Regenerated Oxidized Cellulose as a Sealant and Adhesive in Endoscopic Endonasal Skull Base Reconstruction

Abstract

Introduction An ideal and long-lasting adhesive and sealant is essential during endoscopic endonasal skull-base surgery to hold the reconstruction intact and prevent cerebrospinal fluid (CSF) permeation until complete healing occurs. Fibrin glue is the most common material used. Regenerated oxidized cellulose (ROC) has not been mentioned in the literature as sealant and adhesive, and, hence, we intended to study this role. Objective To evaluate the role of ROC as tissue sealant and adhesive in the reconstruction of skull-base defects in endoscopic endonasal skull-base surgery. Methods We retrospectively analyzed the medical records of patients who underwent endoscopic endonasal skull-base surgery with skull-base defect and intraoperative CSF leak, for which reconstruction was performed using fibrin glue or ROC, or both, as a sealant and adhesive. The type of sealant and adhesive used and postoperative CSF leak rates with different agents used were analyzed. Results A total of 64 patients were investigated. Fibrin glue alone was used initially in 6 patients, of which 4 (66.6%) experienced postoperative CSF leak. Both fibrin glue and ROC were used in 26 patients, among which 2 (7.6%) exhibited postoperative CSF leak. Regenerated oxidized cellulose alone was used in 24 patients, wherein 2 (8.3%) presented with postoperative CSF leak. Fibrin glue alone was once again used later in the learning curve in 8 patients, of which 2 (25%) experienced postoperative CSF leak ( p = 0.002). Conclusion Fibrin glue provides intraoperative watertight seal. Regenerated oxidized cellulose has better intraoperative and long-term sealant and adhesive action in endoscopic endonasal skull-base reconstruction.

Keywords: CSF leak; Surgicel; regenerated oxidized cellulose; tissue adhesive; tissue sealant.

Fig. 1

A case of suprasellar meningioma for which endoscopic transplanar, tubercular approach was performed. ( A,B ) Preoperative magnetic resonance imaging scans. ( C ) Tumor dissection. Abbreviations: T, fibrous tumor; ON, right optic nerve. Note: white (<), right supraclinoid internal carotid artery. ( D,E ) Posttumor removal. Abbreviations: A1R, A1 segment of right anterior cerebral artery; A1L, A1 segment of left side; ACOM, anterior communicating artery; GR, gyrus rectus; LO, left optic nerve; OC, optic chiasma, RO, right optic nerve, S-P, pituitary stalk. Note: white (>), left superior hypophyseal artery. ( F,G ) Hadad flap with single layer of Surgicel used mainly at the margins to adhere the flap to the underlying bone. ( H ) – One-month postoperative cavity showing the mold of crust and the flap incorporated with a healthy mucosal healing. ( I,J ) Postoperative day 1 computed tomography scan showing complete excision of tumor.

Fig. 2

( A–C ) A case of sellar, suprasellar secreting pituitary macroadenoma, resected by transsellar approach; however, there was a small rent in the tuberculum dura causing cerebrospinal fluid (CSF) leak while cauterizing a superior intercavernous sinus bleed. A three-layered reconstruction was done with fibrin glue alone as sealant/adhesive. The patient had postoperative CSF leak following pack removal on day five, for which a CSF leak repair revision was done using Surgicel and fibrin glue as sealant/adhesive. ( A ) Primary surgery where only fibrin glue was used as sealant/adhesive over the three-layered reconstruction. ( B ) Revision surgery showing the site of leak at the level of tuberculum sellae anterior to the superior intercavernous sinus. Notes: white (<), site of leak; white (^), superior intercavernous sinus. ( C ) Surgicel and fibrin glue were used as sealant/adhesive. ( D–F ) A case of sellar suprasellar growth hormone secreting pituitary macroadenoma with right Knosp 2 cavernous sinus involvement, resected by transsellar approach, three-layered reconstruction with the last layer as a Hadad flap, and then Surgicel alone used as sealant/adhesive. ( D ) Notes: black (*), right cavernous internal carotid artery; black (<), posterior compartment of cavernous sinus; white (<),superior compartment of right cavernous sinus.

Fig. 3

( A,B ) Hadad flap in position as a third layer in a transsellar approach and secured with Surgicel alone as sealant/adhesive. ( C ) Three weeks postoperative picture. Note: black (>), showing the incorporation of the margins of the flap. The mold of crust can be seen separating on its own. ( D ) A 1.5-cm left cribriform defect with spontaneous cerebrospinal fluid leak reconstructed with three layers and held in position with Surgicel and fibrin glue. ( E ) Six weeks postoperative picture. Note: black (>), shows flap incorporation and mucosalization.

Fig. 4

( A ) – Magnetic resonance imaging (MRI) coronal view of a case of growth hormone secreting sellar, suprasellar pituitary macroadenoma with Knosp 2 left cavernous sinus involvement. ( B ) Post complete excision of tumor. Abbreviation: D, descended diaphragm. Note: Black (^), small rent in the diaphragm due to removal of tumor firmly adherent to the diaphragm. ( C ) Left cavernous sinus. Notes: black (*), left cavernous ICA; black (>), superior compartment of left cavernous sinus. ( D,E ) Three-layered reconstruction with Surgicel alone as sealant/adhesive. ( F ) Six months postoperative endoscopic view showing complete mucosalization. ( G ) Six months postoperative MRI showing. Note: white (^), flap incorporation, descended normal pituitary gland, and stalk.

Fig. 5

( A ) - A case of bilateral spontaneous cerebrospinal fluid (CSF) leak with complete cribriform plate defect. Notes: black (*), cribriform defect; black (^), right frontal sinus. ( B,C ) Three-layered reconstruction with fat, fascia lata, and Hadad flap with Surgicel alone used as sealant/adhesive. ( D ) Posttraumatic right side posterior table of frontal sinus encephalocele with active CSF leak. Note: black (^), encephalocele. ( E ) Encephalocele reduced. Note: black (^), margins of bony defect. ( F ) Three-layered reconstruction with Surgicel alone as sealant/adhesive.