The submission “Practice patterns of Canadian neurosurgeons in laparoscopic-assisted placement of ventriculoperitoneal shunt” ^{Reference Heppner, Ajlan and Hart1} is submitted by a collaborative neurosurgical resident group from across Canada. This study examines the neurosurgeons’ preferences and practice patterns. The aim of the study was to identify current practices as a prelude to a definitive study on the topic. The survey had 36 participants representing all provinces in Canada. The study was well presented, the methodology was appropriate and the reporting was accurate, with reasonable conclusions being drawn. As would be expected, distal catheter malposition remained the complication most frequently predicted to be reduced by laparoscopic-assisted shunts in this study. As the authors conclude, a multicenter randomized controlled study would be the logical next step.

There are several published studies on the topic. None however has provided the level 1 evidence that would be needed to alter practice. While we would expect a reduction in the lower-end shunt malposition rates, one recent meta-analysis in the pediatric population did not demonstrate this but showed a reduction in surgical time. ^{Reference Cooper, Begley, Zamor and Schulder2} A non-inferiority retrospective analysis of a single institution experience with 104 patients over a 3-year period showed the non-inferiority of laparoscopic-assisted shunting. ^{Reference Gruter, Ruf, Guzman and Soleman3} Curiously, the authors concluded that the surgeon can keep placing shunts the “standard” way. One other meta-analysis, on the other hand, showed a reduction in distal shunt failure rate. ^{Reference Abdelmageed, Sarkar, Shlobi, Davila and Potts4}

Personally, I started performing all new shunts with laparoscopic assistance and image guidance 5 years ago, with the consideration that this would reduce all malposition-related shunt malfunctions. Our own data is undergoing review at the moment. I would suspect that the acceptance of routine laparoscopic shunt placement would be much higher if practical barriers could be addressed. These would include difficulties with scheduling, paucity of OR time and other resources, a feeling of decrease in independence among neurosurgeons, additional time necessary to set up and the development of expertise.