Endoscopic Dacryocystorhinostomy (DCR)
Considerations
Anatomy
Indications
Literature
Preparation
Place two Afrin-soaked pledgets in the nasal cavity
Dress and prepare in the normal surgical sterile fashion
Set up both 0 and 30 degree endoscopes
Equipment
Procedure
Begin with bilateral nasal endoscopy
Infiltrate 3 mL of 1% Lidocaine with 1:100,000 Epinephrine in the area of the axilla of the middle turbinate and over the lateral nasal wall
Gently medialize the middle turbinate
Place a 4% Cocaine-soaked pledget in the middle meatus
Allow adequate time was allowed for the local and topical anesthetic to take effect
Identify the uncinate process and ethmoid bulla
Identify the maxillary line, indicating the junction of the hard bone of the frontal process of the maxilla and the soft lacrimal bone, to approximate the position of the lacrimal sac
Complete the mucosal incisions using a fine-tipped Bovie
A superior horizontal incision 8-10 mm above and anterior to the axilla of the middle turbinate;
An anterior vertical incision about 2/3 the height of the middle turbinate (stops just above the insertion of the inferior turbinate to the lateral nasal wall); and
An inferior horizontal incision starting at the insertion of the uncinate process and brought forward to meet the vertical incision
Elevate the mucosal flap posteriorly using a Freer elevator to expose the bone overlying the lacrimal sac
Tuck the mucosal flap into the middle meatus
With visualization and palpation, identify the hard frontal process of the maxilla and the soft lacrimal bone
Remove the bone of the frontal process of the maxilla and lacrimal bone using a Kerrison and high speed angled drill
Expose the entire lacrimal sac along the lateral nasal wall
Remove any obstructing agger nasi cell
Dilate the superior and inferior punctum of the ipsilateral medial eyelids using a lacrimal probe
Thread the probe through the puncta, canaliculi, common canaliculus, and lacrimal sac individually
Confirm the location of the probe within the lacrimal sac by visualizing the tip moving within the sac
Make a vertical incision using a DCR spear knife through the sac wall as posteriorly as possible to maintain a large anterior flap
Make upper and lower releasing incisions in the anterior flap using a sickle knife
Marsupialize the lacrimal sac by rolling the sac mucosa out on the lateral nasal wall
Trim the mucosal flap into a U-shaped flap so that the superior and inferior mucosal flaps are matched to the raw bone above and below the opened sac
This approximates the lacrimal and nasal mucosa to allow for first intention healing
Place a Nasopore into the middle meatus