Bimanual Two-Forceps Fascia Patchwork Closure for Skull Base Reconstruction in Extended Transsphenoidal Surgery

Deep fascia suturing for skull base reconstruction after extended transsphenoidal surgery (eTSS) remains a technically demanding yet essential step, especially in cases with high-flow intraoperative cerebrospinal fluid (CSF) leaks. Although single-hand techniques with concurrent suctioning are standard, we developed a bimanual two-forceps fascia patchwork closure (BM-FPWC) method to enable precise, efficient deep suturing using both hands. This study aimed to describe the BM-FPWC technique and evaluate the operative time and learning curve associated with the procedure through retrospective analysis.

Among 120 eTSS cases at Toranomon Hospital between June 2024 and January 2025, 34 patients with intraoperative CSF leaks (Esposito grade ≥2) underwent BM-FPWC. Suturing was performed endoscopically using a needle holder and bayonet forceps with both hands, enabled by an endoscope-holding arm. Suturing time and failure rate were compared between earl (n = 17) and late (n = 17) phases to assess the learning curve.

No postoperative CSF leaks were observed. Mean suturing time was significantly reduced from 58.4 ± 11.1 minutes (early phase) to 44.6 ± 15.8 minutes (late phase, P = .0075). The number of failed stitches was also significantly lower in the late phase (P = .0409), whereas the total stitch count remained unchanged.

BM-FPWC is a safe, efficient, and reproducible technique for skull base reconstruction in eTSS. With experience, the procedure becomes faster and more reliable, suggesting its potential as a standard method for bimanual deep suturing in endonasal skull base surgery.