This study was approved by the Institutional Review Board of Ilsan Hospital (NHIMC 2016 07 003 003) which waived the informed consent due to the retrospective nature of the study. A retrospective analysis was conducted of patients with hydrocephalus of various pathologies who underwent a VP shunt surgical procedure between March of 2010 and March of 2017. A total of 82 VP shunt procedures were performed by single neurosurgeon during this period. The patients were divided into two groups, hair shaved and non-shaved, based on preoperative hair preparation. The shaved group included a total of 46 patients who refused the non-shaving technique. The remaining 36 patients received a VP shunt without preoperative shaving.

The patients in the shaved group had their hair removed using clippers and a razor the morning of the surgery. Nonshaved patients used a routine commercial shampoo the morning or night before the day of surgery. Their hair was parted with a fine-tooth comb and was held away from the surgical site by using rubber bands. In order to prevent hair from entering into the incision site, some hair was fixed with staplers at surgical sterile drape (Fig. 1). All patients typically received intravenous antibiotics (cefotetan, a 2nd generation cephalosporin) prophylactically, as well as for 2 days post operation if there were no complications or issues.

For patients in the non-shaved group, absorbable suture materials (Vicryl Rapide 3-0; Ethicon, Somerville, NJ, USA) were used for wound closure, while Nylon or staples were used in the shaved group. When using the absorbable suture materials, the wound was closed with running or subcutaneous suture techniques to approximate the scalp edges. The entire operative field was scrubbed with povidone-iodine soap, and then painted with a povidone-iodine solution or soaked with a mixed solution of 75% alcohol and povidone-iodine solution. The incidence of surgical infection, as well as age and gender of the two groups, was compared and analyzed using chi-squared tests.

Shaving of the whole head has been common practice in neurosurgical procedures since the days of Harvey Cushing [2,3,6,10,12,20]. Shaving allowed for better exposure of the incision line, as well as ease of closure and postoperative wound care, and was known to decrease postoperative infection rate. Although there are pros and cons of scalp shaving in neurosurgery, many neurosurgeons still prefer to practice whole head shaving for cranial surgeries due to the reasons listed. Recently, non-shaved neurosurgery has been the focus of much attention because of quality of life. Many authors reported that shaving of the hair was not related to an increase in infection rates for cranial surgery [5,7,9,13,16,18]. Bekar et al. [4] retrospectively reviewed and compared the rate of infection of 1038 cranial procedures without hair removal and 980 cranial surgeries with hair removal. They reported that there was no significant difference in the rate of infection between patients in each group and concluded that hair removal is not necessary in preparation for any type of cranial surgery. Tanner et al. [19] performed a meta-analysis of 11 randomized clinical trials (total of 5031 people) and concluded that there was no evidence that removing hair decreased infection rate. Furthermore, they recommend that if necessary, clipping and using depilatory creams result in fewer surgical site infections than shaving using a razor.

Although many surgeons know that hair removal may not be related to decreased risk of infection, they hesitate to perform the surgery unshaved because infection is one of the most concerning surgical complications, particularly in shunt surgery. Infections resulting from many neurosurgical procedures can be cured with antibiotic administration, however, most shunt infection cases need to be treated with shunt removal, repeated extraventricular drainage, and prolonged antibiotic use [8,15,17]. Therefore, many neurosurgeons are reluctant to perform a non-shaved surgery during a shunt procedure. It should be noted that most shunt infections were diagnosed within 1–2 months after surgery, indicating that contamination likely occurred during the shunt surgery itself [11,21]. All non-shaved patients in our study were followed for more than 6 months without incident of infection. Thus, we believe that hair removal is not necessary for the purpose of reducing the risk of infection.

From the surgeon’s point of view, these results may provide the evidence needed to demonstrate the efficacy of not shaving in preparation for shunt surgery. From the patient’s point of view, having a non-shaved surgery increases their quality of life as they are able to return to their previous social life earlier than if their head had been shaved [14]. Furthermore, our results may support the practice guideline that scalp shaving could increase the rate of wound infection; therefore, the practice should be abandoned.

We spent approximately 5 to 10 minutes more during preparation to manage the hair for patients who did not have their head shaved than for patients who had their hair removed. However, this additional preparation time is not related with increased infection risk as this is done prior to the procedure itself and there is no open wound. For hospitals and institutes who implement this procedure, proper protocols should be developed that aim to minimize this time for hair preparation. When we first began performing non-shaved surgeries, we would try to split the hair completely to clear it from the incision site, and in some cases, we would remove hair if it interfered with the sutures. However, over time, we found that there were no issues if some of the hairs were caught in the sutures.

This study has a few limitations. First, this was a retrospective comparative study of two surgical policies for a single surgeon. Second, our study had a relatively small number of patients, which is a limitation for some statistical analyses. Therefore, larger, controlled case studies should be conducted before generalizing these results.