Ventriculoperitoneal shunt (VPS) insertion is a neurosurgical procedure done routinely for managing hydrocephalus. However, the technique of shunt insertion remains controversial. In this study, we retrospectively compared the accuracy of shunt placement using ultrasound (US) guidance to freehand insertion. Our secondary aim was to explore the learning curve of using US to guide VPS insertion. This study included 220 patients who underwent VPS placement between January 2018 to December 2021 at a single-centered tertiary hospital. 201 adults and 19 pediatric patients were recruited into the study. Most common causes of hydrocephalus include post-subarachnoid hemorrhage (23.2 %), tumor (24.5 %), and post intracranial bleed (16.8 %). Accuracy of shunt placement was determined by evaluating the location of the shunt catheter tip in the first post-operative imaging and the shunt revision rate. Rates of optimally placed and functioning shunts were higher under US guidance (79.5 % vs 50.6 %) compared to freehand insertion (p <
0.01). Rates of shunt revision within 30 days were statistically higher in freehand VPS insertion (5.7 % vs 0.0 %) compared to US-guided placement even after propensity-matched analysis (p = 0.02). There was no statistical difference in accuracy between shunts placed by consultants and residents in the US cohort (p = 0.71). In conclusion, our study reinforces the benefit of US-guided VPS insertion. Patients who underwent US-guided VPS insertion had statistically significant improvement in shunt accuracy and lower shunt revision rate. The learning curve for surgeons to adopt US guidance in VPS insertion is less steep than thought.