Sellar Reconstruction with Surgicel Onlay: A Review of 61 Consecutive Cases

Background: Adequate sellar reconstruction is critical during endoscopic transsphenoidal pituitary surgery to prevent a postoperative CSF leak, which occurs in an estimated 2–16% of cases in the literature. Several algorithms have been proposed for sellar reconstruction during endoscopic transsphenoidal surgery. A myriad of repair techniques have been described, including vascularized tissue such as the nasoseptal flap, free mucosal grafts, fat grafts, and synthetic dural substitutes, each of which has associated cost and morbidity. We present an effective, technically simple, inexpensive, and low morbidity repair technique for select sellar defects without an identified intraoperative CSF.

Methods: Sixty-one consecutive patients who underwent endoscopic transsphenoidal hypophysectomy and sellar reconstruction with only regenerated oxidized cellulose (Surgicel) were retrospectively reviewed. Patients were selected for this technique if there was no intraoperative CSF leak, anterior diaphragmatic sellar defect, evidence of the diaphragm herniating through the sellar floor, and the tumor size was not prohibitively large.

Results: Sixty-one patients were included—27 were male, 34 were female. Patients had an average age of 54.6 ± 16.6 and an average BMI of 31.8 ± 7.0. Five patients were nightly CPAP users. In all cases, there was no identification of an intraoperative CSF leak, evidence of an anterior diaphragmatic sellar floor defect, or a patulous diaphragm. Gross total resection was achieved in 51/59 cases (86.4%) available for analysis. Average tumor size was 1.9 ± 1.1 cm. Average tumor volume was 5.1 ± 16.8 cm³. All cases were repaired with only layered sheets of Surgicel in an “onlay” fashion. There were no postoperative CSF leaks. There were no cases of postoperative meningitis and complete sphenoid mucosalization was identified in all postoperative endoscopy videos available for review at 3-month follow-up.

Conclusion: The use of Surgicel alone is a safe and effective technique for sellar reconstruction in endoscopic transsphenoidal pituitary surgery cases without an intraoperative CSF leak or anterior diaphragmatic sellar defect identified. In this retrospective series, there were no postoperative CSF leaks despite average tumor size of nearly 2 cm and a high rate of gross total tumor resection. The use of advanced repair techniques is likely unnecessary in the absence of an identified intraoperative CSF leak. Simple repairs are appropriate for many cases and avoid the associated cost and morbidity of more advanced reconstruction techniques.