Endonasal skull base surgery (see Fig. 1) has proven to be a safe, effective, and significantly less invasive surgical approach when compared to open, highly invasive techniques [1]. Nevertheless, one initial difficulty with this minimally invasive approach has been postoperative leakage of cerebrospinal fluid (CSF) [2]. While the incidence of postoperative CSF leaks are low (<1%), the potential consequences are severe and include meningitis, brain abscess, neurologic deficits, brain hemorrhage, and death [1]. Depending on the nature of the surgery, violation of the skull base may be inevitable and is not uncommon during skull base surgery, regardless of the surgical approach. Several techniques for defect repair exist, but all are predicated on graft placement at the defect site (with the exception of the pedicled flap approach). It has been noted that, with current surgical tools, endonasal manipulation and placement of these grafts is difficult [2]. Endonasal graft placement is difficult for a variety of reasons. First, tool manipulability is severely limited by the narrow nasal passage; the surgeon's first challenge is maintaining control of the small graft (potentially as small as one mm) as the tool traverses from the nasal passage to the skull base defect. Further complicating the task of positioning this graft is the high variability in graft types (mucosa, bone, cartilage, or fascia [1]). Each of these grafts has varying rigidity, size, and thickness. Regardless of the graft's properties, the graft needs to be oriented in such a way that it optimally mates with the skull base defect to ensure full coverage or adequate fill, depending on the technique. The tools that are currently in use are either blunt instruments (with no gripping mechanism) that can be used to push the graft into place (with various curvatures) or graspers (forceps or grippers). Each of these tools has limitations; blunt instruments make holding the graft challenging as it traverses the nasal passages, and graspers make the simultaneous orienting of the graft and force application difficult. It is critical to note that these tools are not designed for endonasal graft placement. They are being used because, currently, there is no better solution.
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