Dacryocystorhinostomy Intubation of Nasolacrimal System

DESCRIPTION OF OPERATION:  After adequate intravenous sedation was given, a marking pen was used to demarcate the initial skin incision.  This began 10 mm medial to the left medial canthal area and carried inferolaterally for 15 mm.  Local anesthesia of Xylocaine 2% with 1:100,000 concentration of epinephrine mixed with Marcaine 0.75% in a ratio of 2:1 was injected into the left medial canthal area and left lower eyelid.  In addition, infraorbital nerve block and an anterior ethmoidal nerve block was given with the same solution.  Same solution was injected into the left middle meatus, which was then packed with neuro patties dampened in Afrin.  The patient was prepped and draped in the usual fashion for DCR and a corneal protective lens was placed into the left eye after instillation of topical tetracaine.  Incision was made through the skin and subcutaneous tissues, along the previously demarcated line and dissection was carried down to the lacrimal crest.  An incision was made through the periorbital lacrimal crest and the lacrimal sac was reflected out of the fossa.  Osteotomy, 12 mm in diameter, was then created with the Stryker drill, removing lacrimal bone as well as part of the anterior ethmoid and a portion of the medial maxillary bone.  At this point, the upper and lower canalicular systems were dilated and Bowman probe was passed through the upper and lower systems.  The lacrimal sac was then opened and large amount of mucoid material was recovered from the sac.  A large anterior lacrimal sac flap was created and then a smaller flap was excised.  Corresponding anterior nasal flap was created and again a smaller posterior flap excised.  Crawford tubes were then woven through the upper and lower canalicular systems, through the osteotomy and out through the nose, and then ends of the tubes tied to each other and a 6-0 nylon suture tied around the ends of tube.  This was trimmed and allowed to retract into the left nostril.  Osteotomy was then packed with Gelfoam which had been dampened with dilute solution of gentamicin.  The lacrimal sac flap was then anchored to the nasal mucosa flap with mattress suture of 5-0 chromic, which was then anchored to the subcutaneous tissues.  Subcutaneous closure was performed with additional 5-0 chromic sutures.  The skin edges were reapproximated with 6-0 nylon in a running fashion.  The corneal protective lens was removed.  Surgical site was cleansed and Steri-Strips and Telfa pad applied across the incision.  Gelfilm was then coated with Gentak ointment and placed into the left middle meatus.  Gentak ointment was placed in left eye and the patient left the operating room in good condition, having tolerated the procedure without complications.