Sutured versus Sutureless Dural Substitutes: Experience from a Government Tertiary Care Hospital in India

Abstract

Background

Dural substitutes have emerged as favorable alternatives to autologous grafts. This shift in approach is evident in the growing use of sutureless grafts (e.g., DuraGen) over traditional sutured options (e.g., bovine pericardial patch). This study was conducted to gain insights into the choice between the two in terms of the rate of postoperative complications.

Materials and Methods

This prospective study was conducted between May 15, 2023 and January 31, 2024 at a tertiary-care government hospital in India. The patients received sutured (bovine pericardial patch) or sutureless (DuraGen patch) dural substitutes. Success in both groups was defined by the absence of postoperative complications. Wound healing was evaluated on postoperative day (POD) 3, 10, and 14. Follow-up assessments occurred at 1 and 3 months. Cerebrospinal fluid pooling was assessed by computed tomography (immediately after surgery and on POD 10) and brain magnetic resonance imaging (after 1 month).

Results

A total of 50 patients received sutured (bovine pericardial patch; n = 25) or sutureless (DuraGen patch; n = 25) dural substitutes to repair the dural defect that occurred after resection of cranial (62%) and spinal (20%) tumors. The bovine pericardial patch application was successful in 21 patients (84.0%), whereas the DuraGen patch application was successful in 23 patients (92.0%). The success rates with the bovine pericardial patch were 100% in patients with spinal tumors and patients who underwent foramen magnum decompression, 33.3% in patients with meningocele myelocystocele, and 81.8% in patients with cranial tumors. The success rates with the DuraGen patch were 80% in patients with spinal tumors and 95% in patients with cranial tumors.

Conclusion

Sutureless grafts like DuraGen offer rapid application, reduced infection risk, and suitability for complex areas like the skull base. Sutured grafts may be preferred for larger defects due to their adaptability and inherent strength.

Keywords

bovine pericardial patch - complications - DuraGen - dural defect - neurosurgery

Introduction

Damage to the dura mater due to trauma, surgery, or tumor may require reconstruction of the dural defect. Certain postoperative infections can also result in dural sloughing. A dural substitute is a patch used in neurosurgery to repair a hole or tear (defect) in the dura mater. Despite a century of experimentation, the quest for a perfect dural substitute remains unfulfilled. We have progressed significantly from using unorthodox materials like rubber laminate and gold foil used in the past.[1] The use of autologous grafts, such as pericranium, fascia lata, or temporalis fascia, represented a significant step forward in dural repair. These grafts offer excellent biocompatibility with minimal rejection risk and seamlessly integrate with surrounding tissue due to their native collagen structure.[2] However, there are some challenges with using harvesting autologous grafts. First, they create a second surgical site at the donor region, increasing patient morbidity and potentially limiting the available graft size. Large brain tumors, particularly those originating from the meningeal layer, can leave behind significant dural defects. Repairing such large defects, sometimes measuring up to 10 × 10 cm, is not possible using autologous grafts. Second, these grafts may not be suitable for all patients, particularly those with pre-existing conditions in the harvest area. The ultimate goal in the development of dural substitutes is to mimic the biological response of native tissue. This natural response serves as the gold standard for comparison during the pre-market evaluation of these substitutes.[3]

Xenogeneic collagen grafts, derived from animal tissues, are emerging as promising alternatives to autologous grafts. These grafts are specifically processed to minimize immune rejection, allowing for better integration into the recipient's tissues.[4] Two such xenogeneic grafts available commercially are the bovine pericardial patch (Edwards Lifesciences Corporation, Irvine, California, United States) and DuraGen (Integra LifeSciences Corporation, Plainsboro, New Jersey, United States). The bovine pericardial patch is a sturdy, membrane-like implant derived from processed bovine pericardium. Surgeons suture it directly to the surrounding healthy dura mater. In contrast, DuraGen is a sutureless collagen matrix derived from the bovine Achilles tendon. Due to its structure, it does not require suturing and is instead placed as an “onlay graft” to cover the dural defect.[5] [6] [7] [8] Bovine pericardial patch and DuraGen have become increasingly common in cranial and spinal neurosurgery for repairing dural defects. These patches offer advantages over traditional autologous grafts, such as reduced donor site morbidity and potentially wider availability. Existing studies have documented the efficacy of both these dural substitutes in dural repair.[4] [8] [9] However, some key questions remain unanswered: Is it really necessary to suture the dural patch to minimize the risk of postoperative complications such as leakage of cerebrospinal fluid (CSF), infection, or dural fibrosis? Do patients experience any difference in terms of recovery, long-term function, or complication rates based on whether their dural repair involved a sutured or sutureless patch? This study aims to bridge this knowledge gap by investigating the potential impact of suturing on the efficacy of dural substitutes. By comparing sutured (bovine pericardial patch) and sutureless (DuraGen patch) techniques, we hope to gain valuable insights for optimizing dural repair strategies in neurosurgery.

Materials and Methods

Study Design

This was a single-center, prospective study conducted between May 15, 2023 and January 31, 2024.

Study Population

The study included patients of either sex who required duraplasty using grafts due to the creation of a dural defect while being operated on for different cranial or spinal surgeries. Patients with allergies or hypersensitivities to bovine products and those who were unwilling to participate in the study and remain throughout the requisite follow-up period were excluded.

Study Procedures

The patients received sutured (bovine pericardial patch) or sutureless (DuraGen patch) dural substitutes.

Application of Bovine Pericardial Patch

The bovine pericardial patch is available in a package filled with alcoholic ethylene oxide solution and is opened just before application in the operating theater. For the application, the patch was first washed in heparinized saline and then cut to match the size of the dural defect. The patch is then sutured at the dural rim of the defect to prevent buckling at one end. Then, closure was performed using a round-body needle and nonabsorbable suture such as Prolene 4–0 RB in either a continuous or an intermittent manner. Fibrin glue was used as a sealant over the dural line of the closure to enhance water tightness.

Application of DuraGen Patch

The DuraGen patch is available in a ready-to-use package. This patch was directly placed on the dural defect in an inlay manner without suturing. Fibrin glue was used as a sealant over the dural line of the closure to enhance water tightness.

Study Measures

A case of dural repair in either group was considered a “success” if there were no postoperative complications, for which wound status, CSF pooling, infection, meningitis, pseudomeningocele formation, etc., were assessed and compared between the groups.

Wound status was assessed on postoperative day (POD) 3, POD 10, and after removal of skin sutures on POD 14. Follow-up assessments of wound status were scheduled at 1 and 3 months. CSF pooling was assessed via computed tomography (CT) scans of the brain immediately after the surgery and on POD 10. T2-weighted magnetic resonance imaging of the brain was performed at the 1-month follow-up visit.

Statistical Analysis

The study data were tabulated using Microsoft Excel 365. Categorical variables are presented as numbers and percentages, and continuous data are reported as median (range).

Ethical Approval

All surgical procedures were performed in accordance with the study protocol approved by the ethics committee of the hospital while maintaining the highest standards of surgery and human care. All patients provided informed consent for their data to be included in this report. Images and videos included are only from those patients who consented for their surgery to be photographed, and video recorded.

Results

Demographic and Clinical Characteristics

The study included 50 patients who received sutured (bovine pericardial patch; n = 25) or sutureless (DuraGen patch; n = 25) dural substitutes. In total, there were 24 men and 26 women (overall: 48 vs. 52%; sutured group: 36 vs. 64%; sutureless group: 60 vs. 40%). In the overall population, the most common case type was cranial tumors (62%), followed by spinal tumors (20%), Chiari I malformations (12%), and meningocele myelocystocele (MMC; 6%). [Fig. 1] summarizes the types of cases that required the application of sutured and sutureless dural substitutes. [Table 1] summarizes the size of the repaired defects.

Table 1 Summary of defect types and sizes observed in our study population

Sr. No.	Type of case	Size of defect (cm × cm)	Defect repair (BPP vs. DuraGen)
1 and 2.	Lumbar microdiscectomy for a lumbar prolapsed intervertebral disc	3 × 3	BPP → DuraGen[a]
3.	Resection of left sphenoid wing meningioma	8 × 8	BPP
4.	Resection of epidermoid tumor located in the fourth ventricle of the brain	6 × 6	BPP
5.	MMC	4 × 4	BPP
6.	Resection of recurrent right meningioma located in the frontoparietal convexity region of the brain	12 × 11	DuraGen (two patches of 7 × 7 cm)
7.	IDEM tumor	3 × 3	DuraGen
8.	Lax duraplasty in cerebral edema	7 × 2	BPP
9.	Posterior fossa tumor	5 × 5	BPP
10.	Posterior fossa tumor	6 × 6	BPP
11.	Posterior fossa tumor	8 × 8	BPP
12.	Meningioma	10 × 10	BPP
13.	Meningioma	8 × 8	BPP
14.	Meningioma	7 × 7	BPP
15.	Meningioma	8 × 8	BPP
16.	Meningioma	10 × 10	BPP
17.	IDEM tumor	3 × 3	BPP
18.	IDEM tumor	3 × 3	BPP
19.	IDEM tumor	2 × 2	BPP
20.	IDEM tumor	3 × 3	BPP
21.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
22.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
23.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
24.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
25.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
26.	FMD	Y-shaped duraplasty using 3 × 3 patch	BPP
27.	MMC	6 × 2	BPP
28.	MMC	5 × 1.5	BPP
29.	Glioma	6 × 6	DuraGen
30.	Glioma	5 × 5	DuraGen
31.	Glioma	6 × 6	DuraGen
32.	Endoscopic pituitary	3 × 3	DuraGen
33.	Endoscopic pituitary	4 × 4	DuraGen
34.	Endoscopic pituitary	3 × 3	DuraGen
35.	Depressed fracture with dural tear	2 × 2	DuraGen
36.	Lax duraplasty in cerebral edema	7 × 3	DuraGen
37.	Lax duraplasty in cerebral edema	8 × 2	DuraGen
38.	Lax duraplasty in cerebral edema	6 × 2	DuraGen
39.	Posterior fossa tumor	6 × 6	DuraGen
40.	Posterior fossa tumor	6 × 6	DuraGen
41.	Posterior fossa tumor	5 × 5	DuraGen
42.	Meningioma	7 × 7	DuraGen
43.	Meningioma	5 × 5	DuraGen
44.	Meningioma	5 × 5	DuraGen
45.	Meningioma	7 × 7	DuraGen
46.	Meningioma	8 × 8	DuraGen
47.	Meningioma	6 × 6	DuraGen
48.	IDEM tumor	2 × 2	DuraGen
49.	IDEM tumor	3 × 3	DuraGen
50.	IDEM tumor	2 × 2	DuraGen

Abbreviations: BPP, bovine pericardial patch; FMD, foramen magnum decompression; IDEM, intradural extramedullary; MMC, meningocele myelocystocele.

^a Patient counted under both BPP and DuraGen groups.

Fig. 1 Types of cases that required the application of (A) sutured and (B) sutureless dural substitutes. ^aIncludes cerebellopontine angle tumor, cerebellar tumor, and pineal tumor. FMD, foramen magnum decompression; MMC, meningocele myelocystocele; TTNS, transnasal transsphenoidal.

Success Rate of Dural Repair

Application of the bovine pericardial patch was successful in all 5 patients with spinal tumor (100%), all 6 patients who underwent foramen magnum decompression (FMD; 100%), 1 of 3 patients with MMC (33.3%), and 9 of 11 patients with cranial tumor (81.8%). Overall, the bovine pericardial patch application was successful in 21 of 25 patients (84.0%). Follow-up at 3 months revealed no wound complications in these patients. The application of a bovine pericardial patch was not considered a success because of wound complications in two patients with MMC and two patients with cranial tumors. One patient died due to meningitis.

Application of the DuraGen patch was successful in 4 of 5 patients with spinal tumors (80%) and 19 of 20 patients with cranial tumors (95%). Overall, the DuraGen patch application was successful in 23 of 25 patients (92.0%). Follow-up at 3 months revealed no wound complications in these patients. Wound complications occurred in the remaining two patients, but none had developed meningitis. No deaths occurred due to wound complications or leaks. One patient with a spinal tumor, for whom the patch application was not considered a success, died due to pulmonary complications.

Complications occurred in four cases in the bovine pericardial patch group and two cases in the DuraGen patch group. These cases, considered as “failure,” are presented below.

Cases with Complications in the Bovine Pericardial Patch Group

Case 1

A 60-year-old woman underwent a lumbar microdiscectomy for a lumbar prolapsed intervertebral disc at another hospital. Around postoperative day (POD) 7, she presented to our outpatient department with a frank CSF leak from the surgical wound, but she was afebrile. High-dose antibiotics were administered, and she was scheduled for surgical exploration.

During the surgical exploration, a 3 × 3 cm defect was identified and repaired with the application of a DuraGen patch. Unfortunately, the initial repair with DuraGen failed, and the CSF leak recurred on POD 5. Again, the patient remained afebrile. In the second exploration, the DuraGen patch was found to be unsuitable for re-closure, and a larger 6 × 6 cm bovine pericardial patch was used to achieve a watertight closure. Additionally, a lumbar drain was inserted under direct visualization to divert the CSF. The CSF drain was maintained for 14 days, followed by suture removal. The patient remained CSF leak-free 48 hours after suture removal, indicating successful closure.

It is important to note that the DuraGen patch was not suitable in this case, and application of the bovine pericardial patch was successful.

[Fig. 2] shows the sutured bovine pericardial patch in this case.

Fig. 2 A representative case (60-year-old woman) of bovine pericardial patch application.

Case 2

A 48-year-old woman with left sphenoid wing meningioma and a history of nutritional deficiencies received preoperative injectable iron to correct deficiencies before surgery for resection of the meningioma. After tumor resection, there was a large dural defect (8 × 8 cm), for which bovine pericardial patch reconstruction was performed. The patient initially recovered well, achieving a good Glasgow Coma Scale score of E4 M6 by POD 6.

Unfortunately, on POD 7, a CSF leak developed from the surgical site. A CT scan revealed a developing infarct in the left middle cerebral artery territory. The patient's condition rapidly deteriorated with high fever and decreased alertness. Emergency surgery identified three to four failed dural sutures with active CSF and gliotic brain tissue leakage. The surgical team performed thorough irrigation, suture reinforcement, tracheostomy placement, and initiated broad-spectrum antibiotics.

Despite these interventions, the CSF leak persisted, and the fever worsened. Linezolid and colistin were added to the antibiotic regimen to address a broader range of potential pathogens. Due to uncontrolled meningitis, a decision was made to create a ventriculoperitoneal (VP) shunt to divert CSF. However, the patient's condition continued to deteriorate, and she ultimately succumbed to the complications. Culture results confirmed staphylococcal growth, which likely contributed to the meningitis development. The rapid onset and aggressive progression of the infection suggested a fulminant course.

Case 3

A 9-year-old girl underwent surgery to remove an epidermoid tumor located in the fourth ventricle of her brain. The surgery also involved dural repair (duraplasty) using a 6 × 6 cm bovine pericardial patch. On POD 7, the patient developed a pseudomeningocele, which was confirmed by scans, but hydrocephalus was ruled out. Due to the potential for rapid deterioration in such cases, the medical team acted promptly based on previous experiences.

The pseudomeningocele was aspirated dry, and the patient received a high dose of intravenous meropenem and vancomycin antibiotics (in consultation with a pediatrician) to prevent meningitis. Additionally, she was prescribed weight-adjusted acetazolamide tablets (Diamox) and a tight compressive bandage to promote healing. Anti-inflammatory steroids were administered for 10 days and gradually tapered off.

The patient remained afebrile, and the pseudomeningocele did not recur. Sutures were removed on POD 14, and at the 3-month follow-up, she was doing well and performing normally at school.

Case 4

A 4-year-old boy underwent surgery to repair an MMC. The surgery involved the application of a 4 × 4 cm bovine pericardial patch. On POD 6, the boy developed swelling at the surgical site. He was prescribed weight-adjusted acetazolamide syrup (Diamox) to manage the swelling and a compression bandage to promote healing. The sutures were removed on POD 14, and the procedure was deemed successful.

Cases with Complications in the DuraGen Patch Group

Case 1

A 37-year-old man presented to our hospital with chief complaints of headache for 15 days, swelling over the right parietal region for 10 days, and diminution of vision for 10 days. Histopathological examination revealed a transitional meningioma classified as World Health Organization grade 2. The large (11 × 9 × 7 cm) recurrent right meningioma located in the frontoparietal convexity region of the brain had caused the elevation of the bony calvarial flap after previous surgery for the same tumor 5 years ago (in 2019) at another facility. Despite recommendations, the patient had not received the advised radiation therapy after the initial surgery.

The current surgery aimed for a Simpson Grade 1 resection, which removes as much of the tumor as possible while minimizing brain tissue damage. This approach resulted in a large 12 × 11 cm dural defect. To repair the defect, two DuraGen patches, each 7 × 7 cm, were used in an inlay manner. The patient recovered well initially until POD 7. On POD 7, the patient developed a pseudomeningocele, which was confirmed by scans, but hydrocephalus was ruled out. The pseudomeningocele was aspirated dry, and the patient was prescribed acetazolamide tablets (Diamox) to manage the swelling.

Despite the treatment, a bulge persisted, and by POD 13, a CSF leak developed. To address this leak, a VP shunt was placed to divert CSF away from the surgical site. Additionally, the pseudomeningocele pool was aspirated again. The patient responded well to this intervention and continues to be followed up for monitoring.

[Fig. 3] shows representative images of the case procedures.

Fig. 3 A representative case (37-year-old man) of DuraGen application.

Case 2

A 62-year-old man with a history of chronic obstructive pulmonary disease (COPD), likely caused by chronic cigarette (bidi) smoking, underwent surgery to repair a D6 intradural extramedullary (IDEM) tumor. Before surgery, the patient was prescribed active chest and breathing exercises.

The surgery was performed via a transthoracic approach. An implantable diaphragmatic contraction device was placed on the operated side to assist with diaphragmatic function. The surgical team recognized the importance of maintaining good lung function in this patient with COPD and initiated active chest physical therapy with breathing exercises as early as POD 1.

Unfortunately, on POD 5, the intercostal drainage (ICD) showed a frank CSF leak. This situation presented a dilemma because breathing exercises were crucial for the patient's COPD management, but these exercises might have worsened the CSF leak. To address the CSF leak, the breathing exercises were temporarily halted, and acetazolamide tablets (Diamox) were started to manage the fluid buildup. The medical team also involved chest physicians and physical therapists to create a revised COPD management plan that minimized the risk of further CSF leakage.

By POD 10, the CSF leak had significantly decreased, allowing for the removal of the ICD. However, the patient developed rapid-onset bronchopneumonia, which led to respiratory failure and ultimately death.

Discussion

This study sought to address a critical gap in the current application of dural substitutes in cranial and spinal neurosurgery. Evidence from a sample of 50 patients in which the bovine pericardial patch and DuraGen patch were used for repairing dural defects at a government hospital in India showed that the choice of dural substitute depends on the location of the dural defect. While both sutureless and sutured grafts offer effective solutions for the repair of dural defects, their specific advantages guide selection.

The native bovine pericardium possesses a three-layered structure, with an inner serosa composed of mesothelial cells, a middle fibrosa—the thickest layer—containing diversely oriented and wavy collagen and elastin bundles, and an outer epipericardial connective tissue layer that partly connects with the pericardiosternal ligaments.[10] Commercially available patches undergo processing to remove cells (acellular), preventing the transfer of bovine proteins. Glutaraldehyde is commonly used in the processing as it crosslinks −NH₂ groups of lysine and hydroxylysine or the N-terminus of amino acids to form amine linkages. These amine linkages form covalent bonds between adjacent proteins that are stable at physiological temperature and pH. Covalent bonding increases the patch's durability, reduces biodegradation, and minimizes antigenicity.[10]

DuraGen, in contrast, represents a next-generation approach. This dural substitute comprises purified type I collagen derived from the bovine Achilles tendon.[11] The collagen matrix serves a dual purpose: it supports the ingrowth of the patient's own fibroblasts and facilitates the formation of a fibrin clot, which is fully reabsorbed once the wound heals. The patch builds its tensile strength using the host materials as it integrates with the host, eliminating the need for suturing. The lack of need for suturing translates into several potential benefits, including reduced surgical time, minimized resource utilization, and potentially equivalent clinical outcomes compared with sutured grafts.[12] This study was designed to investigate these possibilities by directly comparing the outcomes of sutureless DuraGen with sutured bovine pericardial patches. Overall, the success rate with the sutureless DuraGen graft was higher than that with the sutured bovine pericardial graft (92 vs. 80%).

Among the cranial tumor cases, one case of a large recurrent meningioma in the DuraGen group was considered a failure. Here, the defect was so large that even the largest available (7 × 7 cm) DuraGen graft was not sufficient. To bridge the gap, two grafts had to be placed side-by-side. This is what probably led to failure because, in the case of sutureless grafts, establishing a good host–graft interface is critical, and graft–graft integration is weak in the case of sutureless grafts. In contrast, for sutured grafts, even the graft–graft interface is good since they do not require host materials to reach the blood supply and establish good integration. Among all our cases, this was the only case in which we had to suture two pieces of the bovine pericardial patch to achieve successful integration. This case highlights the potential limitations of sutureless grafts in situations with very large dural defects.

It is important to note that in cases in which emergent fronto-temporo-parietal (FTP) decompressive craniectomy was needed, DuraGen was used to achieve excellent results. In these situations, it is not desirable to prolong surgery by suturing the edges. Use of the sutureless DuraGen patch in these cases was, therefore, beneficial and successful.

Early-onset meningitis is a complication typically associated with CSF leakage. In a nationwide study from the Netherlands, 71% of the patients who experienced recurrent meningitis had a known CSF leakage.[13] In this regard, another very important observation about the use of DuraGen in this study is that even in the case of CSF leakage after DuraGen application, the patients did not develop meningitis immediately. However, three patients with cranial tumors in the sutured graft group experienced complications involving CSF leaks and subsequent meningitis. The first case in the sutured group was of an elderly, underweight, and impoverished woman with a left sphenoid wing meningioma. The second case was of an elderly woman with an operated cerebellopontine angle schwannoma with postoperative high intracranial pressure. In both these cases, meningitis of rapidly increasing severity developed immediately after the onset of the CSF leak. Now, whether meningitis was the cause of the failure or the failure of reconstruction led to meningitis, there was potentiation of the meningitis in this group. The bovine pericardial patch is reported to cause an inflammatory epicardial reaction in cardiac surgeries due to the presence of some native animal tissue.[14] [15] DuraGen has a decreased inflammatory potential because it is just a collagen extract with lesser chances of native animal tissue being present in the patch.

The third case of cranial tumor in the bovine pericardial patch group involved a CSF leak from a resected fourth ventricle epidermoid. However, we took early action to prevent the development of meningitis. Our strategy included promptly ruling out high intracranial pressure, initiating acetazolamide treatment, and employing a highly aggressive course of antibiotics (Diamox). This swift intervention likely played a crucial role in preventing meningitis.

All cases of spinal tumors in the bovine pericardial patch group were considered successful, whereas 80% of spinal cases in the DuraGen group were successful. There was one case of spinal microdiscectomy in which the initial application of DuraGen after tumor resection failed and the application of a bovine pericardial patch produced better results and another case of D6 IDEM in which DuraGen failed to repair the dural defect. The first case of failure could be because of early mobilization and the second case because of breathing exercises. In spinal cases, early mobilization and breathing exercises can hinder the repair using DuraGen by not allowing enough time for the native inflammatory reaction to provide strength to the sutureless graft and hence time for integration. In these cases where early mobilization or breathing exercises are needed, it is desirable to use sutured grafts, which have maximal tensile strength because of externally applied sutures and need less time for integration. Similarly, we recommend using the bovine pericardial patch in FMD or craniovertebral junction (CVJ) surgery cases, wherein we observed 100% success.

DuraGen proved to be an excellent choice for skull base defect repair when suturing the patch is not feasible. We achieved a 100% success rate using DuraGen in three transnasal transsphenoidal pituitary surgery cases.

In our cases, overall, impaired wound healing, development of high intracranial pressure, and poor nutritional status were responsible for case failure. There was no observed influence of sex on the success of patch application. Sutureless grafts offer faster application times and potentially eliminate the need for additional suturing during the primary surgery. There are no significant differences between the cost of sutured and sutureless grafts of the same size, and the choice between sutured and sutureless grafts depends on the specific surgical needs. Our observations regarding the sutureless DuraGen substitute are presented in [Table 2]. We highlight that the findings presented in this article are based on our experience at a single center and that one cannot assume nonsuperiority of sutured autologous grafts, given the circumstantial nature of the evidence.

Table 2 Advantages of using the sutureless DuraGen dural substitute and precautions to be taken

Pros	Precautions
• The patch is fully reabsorbed once the wound heals	• Sutureless grafts may not be suitable for repairing very large dural defects
• The patch builds its tensile strength using the host materials as it integrates with the host, eliminating the need for suturing	• Graft–graft adhesion may not be optimal and may lead to CSF leakage; use of multiple adjacent patches is not recommended
• No suturing translates into reduced surgical time, making these sutureless substitutes suitable for emergency situations where rapid surgical decompression is required	• Early mobilization may hinder host–graft integration
• No suturing also means minimized resource utilization
• DuraGen is associated with reduced risk of infections after CSF leakage, if it does occur

Abbreviation: CSF, cerebrospinal fluid.

Conclusion

Sutureless grafts allow for shorter surgery times, which can be beneficial for procedures like lax duraplasty with FTP decompression in cases of brain edema. For skull base defects where suturing the patch is difficult due to location, sutureless grafts offer a viable solution. Sutureless grafts pose a lower risk of infection and meningitis progression compared with sutured grafts, where leaks can necessitate graft removal and aggressive treatment. However, sutureless grafts may be less effective for repairing larger defects (10 × 10 cm or larger) that require multiple patches. If a sutureless graft fails, a sutured graft can be used as a salvage procedure.

Sutured grafts provide inherent tensile strength, allowing for faster integration with surrounding tissues. This benefit is crucial in spinal and CVJ surgeries, where it facilitates earlier mobilization and breathing exercises for patients. Sutured grafts are suitable for repairing larger defects. Surgeons can use two or more pieces together to cover extensive areas.

In conclusion, both sutureless and sutured biologic grafts offer valuable advantages for different surgical scenarios. The choice between them depends on factors like surgical approach, defect size, and patient recovery needs.

Conflict of Interest

None declared.

Acknowledgments

Medical writing and editorial support were provided by Vinay Sridhar, MPharm (Pharmacology), ELS, ISMPP-CMPP, a freelance medical writer.

• References

• 1 Velho V, Hinduja M, Kharosekar H, Naik H. Role of pericardial patch in neurosurgery: institutional experience. Neurol India 2024; 72 (02) 292-296
• 2 Williams LE, Vannemreddy PS, Watson KS, Slavin KVJSNI. The need in dural graft suturing in Chiari I malformation decompression: a prospective, single-blind, randomized trial comparing sutured and sutureless duraplasty materials. Surg Neurol Int 2013; 4: 26
• 3 Rosen DS, Wollman R, Frim DMJPN. Recurrence of symptoms after Chiari decompression and duraplasty with nonautologous graft material. Pediatr Neurosurg 2003; 38 (04) 186-190
• 4 Moskowitz SI, Liu J, Krishnaney AAJON. Postoperative complications associated with dural substitutes in suboccipital craniotomies. Neurosurgery 2009; 64 (03) ons28-ons33 , discussion ons33–ons34
• 5 Danish SF, Samdani A, Hanna A, Storm P, Sutton L. Experience with acellular human dura and bovine collagen matrix for duraplasty after posterior fossa decompression for Chiari malformations. J Neurosurg 2006; 104 (01) 16-20
• 6 Litvack ZN, West GA, Delashaw JB, Burchiel KJ, Anderson VCJN. Dural augmentation: part I-evaluation of collagen matrix allografts for dural defect after craniotomy. Neurosurgery 2009; 65 (05) 890-897 , discussion 897
• 7 Maurer PK, McDonald JVJJON. Vicryl (polyglactin 910) mesh as a dural substitute. J Neurosurg 1985; 63 (03) 448-452
• 8 Stendel R, Danne M, Fiss I. et al. Efficacy and safety of a collagen matrix for cranial and spinal dural reconstruction using different fixation techniques. J Neurosurg 2008; 109 (02) 215-221
• 9 Anson JA, Marchand EPJN. Bovine pericardium for dural grafts: clinical results in 35 patients. Neurosurgery 1996; 39 (04) 764-768
• 10 Li X, Guo Y, Ziegler KR. et al. Current usage and future directions for the bovine pericardial patch. Ann Vasc Surg 2011; 25 (04) 561-568
• 11 Kshettry VR, Lobo B, Lim J, Sade B, Oya S, Lee JH. Evaluation of non-watertight dural reconstruction with collagen matrix onlay graft in posterior fossa surgery. J Korean Neurosurg Soc 2016; 59 (01) 52-57
• 12 Barton MJ, Morley JW, Stoodley MA, Lauto A, Mahns DAJNR. Nerve repair: toward a sutureless approach. Neurosurg Rev 2014; 37 (04) 585-595
• 13 Ter Horst L, Brouwer MC, van der Ende A, van de Beek D. Community-acquired bacterial meningitis in adults with cerebrospinal fluid leakage. Clin Infect Dis 2020; 70 (11) 2256-2261
• 14 Skinner JR, Kim H, Toon RS, Kongtahworn C, Phillips SJ, Zeff RH. Inflammatory epicardial reaction to processed bovine pericardium: case report. J Thorac Cardiovasc Surg 1984; 88 (5, Pt 1): 789-791
• 15 Peivandi AD, Martens S, Heitplatz B, Guseva A, Mueller KM, Martens S. Industrial processing induces pericardial patch degeneration. Front Surg 2022; 9: 881433

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Artikel online veröffentlicht:
30. Dezember 2025