Mastering continous dural closure with Mycro

Why dural closure matters

Whenever dura mater is opened, cerebrospinal fluid (CSF) leakage poses a significant risk during cranial and spinal neurosurgical cases. Potential complications arising from CSF leakage encompass persistent CSF fistula, pseudo-meningocele formation, or secondary infections such as meningitis or cerebritis. These complications can significantly elevate morbidity and mortality rates, prolong hospital stays, and escalate healthcare costs. [1]

This is why careful dural closure planning is crucial to minimize complications.

In clinical practice, a multitude of sutures techniques and grafts are utilized, with new materials being continually introduced. Whenever possible, autologous grafts remain the preferred choice due to their biocompatibility and lower infection risk. However, the existing literature remains inconclusive regarding the use of one technique (autologous vs non-autologous graft) over the other. [2].

This blog post guides medical students and residents on mastering continous cranial dural closure using Mycro Kit, Training system for anastomoses and microsutures, focusing on step-by-step training and common errors to avoid.

Mycro | Training Kit for Anastomoses and Microsutures by UpSurgeOn

Step-by-step continuous dural closure

1. Preparation

Gather your material:  

  • Needle holder
  • Scissors
  • Forceps
  • Suture material
  • Mycro Kit with Brain Pod and Dural Membrane on top of it

2. Place cardinal sutures

To create cardinal suture, place four square knots as explained below to the north, south, east, and west as in a compass.

  1. Grasp the needle holder in your dominant hand and firmly secure the needle at about two-thirds of its length.
  2. Use your non-dominant hand with forceps to elevate the dura on the opposite side of the planned suture site, providing clear visualization.
  3. Insert the needle perpendicularly through one dural edge roughly 0.5 cm centimeter away from the edge (ideally, half the needle length). Follow the needle’s curvature to ensure it penetrates dura-
  4. Grasp the opposing dural edge with forceps and pass the needle through it at a corresponding point, maintaining the same distance and perpendicular angle used on the first side.
  5. Create a square knot.
  6. Repeat for each of the cardinal suture.
Microsuture on Mycro Training Kit

3. Proceed with Uninterrupted Continous Suture

As already explained here, beginning from the lowest point fo surgical field work your way upwards to proceed with uninterrupted continous suture.

  1. Place a square not but cut only one of the suture ends close to the knot, leaving a short tail.
  2. Grasp the needle with the needle holder in the dominant heand and insert it again perpendicular to the dura. With a fluid motion of the wrist, rotate the needle through the dermis and exit the needle on the skin simmetrically on the contralateral side.
  3. Repeat: Continue placing stiches, each one incorporating the previous suture loop, until you have closed the whole dural opening.
  4. Place a square knot at the end.

Remember: Equal needle bites of depth and distance from the wound should be taken to allow wound edges to oppose equally and neatly.

Common errors

  • Needle Selection: Choose an atraumatic needle (designed to minimize tissue damage) to minimize dural tears.
  • Needle Mounting: Mount the needle 3/4 of the way from its base for optimal control and maneuverability.
  • Suture Tension: Avoid excessive pulling on the suture, as this can lead to dural stretching and potential leakage.
  • Suture Placement: Begin at the lowest point in the surgical field and work your way upwards.
  • Suture Pattern: Start with well-placed cardinal sutures (corner anchor points) before proceeding with a continuous running suture.
Example of continuous microsuture performed on Mycro Training Kit

Conclusion

Dural closure is a cornerstone skill for neurosurgeons. Here’s a roadmap to mastering the simple running suture:

1. Deepen Your Understanding:

  • Indications: Train yourself to recognize when one technique should be used over the other.
  • Common Errors: Recognize potential pitfalls to avoid during the process.

2. Hone Your Skills:

  • Practice Makes Perfect: Regular practice on Mycro could be key. The more you practice, the more comfortable you will become.

3. Elevate Your Practice:

  • Track Your Progress: Record your practice sessions to monitor your improvement and identify areas needing further work.
  • Seek Expert Guidance: If possible, seek feedback from experienced practitioners who can offer valuable tips and identify areas for refinement.

By following these steps and dedicating time to practice, aspiring surgeons, nurses, and medical students can develop the dexterity and confidence needed to perform sutures with precision. This, in turn, contributes to positive patient outcomes and optimal wound healing.

References

[1] Carretta A, Epskamp M, Ledermann L, et al. Collagen-bound fibrin sealant (TachoSil®) for dural closure in cranial surgery: single-centre comparative cohort study and systematic review of the literature. Neurosurg Rev. 2022;45(6):3779-3788. doi:10.1007/s10143-022-01886-1

[2] Ebel F, Wanderer S, Jesse CM, et al. A standardized model for in vitro testing of sutures and patches for watertight dural closure. J Neurosurg. 2021;136(5):1485-1494. Published 2021 Oct 8. doi:10.3171/2021.5.JNS21369

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Mastering continous dural closure with Mycro

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