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

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

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 pituitary 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 complications. 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.

Highlights

Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery
Materials and Methods: We report a case of massive CSF leak following endonasal transsphenoidal surgery for pituitary macroadenoma
While some authors suggest that hemostatic material and fibrin glue may be adequate [12], most authors recommend either multi-layered inlay-underlay grafting [11,13] in addition to onlay bony buttress or pedicled vascularized nasoseptal flap (NSF) [14]

Summary

Introduction

Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery. 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. The use of a pedicled NSF, both for simple transsellar defect and for extended endonasal approach, is considered by many authors as a key step in anterior skull base reconstruction [14]. Low complication rate is associated with the use of NSF; development of a mucocele underneath the septal flap due to persistent nasal glandular secretion has been reported [15] It may not be available if tumor resection has compromised vascular supply or septal architecture. The onlay placement of a bony buttress can be difficult when the size of the sellar defect extends to the carotid arteries and optic nerves because no bony edges

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Conclusion