|
A facility reported that during ventriculoperitoneal (vp) shunt implantation for hydrocephalus procedure, tunneling for the placement of the distal (peritoneal) catheter was performed without complications.After implanting the ventricular catheter into the cerebral ventricle, at the time of connecting the ventricular catheter to the valve, the surgical team observed that the catheter presented a perforation/tear at the connection site.The damaged segment was cut, and the connection attempt was repeated; however, the same issue occurred three consecutive times.Proper coupling was only achieved after extremely delicate handling.In the next step, when positioning the valve in the lateral pocket of the patient¿s head, the device presented bilateral opening, with the onset of cerebrospinal fluid leakage.According to the team¿s report, the material appeared more fragile than usual, resembling a dried or brittle condition, becoming damaged even under careful handling and within standard technique.The issue with the product delayed the procedure by approximately 30 minutes; however, there was no injury to the patient.
|