Comment on Kitano, M., et al.: Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery

Ahn and Kim demonstrate a suturing technique to close dural defects after transsphenoidal and extended transsphenoidal approaches. The technique entails a specifically designed forceps to cinch the knot down in the depths of the field. The Author's used the technique in 21 consecutive patients (16 extended transsphenoidal, 5 routine transsphenoidal approaches) with good results. Overall, this is a clever technique and modification of instruments to perform this sutured closure, which is well illustrated. The technique will be of interest to surgeons who perform extended transsphenoidal surgery, in which conventional packing techniques frequently fail to prevent postoperative CSF leaks with removal of the tuberculum or planum sphenoidale (1). Of note was that their learning curve in performing this closure went from 9 hours (!) to approximately 1 hour. This is a major issue for routine transsphenoidal closure of sellar defects, in which conventional packing is rapid and effective (taking only a few minutes), and its associated postoperative leaks approach 1% when performed by experienced surgeons. The other limitation of this technique is the removal of tumors that extend laterally to involve the cavernous sinus, in which a dural cuff may not be present to place a suture, and of those of the anterior or posterior cranial base, in which it is necessary to remove more bone to enable the exposure of an adequate dural margin. The Author's have provided their valuable experience and instrumentation, which adds further to our armamentarium to effectively reduce postoperative CFS leaks with transfacial exposures.