Suturing and Closure of Diaphragma Sella to Augment Sellar Floor Repair after Endonasal Endoscopic Resection of Large Pituitary Adenoma.

Large pituitary adenoma often pushes the diaphragma sella and extends to the suprasellar compartment. The thinned out diaphragma may get opened during endonasal endoscopic surgery and pose high risk for cerebrospinal fluid (CSF) leak. Such larger defects are difficult to plug with fat graft that tends to slip in to the subarachnoid space. Here, we describe a unique technique of closure of diaphragma sella that augment repair of the skull base in such cases.  The free edge of diaphragma sella was sutured with the anterior tuberculum sella dura in five cases of large pituitary adenoma that needed extra arachnoidal resection. Suturing was done with 6-0 prolene using endoscopic needle holder that converted a large diaphragm defect in to a smaller arachnoid rent and was easily plugged with fat graft.  None of these patients had postoperative CSF leak.  Though technically difficult, direct repair of the diaphragma sella is possible. This augments the skull base reconstruct and effectively reduces the chances of postoperative CSF leak.