Introduction: Endoscopic skull base and pituitary surgery provides a unique set of technical challenges that must be overcome while progressing along the learning curve. Currently, there is no known simulation model for endoscopic surgical repair of skull base cerebrospinal fluid (CSF) leaks. We developed a reproducible and realistic training environment to prepare neurosurgical trainees for management of CSF leak during endoscopic endonasal surgery.
Methods: Cadaveric dissections were performed at the USC/Keck School of Medicine Fresh Tissue Dissection Laboratory. A perfusion pump was used to infuse fluorescein-dyed saline intrathecally through a cervical laminectomy and durotomy to reconstitute the ventricular and subarachnoid spaces. A standard endonasal approach to the sellar region was performed. After initiation of perfusion using fluorescein-dyed saline, a CSF leak was created in the suprasellar arachnoid. Trainees repaired the CSF leak using a combination of fat, fascia lata, and pedicled naso-septal flaps. A 5-point questionnaire was used to assess pre- and post-training confidence scores.
Results: Intrathecal perfusion of saline with fluorescein into the ventricular and subarachnoid spaces served as a successful and realistic model for intraoperative CSF leak. Residents developed the psychomotor skills required to achieve CSF leak repair using fat and fascial grafts, in addition to preparation and rotation of vascularized naso-septal flaps. Fluorescein was useful in confirming adequate repair of the CSF leak. All trainees reported a realistic experience enhanced by addition of the perfusion model.
Conclusions: As endoscopic skull base surgery continues to rapidly evolve, achieving competency in skull base reconstruction and repair of high flow CSF leaks will be an increasingly essential component of the neurosurgical training process. The addition of a fluorescein-dyed intrathecal perfusion system to a cadaveric simulation scenario is among the most realistic training models available for developing CSF-leak repair skills using various grafts and pedicled naso-septal flaps.
Patient Care: This research will improve surgical training thereby improving patient care
Learning Objectives: Creation and validation of a training model for CSF leak repair