O.P. Akopyan, Yu.V. Shulev, D.A. Rzaev
Municipal Multi-Field Hospital N 22, Saint Petersburg, Russia
Liquorrhea is one of the most frequent complications of skull base surgery. According to different authors, the rate of postoperative liquorrhea varies from 1% up to 3%. Difficulties of its exact estimation are connected with heterogeneity of skull base pathology, variety of approaches and methods of reconstruction. Acute postoperative liquorrhea leads to meningitis in 20-25% of cases. Development of postoperative liquorrhea, meningitis and pneumocephalus increases a period of stay in hospital and cost of treatment. One of the main surgical stages is hermetic sealing of dura and reconstruction of postoperative defects. Literature contains description of numerous methods of hermetic sealing of dura and skull base plasty (free grafts, local or regional grafts, free vascular pedicle grafts, biologic tissue glues). Today there are no unified approaches to choosing an optimum method of skull base plasty.
The goal of the present study was improving methods of skull base plasty, aimed at prevention of postoperative liquorrhea.
Materials and Methods. There were 349 patients with different tumors of a skull base and trigeminal neuralgia, operated in 1996-2004. We used transglabellar-transethmoidal (30), subfrontal-transbasal (9), transsphenoidal (8), superciliary (10), orbitozygomatic (6), transzygomatic subtemporal (11), transpyramidal (6), retrosigmoid (148), paramedian suboccipital (72) and middle suboccipital (49) approaches.
Dura sealing was performed with applying sutures in 163 cases without any additional plasty. The second group was represented by 19 cases with plasty by local vascularized grafts (periosteal graft, temporal muscle graft). The third group included 41 patients, in whom plasty was performed by free autografts (fascia, muscle). Free fat autograft (isolated or combined with biological tissue glue) was used for sealing dura and skull base plasty in 131 patients of the fourth group. This autograft was applied for plasty of small and medium defects of a skull base, as well for reconstruction of the saddle in transsphenoidal surgery. Material for plasty was taken from the gluteal area or anterior abdominal wall through a suprapubic of paraumlibical incision (2-3 cm).
Results. The analysis of different methods of dura and skull base plasty demonstrated an advantage of fat autograft, which consisted in its flexibility, ability to repeat a defect form and to fill it completely, tendency to good revascularization. It ensured full-value sealing of dura. Fat was characterized by good visualization in postoperative CT- or MRI-images, permitting to estimate a degree of tumor removal. Use of fat autograft did not demand subsequent reconstruction, when a bone defect size was less than 4 cm. Easiness of its taking and simplicity of use condition its wide spread in skull base surgery, where a depth and narrowness of a wound limit technical potentialities. This method gives a good cosmetic result. Use of free fat autograft with the purpose of dura sealing allowed to reduce the rate of postoperative liquorrhea up to 4%.
Conclusion. Free fat autograft, applied for sealing and plasty of a skull base is an effective and convenient method of isolation of subdural spaces, which makes it possible to reduce a rate of postoperative complications.