Download PDF
J Neurol Surg B Skull Base 2013; 74(05): 305-310
DOI: 10.1055/s-0033-1348952
Original Article
Georg Thieme Verlag KG Stuttgart · New York

One-Piece Modified Gasket Seal Technique

Aaron Wessell
1   School of Medicine, George Washington University Medical Center, Washington, District of Columbia, USA
,
Ameet Singh
2   Division of Otolaryngology, Department of Surgery, George Washington University Medical Center, Washington, District of Columbia, USA
,
Zachary Litvack
3   Department of Neurosurgery, George Washington University Medical Center, Washington, District of Columbia, USA
› Author Affiliations
Further Information

Publication History

10 February 2013

22 May 2013

Publication Date:
13 June 2013 (online)

Also available at
    Permissions and Reprints

Abstract

Objectives Review the effectiveness of a modified gasket seal technique utilizing a porous high-density polyethylene plate/rectus sheath fascia construct without fat grafting for primary closure of anterior defects following endoscopic skull base surgery.

Design Retrospective review (2011–2012).

Setting Single academic medical center.

Methods A retrospective review of five patients who underwent expanded endoscopic endonasal surgery for various pathologies (two craniopharyngiomas, two tuberculum meningiomas, and one planum meningioma) was performed. Skull base closure was performed using a one-piece modified gasket seal technique. Primary outcome measures included postoperative cerebrospinal fluid (CSF) leaks and donor site morbidity.

Results There were no postoperative CSF leaks. Two patients experienced aseptic meningitis treated with a 14-day course of steroids. Two patients experienced new postoperative chronic/recurrent sinusitis treated with oral antibiotics and topical nasal therapy. There was no donor site morbidity such as infection, hematoma, or hernias.

Conclusions The one-piece modified gasket-seal closure is a safe and effective method for reconstruction of endonasal defects of the anterior skull base. Rectus sheath fascia is an appropriate dural substitute for free tissue grafting with low donor site morbidity. The construction of the one-piece graft significantly decreases operative time and lowers the learning curve for multilayered closure.

Keywords

CSF leak - endoscopic - skull base - gasket seal
 

  • References

  • 1 Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Divitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001; 49 (2) 473-475 , discussion 475–476
    CrossrefPubMedGoogle Scholar
  • 2 Cavallo LM, Messina A, Esposito F , et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 2007; 107 (4) 713-720
    CrossrefPubMedGoogle Scholar
  • 3 de Divitiis E, Cavallo LM, Cappabianca P, Esposito F. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2. Neurosurgery 2007; 60 (1) 46-58 , discussion 58–59
    PubMedGoogle Scholar
  • 4 Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 2009; 64 (4) 677-687 , discussion 687–689
    CrossrefPubMedGoogle Scholar
  • 5 Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery 2006; 59 (1) (Suppl. 01) ONS50-ONS57 , discussion ONS50–ONS57
    PubMedGoogle Scholar
  • 6 Harvey RJ, Nogueira JF, Schlosser RJ, Patel SJ, Vellutini E, Stamm AC. Closure of large skull base defects after endoscopic transnasal craniotomy. Clinical article. J Neurosurg 2009; 111 (2) 371-379
    CrossrefPubMedGoogle Scholar
  • 7 Kaptain GJ, Vincent DA, Laws Jr ER. Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery 2001; 48 (1) 232-233 , discussion 233–234
    CrossrefPubMedGoogle Scholar
  • 8 Kassam AB, Thomas A, Carrau RL , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (1) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
    CrossrefPubMedGoogle Scholar
  • 9 Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 2008; 62 (5) (Suppl. 02) E342-E343 , discussion E343
    PubMedGoogle Scholar
  • 10 Luginbuhl AJ, Campbell PG, Evans J, Rosen M. Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 2010; 120 (5) 876-880
    PubMedGoogle Scholar
  • 11 Seiler RW, Mariani L. Sellar reconstruction with resorbable vicryl patches, gelatin foam, and fibrin glue in transsphenoidal surgery: a 10-year experience with 376 patients. J Neurosurg 2000; 93 (5) 762-765
    CrossrefPubMedGoogle Scholar
  • 12 Garcia-Navarro V, Anand VK, Schwartz TH. Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurgery 9 November 2011 (Article in Press DOI: 10.1016/j.wneu.2011.08.034)
    PubMedGoogle Scholar
  • 13 Hadad G, Bassagasteguy L, Carrau RL , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
    CrossrefPubMedGoogle Scholar
  • 14 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg 2012; 77 (2) 329-341
    CrossrefPubMedGoogle Scholar
  • 15 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 2012; 77 (5-6) 713-724
    CrossrefPubMedGoogle Scholar
  • 16 Mascarenhas L, Moshel YA, Bayad F , et al. The transplanum transtuberculum approaches for suprasellar and sellar-suprasellar lesions: Avoidance of CSF leak and lessons learned. World Neurosurg 2013; . [Epub ahead of print] 2013 Feb 9. pii: S1878-S8750(13)00297-0
    PubMedGoogle Scholar
  • 17 Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 2009; 64 (4) 677-687 , discussion 687–689
    CrossrefPubMedGoogle Scholar
  • 18 Gardner PA, Kassam AB, Snyderman CH , et al. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg 2008; 109 (1) 6-16
    Google Scholar
  • 19 Gardner PA, Kassam AB, Thomas A , et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008; 63 (1) 36-52 , discussion 52–54
    CrossrefPubMedGoogle Scholar
  • 20 Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 2007; 106 (3) 400-406
    CrossrefPubMedGoogle Scholar
  • 21 Padhye V, Naidoo Y, Alexander H , et al. Endoscopic endonasal resection of anterior skull base meningiomas. Otolaryngol Head Neck Surg 2012; 147 (3) 575-582
    CrossrefPubMedGoogle Scholar
  • 22 Kaptain GJ, Kanter AS, Hamilton DK, Laws ER. Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery. Neurosurgery 2011; 68 (1, Suppl Operative): 144-150 , discussion 150–151
    PubMedGoogle Scholar
  • 23 Kaptain GJ, Vincent DA, Sheehan JP, Laws Jr ER. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 2001; 49 (1) 94-100 , discussion 100–101
    CrossrefPubMedGoogle Scholar
  • 24 Eloy JA, Choudhry OJ, Shukla PA, Kuperan AB, Friedel ME, Liu JK. Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: is there an increased risk of postoperative cerebrospinal fluid leak?. Laryngoscope 2012; 122 (6) 1219-1225
    CrossrefPubMedGoogle Scholar
  • 25 Dias FL, Sá GM, Kligerman J , et al. Complications of anterior craniofacial resection. Head Neck 1999; 21 (1) 12-20
    CrossrefPubMedGoogle Scholar
  • 26 Wanamaker JR, Mehle ME, Wood BG, Lavertu P. Tension pneumocephalus following craniofacial resection. Head Neck 1995; 17 (2) 152-156
    CrossrefPubMedGoogle Scholar
  • 27 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 2007; 60 (4) (Suppl. 02) 295-303 , discussion 303–304
    PubMedGoogle Scholar
  • 28 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (1) E8
    PubMedGoogle Scholar
  • 29 Jane Jr JA, Kiehna E, Payne SC, Early SV, Laws Jr ER. Early outcomes of endoscopic transsphenoidal surgery for adult craniopharyngiomas. Neurosurg Focus 2010; 28 (4) E9
    Google Scholar
  • 30 Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Neurosurgery 2010; 67 (3, Suppl Operative): ons150-ons158 , discussion ons158
    CrossrefPubMedGoogle Scholar
  • 31 Kong DS, Kim HY, Kim SH , et al. Challenging reconstructive techniques for skull base defect following endoscopic endonasal approaches. Acta Neurochir (Wien) 2011; 153 (4) 807-813
    CrossrefPubMedGoogle Scholar
  • 32 Citardi MJ, Cox III AJ, Bucholz RD. Acellular dermal allograft for sellar reconstruction after transsphenoidal hypophysectomy. Am J Rhinol 2000; 14 (1) 69-73
    CrossrefPubMedGoogle Scholar
  • 33 Kremer P, Forsting M, Ranaei G , et al. Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting residual adenoma. Acta Neurochir (Wien) 2002; 144 (5) 433-443
    CrossrefPubMedGoogle Scholar
  • 34 Slavin ML, Lam BL, Decker RE, Schatz NJ, Glaser JS, Reynolds MG. Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients. Am J Ophthalmol 1993; 115 (3) 368-371
    PubMedGoogle Scholar
  • 35 Berghaus A, Mulch G, Handrock M. Porous polyethylene and proplast: their behavior in a bony implant bed. Arch Otorhinolaryngol 1984; 240 (2) 115-123
    PubMedGoogle Scholar
  • 36 Frodel JL, Lee S. The use of high-density polyethylene implants in facial deformities. Arch Otolaryngol Head Neck Surg 1998; 124 (11) 1219-1223
    CrossrefPubMedGoogle Scholar
  • 37 Wellisz T, Kanel G, Anooshian RV. Characteristics of tissue response to Medpor porous polyethylene implants in the human facial skeleton. J Long Term Eff Med Implants 1993; 3 (3) 223-35
    PubMedGoogle Scholar
  • 38 Williams JD, Romo III T, Sclafani AP, Cho H. Porous high-density polyethylene implants in auricular reconstruction. Arch Otolaryngol Head Neck Surg 1997; 123 (6) 578-583
    CrossrefPubMedGoogle Scholar
  • 39 Flynn BC, Nemergut EC. Postoperative nausea and vomiting and pain after transsphenoidal surgery: a review of 877 patients. Anesth Analg 2006; 103 (1) 162-167
    CrossrefPubMedGoogle Scholar
  • 40 Amir A, Gatot A, Zucker G, Sagi A, Fliss DM. Harvesting large fascia lata sheaths: a rational approach. Skull Base Surg 2000; 10 (1) 29-34
    PubMedGoogle Scholar
  • 41 Dubiel WT, Wigren A. Functional status of the lower extremity after resection of fascia lata. A clinical and physiological follow-up study in patients with fascia lata heart valve replacement. Acta Orthop Scand 1974; 45 (4) 599-613
    PubMedGoogle Scholar
  • 42 Wheatcroft SM, Vardy SJ, Tyers AG. Complications of fascia lata harvesting for ptosis surgery. Br J Ophthalmol 1997; 81 (7) 581-583
    CrossrefPubMedGoogle Scholar
  • 43 Spotnitz WD, Falstrom JK, Rodeheaver GT. The role of sutures and fibrin sealant in wound healing. Surg Clin North Am 1997; 77 (3) 651-669
    CrossrefPubMedGoogle Scholar
  • 44 Kassam A, Horowitz M, Carrau R , et al. Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study. Neurosurgery 2003; 52 (5) 1102-1105 , discussion 1105
    CrossrefPubMedGoogle Scholar
  • 45 Fandiño M, Macdonald K, Witterick I, Singh D, Whyne C. Determining the best graft-sealant combination for skull base repair using a soft tissue in vitro porcine model. Int Forum Allergy Rhinol 2013; 3 (3) 212-216
    CrossrefPubMedGoogle Scholar