Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions

Abstract

The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.

Surgical outcome of the endoscopic endonasal approach for non-functioning giant pituitary adenoma

“…[26][27][28] In the present series, nonetheless, we always aimed to perform intracapsular resection with preservation of the capsule, which consisted mainly of both thinned diaphragm and arachnoid membrane. While an extracapsular excision would offer the best chance for resection of giant adenoma, we believe that the tumor capsule can protect the surrounding vital structures, including the optic apparatus and the carotid artery, from surgical manipulation.…”

Transnasal trans-sphenoidal endoscopic repair of CSF leak secondary to invasive pituitary tumours using a nasoseptal flap

“…Whilst these grafts have been successful, problems arise due to the requirement of an additional surgical incision (thereby increasing the rate of local complication at that site) and post-operative CSF leak despite grafting. The development of a variety of substitute tissue has led more recently to heterologous grafting [10,[12][13][14][15][16][17]. There are various advantages and disadvantages described for these materials, including the adjunctive cost, lack of material pliability and imaging artefact.…”

“…Whilst the cause of CSF leak in these cases is different to the usual post-operative CSF leak, the aims and principles of repair remain the same-to form a watertight dural seal and establish a barrier between the sterile cranial cavity and the contaminated sino-nasal tract, thus decreasing the risk of ascending bacterial meningitis. This normally involves multi-layering of tissue, but recent work by Carvallo et al [10] suggests that such repair can best be accomplished using a single extradural overlay/onlay technique.…”

Surgical Approaches

“…On the other hand, the major challenge in the transsphenoidal route still remains the post-surgical cranial base repair. The rate of postoperative CSF leak in both endoscopic and microscopic transsphenoidal surgery has been reduced thanks to the development of specific paradigms for skull base reconstruction and (Cappabianca et al, 2001(Cappabianca et al, , 2002(Cappabianca et al, , 2010Kelly et al, 2001;Hadad et al, 2006;Esposito et al, 2007;Cavallo et al, 2007b;Leng et al, 2008;Kassam et al, 2008c). However, the expansion of endonasal approaches to different areas of the skull base for the removal of several lesions, such as craniopharyngiomas, has led to the re-emergence of the post-operative CSF leak as a major issue for this kind of surgery (Kassam et al, 2008c;Cavallo and Esposito, 2010;Malik et al, 2012;Cappabianca et al, 2013).…”