Surgery: Endonasal Dacryocystorhinostomy (DCR)

Dr. Patrick Yang: This is Patrick Young, an oculoplastic surgeon, clinical instructor, presenting this case from Victoria, British Columbia in Canada. And I’m here presenting a procedure for endonasal dacryocystorhinostomy of the left side today. Here you can see I’m using a 2% epinephrin with lidocaine to inject into the nasal passage. There the injection was in the lateral wall of the nasal cavity, as well as into the middle turbinate. Sometimes when the middle turbinate is too close to the lateral wall, it’s hard to gain access to the proper surgical site. So, a Freer elevator can be used to reflect the middle turbinate medially, to allow for a better visualization. But here, it is quite clear. Here, I’m packing the nose with a one in 1000 epinephrin soaked neurosurgical Patty. And this is to maintain proper hemostasis and therefore better visualization.

Here, I’m using a Kerrison 90-degree rongeur to remove bone and soft tissue, which is covering the nasal SAC from this angle. I’m using my hand externally on the nasal bridge and pushing so that I can see the nasal sack bouncing around, and that way I can know that I’m in the correct area. I continue to take progressive bites of the bone here, of the maxillary and the lacrimal bones. And it slowly reveals the lacrimal sack. It’s important to always be able to visualize the tip of your Kerrison rongeur, so that you can see exactly what tissue you’re taking. And here a suction is used to help with the visualization. You can start seeing a clear view of the lacrimal sac there.

And you can again see it bouncing as I pushed from the outside. There, I’m using Takahashi forceps, to remove some excess tissue.

Here’s the suction again. And as you can see, you can see the nasal mucosa there a clear view of the little tip of the bone, as well as the lacrimal sac underlying. I’ve switched to the 45-degree Kerrison rongeur and you could see a clear bouncing of the lacrimal sack there. Here I take another bite with a 45-degree Kerrison rongeur, sometimes you can just use the 90-degree rongeur for the whole case, but for some anatomy using that 45 degree rongeur allows for better removal of the lacrimal bone and the maxillary bone, that’s overlying the lacrimal sack. And as you see, I take clean bites. I make sure not to twist or pull as that can cause fractures and even spiral fractures of the bone towards the cribriform plate. And that’s something that one would want to avoid, as that may result in, complications such as CSF leaks. If you landmark properly with the middle turbinate in view, one can see that the proper access to lacrimal sack is not that challenging from the endonasal approach. And I do like to create a larger osteotomy than perhaps the average endonasal surgeon, this is because this allows for an easier opening of the SAC and also ensures that the new passage that is created for the DCR remains painted.

Just about done my osteotomy here, making sure I’ve taken a nice circle of bone so that the lacrimal sac is nicely exposed. Intermittently I have a suction to allow for better viewing.

Although my assistant is holding the scope in this case, sometimes I am operating on my own and I would hold the scope with my left hand and use the rongeur with the right-hand or vice versa, depending on which side of the patient we’re on. Here, you can see the clear bouncing of the lacrimal SAC and a very nice osteotomy, nice and open. This will ensure that it doesn’t close after the surgery.

One note regarding packing of the nose is that I used one in 1000 epinephrin and I have that dyed blue. And so that when it’s dyed blue on the neurosurgical Patty, I know that it is the one in 1000 epinephrin and this is not something that should be injected. What we injected for hemostasis and anesthesia earlier was a lidocaine 2% with epinephrin. If one were to accidentally inject the packing solution, this may actually kill the patient as it would cause arrhythmias with that high concentration of epinephrin. So please do keep in mind, that when injecting only inject the lidocaine 2% with epinephrin. And keep in mind that the one in 1000 epinephrin is just for packing of the nose. So here I go again and pack with a neurosurgical Patty and here I’m outside of the nose now and using a olive tip stent to insert through the lacrimal system, through the punctum and through the superior canaliculus and through the common canaliculus and into lacrimal sac. And as you can see, I was tenting out the lacrimal SAC, and now I’m using a sickle knife to incise the lacrimal SAC.

I tried to create a C shaped incision. So, at the top there, I’ve turned the blade around and created a cut. So, it’s almost like a backward C here, and you can see the olive tip stent protruding out of the lacrimal sac. I sometimes use the Crawford tube or olive tip stent. And there, you can see the lacrimal SAC is opened with a C shaped incision.

The anterior flap was removed or twisted off using a Takashi forceps. That step can also be performed using a Kerrison rongeur, to take a bite of the anterior flap, that just ensures the potency. Here, I’m using the sickle blade again, and creating back cuts. This is just a special step that I don’t always do, but it helps to maintain the patency of the lacrimal sac. Since if it were just an incision, it may close up, but cutting it in a C shape and then kind of an eight shape, you can see that it’s opened up bigger and there I’m using the Kerrison rongeur to take a nice bite of the flap of the lacrimal SAC, therefore resulting in a large hole or defect in the lacrimal sac, which again, ensures patency. Next, I use Takahashi forceps to take hold of the olive tip and pull it through, out of the nose.

My next step would be, inserting the other end of the olive tip stent through the inferior punctum, through the inferior canalicular, through the common canaliculus and into the sac here. And as you can see, it’s protruding out of the same hole in the lacrimal sac that we’ve created. There, you could see the common canaliculus almost. Here I’m using a glide to retrieve the probe, but you can use the suction or the Takahashi forceps. I’ve pulled both tubes in, through the punctum, through the osteotomies and the opening of the lacrimal sac and into the nose and out of the nostril. And there’s a good view of the inside of lacrimal sac with the two tubes coming out.

I am using Takahashi forceps to remove some extra soft tissue.

And there you have it, that is an endonasal DCR. The next step would be to tie the tubes off externally and to suture the tube to the lateral wall and make sure there’s not too much tension on the medial canthus, so not to cause a cheese wiring of the Silicon tube through the canalicular system. So just have it loosely abutted to the canalicular system through the upper and lower puncti. Tie the tube with a six O proline suture to the lateral wall of the nasal passage, just inferiorly near the Nair. This stent remains in place for a few months, and this varies. I like to keep it in for three months and remove it postoperatively in the clinic.