Dacryo-cysto-rhinostomy
The origin of Dacryo
In Marseilles, Prof. Aubaret developed the Dacryo by the external, facial route, inventing a needle to suture the pituitary sac, retractors and other instruments. My father Robert Delord brought the Aubaret technique to Prof. Paufique in Lyon in 1943, and since 1946 we have been making modifications to improve reliability and comfort for patients.
The three stages of dacryocystitis
Stage 4 A
Chronic obstructive dacryocystitis
Stage 4 B
Acute dacryocystitis:
- Rubor Calor Dolor Tumor.
Stage 4 C Complicated dacryocystitis
a lacrimal sac abscess that may spread
- to the orbit perforate the skin and sometimes form a fistula
difficult to treat,
- or cheek.
The surgical technique
We prefer external DCR.
THIS IS THE TECHNIQUE THAT STATISTICALLY GIVES BETTER RESULTS THAN THE ENDO-NASAL APPROACH. BY VALERO IN 1981. THIS TECHNIQUE HAS EXISTED FOR MORE THAN A CENTURY, AND IT IS BOTH POSSIBLE AND EXCITING TO IMPROVE IT AND PERFECT IT TO MAKE IT AS EFFECTIVE AS POSSIBLE.
Why the external route?
-For the simplicity of the bag approach
-Only one surgical team required,
-Inexpensive equipment
-Local anesthesia can be administered.
-Intraoperative complications are rare and, above all, manageable.
Increase the chances of long-term success of this otorhino-ophthalmological operation
1) Operative indication: The operation must be necessary and the indication sufficient (stage 4 epiphora in our classification, more or less complicated).
2) The preoperative check-up must be complete and usually include an ENT examination.
3) The bag must be marsupialized as widely and tightly as possible, using the nasal cavities for this purpose:
4) The bony opening between the lacrimal sac and the nasal cavity should be as wide as possible;
5) The skin incision should be at least 2 cm long, medial to the path of the angular vessels, far from the internal angle, close to the nasal ridge. Do not look for the medial canthal tendon.
6) The area of bone with the lowest resistance (clean bone-rising branch junction) must be tackled.
7) In the event of a sac abscess or the presence of pus after bacteriological sampling, intraoperative lacrimal lavage with Povidone-iodine (5%) should not be overlooked.
8) The presence of sac tumours should not be underestimated.
9)Each anatomical level must be respected and reconstructed plane by plane: deep planes, posterior mucosa of the sac, posterior pituitary flap.
10) If possible, place 3 posterior points;
-anterior mucosa of the anterior pituitary flap;
-Middle plane: the periosteal layer with its medial canthal tendon
must be placed in front of the sac-pituitary anastomosis. 10. The skin should be sutured with separate stitches, to direct healing, and the perfect fit will avoid postoperative contamination.
and the biological glue will finalize a perfect seal
for the next 10 days...
An anterior ethmoidal cell, larger than the others, is often found: the ager nasi.
Should we only perform DCR externally? Certainly not!
As is often the case in surgery, you should only use the technique you have mastered.
Classically, the reliability of the external route has been proven. Like the endo-nasal route, it requires serious training.
The endo-nasal route has its indications BUT, as is often the case in surgery, you should only use the technique you have mastered. Traditionally, the reliability of the external approach has been proven. Like the endonasal route, it requires serious training.
Post-operative care
- An order is drawn up proposing:
- 5 days of decongestant nasal sprays, possibly with sulfur,
- Antibiotic and corticosteroid eye drops for 2 weeks,
- In the nose, use a saline solution no more than once a day,
- Home care per AM 8 days, to change the dressing, apply ointment and eye drops, and greasy tulle,
- Give advice on hygiene (no water in the eyes, etc.).
- Do not remove or cut the drain.
Patients are seen again 8 days later to check the lacrimal duct along the drain and warn of the possibility of haemorrhaging when the eschar falls, then 2 weeks later to clean the nose, remove the scabs and direct the skin scar.
Silastic drains are removed in consultation as late as possible (sometimes up to a year) and at the patient's request, unless the patient is responsible.
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