Endonasal Suturing of Nasoseptal Flap to the Nasopharyngeal Fascia Using the V-Loc Wound Closing Device

Background Cerebrospinal fluid (CSF) leak after an endoscopic endonasal approach to intradural pathologies remains one of the more common complications. Various closure techniques have been developed with success at mitigating this risk. Endonasal suturing of graft materials offers the advantage of creating a watertight seal to promote healing and assist in preventing postoperative CSF leaks. We present the first case using the V-Loc wound closing device (Covidien, Dublin, Ireland) to successfully seal off a postoperative CSF leak.

Methods We present the first case of a 42-year-old man who presented with headaches and partial left sixth nerve palsy and was found to have a clival mass with intradural extension. He underwent partial resection at an outside hospital. He was subsequently referred to our facility for further tumor resection. His second surgery was a gross total resection; however, he developed a postoperative CSF leak. It was found that the leak was occurring at the lower end of our reconstruction and suturing the nasoseptal flap to the nasopharyngeal fascia would be beneficial. Using the V-Loc system and a lumbar drain, a watertight seal was created and the patient healed successfully without further leaking.

Results CSF leakage after the expanded endonasal approach to intradural pathology is one of the most common complications. Improvements in technique have improved outcomes; however, further improvements can be made. Endonasal suture is difficult given limited access and limited equipment. Difficulty arises particularly with tying knots. The absorbable V-Loc system mitigates some of these problems because it does not require the surgeon to tie knots. The suture is barbed and is tightened by threading the needle through a prefabricated loop at the end of the suture which locks in place. Furthermore, each throw of the suture through tissue maintains the tightness of the seal as the barbs catch the tissue and prevent pulling out. After successful closure, the needle can be simply cut off and the wound remains sealed.

Conclusion The V-Loc wound closure system is a safe and effective method to correct postoperative CSF leaks after endoscopic endonasal skull base surgery. This device could be used as an adjunct to other closure techniques to prevent postoperative CSF leaks.