Utilizing Surgicel for Simple Closure of Postoperative Sellar Defects: The Jefferson Experience

Introduction: Endoscopic endonasal surgery the has become the golden standard for treatment of routine sellar lesions due to its minimally invasive nature, high success rate, and low procedural morbidity. However, postoperative cerebrospinal fluid (CSF) leaks remain an undesired surgical complication of this surgery and effective techniques to repair dural defects are an ongoing challenge. In addition, though a wide variety of materials have been used, such as autologous fascia, fat plugs, and synthetic sealants and glues, they either require additional morbidity and discomfort to the patient or can elicit a host reaction when placed. To avoid these complications, we propose using a simple epidural Surgicel onlay over the defect created from resection of routine sellar lesions.

Materials and Methods: We reviewed the surgical experience of the senior authors (>1,000 cases) to identify patients who underwent endoscopic endonasal resection of pituitary adenomas in which a simple Surgicel onlay repair was performed. Patients who did not undergo this simple closure technique were excluded. In general, this repair technique was not utilized if an intraoperative cerebrospinal fluid was detected or if a patulous diaphragm was visualized. Additionally, any patients whose defects were closed with other materials used such as Gelfoam®, autologous fat, fascia lata, dural substitute, or any dural sealant were excluded from study. After exclusion criteria were applied, 150 patients were selected for analysis. Patient demographics, tumor characteristics, and surgical outcomes were recorded.

Results: For our cohort, the average age was 61.5 (range: 17–94), 73 were females (48.7%) versus 77 males (51.3%), and average BMI was 30.8 (range: 19–61.6). Twenty-six patients (17.3%) had prior transsphenoidal surgery, and one patient had prior radiation. Tumors size ranged from 0 to 5 cm with the majority falling between 1–2 cm (39.3%) and 2–3 cm (28%). All lesions were located within the sella; however, several extended to the cavernous sinus, suprasellar cisterns, and/or the clivus. The most common tumors were non-functional adenomas, followed by growth hormone-secreting adenomas, however ACTH-secreting adenomas, prolactinomas, and Rathke’s cleft cysts were also represented.

Only two postoperative CSF leaks (1.3%) were identified and were successfully repaired after detection. No intraoperative CSF leaks were noted, and no intraoperative lumbar drains were placed. No patients experienced post-operative meningitis or any host reactions from Surgicel placement.

Discussion/Conclusion: The use of a simple epidural Surgicel onlay is an extremely effective tool for closure and prevention of postoperative CSF leak in patients undergoing routine endoscopic endonasal surgery to remove sellar masses. Using this technique, we report only two patients (1.3%) having postoperative CSF leak. Our method exhibits minimal postoperative morbidity free of host reactions which can accompany multi-layered synthetic repairs that have been previously described. Overall, this simple onlay repair is an easily repeatable and highly effective technique to prevent postoperative CSF leak resulting from routine resection of pituitary lesions.