Optimizing dural opening and closure in endonasal transsphenoidal surgery: Technical considerations for incision...

Dural opening and closure represent a crucial yet under-discussed aspect of transsphenoidal surgery (TSS), where the operative field is narrow and cerebrospinal fluid (CSF) leakage remains a significant complication. In 2010, we abandoned the conventional cruciate dural incision and began developing optimized designs that provide wide exposure, minimal interference, and facilitate watertight closure. After investigating various incision types, we empirically established a modified H-shaped dural incision in 2011. This design minimizes the interdural gap, enabling effective dural flap tenting and suturing, and has since become our standard dural incision in TSS. Planar geometrical analysis further supported this design as optimal, demonstrating that it requires the shortest total incision length among the evaluated techniques. Additionally, a combined Y and upside-down T-shaped incision proved effective for extended TSS, while sideways Y-shaped and straight incisions were advantageous in cases where a large dural window was unnecessary. Between 2011 and 2022, we applied tailored dural incisions in 628 endonasal TSS, with selection based on tumor type, location, and extent. The modified H-shaped incision was the most commonly used (61.0%), particularly in midline non-functioning pituitary neuroendocrine tumors. Compared with the cruciate incision, it reduced the total incision length and did not increase the postoperative CSF leakage rate (1.91%, vs. 0.48%, p = 0.019). Our findings suggest that strategic selection of dural incision designs, combined with primary dural suturing, improves intraoperative handling and reduces postoperative complications. These results highlight the need to re-evaluate traditional dural opening techniques in the era of high-definition endoscopic and extended TSS.