Introduction
The microvascular decompression (MVD) Janetta procedure has established itself as a reliable method for treating trigeminal neuralgia. In recent years, endoscopic techniques have gained importance.
Materials and Methods
The endoscopic procedures were performed by a surgeon who was new to this technique. The comparison criteria included operation time, outcomes, complications, pain reduction, and follow-up progression.
Results
The average operation time was 1 hour and 45 minutes. The length of hospital stay averaged 7 days for patients undergoing endoscopic decompression. Persistent deficits were observed in 3% of the endoscopic patients (due to bleeding). Pain reduction was assessed using the Visual Analog Scale (VAS), with reporting a decrease from 8.3 to 0.8.
Conclusion
Pure endoscopic decompression yields comparable and promising results to the traditional microsurgical technique. The learning curve for an experienced neurosurgeon is flat, indicating that the initial outcomes of the endoscopic method are equivalent to those of the established microsurgical technique. These results suggest that the endoscopic technique represents an effective alternative for the treatment of trigeminal neuralgia.


pure endoscopic procedure for trigeminus neuralgia - detailed presentation of the surgical technique

The method of surgery is almost the same as the biportal endoscopic lateral foraminotomy. Under general or epidural anesthesia, the patient was positioned by waterproofing with a prone position. Using a C-arm, make two holes in the ipsilateral side. It is based on the isthmus line above and below the disc space, near the pedicle lateral line at a 1cm distance. After fixing the scope to the isthmus, check the scope position through C-arm, and start surgery. If the superior articular facet and isthmus are drilling, you can see the ligamentum flavum. Continues drilling by detaching ligamentum flavum with the transverse process and mammillary process bones. After removing the ligamentum flavum, dura and root margin are checked and decompression is performed. After that, extension the incision a little more (about 2 cm) and perform a percutaneous pedicle screw. After that, increase the incision a little more and apply the dynamic rod by removing the fasciae between the two pedicle screws. After this process is over, add a scope to remove hematoma, place JP-drain, and suture.

A solution to radiculopathy due to osteoporotic compression fracture : biportal endoscopic foraminotomy combines mono segment fixation. 

We thank our colleagues for their highly valuable contributions to this collection of methods. The authors thank the Affiliated Hospital of Southeast University for its cooperation, including the recruitment and follow-up of patients with hydrocephalus. The authors also thank the patients who participated in this study. This study was supported by grants from the Science and Technology Program of Nantong City, No. KEY003; Nantong Young Medical Expert (No. 46); the Science and Technology Program of Nantong Health Committee, No. MA2019003, No. MA2021017, MSZ2024038, MSZ2025012; Science and Technology Program of Nantong City, No. JCZ2022040; and Kangda College of Nanjing Medical University, No. KD2021JYYJYB025, No. KD2022KYJJZD022, No. KD2024KYJJZD289, KD2025JYYJZD009; Research Project on Teaching Reform of Nantong University, No. 2025J23; Jiangsu Province Occupational Health Research Project, No. JSZJ20251217.

The study protocol was approved by the Ethics Committee of Nantong First People&#39;s Hospital, Southeast University (No. 2025KT029), and informed consent was obtained from all participants.
Patient characteristics 
This study included 48 adult patients with hydrocephalus. Among them, 24 patients with skull defects (observation group) underwent ventriculoperitoneal shunt surgery assisted by B-ultrasound between January 2022 and December 2024. The other 24 patients with repaired skull defects (the control group) received traditional ventriculoperitoneal shunt treatment from January 2021 to December 2023.
The diagnosis and management of hydrocephalus have a long-established history. For this research, hydrocephalus was diagnosed based on prior literature, and patients were included in the study group, as referenced in1,2.
The inclusion criteria were: (1) participants aged 25&#8211;75 years; (2) diagnosis of hydrocephalus based on clinical symptoms and imaging examinations, such as head CT or MRI; (3) undergoing initial ventriculoperitoneal shunt surgery; (4) complete absorption of intracranial hemorrhage; (5) positive outcomes from preoperative lumbar puncture or lumbocisternal drainage; (6) no preoperative infections in the abdomen or brain, or resolved infections with normal cerebrospinal fluid cell counts; (7) follow-up duration exceeding 2 months after surgery; (8) informed consent provided by the patient or guardian.
Exclusion criteria involve: (1) contraindications to surgery, such as severe cardiopulmonary dysfunction; (2) prior abdominal surgery, radiotherapy, or chemotherapy; (3) history of tumors, including brain or abdominal malignancies in any location, such as the brain or abdomen; (4) hydrocephalus resulting from infections.
Surgical procedure 
A thorough preoperative discussion was essential to devise the surgical strategy, with B-ultrasound specialists included to collaboratively shape the plan. All patients underwent general anesthesia. The patient was placed supine, with the incision line marked from the opposite side of the skull defect to the subxiphoid abdominal region, and draped with sterile surgical towels after standard disinfection, ensuring the skull defect area remains accessible for B-ultrasound monitoring and guidance. Kocher&#39;s point (the contralateral side of the decompressive craniectomy) was commonly selected for ventricular puncture (see Figure 1), situated at the anterior midline opening of the coronal suture, supported by clinical evidence of greater precision and improved outcomes. A linear 3 cm incision was then made, the soft tissue was expanded with a mastoid spreader, a 1 cm burr hole was drilled with an electric drill, and hemostasis was achieved. Then, the dura is cauterized before incision. Following this, a 4 cm curved incision was created 2&#8211;3 cm from the scalp incision to isolate and form the valve pocket. An incision is made at the midpoint of the subxiphoid process. A subcutaneous tunnel was used with a tunneling device, guiding the abdominal segment of the shunt tube to the curved scalp incision. If the tunnel has an angle, small auxiliary incisions were made, if needed, to facilitate passage and guide the abdominal segment of the shunt tube to the curved scalp incision. The shunt tube was connected to the shunt valve outlet and fixed with silk sutures. The dura is incised in a &#34;+&#34; shape, hemostasis was achieved with an electric coagulator, and ventricular puncture was performed using the shunt&#39;s ventricular segment.
A portable B-ultrasound unit was positioned on the skull defect (Figure 2). An appropriate small probe was employed to modify the orientation and conduct observations, thereby revealing the location of the frontal horn of the lateral ventricle. The surgical procedure should be aligned with the sagittal plane and matched with the direction of the imaginary line connecting the two external auditory canals. Under real-time B-ultrasound monitoring, the puncture was performed gradually to ensure precise placement at the frontal angle of the lateral ventricle (see Figure 3A,B).
After removing the needle core, cerebrospinal fluid outflow was observed. The catheter tip position must be monitored and adjusted to ensure proper shunt tube placement in the ventricle under B-ultrasound guidance. After determining the intraventricular catheter length, if cerebrospinal fluid outflow was observed, the catheter was secured to the skull opening with sutures. The ventricular segment&#39;s exit end is guided subcutaneously to the curved incision; part of the ventricular drainage tube is withdrawn as needed, connected to the shunt valve inlet, and fixed using silk sutures. After compressing the valve to verify patency, the abdominal portion of the shunt tube was inserted into the abdominal cavity, and the head and abdominal incisions were sutured separately. If simultaneous cranioplasty was indicated, the skull repair procedure was performed after re-disinfecting the surface.
Outcome measures 
Clinical outcome definitions 
Recovery: intracranial pressure was stable, symptoms such as pain, nausea, and visual impairment were absent, and quality of life returned to normal, marked improvement: Intracranial pressure remains basically stable, and the above clinical symptoms are significantly alleviated; effective: slight decrease in intracranial pressure and slight relief of symptoms; ineffective: Intracranial pressure remains unchanged compared to before treatment, and symptoms have not changed or worsened; death: death occurring within 2 months after surgery after the operation.
The total partial improvement rate was calculated as the recovery rate plus the death rate, which occurs within 2 months after surgery, and the marked improvement rate. The comparison of surgery-related indicators includes the operative duration of the two groups. Complications include shunt tube obstruction, abdominal organ injury, intracranial hematoma, and abdominal infection.
Statistical analysis 
Statistical software (see Table of Materials) was used to identify differences in surgical outcomes and complications following B-ultrasound-guided ventriculoperitoneal shunt surgery. Chi-square tests were applied to assess postoperative effectiveness and complication rates. Independent samples t-tests were used to compare continuous variables between two groups. All tests were two-tailed, and P &#8804; 0.05 was considered statistically significant, with a P &#60; 0.05 indicating statistical significance.

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	<li>Hochstetler A, Raskin J, Blazer-Yost BL. Hydrocephalus: historical analysis and considerations for treatment. Eur J Med Res. 2022;27(1):168.</li>
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	<li>Hamilton MG, Williams MA, Edwards S, Tullberg M. Guidelines for diagnosis and management of idiopathic normal pressure hydrocephalus. Neurosurg Clin N Am. 2025;36(2):199-205.</li>
	<li>Gao Z, et al. Analysis of hydrocephalus after decompressive craniectomy for traumatic brain injury. Pak J Med Sci. 2025;41(8):2237-2242.</li>
	<li>Romualdo SMF, et al. Post-traumatic hydrocephalus after decompressive craniectomy: a multidimensional analysis of clinical, radiological, and surgical risk factors. Neurosurg Rev. 2025;48(1):523.</li>
	<li>Dasher N, Katzen HL. The neuropsychology of adult hydrocephalus. Neurosurg Clin N Am. 2025;36(2):157-170.</li>
	<li>Zhang Q, et al. Neutrophil extracellular trap-mediated impairment of meningeal lymphatic drainage exacerbates secondary hydrocephalus after intraventricular hemorrhage. Theranostics. 2024;14(5):1909-1938.</li>
	<li>Karimy JK, et al. Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets. Nat Rev Neurol. 2020;16(5):285-296.</li>
	<li>Ho YJ, et al. Effectiveness and safety of ventriculoperitoneal shunt versus lumboperitoneal shunt for communicating hydrocephalus: a systematic review and meta-analysis with trial sequential analysis. CNS Neurosci Ther. 2023;29(3):804-815.</li>
	<li>Isaacs AM, Ball CG, Hamilton MG. Neuronavigation and laparoscopy-guided ventriculoperitoneal shunt insertion for the treatment of hydrocephalus. J Vis Exp. 2022;(188):e62678. doi:10.3791/62678.</li>
	<li>Wang Z, et al. Lumboperitoneal and ventriculoperitoneal shunt surgery for posthemorrhagic communicating hydrocephalus: a comparison. World Neurosurg. 2019;127:e638-e643.</li>
	<li>Fan X, Tao S. Comparison of ultrasound-guided puncture drainage and incision drainage for deep neck abscess. Gland Surg. 2021;10(4):1431-1438.</li>
	<li>Wang L, et al. Application of a three-dimensional visualization model in intraoperative guidance of percutaneous nephrolithotomy. Int J Urol. 2022;29(8):838-844.</li>
	<li>Kestle JR. Shunt malfunction. J Neurosurg. 2010;113(6):1270-1271.</li>
	<li>Kestle JR. Shunt insertion. J Neurosurg. 2013;119(1):64.</li>
	<li>Palys V, Holloway KL. Frameless functional stereotactic approaches. Prog Neurol Surg. 2018;33:168-186.</li>
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</ol>

All authors have read and approved the submission of the manuscript. The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper.

Ventriculoperitoneal shunting (VPS) has been a routine method for treating communicating hydrocephalus2,6. Clinically, hydrocephalus manifests through impaired consciousness, worsening of symptoms after initial improvement, or persistent worsening, specifically causing deepening of coma, dizziness, headaches, nausea, vomiting, slowed reactions, and progressive swelling at the cranial decompression site, accompanied by gradually increasing and stiffening tension in the bone window3,6. CT and MRI show signs of ventricular enlargement, exudative edema around the ventricles, and narrowing and compression of the cerebral sulci and cisterns. The main causes of hydrocephalus include traumatic or spontaneous subarachnoid hemorrhage, and bloody cerebrospinal fluid in the meninges, leading to aseptic inflammation, which is prone to meningeal adhesion and even blockage of arachnoid particles, resulting in impaired cerebrospinal fluid circulation and absorption7,8. In terms of treatment, lumbar puncture or lumbar cisternal drainage was performed first to relieve symptoms, and a ventriculoperitoneal shunt was placed when cerebrospinal fluid reached the indications for shunt surgery. As a classic and reliable treatment method, it has a 100-year history, and its curative effect has been widely recognized in clinical practice.
The main purpose of hydrocephalus shunt surgery is to drain cerebrospinal fluid from the ventricle to the abdominal cavity to reduce intracranial pressure and increase cerebrospinal fluid drainage or provide an alternative drainage pathway9. In traditional ventriculoperitoneal shunt surgery, the blind puncture technique used to access anatomical structures carries risks of inaccurate puncture, multiple puncture attempts, or improper placement of the postoperative catheter. In clinical practice, it is often observed that the lateral ventricle shunt is poorly positioned, such as ventricular hemorrhage caused by the shunt being close to the choroid plexus, penetrating into the contralateral ventricle, entering the third ventricle, extravasation of the catheter after ventricular shrinkage, or insertion into the brain parenchyma by mistake10. These factors may affect the efficacy of the surgical shunt and even lead to surgical failure11. In addition, ventricular shrinkage puncture may lead to brain tissue injury, bleeding, cerebrospinal fluid turbidity, and increased risks of shunt blockage and infection, thus increasing surgical complications and causing additional injury to patients. This not only aggravates the condition but also may lead to multiple problems, such as medical disputes. The occurrence of these conditions is related to the technique and experience of the surgeon, as well as the swelling of the brain tissue in the skull defect area, the displacement of the ventricle to the defect caused by the softening of the brain tissue, and the displacement of the ventricle caused by subdural effusion in some cases. Individual differences and imprecise positioning, combined with blind puncture techniques, remain the main causes of unsatisfactory catheter placement.
Historically, attempts have been made to enhance surgical accuracy through navigation technology; however, its inherent immobility and exorbitant cost have hindered its widespread adoption in clinical settings10. In contrast, B-mode ultrasound has considerable clinical potential because it provides real-time imaging and is widely available. Nonetheless, B-ultrasound technology, despite its real-time capabilities and wide availability, is constrained by limited tissue penetration, particularly its inability to pass through the skull, thereby restricting its range of applications. In clinical practice, craniotomy decompression is usually performed for patients with craniocerebral injury or hypertensive intracerebral hemorrhage, especially for patients with a transtentorial herniation in which craniotomy hematoma removal is required, due to high intracranial pressure during surgery or expected postoperative brain swelling, resulting in a postoperative skull defect4,5. For patients with such skull defects, B-ultrasound imaging is feasible because the defect site lacks the cranium. Therefore, we performed B-ultrasound-assisted surgery for these patients.
For patients presenting with hydrocephalus coupled with skull defects, B-ultrasound guidance was employed, with frontal angle puncture chosen for ventriculoperitoneal shunt placement. This method has the following advantages: First, the puncture positioning is accurate. With real-time B-ultrasound monitoring, the choroid plexus and other critical intraventricular structures become distinctly visible, thereby ensuring puncture accuracy and affording the surgeon the flexibility to adjust puncture depth and direction as needed. The surgeon can adjust the puncture depth and direction as needed, increasing the likelihood of successful single-attempt puncture and reducing reliance on blind puncture. At present, B-ultrasound is widely used for precise positioning in surgical procedures across a range of diseases, including deep vein catheterization, abdominal surgeries, intracranial tumor surgeries, and liver tumor surgeries, with consistently satisfactory results12,13. Second, the puncture process takes a short time. Leveraging minimally invasive technology, the puncture process has become safer, and real-time positioning techniques have reduced operating time, enhancing efficiency. Third, postoperative complications are fewer. This method reduces the risk of shunt blockage and infection, especially avoiding complications such as bleeding due to repeated punctures. Because frontal puncture avoids the choroid plexus, it reduces the risk of choroid encapsulation and blockage, lowers the risk of tube blockage, and provides a stable position. Fourth, this technique enhances the surgeon&#8217;s confidence. Surgery is performed under controlled and visual conditions, and the surgeon can confidently assess the risk of surgery, especially in the early stage of hydrocephalus, when the ventricle enlargement is small, and the puncture location is limited, which may affect the confidence of the surgeon and lead to a delay in surgery or prolongation of operative time. The precision and reliability of catheter placement are paramount for ensuring the surgeon&#39;s confidence and the overall success of medical procedures14,15. Fifth, the technique is easy to perform. Compared with the stereotactic technique, frontal horn puncture guided by B-ultrasound is more convenient. Finally, B-mode ultrasound equipment is widely available and inexpensive. At present, most hospitals can be equipped with B-ultrasound, which is easy to obtain, and compared with the neural navigation system, it is more economical and easier to implement widely16,17.
In this study, operative duration, clinical efficacy at 2 months, and complication rates were evaluated 2 months after surgery; complication rates did not reach statistical significance, but the numerical differences were still considered to have potential clinical significance.
During the B-ultrasound-guided surgery, we accumulated the following experience: First, prior to surgery, we engaged in thorough communication with the B-ultrasound specialist to discuss the patient&#39;s condition and assess the suitability of B-ultrasound examination; Second, preoperatively, ultrasound was used to examine the skull defect site, allowing us to assess ventricular anatomy, confirm the puncture site with the B-ultrasound specialist, and devise the puncture direction and surgical trajectory. For surgical incision and puncture positioning, we usually perform preliminary positioning and adjustments using conventional methods, then use B-ultrasound for real-time guidance during puncture placement. Third, the B-ultrasound scan should be deflected from different angles, and coronal and sagittal scans should be performed to clearly distinguish the ventricular structure. For comprehensive visualization, the long axis of the shunt tube should be kept parallel to the scanning plane. During the operation, the probe should be placed as close as possible to the center of the frontal angle of the lateral ventricle to reduce the risk of contact with the ventricular wall. Ultimately, the involvement of skilled and experienced ultrasound specialists can enhance the precision of surgical procedures and reduce the duration of the operation.
Several limitations should be acknowledged. First, prospective studies are still needed to strengthen the evidence. Second, the sample size, while sufficient to demonstrate the primary outcome, limits the power to detect differences in secondary outcomes. Third, at present, other technologies, such as neuronavigation, remain in clinical use. Further research and comparative studies are needed to evaluate differences among these techniques. Fourth, due to the small number of cases of skull defects accompanied by hydrocephalus, this study was unable to compare the use and non-use of B-ultrasound guidance in this group. Instead, it adopted B-ultrasound-guided shunt placement for patients with a skull defect accompanied by hydrocephalus and compared it with traditional shunt placement for patients with a repaired skull defect, which has limitations. Finally, the technique is inherently limited to patients with existing skull defects, restricting its broader applicability.
The patients selected in this study underwent ventriculoperitoneal shunt surgery using B-ultrasound-assisted technology. This surgical approach offers advantages including intuitive visualization, real-time monitoring, high sensitivity, precise navigation, ease of operation, cost-effectiveness, and environmental friendliness. These characteristics make the surgical process simpler and safer, ensure puncture accuracy, and effectively avoid iatrogenic brain injury, thereby reducing the incidence of surgical complications and achieving satisfactory results, supporting further clinical evaluation. However, it should be noted that due to the limited penetration of ultrasound through the skull, it is currently applicable mainly to patients with hydrocephalus accompanied by skull defects.
Future research should focus on prospective randomized trials to further validate these findings and explore the cost-effectiveness of implementing this technique more broadly. Additionally, advancements in ultrasound technology may eventually overcome the current limitation of requiring skull defects for optimal imaging.

Hydrocephalus is a neurological disorder resulting from abnormal production, impaired circulation, or impaired absorption of cerebrospinal fluid. This results in cerebrospinal fluid accumulation within the ventricles and the cranial cavity, causing increased intracranial pressure1,2. Typically, the condition involves enlarged ventricles, interstitial brain edema, compression of brain tissue, and severe clinical manifestations3. Surgical treatment is often required.
Additionally, certain individuals with hydrocephalus have undergone decompressive craniectomy4,5. This commonly occurs after traumatic brain injury or cerebral hemorrhage, and the bone flap is removed to alleviate pressure. decompressive craniectomy effectively lowers intracranial pressure and boosts cerebral perfusion, offering vital survival chances4. Nevertheless, postoperative hydrocephalus demands prompt management.
As a non-invasive method, B-ultrasound is widely used in clinical practice, delivering effective results for tasks such as identifying blood vessels or guiding procedures. Nevertheless, its use for intracranial localization in neurosurgery is constrained by the skull. In the past, ultrasound technology was less frequently used in neurosurgery. This study focused on patients with hydrocephalus and skull defects, using B-ultrasound to identify ventricular structures and guide ventricular puncture. This research aimed to meticulously record and evaluate the treatment protocols, postoperative recovery, and long-term outcomes for these patients, while clarifying the effect of B-ultrasound on ventriculoperitoneal shunt procedures in this group. By assessing these cases, we aim to enhance comprehension of B-ultrasound-assisted ventriculoperitoneal shunting, refine therapeutic strategies, and ultimately improve patients&#8217; quality of life and clinical outcomes.

<table><tbody><tr><td>Codman Shunt</td><td>Johnson &amp;amp; Johnson, United States</td><td>82-6100</td><td></td></tr><tr><td>Drill</td><td>Beijing Honghu Medical Devices Co., LTD</td><td>HK-208</td><td></td></tr><tr><td>iodophor disinfectant</td><td>Taizhou Tiancheng Medical Supplies Co., LTD</td><td>PVI-500</td><td></td></tr><tr><td>Mastoid spreader</td><td>Shanghai Jinzhong Medical Devices Co., LTD</td><td>JZ-312</td><td></td></tr><tr><td>Portable Mindray Z50S B-ultrasound</td><td>Mindray Company, China</td><td>Z50S</td><td></td></tr><tr><td>Sterile gauze</td><td>Nantong Meilihe Medical Devices Co., LTD</td><td>MLH-GZ-01</td><td></td></tr><tr><td>Suture</td><td>Johnson &amp;amp; Johnson, United States</td><td>VP-922</td><td></td></tr><tr><td>SPSS26.0&amp;nbsp;</td><td>version 26.0, IBM Corp., Armonk, NY, USA</td><td>&lt;a href=&quot;https://www.ibm.com/support/pages/ibm-spss-statistics-26-documentation&quot;&gt;https://www.ibm.com/support/pages/ibm-spss-statistics-26-documentation&lt;/a&gt;</td><td>Statistical software</td></tr></tbody></table>

Hydrocephalus combined with a skull defect is a common clinical condition in neurosurgery. It often occurs secondary to decompressive craniectomy after severe craniocerebral injury or cerebral hemorrhage. For such patients, due to the concurrent presence of a skull defect, the puncture and localization of conventional ventriculoperitoneal shunt surgery are somewhat difficult, and the risk of complications is relatively high. This study aimed to evaluate the efficacy of ultrasound-guided ventriculoperitoneal shunting in patients with hydrocephalus associated with skull defects. This study retrospectively analyzed the clinical data of 48 patients with hydrocephalus. Among them, 24 patients had combined skull defects. The observation group underwent ultrasound-assisted ventriculoperitoneal shunting (VPS), whereas the control group underwent traditional VPS. The study compared the success rate of a single puncture during the operation, the operation time, the clinical improvement 2 months after the operation, and the incidence of complications. The results showed that, compared with traditional ventriculoperitoneal shunting, B-ultrasound-assisted shunting provided real-time assessment. It not only causes less trauma and significantly improves puncture accuracy during the operation but also does not prolong the operation time. Moreover, it can allow real-time visualization of the catheter trajectory in patients with skull defects and postoperative hydrocephalus. The complication and efficacy rates of this method did not differ significantly between groups; the numerical differences warrant confirmation in larger prospective studies, improve the reliability of intraoperative operations, and have significant clinical promotion value in treating such patients.

The two groups showed no statistically significant differences in sex, age, severity of preoperative hydrocephalus, or skull defect (P &gt; 0.05; Table 1). All 24 patients in the observation group underwent successful initial punctures. Postoperative head CT scans confirmed precise shunt tube placement in the frontal angle of the lateral ventricle, on the day after surgery, with no evidence of puncture tract complications or intraventricular hemorrhage. In the control group, six patients required multiple puncture attempts: two required three attempts and four required two attempts; by contrast, no patients in the observation group required multiple punctures, demonstrating a statistically significant difference between the groups (χ2 = 4.762, P = 0.029). Operative duration for the observation group averaged 96.48 min ± 12.37 min, slightly exceeding the control group's 93.65 min ± 11.28 min, though this difference was not statistically significant (P &gt; 0.05). At the 2-month follow-up, the observation group's overall efficacy rate was 75% (18/24), surpassing the control group's 66.67% (16/24) (Table 2), but this difference was not statistically significant (P = 0.75). Complication rates were 8.33% (2/24) in the observation group and 12.50% (3/24) in the control group; although not statistically significant (P = 1.00), a numerical difference was noted (Table 3).
DATA AVAILABILITY: 
All the raw data are uploaded as a supplementary file (Supplementary File 1).
<img alt="Cranial deformation diagram showing skull modification process directions and techniques." class="xfigimg" src="/files/ftp_upload/71321/71321fig1.jpg" data-altupdatedat="1788235205000" data-alt="Figure 1"> 
Figure 1: Surgical incision selection. Kocher's point was selected on the side opposite the decompressive craniectomy. A line incision was made approximately 2–3 cm from the scalp incision, exposing the skull and providing access for hole placement (the arrow indicates the incision site). <a href="https://www.jove.com/files/ftp_upload/71321/71321fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<img alt="Cranial surgery diagram; showing trepanation techniques with surgical tools and entry points." class="xfigimg" src="/files/ftp_upload/71321/71321fig2.jpg" data-altupdatedat="1788235205000" data-alt="Figure 2"> 
Figure 2: Intraoperative B-ultrasound guidance. A portable B-ultrasound device was placed over the skull defect area. The probe was used to identify the ventricle location and guide the puncture needle in real time, ensuring accurate catheter placement. <a href="https://www.jove.com/files/ftp_upload/71321/71321fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Ultrasound and CT scan images showing brain and abdominal structures, arrows indicate lesions." class="xfigimg" src="/files/ftp_upload/71321/71321fig3.jpg" data-altupdatedat="1788235205000" data-alt="Figure 3"> 
Figure 3: Intraoperative and postoperative confirmation of catheter placement. (A) Intraoperative B-ultrasound image showing the puncture needle entering the ventricle (arrow indicates catheter). (B) Postoperative head CT scan of a patient who underwent simultaneous cranioplasty, confirming appropriate drainage tube positioning within the ventricle (arrow indicates the drainage tube). <a href="https://www.jove.com/files/ftp_upload/71321/71321fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2">Group</td>
			<td rowspan="2">N</td>
			<td rowspan="2">Age (years)</td>
			<td colspan="2">Gender</td>
			<td colspan="3">Hydrocephalus severity</td>
		</tr>
		<tr>
			<td>male</td>
			<td>female</td>
			<td>mild</td>
			<td>moderate</td>
			<td>severe</td>
		</tr>
		<tr>
			<td>Observation group(Skull defect + ultrasound guidance + ventriculoperitoneal shunt)</td>
			<td>24</td>
			<td>63.29 ± 9.24</td>
			<td>16</td>
			<td>8</td>
			<td>14</td>
			<td>6</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Control group(Repaired Skull defect + Traditional ventriculoperitoneal shunt)</td>
			<td>24</td>
			<td>58.20 ± 16.43</td>
			<td>15</td>
			<td>9</td>
			<td>12</td>
			<td>6</td>
			<td>6</td>
		</tr>
		<tr>
			<td>t/χ2  value</td>
			<td></td>
			<td>1.1</td>
			<td colspan="2">0</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>P</td>
			<td></td>
			<td>P &gt; 0.05</td>
			<td colspan="2">1</td>
			<td colspan="3">P &gt; 0.05</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of general information between the two groups. Demographic and baseline clinical characteristics, including age, sex, severity of preoperative hydrocephalus, and skull defect status, are presented. Data are expressed as mean ± standard deviation or number (%). Observation group(Skull defect + ultrasound guidance + ventriculoperitoneal shunt) and Control group(Repaired Skull defect + Traditional ventriculoperitoneal shunt).
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Group</td>
			<td>Recovery</td>
			<td>Significant effect</td>
			<td>Effective</td>
			<td>Ineffective</td>
			<td>death</td>
			<td>Total effective</td>
		</tr>
		<tr>
			<td>Observation group</td>
			<td>5</td>
			<td>13</td>
			<td>4</td>
			<td>1</td>
			<td>1</td>
			<td>18 (75%)</td>
		</tr>
		<tr>
			<td>Control group</td>
			<td>6</td>
			<td>10</td>
			<td>6</td>
			<td>2</td>
			<td>0</td>
			<td>16 (66.67%)</td>
		</tr>
		<tr>
			<td>Chi-square tests</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
			<td>0.4033</td>
		</tr>
		<tr>
			<td>P</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
			<td>0.525</td>
		</tr>
	</tbody>
</table>
Table 2: Comparison of clinical efficacy two months after surgery between the two groups. Treatment outcomes were categorized as recovery, marked improvement, effective, ineffective, or death. The total effective rate was calculated as the sum of the recovery rate and the marked improvement rate. Data are presented as counts (%).
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Group</td>
			<td>case</td>
			<td>Puncture bleeding</td>
			<td>Shunt clogging</td>
			<td>infection</td>
			<td>poor wound healing</td>
			<td>Low cranial pressure syndrome</td>
			<td>Abdominal organ injury</td>
			<td>digestive tract symptom</td>
			<td>total</td>
		</tr>
		<tr>
			<td>Observation group</td>
			<td>24</td>
			<td>0</td>
			<td>0</td>
			<td>1</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>1</td>
			<td>2(8.33%)</td>
		</tr>
		<tr>
			<td>Control group</td>
			<td>24</td>
			<td>1</td>
			<td>1</td>
			<td>1</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>3(12.5%)</td>
		</tr>
		<tr>
			<td>χ2</td>
			<td></td>
			<td colspan="7">0.00</td>
			<td></td>
		</tr>
		<tr>
			<td>P</td>
			<td></td>
			<td colspan="7">1.00</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 3: Comparison of postoperative complications between the two groups. Complications included shunt tube obstruction, abdominal organ injury, intracranial hematoma, and abdominal infection. Data are presented as counts (%).
Supplementary File 1: Raw study data. Individual patient data for all 48 participants, including demographics, surgical parameters, clinical outcomes, and complication records, were used for statistical analysis in this study. <a href="https://www.jove.com/files/ftp_upload/71321/Supplementary%20File%201.xlsx" target="_blank">Please click here to download this file.</a>

During ventriculoperitoneal shunt surgery, the puncture and positioning of the drainage tube are critical, as they significantly affect the outcome. We assessed whether intraoperative B-ultrasound guidance improves ventricular puncture accuracy during ventriculoperitoneal shunting (VPS) in hydrocephalus patients with skull defects.

feasibility-b-ultrasound-assisted-shunting-for-hydrocephalus-patients

Feasibility of B-Ultrasound-Assisted Shunting for Hydrocephalus Patients with Skull Defect Versus Traditional Ventriculoperitoneal Shunting

Hydrocephalus combined with a skull defect is a common clinical condition in neurosurgery. It often occurs secondary to decompressive craniectomy after ...

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Feasibility of B-Ultrasound-Assisted Shunting for Hydrocephalus Patients with Skull Defect Versus Traditional Ventriculoperitoneal Shunting

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