Endonasal Diaphragmatic Suturing for Restoration of Native Anatomical Layers: Technical Note.

Preventing postoperative cerebrospinal fluid (CSF) leakage in the presence of high-flow intraoperative leakage remains one of the most challenging issues in endoscopic transsphenoidal surgery (ETS), even when multilayered skull base reconstruction is performed1-5. Recent reports on dural suturing in ETS have revealed the importance of restoring native anatomical barriers, demonstrating very low postoperative leakage rates when primary closure is achieved6-11. Based on this concept, we applied direct suturing of the diaphragma sellae to immediately reconstruct the perforated arachnoid barrier and obtain real-time control of intraoperative CSF leakage12. In this video, we present a representative case in which diaphragmatic suturing successfully stopped high-flow leakage during tumor removal, enabling secure reconstruction and uneventful postoperative recovery. We further describe a consecutive series of four patients who underwent this technique; in all cases, intraoperative leakage resolved immediately after suturing, without deterioration of pituitary function or additional complications. Gross total resection was consistently achieved, and postoperative courses were favorable. In all four cases, multilayered reconstruction was performed, and no postoperative CSF leakage occurred. Direct diaphragmatic suturing offers an anatomically reasonable and rapid method for managing high-flow intraoperative CSF leakage, providing a valuable strategic option when conventional reconstruction alone is insufficient. This approach may result in postoperative patient comfort and recovery by enabling reliable intraoperative control of CSF leakage and reducing dependence on extensive nasoseptal flaps, or prolonged lumbar drainage.