Paper: Endoscopic reconstruction of large anterior skull base defects with opening of the sellar diaphragm. Experience at a tertiary level university hospital.

Review: This paper caught my eye as it speaks of repairing large defects endoscopically.  However, most cases are trans-sphenoidal approaches, and I wonder how large they could be?   The size of the defects has not been quantified.  Gasket closure for anterior skull base defects is not a new thing.  However, authors have made three unique contributions.  One, they have added another layer of fascia lata.  The addition of another layer seems to has not bitten into their surgical time.  However, placing fascia lata inlay graft amidst CSF pulsations is fun.  For me, it’s like an amateur center-forward trying to score a goal, and there two (not one) world-class professional goalies trying to prevent you!  LOL! Two, they have used the middle turbinate flap.  This is my favorite one.  I have seen a few surgeons sacrificing the middle turbinate during trans-sphenoidal surgery.   It can eliminate all the morbidities of the naso-septal flap.  We can use the middle turbinate flap for primary closure and keep the Hadad flap for revisions! LOL!  Three, they rejected (the dreaded) Fogarty balloon catheter.  I always hated the Fogarty balloon and all the inconvenience it caused to the patients.  One crucial point to be noted here is, the Fibrin glue is sprinkled over the mucoperiosteal flap and not underneath it.  Fibrin glue is not a Fevicol gum! It is our earlier personal experience also that, Fibrin glue can prevent adhesion formation and sealing of the CSF leak when used under the mucoperiosteal flap.  I liked it anyway.     

Dr. Prahlada N.B