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

background: proposing a strategy for sellar reconstruction in endoscopic transsphenoidal transsellar approach for pituitary adenoma. methods: 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. result: 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. conclusion: 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.