The Suture-Pull as a Refinement of the Gasket Implant Technique for Reconstruction after Endoscopic Skull Base Surgery

Karim Elayoubi, Alexander G. Weil, Ioannis Nikolaidis, Robert Moumdjian, Martin Desrosiers

Divisions of Neurosurgery, University of Montreal, Montreal, Canada.
Divisions of Otorhinolaryngology, University of Montreal, Montreal, Canada.

DOI: 10.4236/ijohns.2012.13018                

Abstract

Introduction: Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery. The use of an endocranial “gasket” plug has been reported for this and is used in our institution. We present a simple refinement of the “gasket” technique using commonly available materials that helps ensure proper size and positioning of the gasket by applying stress on a suture attached on the center of the gasket implant. Materials and Methods: We report a case of massive CSF leak following endonasal transsphenoidal surgery for pitui- tary macroadenoma. The skull base was reconstructed in a multi-layered fashion with fascia lata and bony buttress reinforced with a vascularized nasoseptal flap. In order to avoid implant slippage from too-small size or malpositioning, we performed a “stress test” using traction applied to a suture attached to the center of the implant (Medpor®), which allowed us to confirm intraoperatively that the buttress was positioned securely. Results: The patient did well without recurrence of CSF leak. At two-year follow-up, there has been no recurrence of CSF leak or occurrence local complica- tions. We have not verified whether bony regrowth into the implant has occurred. Conclusion: The suture-pull refinement of the gasket implant technique is a simple, inexpensive and low risk method to assure secure endocranial positioning over the skull base defect, and may prevent CSF leak resulting from too-small sizing or buttress malpositioning.

Keywords

CSF Leak, Nasoseptal Flap, Skull Base Closure, Transsphenoidal Surgery

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	C. D. Gandhi, L. D. Christiano, J. A. Eloy, C. J. Prestigiacomo and K. D. Post, “The Historical Evolution of Transsphenoidal Surgery: Facilitation by Technological Advances,” Neurosurg Focus, Vol. 27, No. 3, 2009, p. E8. doi:10.3171/2009.6.FOCUS09119
[2]	P. M. Black, N. T. Zervas and G. L. Candia, “Incidence and Management of Complications of Transsphenoidal Operation for Pituitary Adenomas,” Neurosurgery, Vol. 20, No. 6, 1987, pp. 920-934.
[3]	P. Cappabianca, L. M. Cavallo, F. Esposito, V. Valente and E. de Divitiis, “Sellar Repair in Endoscopic Endonasal Transsphenoidal Surgery: Results of 170 Cases,” Neurosurgery, Vol. 51, No. 6, 2002, pp. 1365-1372.
[4]	C. Martin-Martin, G. M. Capoccione, R. S. Garcia and F. Espinosa-Restrepo, “Surgical Challenge: Endoscopic Repair of Cerebrospinal Fluid Leak,” BMC Research Notes, Vol. 5, 2012, p. 459. doi:10.1186/1756-0500-5-459
[5]	I. Ciric, A. Ragin, C. Baumgartner and D. Pierce, “Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience,” Neurosurgery, Vol. 40, 2007, pp. 225-237. doi:10.1097/00006123-199702000-00001
[6]	F. Esposito, J. R. Dusick, N. Fatemi and D. F. Kelly, “Graded Repair of Cranial Base Defects and Cerebrospinal Fluid Leaks in Transsphenoidal Surgery,” Neurosurgery, Vol. 60, No. 2, 2007, pp. 295-304. doi:10.1227/01.NEU.0000255354.64077.66
[7]	D. F. Kelly, R. J. Oskouian and I. Fineman, “Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery,” Neurosurgery, Vol. 49, No. 4, 2001, pp. 885-890.
[8]	H. Nishioka, H. Izawa, Y. Ikeda, H. Namatame, S. Fukami and J. Haraoka, “Dural Suturing for Repair of Cerebrospinal Fluid Leak in Transnasal Transspenoidal Surgery,” Acta Neurochirurgica, Vol. 151, No. 11, 2009, pp. 1427-1430.
[9]	G. T. Tindall, E. J. Woodard and D. L. Barrow, “Pituitary Adenomas: General Considerations,” In: M. L. J. Apuzzo, et al., Eds., Brain Surgery: Complication Avoidance and Management, Churchill Livingstone, New York, 1993, pp. 269-276.
[10]	E. Kim and P. T. Russell, “Prevention and Management of Skull Base Injury,” Otolaryngologic Clinics of North America, Vol. 43, No. 4, 2010, pp. 809-816. doi:10.1016/j.otc.2010.04.018
[11]	A. Tabaee, V. K. Anand, S. M. Brown, J. W. Lin and T. H. Schwartz, “Algorithm for Reconstruction after Endoscopic Pituitary and Skull Base Surgery,” Laryngoscope, Vol. 117, No. 7, 2007, pp. 1133-1137. doi:10.1097/MLG.0b013e31805c08c5
[12]	L. Seda, R. B. Camara, A. Cukiert, J. A. Burratini and P. P. Mariani, “Sellar Floor Reconstruction after Transsphenoidal Surgery Using Fibrin Glue without Grafting or Implants: A Technical Note,” Surgical Neurology, Vol. 66, No. 1, 2006, pp. 46-49. doi:10.1016/j.surneu.2005.10.021
[13]	G. Zielinski, J. K. Podgorski, A. Koziarski and Z. Potakiewicz, “Reconstruction of the Sellar Floor in Transsphenoidal Surgery: Our Experience in 818 Patients,” Neurologia I Neuroriurgia Polska, Vol. 40, No. 4, 2006, pp. 302-311.
[14]	M. R. Patel, M. E. Stadler, C. H. Snyderman, R. L. Carrau, A. B. Kassam, A. V. Germanwala, et al., “How to Choose? Endoscopic Skull Base Reconstructive Options and Limitations,” Skull Base, Vol. 20, No. 6, 2010, pp. 397-493. doi:10.1055/s-0030-1253573
[15]	R. Vaezeabshar, P. H. Hawang, G. Harsh and J. H. Turner, “Mucocele Formation under Pediculated Nasoseptal Flap,” American Journal of Otolaryngology, Vol. 33, No. 5, 2012, pp. 634-636. doi:10.1016/j.amjoto.2012.05.003
[16]	H. M. Hegazy, R. L. Carrau, C. H. Snyderman, A. Kassam and J. Zweig, “Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis,” Laryngoscope, Vol. 110, No. 7, 2000, pp. 1166-1172. doi:10.1097/00005537-200007000-00019
[17]	L. Z. Leng, S. Brown, V. K. Anand and T. H. Schwartz, “‘Gasket-Seal’ Watertight Closure in Minimal-Access Endoscopic Cranial Base Surgery,” Neurosurgery, Vol. 62, Suppl. 2, 2008, Discussion ONSE343.
[18]	J. L. Vezina, J. Hardy and M. Yamashita, “Microadenomas and Hypersecreting Pituitary Adenomas,” Arq Neuropsiquiatr, Vol. 33, No. 2, 1975, pp. 119-127.