Four-Leaf Clover-Shaped Dural Closure Using a Knotless Barbed Suture in Endoscopic Transsphenoidal Surgery

Several literatures reported that suturing dura was reliable in preventing postoperative cerebrospinal fluid (CSF) leak in transsphenoidal surgery. However, suturing and knotting is technically challenging and time consuming in the transsphenoidal approach. We herein introduced the barbed suturing technique in endoscopic transsphenoidal surgery to simplify the dural suturing procedure. We just sutured the four corners of the cross incised dura using a knotless barbed suture. The shape of the sutured dura liked a four-leaf clover ([Fig. 1]). Since August 2015, we have been using the barbed sutures for dural suturing in 21 cases underwent endoscopic transsphenoidal surgery. We found that dural closure using a knotless barbed suture was easy to master and significantly shorten the suturing time. Intraoperative CSF leakage was graded based on Kelly’s classification. Intraoperative CSF leak was encountered in 11 patients. Three of them were high-flow CSF leak. In the cases of low-flow CSF leak (grades 1 and 2), dura was sutured using a barbed suture. In the cases of high-flow CSF leak (grade 3), multilayered reconstruction including four-leaf clover-shaped dural suture was performed. None of these cases developed into postoperative CSF leak. Four-leaf clover-shaped dural closure using a knotless barbed suture is a simply and reliable technique in endoscopic transsphenoidal surgery.

Fig. 1 The diagram of dural suturing using a knotless barbed suture. (A) The first stitch at the top left corner was secured by passing through a looped end. (B) Suturing 4 corners of the sellar dura in the anticlockwise sequence (1–4). The last stitch returned to the top left corner (5). The intraoperative screenshots of dural suturing using a knotless barbed suture. (C) The cross-incised dura. (D) The first stitch at the top left corner. (E). The four corners were stitched together. No knot was made in the suturing procedure.