Background Endoscopic endonasal surgery (EES), particularly extended approaches, often introduces formidable reconstruction challenges. Various techniques include dural substitute inlays and/or onlays, autologous fat grafts, and mucosal grafts. These are secured by plates, glue, or other buttresses. Here, we describe our experience with primary closure of skull base dural and/or arachnoid defects of selected cases using titanium clips.
Methods A retrospective database analysis revealed 14 patients (of 760) who underwent EES between June 2010 and August 2017 for which titanium clips were used for primary dural or arachnoid closure. Pathologic diagnoses were pituitary adenoma (10), clival chordoma (2), Rathke's cleft cyst (1), and epidermoid (1). Intra-op CSF leaks were Kelly Grade III (3), Grade II (6), Grade I (4), and Grade 0 (2). One patient had two separate defects repaired. For the latter, sellar dura was apposed to support prolapsed diaphragma. Medium Weck clips were used earlier in the series, supplanted by LeMaitre Anastoclips (3).
Results Primary obliteration of CSF leak via closure of diaphragma arachnoid was achieved in four of five cases, and retroclival arachnoid in two of three cases. Partial closure was achieved in the other two arachnoid cases. In three cases, anterior diaphragma tears were successfully obliterated by clip apposition to dura. In the remaining two cases, sellar dura was apposed with clips over underlying fat. The primary closure was augmented with Haddad-Bassagasteguy nasoseptal flap onlays in 11 cases, and free mucosal flaps in 2 cases.
One postoperative leak occurred on day 6 in an obese giant pituitary adenoma patient with no recognized intraoperative leak for which the dura had been reapproximated over the prolapsed diaphragma. A nasoseptal flap was placed at reoperation.
Conclusion primary closure of skull base defects is technically possible using titanium clips in selected patients.
