Vertical Vector Surgical Knot in Endoscopic Endonasal Surgery and Repair: An Exonasal Knot for Endonasal Application

Developing innovative surgical approaches through narrow anatomic corridors requires continual adaptation surgical techniques and maneuvers. Regarding skull base surgery, endoscopic endonasal approaches have become extremely popular, resulting in lower patient morbidity, without sacrificing clinical outcomes. Although surgical approaches have changed dramatically over the last few decades, suturing and knot tying in these narrow corridors have not been developed at the same pace. Endoscopic repair of skull base defects after endoscopic endonasal surgery is often achieved with 90–95% success through multilayered reconstruction with a variety of grafts or flaps, sealants, and possibly sinonasal packing to avoid postoperative cerebrospinal fluid leaks. These high success rates are achieved without any direct suturing of the grafts/flaps to adjacent tissues. In some situations, perhaps suturing could limit the risk of graft/flap migration, and increase the chance of graft/flap water-tight closure and integration. The utility of endonasal suturing of grafts/flaps is largely unknown because intranasal geometry restricts the hand and instrument movements needed to achieve traditional surgeons’ or square knots. The current study demonstrates a suturing technique resulting in a facile surgical knot through vertical vector motions, making it an ideal candidate when operating through narrow corridors. The advantages of this technique are its cost-effectiveness, the ability to use any type of needle or suture for tissue approximation, and the elimination of horizontal vectors and maneuvers which are limited in endonasal. This facile knot can be employed during endoscopic endonasal surgery potentially to facilitate watertight closure in scenarios where it is felt necessary or when repairing vascular structures.