Endoscopic dacryocystorhinostomy: creation of a large marsupialized lacrimal sac

Abstract

This retrospective study describes and evaluates the effectiveness of a modified technique of conventional endoscopic dacryocystorhinostomy (DCR) that minimizes the obstruction of a neo-ostium by creating an enlarged marsupialized lacrimal sac using mucosal flaps. Forty-two patients who had undergone 46 endoscopic DCR at a tertiary medical center, from 2002 to 2004, for correction of lacrimal system obstruction were investigated. The surgical technique involves elevation of a nasal mucosal flap, full sac exposure using a power drill, and shaping of the mucosal flap to cover denuded bone and juxtapose exposed sac mucosa. Postoperative symptoms and endoscopic findings of the neo-ostium were evaluated. Mean duration of follow-up was 5.9 months. An eighty-three percent primary success rate was observed, without any serious complications. Obstruction of the neo-ostium with granulation tissue was observed in eight cases, among which six underwent revision with success in all cases. Overall, 44 (96%) of 46 cases experienced surgical successes. Endoscopic DCR, a procedure in which a large marsupialized lacrimal sac is created from mucosal flaps, yields a very satisfactory success rate with straightforward and highly successful revision available for those in whom the primary procedure yields a substandard result.

Fig. 1

(A) A nasal mucosal flap is being elevated after a reverse "C" shaped incision on the mucosa of the lateral nasal wall with slit knife just anterior to the insertion of middle turbinate. (B) The maxillary bone covering the lacrimal sac is drilled out with a curved diamond dacryocystorhinostomy bur (15°, 2.9 mm, Xomed Co., Jacksonville, Florida, U.S.A.). (C) The extent of the lacrimal sac is verified with lacrimal probe (arrow) and the sac wall is tented to allow incision. The vertical incision is made with a slit knife. (D) The mucosal flap covers the exposed bony portion after cutting and trimming. The edges of the exposed lacrimal sac (arrow) are everted to match the nasal mucosa and the sac lumen is filled with gelfoam (asterisk) to keep the flap anastomosis in position. A silicone bicannalicular tube is seen through the new opening. LNW, lateral nasal wall; MT, middle turbinate; S, septum; LS, lacrimal sac; MF, mucosal flap.

Fig. 2

A wide neo-ostium made by marsupialization of the lacrimal sac (arrow) at six months after surgery. MT indicates the middle turbinate.