Fascial sling technique for dural reconstruction after translabyrinthine resection of acoustic neuroma: technical note

Abstract

<jats:p>Reconstruction of presigmoid dural defects after resection of acoustic neuromas via the translabyrinthine approach is paramount to prevent postoperative CSF leakage. However, primary dural reapproximation and achieving a watertight closure of the dural defect in this anatomical region are quite difficult. Standard closure techniques after the translabyrinthine approach often involve packing an abdominal fat graft that plugs the dural defect and mastoidectomy cavity. This technique, however, may pose the risk of direct compression of the fat graft on the facial nerve and brainstem. Nonetheless, even with the evolution in dural repair techniques, postoperative CSF leaks can still occur and provide a route for infection and meningitis. In this report, the authors describe a novel dural “sling” reconstruction technique using autologous fascia lata to repair presigmoid dural defects created after translabyrinthine resection of acoustic neuromas. The fascia lata is sewn to the edges of the presigmoid dural defect to create a sling to suspend the fat graft within the mastoidectomy defect. A titanium mesh plate embedded in porous polyethylene is secured over the mastoidectomy defect to apply pressure to the fat graft. In the authors' experience, this has been a successful technique for dural reconstruction after translabyrinthine removal of acoustic neuromas to prevent postoperative CSF leakage. There were no cases of CSF leakage in the first 8 patients treated using this technique. The operative details and preliminary results of this technique are presented.</jats:p>

Anatomical and computed tomographic analysis of the transcochlear and endoscopic transclival approaches to the petroclival region

“…Using current techniques, the transcochlear and the EEA are limited in options for reconstruction. Both come with the risk of CSF leak if surgical lesions are not reconstructed properly . Watertight closure of dural defects involved with transcochlear approaches are never achieved.…”

“…However, this can produce compression of CN VII, and if CSF leaks do occur they provide conditions for infection and meningitis. 22,24 With the EEA, reconstruction techniques have improved the occurrence and management of CSF leaks. The pedicled nasoseptal flap is preferred for the closure of the surgical corridor in the majority of cases, although sufficient planning must be employed to preserve the flap.…”

Comparative surgical anatomy of endoscopic and open approaches to the skull base

“…The maxillary sinus was identified as a natural surgical corridor to access the nasal cavity, orbit and the infratemporal fossa. A classical or modified Caldwell-Luc approach has been used for the surgical treatment of chronic maxillary sinusitis, and to provide access for a vidian neurectomy, ligation of the internal maxillary artery, orbital decompression and access to the retro-bulbar space [21,22]. However, the advent of endoscopic sinus surgery diminished the use of the Caldwell-Luc considerably [21].…”

“…The removal of a pterional bone flap requires a large incision to the head and potentially altering the aesthetic appearance. 7,15,22 With EEA there are no externally visible incisions, as all of the surgery is done within the nasal cavity. The minimally invasive nature of the surgery leaves the face and head without the need for cosmetic repair.…”

“…In certain cases, this can eliminate the possibility of en bloc excision of the tumor. 10,22 To avoid seeding of the cancer to the surrounding tissue, en bloc tumor removal has been preferred in malignant cases.…”