Dr. E. Sivakumar M.S. D.L.O. D.N.B.
Synonyms: Endoscopic DCR, Dacryocystorhinostomy
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.
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
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.
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
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
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
site contents © Copyright drtbalu 2006, All rights