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

BACKGROUND AND OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.