Neurosurg Rev DOI 10.1007/s10143-015-0614-6

ORIGINAL ARTICLE

Fascia patchwork closure for endoscopic endonasal skull base surgery Yudo Ishii & Shigeyuki Tahara & Yujiro Hattori & Akira Teramoto & Akio Morita & Akira Matsuno

Received: 25 June 2014 / Revised: 30 September 2014 / Accepted: 16 November 2014 # Springer-Verlag Berlin Heidelberg 2015

Abstract With the development of endoscopic technology and surgery, resection of midline skull base tumors has been achieved using endoscopic endonasal skull base (EESB) approaches. EESB approaches reportedly have a greater risk of postoperative cerebrospinal fluid (CSF) leakage. Recently, the introduction of the nasoseptal flap (NSF) decreased dramatically the incidence of CSF leakage, but the use of an NSF increases the risk of disturbing the function of the nose. Here, we report our new technique called Bfascia patchwork closure^ for closure after EESB surgery and its outcome. All 48 cases involved midline skull base tumors resected via EESB approaches. Of them, 32 cases were closed by the fascia patchwork technique after tumor resection, and there was no incidence of CSF leakage. Moreover, 6 of the 32 cases were closed without the use of an NSF, indicating that the fascia patchwork closure approach is effective as part of a multilayer closure for the prevention of CSF leakage. The establishment and popularization of this technique might result in the further development of EESB surgery and also an improvement of postoperative nasal function.

Electronic supplementary material The online version of this article (doi:10.1007/s10143-015-0614-6) contains supplementary material, which is available to authorized users. Y. Ishii (*) : A. Matsuno Department of Neurosurgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo 173-8605, Japan e-mail: [email protected] S. Tahara : Y. Hattori : A. Morita Department of Neurosurgery, Nippon Medical School, Tokyo, Japan A. Teramoto Department of Neurosurgery, Japan Labour Health and Welfare Organization Tokyo Rosai Hospital, Tokyo, Japan

Keywords Cerebrospinal fluid leakage . Closure . Endoscope . Pituitary . Skull base

Introduction Midline skull base tumors, such as meningiomas, craniopharyngiomas, and large pituitary adenomas, have been removed commonly using various transcranial skull base approaches [1, 28, 41, 53, 54, 60, 62]. Over the past 25 years, the microsurgical transsphenoidal approach has been utilized to remove skull base tumors as a minimally invasive surgical technique [2, 4, 13, 15, 22, 50]. With the development of endoscopic technology and surgery, resection of these tumors has been achieved using endoscopic endonasal skull base (EESB) approaches [5, 9, 23, 26, 33, 46, 47, 55, 58]. This approach is considered to have a greater risk of postoperative cerebrospinal fluid (CSF) leak because of the use of reconstruction methods with free grafts [8, 14, 18, 24, 30, 31, 43, 48, 52]. Recently, several techniques have been developed to reduce dramatically this risk, including a gasket seal [25, 44] and a vascularized nasoseptal flap (NSF) [29, 49]. An NSF is a pedicled regional flap with an axial blood supply derived from the posterior septal branches of the sphenopalatine artery. Several reports have described favorable rates of postoperative CSF leakage using this and other vascularized reconstructive techniques [21, 38, 51, 61]. However, in addition, functional disorders of the nose have been described with this approach [39, 40]. To establish a new method for complete closure after EESB surgery, we have used the fascia patchwork technique to close large dural defects extensively since January 2011. Here, we report the details of this technique and its efficacy for preventing CSF leakage.

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Materials and methods Patients From April 2001 to July 2014, we performed 1364 endoscopic endonasal surgeries, of which 54 were EESB surgeries. Among these, 3 petrous apex tumors, 2 ENT malignancies, and 1 germ cell tumor were excluded because our operative strategy consisted of mass reduction and decompression or biopsy in these cases. The remaining 48 cases are summarized in Table 1 and included 22 pituitary adenomas that extended to the intracranial space, 10 craniopharyngiomas, 11 meningiomas (8 tuberculum sellae meningiomas, 1 sphenoid planum meningioma, 1 cavernous sinus meningioma, and 1 clival meningioma), 3 clival chordomas, 1 pituicytoma, and 1 ependymoma. All were resected using a binostril approach and a so-called expanded endonasal approach with widely opening of anterior skull base or clivus. A new closure strategy described in the following section was adapted since January 2011 and was performed in 32 cases. The remaining 16 cases were closed by fat insertion and an NSF. A lumbar CSF drainage was not used at all during and after operation. Fascia patchwork closure As preparation for closure, an NSF was made before removing the tumor in all cases, and the dura was carefully opened, if possible, without cutting off or coagulation. Following resection, closure was started by sewing those dural edges that could be seamed directly together with 5-0 or 6-0 nylon sutures, as much as possible. For sutures, we used deep suturing needle Table 1

holders (8055-02; FUJITA, Tokyo, Japan) and small alligator forceps (8042-13 15; FUJITA, Tokyo, Japan). After that, the dural gap was closed by a patchwork technique, using fascia lata or abdominal fascia that was a size larger than the gap (Fig. 1). The fascia was laid in the intracranial epi-arachnoid space and patch-sutured around its entire circumference, yielding an inlay patch (Fig. 1c–j) [10]. During suturing, it is very difficult and complicated to bring a needle in the appropriate direction, but by holding the middle of the needle, the direction can be changed easily by hitting the tip or tail (Fig. 1h). Making knots in the deep field is also very complicated, but by using the Beasy-slip knot^ technique that we described previously [32], knots can be tied easily in the operative field by slipping them into position without the use of a knot pusher, and the sutures can be tied securely (Fig. 1i). Finally, the previously prepared NSF is applied to cover the entire operative field.

Results For tumor removal, total resection was accomplished in 25 cases (52.1 %). The details are summarized in Table 1. Residual regions included the cavernous sinus, the outside of the intracranial part of the internal carotid artery, the lower lateral part of the posterior clivus, and the posterior pituitary stalk. Complications included 2 new pituitary dysfunctions, 1 in a pituitary adenoma case, and 2 in a craniopharyngioma case; 4 cases of permanent diabetes insipidus in craniopharyngiomas; and postoperative anosmia in 1 pituitary adenoma and 1 cavernous sinus meningioma. CSF leakage was seen in 3 cases (6.3 %), 2 pituitary adenomas, and 1 tuberculum sellae meningioma; in

Summary of our endoscopic endonasal skull base surgeries

Tumor type

Total resection (%)

Residual sites (n)

Complications (n)

Pituitary adenoma

8/22 (36.4 %)

Craniopharyngioma

6/10 (60.0 %)

Cavernous sinus (10) Outside ICAa (4) Posterior pituitary stalk (4)

Pituitary function (1) Anosmia (1), CSFL (2) Pituitary function (1) DI (4)

7/8 (87.5 %) 0/1 (0 %) 0/1 (0 %) 0/1 (0 %) 3/3 (100 %)

Outside ICA (1) Outside ICA (1) Cavernous sinus (1) Posterior clivusb (1)

CSFL (1) None Anosmia (1) None None

0/1 (0 %) 1/1 (100 %) 25/48 (52.1 %)

Outside ICA (1)

None None

Meningioma Tuberculum sellae Sphenoid planum Cavernous sinus Clivus Chordoma Others Pituicytoma Ependymoma Total

CSFL cerebrospinal fluid leakage, DI diabetes insipidus, ICA internal carotid artery a

Outside of the intracranial part of the ICA

b

Lower lateral part of the posterior clivus

Neurosurg Rev Fig. 1 A representative case of fascia patchwork closure after resection of a craniopharyngioma (64-year-old woman). a, b Preoperative MRI showed a suprasellar mass extending upward adjacent to the pituitary stalk. c After resection, a large dural gap was observed and intracranial structures were exposed. The first suture was made at the forefront of the dural gap, where d suturing was the most difficult, e with a stitch passed through the fascia beforehand. f–i Then, the subsequent sutures were applied in turn as a patchwork, yielding an inlay patch. j Complete closure with the fascia patchwork technique was accomplished and there was no CSF leakage intraoperatively. It took 25 min for the closure. k, l Postoperative MRI showed a small residual tumor at the pituitary stalk

Table 2

Effect of the fascia patchwork closure technique Fascia patchwork closure group (n=32)

CSFL + CSFL − % of CSFL

Non-fascia patchwork group (n=16)

NSF +

NSF −

NSF +

NSF −

0 26 0%

0 6

3 13 18.8 %

– –

CSFL cerebrospinal fluid leakage, NSF nasoseptal flap

these cases, closure was made by fat insertion and an NSF without using the fascia patchwork technique. There was no CSF leakage in the 32 cases of the fascia patchwork closure group. Moreover, in recent 6 cases of the fascia patchwork closure group, an NSF was not used because there was no CSF leak after making a fascia patchwork technique (Table 2).

Discussion The removal of midline anterior skull base tumors via a purely endoscopic endonasal approach was described initially by Jho

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and colleagues [33] and Cappabianca et al. [5]. After further popularization by Kassam and Snyderman [17, 26, 27, 36, 37], and Cavallo and Cappabianca [5–7], the EESB approach became more accepted and performed widely. Besides the many advantages of this approach, such as its minimally invasiveness and superior cosmesis, in managing tuberculum sellae meningioma, EESB surgery resulted in improved visual outcome due to decreased manipulation of the optic apparatus [57] and enabled the early devascularization of tumors [23]. Although the EESB approach was an outstanding strategy for resecting midline anterior skull base tumors, it was associated with a greater risk of CSF leakage. The pioneers of this technique reported that the overall CSF leakage rate was 32 % [12, 15, 16, 20, 26, 58]. Many patients required a long period of bed rest or lumbar spinal drainage; in the worst case, repeat surgery was necessary. Early methods for the reconstruction of large skull base defects depended on the use of local flaps, free tissue, and artificial materials [3, 11, 14, 18, 19, 24, 34, 35, 42, 45, 56, 59]. The introduction of the NSF decreased dramatically the incidence of CSF leakage. The occurrence rate of CSF leakage after using an NSF was 4–5 % [21, 38, 61]. Although our overall incidence of the CSF leakage was favorable by using NSFs, we thought that it was necessary to establish a new method for complete closure after EESB surgery. The fascia patchwork closure technique is a type of free tissue graft, but is novel in its use of patchwork sutures. The fascia, which is a size larger than the dural gap and placed in the intracranial epi-arachnoid space, is patch-sutured around its entire circumference, yielding an inlay patch. That is, as the rest of the sutured fascia overlaps the dural edge on the intracranial side, the fascia is pressed down by intracranial pressure and adheres to the dura. When using this technique on 32 cases, there was no incidence of CSF leakage. Deep suturing in endoscopic surgery is difficult because it is problematic to determine depth due to the two-dimensional view. Practice gives an improved sense of depth, and sutures can be tied in clear view without being obscured by hands or instruments because the viewpoint is at the bottom of the operative field. Knots can be made quickly and securely in the deep field by using the Beasy-slip knot^ technique that we reported previously [32]. It took from 15 to 30 min for the closure using these techniques. In recent six cases, by using only fascia patchwork closure, there was no incidence of CSF leakage, even in the absence of an NSF. Though it is not enough number of cases to be able to emphasize the efficacy of using fascia patchwork closure alone for conquering CSF leakage, this technique is effective at least as part of a

multilayer closure after EESB surgery. Refraining from the use of an NSF could lead to the preservation of nose function. The establishment and popularization of this fascia patchwork closure technique might lead to the further development of EESB surgery.

Conclusions The EESB approach is an outstanding strategy for resecting midline anterior skull base tumors. It requires specialized technical skills with an endoscope and instrumentation as well as the ability to reconstruct large skull base defects to prevent postoperative CSF leakage. Surgeons should be skilled in complete closure after resection of tumors and also should master the described suturing techniques as part of a multilayer closure approach in patients with large skull base defects. Acknowledgments None of the authors received a financial assistance or has a remunerative association with any of the manufacturers mentioned in the manuscript.

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Comments Luigi Maria Cavallo, Domenico Solari, and Paolo Cappabianca, Naples, Italy In recent times, neurosurgical community has been observing the widespread and refinement of the extended endonasal surgery for the treatment of intradural lesions, especially with the endoscopic technique, lately attributing a role in the armamentarium of skull base approaches. On the other hand, lights have been pointed toward its major drawback, i.e., the postoperative CSF leakage. Skull base reconstruction techniques after extended approaches are developing to respond to the almost inadmissible initial postoperative CSF leak rates. In the attempt to fix the problem, many ideas have been proposed in regard to reconstruction techniques, which can be used in several different methods, individually or combined in a multilayer fashion. In these terms, the present contribution should be considered praiseworthy as it offers another option to be considered for osteodural repair for those who are involved in such continuously evolving kind of surgery. The idea of suturing dura, as in conventional transcranial surgery, seems though effective and has been already described by different authors [1, 3, 5, 8, 9]. However, the fact that this technique is very technically demanding and time consuming prevents at the moment its wide acceptance and diffusion. Both these factors could increase the risk of failure without an adequate expertise, especially considering that these maneuvers should be carried out at the end of a surgical procedure. For such a reason, a surgical team made up by a neurosurgeon and an otolaryngologist, sharing fatigues and increasing competences, is advisable. Moreover, the effectiveness showed by their results makes the authors able to afford the use of this technique only as a step of a multilayer reconstruction technique, being the success related to a combined strategy. No consensus has been yet established in regard to the material or materials’ combination that can be considered ideal for the repairing of osteo-dural defects. Nowadays, we can assess that after an endoscopic endonasal approach extended to the skull base, a multilayer reconstruction technique, addressing properly each compartment from the subarachnoidal to the epidural, is required. Indeed, this careful and peer attitude for this aspect of the surgery has permitted to render postoperative CSF leakage rates acceptable [2, 4, 6, 7]. References 1. Ahn JY, Kim SH (2009) A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 65 (6 Suppl):65–71; discussion 71–62. 2. Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D’Enza AI, Esposito F, Pasquini E (2014) The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 121 (1):100–113. 3. Ishii Y, Tahara S, Oyama K, Kitamura T, Teramoto A (2011) Easy slip-knot: a new simple tying technique for deep sutures. Acta Neurochir (Wien) 153 (7):1543–1545; discussion 1545. 4. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB (2011) Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg 114 (6):1544–1568. 5. Kitano M, Taneda M (2004) Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery 54 (3):653–660; discussion 660–651. 6. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, TylerKabara EC, Wang EW, Snyderman CH (2013) Endoscopic endonasal

Neurosurg Rev surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg 119 (5):1194–1207. 7. Leng LZ, Greenfield JP, Souweidane MM, Anand VK, Schwartz TH (2012) Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery 70 (1):110–123; discussion 123–114.

8. Nishioka H, Izawa H, Ikeda Y, Namatame H, Fukami S, Haraoka J (2009) Dural suturing for repair of cerebrospinal fluid leak in transnasal transsphenoidal surgery. Acta Neurochir (Wien) 151 (11):1427–1430. 9. Sakamoto N, Akutsu H, Takano S, Yamamoto T, Matsumura A (2013) Useful ‘sliding-lock-knot’ technique for suturing dural patch to prevent cerebrospinal fluid leakage after extended transsphenoidal surgery. Surgical Neurology International 4:19.

Fascia patchwork closure for endoscopic endonasal skull base surgery.

With the development of endoscopic technology and surgery, resection of midline skull base tumors has been achieved using endoscopic endonasal skull b...
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