Skull Base Reconstruction Following Endoscopic Transsellar Approach, Utilization of Three-Layer Grafting Technique
Abstract
Background: Endoscopic transsellar approaches effectively access skull base lesions but risk cerebrospinal fluid leaks. Three-layer grafting techniques reliably reinforce dural closure, reducing complications and supporting optimal healing.
Aim: Assessment of the efficacy and safety of the modified protocol for skull base reconstruction which is done by utilizing a three-layer grafting technique (Facia-Fat-Facia) for the patients who developed intraoperative CSF leak necessitating an immediate repair regardless the degree of the leak at time of repair.
Methods: A prospective study had been conducted at Skull Base Center and Neurosurgical Department of Ghazi Al-Hariri Martyr Hospital for Surgical Specialties, Medical City Complex of Baghdad through a period of 18 months, between January 2022 and June 2023, during which 43 patients with different pathologies underwent pure endoscopic endonasal sellar approach. Intra-operative CSF leaks were classified into four grades according to Esposito et al. Sellar reconstruction was performed by utilizing a three-layer grafting technique (Facia-Fat-Facia) for all patients regardless the degree of the leak at time of repair. Authors did not use any vascularized flaps or tissue glues and did not include any procedures of CSF diversions such as lumbar drainage.
Results: Among the 43 (29 adenomatous pathology and 14 non-adenomatous), CSF leak was 34.88% Grade I, 41.86 Grade II and 23.26 Grade III. A minimum of 18 months follow-up showed development of two postoperative CSF leaks (4.65%), one pneumocephalus (2.32%) and one bacterial meningitis (2.32%) cases.
Conclusion: Utilizing autologous facia lata and fat grafting in this modified three layered fashion is effective, reliable and safe procedure for reconstructing skull base defects regardless the CSF leak grading and severity, taking in consideration its tissue compatibility, availability and the ease of harvesting with negligible donor site morbidity, flexibility in size of the graft needed, it’s a good substitute for vascularized regional flaps in cases of unavailability of difficult to be harvested and lastly, it’s adding no cost on the patient when compared to other synthetic and artificial grafting substitutes avoiding the use of highly costed tissue glues and other synthetic sealant agents in most of cases.
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