RU2668476C1 - Method of lacrimal sac plastic repair - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to ophthalmology and can be used in the surgical treatment of dacryocystitis and stenosis of the nasolacrimal duct by plastic repair of a lacrimal sac during endoscopic endonasal dacryocystorhinostomy surgery. In the projection of the lacrimal sac, two mucoperiosteal flaps are formed on the stalk, the first one at the level of the frontal process of the maxillary bone with a base at the level of attachment of the inferior nasal shell, the second is adjacent to it, at the level of the lacrimal bone, with the base located vertically. Recline the flaps and expose the bone wall of the lacrimal fossa, in which an oval "window" is formed. Conduct a vertical incision in the medial wall of the lacrimal sac, supplement it with a cut along the upper edge of the bone window, the formed flap recline. Second mucoperiosteal flap is put in place, and a strip of the stalk located on the upper part of the flap is cut off at its edge. Expand it to 90° and close the upper part of the bone "window". Return to the first mucoperiosteal flap.EFFECT: method provides primary healing of the postoperative surface with prevention of scarring in the area of the dacryostoma and relapse of the disease by closing the exposed bone at all boundaries of the formed anastomosis.1 cl, 7 dwg, 1 ex

Description

The invention relates to ophthalmology and can be used in the surgical treatment of dacryocystitis and stenosis of the nasolacrimal duct by plastics of the lacrimal sac during surgery of endoscopic endonasal dacryocystorhinostomy (EDEDC).

Dacryocystitis and narrowing of the lacrimal ducts are one of the common problems in ophthalmology, and purulent discharge and profuse lacrimation significantly worsen the quality of life of patients. The spread of dacryocystitis to surrounding tissues leads to the development of phlegmon, the treatment of which requires adequate antibiotic therapy and sometimes outpatient drainage of purulent foci. This explains the need for correction of such conditions. Due to the low effectiveness of conservative treatment, the development and improvement of surgical operations aimed at restoring patency of the tear ducts continues. The gold standard for the treatment of this pathology is endonasal dacryocystorhinostomy. One of the postoperative complications is the formation of granulations in the dacryostomy area, which leads to its narrowing and, as a result, reduced functional results.

The protocol of the operation of EEDCR for different authors has a similar character, with the exception of the implementation of plastics of the lacrimal sac. There are many different techniques for performing plastic anastomosis. In 2004, the authors (MassegurH, TriasE, Adema JM. Endoscopicdacryocystorhinostomy: modifiedtechnique. Otolaryngol Head Neck Surg. 2004 Jan; 130 (1): 39-46.) Proposed an endoscopic technique involving the special formation of the anterior and posterior flap of the nasal mucosa with in order to lay under the posterior flap the mucous membrane of the lacrimal sac. This provides full cover for the bone window at the back, but the upper part is not covered.

I, Caner Mercan G,

E,

M,

H. Endoscopic dacryocystorhinostomy: outcomes using mucosal flap preserving technique. EurArchOtorhinolaryngol.2013 May; 270(5):1661-6). Лоскут слизистой полости носа укладывался на изначальное место после формирования большого костного окна и разделения слизистой слезного мешка на передний и задний лоскуты с интубацией лакримальных стентов. К недостаткам метода можно отнести полное закрытие дакриостомы слизистой полости носа, за исключением места прохождения лакримальных имплантатов. Это может привести к зарастанию соустья после удаления трубок.There is also a known method of forming anastomosis in a modification of the Wormald technique. (

I, Caner Mercan G,

E

M

H. Endoscopic dacryocystorhinostomy: outcomes using mucosal flap preserving technique. EurArchOtorhinolaryngol. 2013 May; 270 (5): 1661-6). A flap of the nasal mucosa was placed in its original place after the formation of a large bone window and division of the mucous membrane of the lacrimal sac into the front and back flaps with intubation of lacrimal stents. The disadvantages of the method include the complete closure of the dacryostomy of the nasal mucosa, with the exception of the passage of lacrimal implants. This can lead to overgrowth of the anastomosis after removal of the tubes.

Surgical technique is also known, including the creation of a large flap of the nasal mucosa and flap of the lacrimal sac, the bases of which are located posterior to the anastomosis (Majumder A, Singh M, Das C, Das S, Hazra TK. Endonasal dacryocystorhinostomy with mucosal flaps: our experience. Indian J Otolaryngol Head Neck Surg. 2013 Aug; 65 (Suppl 2): 371-5.). A flap of the nasal mucosa is cut into the upper and lower, respectively, laying on the edges of the dacryostomy, and a flap of the mucous membrane of the lacrimal sac on the posterior edge of the anastomosis. The advantages of this method are: covering the exposed bone with the lower and back flaps, which prevents the occurrence of complications. But with this arrangement of fragments of the mucous membrane of the nasal cavity, it is not possible to cover a portion of the bone located in the upper part of the dacryostomy.

The closest analogue of the proposed method is a method of plasty of nasolacrimal anastomosis with endonasal endoscopic dacryocystorhinostomy. Anesthesia is performed, a hard endoscope connected to a video camera is inserted into the nasal cavity. Then a flap is cut out from the mucous membrane of the lateral wall of the nasal cavity of the U-shaped in the area of the projection of the lacrimal sac - in front of the attachment site of the middle nasal concha. Turn it down. Next, a bone window is formed in the frontal process of the upper jaw and in the lacrimal bone in the projection area of the cut flap and the same size as the flap. Then, with the working tip of the Surgitron radio wave apparatus, a U-shaped flap is formed from the anterior-medial part of the lacrimal sac wall, with a base down and the same size as the bone window, and it is turned down. Then evacuate the contents of the bag by aspiration. Next, the cut flaps of the lacrimal sac and nasal mucosa are compared and connected by microsurgical sutures on the marginal tissue of the flaps using a microsurgical needle holder inserted endonasally. In this case, the flap cutting is carried out using a Surgitron-DF 120 radio wave apparatus with a frequency of 4 MHz. When cutting a flap of the nasal mucosa, an L-shaped electrode is used, and when cutting a flap of a lacrimal sac, a needle electrode is used, exposing the needle of which, in length, is carried out each time depending on the wall thickness of the lacrimal sac in the dissection zone. Before cutting the flap, the bag is filled through the lacrimal tubule with viscoelastic and the retinal collet tweezers are inserted into the bag in the same way, which when cutting the flap from the bag wall, when joining the flaps, as well as when suturing, is used bimanally with the endonasal instrument. (RU 2335264 C1, 03/27/2007). With this method, expansion of the dacryostomy area is achieved, however, incomplete covering of the operation area with mucous flaps reduces the effectiveness of the intervention due to complications in the form of overgrowing of the anastomosis in the postoperative period.

The objective of the proposed method is to further improve endonasal endoscopic dacryocystorhinostomy.

The technical result of the invention is the primary healing of the postoperative surface with the prevention of scarring in the dacryostomy, and, consequently, the recurrence of the disease.

The technical result is achieved due to the formation of flaps of the nasal mucosa and mucous membrane of the lacrimal sac for subsequent closure of the bare bone at all borders of the formed anastomosis.

We performed 28 operations in patients with dacryocystitis according to the proposed method. All patients underwent radiography with contrasting of the tear ducts to visualize the anatomical location of the lacrimal sac. In the late postoperative period (after 2 years) in all cases there was no recurrence.

The method is illustrated by the following and drawings:

FIG. 1 - the formation of two adjacent mucoperiostal flaps on the leg.

FIG. 2 - formation of an oval window shape.

FIG. 3 - formation of a fragment in the medial wall of the lacrimal sac.

FIG. 4 - folding of the formed fragment.

FIG. 5, 6 - the return of the mucoperiostal flap into place with cutting off the strip on the leg at its edge with its unfolding.

FIG. 7 - return to the place of the first mucoperiostal flap.

1- mucoperiostal flap on the leg, formed at the level of the frontal process of the maxillary bone with the base at the level of attachment of the lower nasal concha;

2 - the second mucoperiostal flap adjacent to the first, formed at the level of the lacrimal bone, with the base located vertically;

3 - oval-shaped “window” in the bone wall of the lacrimal fossa;

4 - a vertical incision in the medial wall of the lacrimal sac, supplemented by a cut along the upper edge of the bone window;

5- cutting off the strip on the leg located in the upper part of the second mucoperiostal flap returned to the place;

6- unfolding the strip 90 ° and closing the upper part of the bone “window” to it;

7- return to the place of the first mucoperiostal flap.

The method is as follows.

The operation is performed under local anesthesia with intravenous sedation. In the projection of the lacrimal sac, two mucoperiostal flaps are formed on the leg, the first at the level of the frontal process of the maxillary bone with the base at the level of attachment of the lower nasal concha, the second adjacent to it, at the level of the lacrimal bone, with the base located vertically, fold the flaps and expose the bone wall lacrimal fossa. An oval “window” is formed, then a vertical incision is made in the medial wall of the lacrimal sac, supplemented by a cut along the upper edge of the bone window. The formed flap is folded back, the second mucoperiostal flap is put in place, and a strip on the leg located at the top of the flap is cut off at its edge, turned 90 ° and the upper part of the bone “window” is closed, after which the first mucoperiostal flap is returned.

Example 1

Clinical example. Patient O.K., 48 years old, came to the clinic with complaints of lacrimation from the left eye for 12 months, purulent discharge from the left eye. When pressing on the area of the lacrimal sac on the left of both lacrimal openings purulent discharge comes out. When washing on the left, the lacrimal passages are not passable with regurgitation and purulent discharge through the opposite tubule. Radiography with contrasting of the tear ducts was performed, revealing obliteration at the level of the neck of the lacrimal sac. In the operating room, after intravenous sedation, installation of proxymethacaine 0.5% and infiltration anesthesia of the lacrimal tubules with a solution of lidocaine 2%, anemia of the nasal cavity and infiltration anesthesia with a solution of articaine with epinephrine 1: 100000, the middle nasal passage was revised using a rigid endoscope 4 mm Hopkins II with optics 30 °. In the projection of the lacrimal sac, two mucoperiostal flaps were formed on the pedicle, the first at the level of the frontal process of the maxillary bone with the base at the level of attachment of the lower nasal concha, the second adjacent to it, at the level of the lacrimal bone, with the base located vertically. Flaps were thrown back and the bone wall of the lacrimal fossa was exposed, in which an oval “window” was formed, then a vertical incision was made in the medial wall of the lacrimal sac. It was supplemented with a cut along the upper edge of the bone window, the formed flap was thrown back, the second mucoperiostal flap was put in place, and a strip on the leg was cut off at its edge, located in the upper part of the flap, turned it 90 ° and closed the upper part of the bone “window”, after which brought back the first mucoperiostal flap. Tamponization with hemostatic sponges. In the postoperative period prescribed antibacterial and anti-inflammatory eye drops, washing the nasal cavity. At the examination after 1 month the patient did not complain, at the endoscopic examination, the functioning dacryostomy is preserved, the lacrimal passages are passable. At the examination after 6 months, the patient did not complain, at the endoscopic examination, the functioning dacryostomy remains, the lacrimal passages are passable.

Claims (1)

Method for lacrimal sac plasty, characterized in that in the projection of the lacrimal sac two mucoperiostal flaps are formed on the pedicle, the first - at the level of the frontal process of the maxilla - with the base at the level of attachment of the lower nasal concha, the second - adjacent to it, at the level of the lacrimal bone, s with a vertical base, flaps are reclined and the bone wall of the lacrimal fossa is exposed, in which an oval “window” is formed, then a vertical incision is made in the medial wall of the lacrimal sac, supplemented with a cut along the top to the edge of the bone window, the formed flap is folded back, the second mucoperiostal flap is put in place, and a strip on the leg located at the top of the flap is cut off at its edge, rotated by 90 ° and the upper part of the bone “window” is closed, and then returned to the place the first mucoperiostal flap.

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