Abstract
Background
With technical improvement, accumulating lesions could be resected using endoscopic endonasal surgery. However, cerebrospinal fluid leakage is still a concern. Intraoperative dural defect reconstruction is critical.
Method
We developed a new knotting technique for dural closure during endoscopic skull base surgery. We presented a step-by-step description of the fascia lata inlay and autologous dural patch intermittent suturing method following cross-reinforcing principles and emphasized the key points of the novel intranasal knotting technique.
Conclusion
The new intranasal knotting and suturing technique is a feasible method to close the dura and to prevent cerebrospinal fluid leakage.
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References
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Key points
1. Dural suturing technique. It is useful in increasing the anti-pressure and counter-shift capability of the reconstruction materials, which is expected to facilitate fast recovery.
2. Cross-reinforcing principles. We use three layers of interacted grafts for reconstruction, including sutured fascia lata inlay, upper-left pedicled inferiorly rotated autologous dural patch and lower-right pedicled superiorly rotated NSF.
3. Plan the reconstruction during dural opening. To leave enough dural edge for suturing.
4. Pedicled autologous dural patch. It is harvested with its pedicle at the distal end of NSF, which might bear inadequate blood supply.
5. Subdural inlay suturing. It is achieved by controlling the penetrating point and direction of the needle [5, 6].
6. Intranasal knotting nuances. To stand the string to maintain the instrument coaxial motion in the vertical direction parallel to the endoscope.
7. The standing part of the string should not be too long to ensure the tying maneuver performed close to the suturing point.
8. Intranasal knotting instrument. Slim up-angled deep suturing needle holder is required to allow the visibility of the instrument tip during knotting. Rotatability rod makes it competent for multi-angle maneuverability.
9. Dynamic movements of the endoscope by assistant are helpful for knotting.
10. Be practical. Watertight suturing is ideal but not pursued due to time consuming, but large weak point should be avoided. Square knot is ideal, but running knot could also provide enough strength.
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Video 1
This video demonstrates cross-reinforcing suturing and intranasal knotting for dural defect reconstruction during endoscopic endonasal craniopharyngioma resection (MP4 84,467 kb)
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Heng, L., Zhang, S. & Qu, Y. Cross-reinforcing suturing and intranasal knotting for dural defect reconstruction during endoscopic endonasal skull base surgery. Acta Neurochir 162, 2409–2412 (2020). https://doi.org/10.1007/s00701-020-04367-w
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DOI: https://doi.org/10.1007/s00701-020-04367-w