Endoscopic dacryocystorhinostomy

By

Dr. E. Sivakumar M.S. D.L.O. D.N.B.

Synonyms: Endoscopic DCR, Dacryocystorhinostomy (intranasal)

It is advantageous to access the lacrimal sac through the nasal cavity.  By this intranasal approach incision over the face is avoided, the lacrimal pump mechanism is preserved.  This procedure is very safe and can be performed under local anesthesia as a day care procedure.  For anatomy of the lacrimal appratus please vist: http://www.drtbalu.com/Endo_dcr.html.

For this surgery a 4mm 0 degree wide angled nasal endscope was used.  The patient was premedicated with intra muscular injections of : 1. 1 ampule fortwin , 2. 1 ampule phenergan, and 3. 1 amplule atropine. 

Anesthesia used:  4% xylocaine mixed with 1 in 10,000 adrenaline for topical anesthesia.  Cotton pledgets dipped in this solution is used to pack the nasal cavity.  Before attempting to pack the nose the cotton pledgets must be squeezed dry of xylocaine solution to avoid xylocaine overdosage and toxicity.  It is safe to use only 7 ml of 4% xylocaine for topical nasal packing.  Three pledgets are used for packing.  One each is placed inside each meatus.  The packing must be left in place for atleast 15 minutes for optimal effect.

Surgical procedure:  A 4mm 0 degree wide angled endoscope is passed through the nasal cavity.  The cotton pledgets are removed.  The middle turbinate is identified.  This structure is crucial for the identification of the sac.  2% xylocaine mixed with 1 in 1 lakh adrenaline is used for infiltration.  The following areas are infiltrated with 1/2 cc of this solution:
1.  The root of the middle turbinate
2. The substance of the middle turbinate
3. The lateral nasal wall just lateral to the tip of the middle turbinate

The most important landmark for the location of the lacrimal sac is now looked for i.e. Maxillary line.  This is nothing but a mucosal projection present in the lateral nasal wall.

Incision:

     After localising the position of the sac endoscopically, the lateral wall mucosa is incised with a sickle knife and is elevated using a Freer elevator.  It will be of immence help if this incision could be placed well anterior to the location of the sac as this will allow adequate exposure of bone.  The incision is made vertically from inferior to superior.  After elevation the mucosa is removed using a Blakesley forceps.

Bone removal:

     The bone over the lacrimal sac area can be removed either by a punch forceps or by chiselling out the area.  The sac should be exposed adequately.  The position of the sac can be confirmed by asking the assistant to apply intermittent pressure to the orbit and looking for transmitted pulsations in the lateral wall of the nasal cavity. 

Incising the sac:  The sac is then incised using a sickle knife.  It is better to completly remove the medial wall of the sac to ensure trouble free drainage.  Here in this video you will be seeing pus streaming out of the sac.