This is an urgent procedure which is performed at the bedside. Although the shunt is infected, it is a sterile procedure as most often the infection is in the CSF. In shunts that have been newly placed, externalization can be very easy. However, shunts that have been in place for over 6 weeks require a significant amount of dissection to remove as they have become scarred in place.
Externalization is usually performed at a point where the shunt is fairly superficial and palpable, e.g., at the clavicle or over a rib. Sterile technique is used and local anesthetic is infiltrated in the region (more anesthetic will be required if the catheter is scarred in). A 1-cm incision is made either parallel to the tubing or perpendicularly across the tubing. Care must be taken not to cut the shunt. The catheter is then
separated from the underlying scar tissue using sharp and blunt dissection. Cautery, when available, makes the dissection very easy with minimal risk of catheter injury. The shunt tract and tubing should be frequently palpated to ensure that the dissection is in the correct direction.
Once the catheter is isolated, the distal tubing is pulled out and connected to a collecting bag. The incision can then be partially closed with 1 or 2 interrupted sutures next to the exiting catheter and the collecting bag placed at the bedside.
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