Sellar reconstruction algorithm in endoscopic transsphenoidal pituitary surgery: experience with 240 cases

Proposing a strategy for sellar reconstruction in endoscopic transsphenoidal transsellar approach for pituitary adenoma. 240 patients with pituitary adenoma underwent pure endoscopic endonasal transsphenoidal surgery. Intra-operative CSF leaks were classified as grade 0، no observable leak; grade 1، CSF dripping through an arachnoid membrane defect of less than 1 mm; and grade 2، CSF flowing through an arachnoid defect of more than 1 mm. Sellar reconstruction was performed according to our staging system; in stage I، the defect was covered with oxidized cellulose and sphenoid sinus filled up with Gelfoam. In stage II، a layer of fat was applied on the defect and fascia lata placed epidurally. In stage III، one or two layers of fascia were used with adding surgical glue and/or lumbar drainage. Mucosa of sphenoid sinuses was kept intact as much as possible and approximated at the end of procedure. intra-operative CSF leaks grade 0، 1 and 2 resulted in 133 (55. 4%)، 78 (32. 5%) and 29 (12. 1%) patients، respectively. Stage I of reconstruction was used in 126 patients (52. 5%) with no intra-operative CSF leak or sever prolapse of arachnoid membrane. Stage II was performed in 80 patients (33. 3%) with either leak grade 1 (73 patients) or grade 0 with severe prolapse of the suprasellar components induced in the sella (2 cases) or in whom extra-pseudocapsular dissection performed (5 cases). Stage III was performed in 34 cases (14. 2%) with either CSF leak grade 2 (29 patients) or grade 1 with simultaneous severe destruction or removal of sellar floor laterally، superiorly or inferiorly (5 patients) which made it impossible to place the fascia underlay to the bone. A minimum of 18 months follow-up showed development of 2 CSF leaks (0. 8%)، one pneumocephalus (0. 4%) and 2 meningitis (0. 8%) cases. Given the low postoperative CSF leak rate، we demonstrated that our adopted sellar reconstruction strategy focusing mostly on the adopted intra-operative CSF leak grading system is safe and useful for overcoming devastating complications like postoperative CSF leaks.