The dural closure for the retromastoid craniotomy depends upon what kind of pathology was handled through this approach. If the retromastoid craniotomy was performed for microvascular decompression surgery, typically the operative field is very pristine, not much intradural bleeding is encountered and watertight dural closure is not necessary and this philosophy leads to a very minimal risk of postoperative CSF leak through the nose or mastoid air cells. However, if the retromastoid craniotomy was performed for resection of tumors or other pathologies, a watertight dural closure is necessary since the increase of protein or blood release in the intradural cavity during the surgery increases the risk of post operative higher CSF pressures and the chance for a CSF leak. In this video, I'm going to show a typical dural closure for either a tumor or microvascular decompression surgery. You can see the dura was initially opened along the dural sinuses along the transfer singuloid sinus. After the procedure was completed, the dura was closed in using intermittent non-absorbable 3-0 sutures. Please note that opening the dura along the dural sinuses leaves most of the dura over the cerebellum and protects the dura from the intense light of the microscope, and therefore leads to less risk of dural shrinkage and a better and more watertight dural closure can be completed. Importantly, all the mastoid air cells have to be waxed before dural opening and after dural closure. In other words, wax in and wax out. Wax on the way in and wax on the way out.
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