procedures; the results were prepared for clinical
presentation, diagnosis, surgical approach, and surgical goal; and success rate
and prognosis were analyzed and compared with other studies.
RESULTS
A total of 50 patients were included in the study, with overall success rate of
ETV as 88%;
aqueductal stenosis was the most common indication where ETV was used;
 headache and vomiting were the most common presenting complaints
followed by ataxia and visual blurring; and
ETV provided flexibility in its use with biopsy, abscess drainage, temporary
external ventricular drain placement, etc

24. CONCLUSION
ETV being superior to ventriculo-peritoneal shunt for obstructive
hydrocephalus provides flexibility in its use and possibly is a useful
adjunct to prevent postoperative hydrocephalus after endoscopic
intraventricular surgery;
proper case selection in accordance to ETV success score yields a
better success rate.
In experienced hands with proper precautions, perioperative
complications can be kept at minimum.
Wherever possible, in cases of obstructive hydrocephalus, especially
in patients >1 year of age, ETV should be the treatment of choice.
We recommend a proper case selection, including preoperative
detailed reading of sagittal magnetic resonance imaging scan, to
improve the success rate with less complication

25. INDEPTH ANALYSIS
OBJECTIVE
The objective of this study was to retrospectively analyze various
neurosurgical pathologies and their presentation, indication, perioperative
findings, outcomes, complications, and prognosis where ETV was used in our
institute from 2014 to 2019, and calculating the overall success rate of ETV
and comparing the results with other studies.
MATERIALS AND METHODS
The study was conducted in the Department of Neurosurgery, Sri
Venkateswara Institute of Medical Sciences, Tirupati, in the Indian state of
Andhra Pradesh, from 2014 to 2019.
Retrospective data were collected for all patients who underwent ETV for
various indications from Operation Theatre database followed by collection of
further details from Medical Record Section and Radiology database.
A total number of first 50 consecutive cases were included in the study.
A total of 312 patients underwent surgery for hydrocephalus within the study
period (2014–2019), out of which 50 patients underwent ETV.
The criteria for selecting patients were subjective, primarily based on the
presence of obstructive hydrocephalus in majority of cases, whereas in some
cases ETV was performed as an adjunct to ventricular endoscopic procedure.

26. RESULTS
Out of total 50 patients, 35 were male and 15 were female; 38
patients were aged >10 years, 10 patients between 1 and 10 years,
and 2 patients between 6 months and 1 year
Table 1 Age distribution of cases (total 50 cases) in our study,
according to Kulkarni et al’s endoscopic third ventriculostomy
success score age grouping
Age Number of patients
<1 month 0
1–6 months 0
6 months to 1 year 2
1–10 years 10
10–20 years 9
20–40 years 15
40–60 years 10
>60 years 4

27. Table 2 Presenting signs and symptoms according to frequency
Presenting complaints Number of patients
Headache 39
Vomiting 26
Gait disturbance 13
Visual blurring 11
Altered sensorium 9
Giddiness 6
Urinary incontinence 6
Limb weakness 5
Memory deficit 4
Seizures 4
Ophthalmoplegia 4
Facial nerve palsy 3
Fever 3

28. Fig. 1 Primary indications for doing endoscopic third ventriculostomy (total 50 cases)

29. Table 3 Complications (clinical or radiological) associated with ETV ( complications were seen
in 20 out of the 50 cases)
Complications Number of patients
Intraoperative minor
bleed
6
Intraoperative major
bleed
1
CSF leak 3
Meningitis 2
Wound
infection/dehiscence
1
Vomiting 3
Seizures 2
Venous infarct 1
Parenchymal hematoma 1
EDH/SDH 0

30. OVERALL SUCCESS RATE OF ETV
According to the available literature 60 to 90%;
in the present study it was 88%.
depended upon three major factors: age, neurosurgical pathology, and surgeon’s experience.
Success rate obviously improves with surgeon’s experience, but in the long-term follow-up
success rate falls below the immediate success rate, due to reports of delayed failure of ETV most
commonly due to stenosis of third ventricular stoma in long term in some patients.

31. NURSING RESPONSIBILITIES
WHILE RECEIVING THE PATIENT:
PRE-REQUISITES FOR RECEIVING A PATIENT INTO THE OR :-
Name, age , sex and UHID on the operation list.
Patient ID band (clearly legible)
Level of consciousness and mental status (GCS)
Nil per oral (NPO) status.
Pre-operative checklist
Informed surgical consent
Anaesthesia consent

32. CONTD.
Ensure there are no Loose teeth
Ensure that there are no artificial devices (contact lens, dentures, temporary
pacemaker) on patient
Ensure that patient has no Jewellery on them.
Side and site of the surgery must be confirmed.
Ensure that the prescribed preparation of surgical site is done.
Review the patient’s chart for completeness (GRBS, BP, administration of antibiotics
etc)
Enquire about any known Allergies
In case of an adult females, the patient must be on urinary catheter(Male patients and
paediatric female patients can be catherized in the OR.)
Patient must be on diaper.

33. PROCEDURE:-
 Greet the patient with their name and introduce yourself.
 Ensure that the pre operative checklist is completely filled and signed
 Check the pre-requisites for receiving the patient.
 Align and lock the lower section of both the receiving and the ward trolley.
 Transfer the patient carefully to the OR trolley and put up the side rails
 Connect IV fluids , apply head cap and face mask.
 Ensure the patient is comfortable and covered appropriately.
 Document the details in the surgical safety checklist and the preoperative record
 Transfer the patient to the OR.
 Notify the anaesthetist in case of altered vital signs.
 Reassure the patient in case of any anxiety.

34. IN THE OR:-
Ensure that the OT is ready for taking cases with functioning equipments
Ensure that the items required for ETV are soaked completly in cidex for 45
minutes
Ensure that all the items like sterile bins are ready for the planned surgery
Ensure safe shifting of the patient from OT trolley to the OT table
Participate in the ensuring surgical safety checklist.
Ensure smooth functioning of OT by coordinating availability of attenders for
positioning etc.
Provide sterile items to the scrub nurse
Ensure proper positioning of patient with special considerations to the
pressure points and that the cautery plate is fixed properly
Ensure that the patients body is free of any metallic contact
Intimate malfunction of equipment to the concerned professionals
Coordinate the planned surgeries with the multidisciplinary health team
members to avoid any delays or errors

35. RESPONSIBILITIES OF THE SCRUB NURSE:-
Confirm the identity, surgery and the site of surgery before the
patient is taken inside OT
Ensure all the required items and equipments are available for the
planned surgery, eg: burr hole bin, manman, endoscope monitor,
neuronavigation etc
Ensure absolutely sterile preparation of the instruments trolley and
proper draping of the patient
Ensure correct count of the sterile instruments taken
Ensure that the required things for ETV are soaked completely in
cidex for 45 minutes
Ensure that all the cidex soaked equipment is washed in sterile saline
and dried completely
Ensure that all the required equipment and things are taken before
starting the surgery

36. Assist in the surgery while anticipating for an unforeseen event
Ensure sterile collection of CSF and/or biopsy sample in a tamper
proof and leak proof container
Ensure correct count of sharps before and after surgery, any
discrepancy should by intimated immediately to the surgeon
After the surgery, look for any pin site bleeding and assist is suturing
if required
Ensure that the patient is cleaned properly after the surgery
Accompany the patient to the recovery area of the OT and hand over
the patient to the recovery staff
Label the respective samples and ensure that they are promptly send
to laboratory.
Document any extra item used like biomet screws and plates in the
patient file and the OT implants book.

37. IN THE RECOVERY ROOM:-
 Receive the patient in the recovery or the observation unit
 Connect the cardiac monitor, BP cuff and SPO2 probe
 Check the patient’s identity ,surgery done, information
regarding iv fluids, blood transfusion, drain catheter etc
 Administer oxygen via face mask or t- piece
 Position the patient comfortably
 Assess the patients’ airway breathing and circulation

38.  Monitor vital signs and ensure IV fluids are on flow
 Assist the surgical site for excessive bleeding or oozing
 Ensure that this iv lines and drains are secured
 Observe the patient for early postoperative complications and
do the appropriate interventions
 Ensure that all the drains and IV ports are dated and marked
 Assess the GCS periodically and orient the patient to time
place once a patient is awake informed that the surgery is over
 Shift the patient to the recovery ward.

39. THANK YOU