SURGICAL TECHNIQUE

Powered Endoscopic Dacryocystorhinostomy

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Presented by Peter John Wormald, MD, FRACS, FRCS, FCS (SA)

04.01

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Registered marks of Medtronic Xomed, Inc. 891199

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

Powered Endoscopic Dacryocystorhinostomy

Philosophy
Endoscopic DCR is now an accepted treatment of epiphora for both anatomical and functional obstruction in the lacrimal system.1-4 It has a number of significant advantages over the traditional external DCR.2-3 It does not require a facial incision and does not disrupt the pump action of the orbicularis oculi muscle that helps the movement of tears from the eye to the lacrimal sac. In addition, the medial canthal ligament of the eye is not disrupted.2-3 For a large proportion of studies, the success rates of the external and endoscopic DCRs have been comparable.2,4,5 However, recent reports suggest that the success rate of endoscopic laser DCR is not as good as that of external DCR or cold steel DCR.1,3,7 Reports using the Holmium YAG laser and the KTP laser have shown success rates of around 65% to 80%, while those using cold-steel have been around 80 to 90%.1-7 Laser DCR creates a small ostium in the sac as well as a circumferential tissue injury. This combination contributes to a higher closure than the wide opening created with cold steel endoscopic DCR. The size of the ostium is thought to be important for the outcome of DCR surgery, with the creation of a small ostium being cited as the major cause for external DCR failure.6 This has been further corroborated by noting that the success rate with small cicatrized sacs are much lower than those for mucocoeles. However, there still remains a difference between the best results of cold-steel endoscopic DCR (85-90%) and external DCR (95%). Recent research has shown that the current depiction in the literature of the intra-nasal anatomy of the lacrimal sac is incorrect. These illustrations show that the top of the sac is located at the insertion of the middle turbinate (the axilla) or a few millimeters above this.8 Wormald et al showed that the sac is situated significantly higher on the lateral nasal wall, with the top of the sac located an average of 8 mm above the axilla of the middle turbinate.8 If the principle of complete sac exposure is followed, then this thick bone overlying this upper portion of the sac must be removed. This duplicates the surgical exposure achieved with external DCR and allows the entire lacrimal sac to be marsupilized into the lateral nasal wall. With this technique, an ostium is not created in the sac, but the entire sac is incorporated into the lateral nasal wall. This bone overlying this upper portion of the sac is thick (part of the frontal process of the maxilla) and requires either a powered instrument or chisel to remove it. Once complete sac exposure is achieved, the sac can be opened so that sac mucosa and nasal mucosa can be loosely apposed. (This allows primary healing of the edges of the sac and the nasal mucosa.) Wound healing with an external DCR is similar. The nasal mucosa and sac flaps are sutured in apposition.

Ordering information

18-84068 Curved DCR Bur

1 ea

18-82969 Curved Diamond DCR Bur, 2.9mm

1 ea

18-87570 Fiberoptic Canaliculus Intubation Set with Lightpipe

1 ea

37-18010 Dacryocystorhinostomy Sickle Knife

1 ea

37-18020 Dacryocystorhinostomy Spear Knife MCEN73 Lusk MicroBite Through-cutting Forceps 15-17000 MeroGel Nasal Dressing/Sinus Stent & Otologic Packing, 4cm x 4cm

1 ea 1 ea 1/box 2/box

Nota Bene: The technique description herein and the use of instructions for the related procedures are made available by Medtronic Xomed, Inc. to the health care professional to illustrate the authors suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the health care professionals judgment, addresses the needs of the individual patient.

15-17002 MeroGel Nasal Dressing/Sinus Stent & Otologic Packing, 4cm x 4cm, Double Pack

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

The bone above this area thickens considerably and it is not possible to remove the bone over the upper half of the sac unless a powered instrument or chisel is used. The 2.9 mm Curved Diamond DCR Bur (1882969) is ideal for this purpose, as it gives angulation onto the lateral nasal wall while the diamond allows the drill to come into contact with the mucosa of the lacrimal sac, without damaging the sac wall (Figure 4). Cutting burs may remove the bone quicker, but risk damage to the mucosa of the sac. The light pipe can be left in the sac during the bone removal process. This allows the limits of the sac to be confirmed and allows the entire sac to be exposed before it is opened. As bone removal continues superiorly, the agger nasi cell will be opened in the vast majority of cases. If an agger nasi cell is present (and it is in 98% of cases), it should be opened as part of the dissection. If it is not, then bone removal is usually insufficient superiorly. The bone removal continues until the mucosal edge of the original incision is reached. The sac should now be fully exposed. The light pipe can be visualized when placed horizontally through the common canaliculus and it can be used to confirm the limits of the sac. The lacrimal sac should be tented by the light pipe with the pipe angulated more posteriorly than anteriorly. This gives a larger anterior flap than posterior flap after incisions are made into the sac. A Dacryoscystorhinostomy Spear Knife (37-18020) is used to incise the sac wall over the light pipe creating a short posterior and a long anterior flap (Figure 5). The Dacryoscystorhinostomy Sickle Knife (37-18010) is then used to make a superior and inferior releasing incision so that the flap can be rolled anteriorly (Figure 6). A micro-scissors is used to make the superior and inferior releasing incisions in the posterior flap.

Figure 4

The entire sac is now open and the light pipe can be clearly visualized coming in a horizontal plane through the common canaliculus. If the common canaliculus cannot be visualized, the bony dissection and sac opening have not proceeded high enough. The original mucosal flap is retrieved from around the middle turbinate and is draped over the opened lacrimal sac and trimmed with the Lusk MicroBite Through-cutting Forceps. (This instrument is sufficiently sharp to cut loose mucosa, while most throughbiting Blakeslys do not cut cleanly). A U-shaped flap is created with the posterior edge of this flap trimmed until it meets edge-to-edge with the posterior flap of the lacrimal sac, creating posterior mucosal apposition. The superior part of the flap is trimmed so that it covers the raw bone between the lacrimal sac and the mucosal edge to achieve mucosa to mucosa apposition. The same is done with the inferior flap. The lacrimal sac anterior flap seldom is long enough to reach the anterior mucosal edge and a small gap often persists. Lacrimal Silastic tubes are passed through both inferior and superior canaliculi into the nose (FIgure 7). It is important to pull a loop in the corner of the eye so that the Silastic tubes are not under tension in this area. Otherwise, cheese-wiring of the tubes through the puncta can occur. Ligar clips are placed behind the sleeve or the stents are knotted to prevent the sleeve from moving (Figure 8). MeroGel Nasal Dressing/Sinus Stent is cut to be

Figure 7

Figure 5

Figure 8

Figure 6

slightly larger than the lacrimal sac. A small hole is cut in the middle of the MeroGel packing and the Silastic tubes placed through this hole. The MeroGel packing is slid over the tubes to cover the sac and nasal mucosal flaps. Before final placement of the MeroGel packing, the position and apposition of the flaps needs to be checked to ensure that the flaps have not

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

POWERED ENDOSCOPIC DACRYOCYSTORHINOSTOMY

shifted. The Silastic tubes are cut behind the Ligar clips and the operation is compete. No other nasal packs are inserted and the patient is started the next day on saline nasal sprays. A 2-week course of chloromycetin eye drops is given.

Surgical Technique
Pre-operative assessment consists of nasal endoscopy to exclude intra-nasal and sinus pathology with probing and syringing of the lacrimal system. Lacrimal scintillography and dacryocystograms are performed on all patients to investigate both functional and anatomical obstructions within the lacrimal system. Powered endoscopic DCR can be performed either under local or general anaesthetic. The patient is given the choice unless there are contraindications to either technique. The nose is decongested with 1% oxymetazoline and the lateral nasal wall is infiltrated with 2 mls 1:80 000 2% Lidocaine and adrenalin. The initial mucosal incisions are made with a scalpel starting slightly behind, and 8 mm above, the axilla of the middle turbinate (Figure 1). This incision is brought about 8 mm anteriorly before the blade is turned vertically. A vertical incision is made to the height of the middle of the middle turbinate. A horizontal incision is then made posteriorly up to the insertion of the uncinate on the lateral nasal wall under the middle turbinate (Figure 1). A suction Freer is used to elevate the mucosal flap ensuring that the Freer stays on bone while the flap is elevated (Figure 2). The flap is tucked around the anterior end of the middle turbinate and left until the end of the operation. A round knife is used to identify the junction between the hard bone of the frontal process of the maxilla and the thin and soft lacrimal bone. The soft lacrimal bone is flaked off with the round knife and the postero-inferior aspect of the lacrimal sac identified. A light pipe from the Fiberoptic Canaliculus Intubation Set (18-87570) can be placed through the inferior or superior canaliculus into the sac and the location of the sac confirmed. A Hajek Koeffler forward-biting sphenoid punch is used to remove thick bone of the frontal process and expose the anterior inferior part of the lacrimal sac up to the level of the axilla of the middle turbinate (Figure 3).

Figure 1

Post-operative Care
The patient is first seen one month after surgery. Nasal endsocopy is performed to ensure that the ostium has healed. The loop of Silastic tubing in the corner of the eye is cut and the Silastic tubes and sleeve are removed. Flourescein eye drops are instilled in the eye and visualized in the nose. If all is well, the patient is reviewed again at one year post surgery.

Results
The author has performed this technique in more than 65 consecutive unselected primary DCRs with a success rate of 95%, judged on free flow of flourescein eye drops into the nose and an endoscopically visible ostium. Success rates similar to other external and other endoscopic DCR procedures for revision DCR (60% success rate) and DCR in the presence of a common canaliculi obstruction (50% success rate) are more modest.

Figure 2

References
1. 2. 3. 4. 5. 6. 7. 8. Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryocystorhinostomy. Laryngoscope 1994;104:269-274. McDonogh M. Endoscopic transnasal dacryocystorhinostomy. Results in 21 patients. S Afr J Surg 1992;30:107-110. Hehar SS, Jones NS, Sadiq A, Downes RN. Endoscopic holmium: YAG laser dacryocystorhinostomysafe and effective as a day-case procedure. J Laryngol Otol 1997;111:1056-1059. Sprekelsen MM, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 1996;106:187-189. Weidenbecher M, Hosemann W, Buhr W. Endoscopic endonasal dacryocystorhinostomy: results in 56 patients. Ann Otol Rhinol Laryngol 1994;103: 363-367. Welham RA, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71:152-157. Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology 1998;105:1106-1113. Wormald PJ, Kew J, van Hasselt C.A. The intranasal anatomy of the naso-lacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg 2000;123:307-310.

Figure 3