RU2386420C1 - Dacryocystitis surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns ophthalmology and covers creation a fistula between lacrimal sac and nasal cavity. The preparation of a surgical area and anaesthesia of internal angle of eye is followed with a square incision of skin and soft tissues. Soft tissues are dissected by a blunt technique, and internal eyelid crease is cut through. A medial wall of the lachrymal sac is separated from periosteum and partially cut off. After separation of the periosteum, on a lateral wall of nose and within a projection of the lachrymal sac, a hole in the bone of the diametre 6-7 mm is cut out with laser which is also used to coagulate a nasal mucosa in a projection of the hole in the bone. The lasing mode for the hole in the bone is 7 Wt, for nasal mucosa - 4-5 Wt. An upper lip of the wound of the medial wall of the lachrymal sac is sutured to the periosteum above the hole in the bone. The surgery is finished by interrupted suturing of the internal eyelid crease and soft tissues in layers. The skin wound is closed with uninterrupted subcuticular suturing.

EFFECT: application of the invention restores nonrecurring free patency of lachrymonasal passages, prevents bleeding and eliminates cosmetic defect on facial skin.

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Description

The invention relates to medicine, in particular to ophthalmology, and is intended to create an anastomosis between the lacrimal sac and the nasal cavity in the pathology of the vertical section of the tear ducts.

The problem of the treatment of diseases of the tear ducts is still far from over and requires further study and improvement of treatment methods (V. G. Beloglazov, Bulletin of Ophthalmology, No. 1, 2006).

Since the beginning of the 90s of the XX century, endoscopic laser dacryocystorhinostomy with a transcanalicular and endonasal approach, which is sometimes combined with intubation of the tear ducts, has been rapidly developing

alloplastic implants, which undoubtedly deserves attention and distribution due to low invasiveness, perfect cosmetics and a simpler technique of intervention. (M.T.Aznabaev et al. Laser dacryocystorhinostomy, Ufa, 2005, 152 s .; Yu.S. Astakhov et al. Diode laser in the treatment of lacrimation disorders, St. Petersburg, 2007, 27 p.). Technique of transcanalicular laser endoscopic dacryocystorhinostomy: the working end of a light diode laser is administered transcanalicularly after preliminary

expanding the lower lacrimal tubule with a conical probe until it stops in the bone and produce laser-coagulation of the medial wall of the lacrimal sac,

lacrimal bone and nasal mucosa, forming an anastomosis between them. Moreover, the laser radiation power is 7 watts. All manipulations are carried out under endonasal endoscopic control through a monitor.

However, further improvement of this technique is required in connection with relapses of dacryocystitis. According to a number of researchers and their own observations, after laser transcanalicular endoscopic dacryocystorhinostomy, in more than 20% of cases there is a relapse of dacryocystitis up to 12 months after surgery, requiring repeated intervention (G.N. Valieva, A.E. Babushkin, On the issue of effectiveness repeated laser dacryocystorhinostomy, Collection of scientific papers, Ufa, 2007, pp. 99-100.). In addition, the high temperature at the point of contact of the laser beam with the tissues is somewhat alarming, and the intubation material often creates inconvenience, is the reason for the limited ability to work in many professions, and often leads to serious complications.

The most common in the treatment of patients with dacryocystitis is dacryocystorhinostomy with an external approach.

More than 70 options for surgical treatment of dacryocystitis with an external approach are known, positive results in which are achieved in 98% of cases.

A huge number of works devoted to various options for external dacryocystorhinostomia testifies to the colossal work done by ophthalmosurgeons to improve the technique and method of surgery (V.T.Beloglazov, "Bulletin of Ophthalmology", No. 1, 2006, S.8-12).

The closest analogue of the invention is the method of external dacryocystorhinostomy according to Toti ("Eye Surgery" under the editorship of N. A. Pletnev, Medgiz, 1959, S. 266-301). According to this method, an incision is made in the skin and soft tissues up to 3 cm long, which begin 2–3 mm above the inner ligament of the eyelids and lead downward, slightly enveloping the lower orbital margin. Superconductors are superimposed. Soft tissues stupidly exfoliate to visualize the inner ligament of the eyelids. The periosteum is cut and separated outside 0.5-1 cm medial to the internal ligament. A bone window 1.5–2 × 1.2–1.5 cm in size is formed with a milling cutter or chisel. On the corresponding side, the nasal cavity is plugged with gauze turunda. A Gref knife or a scalpel within the opening cuts off the nasal mucosa and the medial wall of the lacrimal sac. Nodal catgut sutures are layered on soft tissues in layers, and nodal sutures are placed on skin wounds.

Among the shortcomings of external dacryocystorhinostomy, there is a high invasiveness, profuse nosebleed during surgery, scarring of the postoperative skin wound in the form of a cosmetic defect, and restrictions on its use.

The technical problem solved by the invention is to reduce the invasiveness of the method, the prevention of postoperative complications.

The technical result when using the invention is the restoration of the free patency of the lacrimal and nasal passages without relapse, the prevention of bleeding, the elimination of a cosmetic defect on the skin of the face, the expansion of indications for the use of the method.

The specified technical result is achieved by the fact that in the method of external dacryocystorhinostomy, including a skin incision, performing a bone “window”, forming a stoma on the nasal mucosa, partial removal of the medial wall of the lacrimal sac, suturing of a skin wound, according to the invention, a skin incision is made up to 10 mm long, bone A “window” and a stoma on the nasal mucosa are formed by a diode laser using a power mode of 7 and 4-5 W, respectively, the upper lip of the wound is sutured to the periosteum above the bone window, after which I apply it to the skin wound continuous seam Halsted.

The proposed method is as follows. After preparation of the surgical field and anesthesia (infiltration-conductive 2% solution of lidocaine 5.0 ml with the addition of 8-10 drops of 0.1% solution of adrenaline, irrigation of the corresponding half of the nose with 10% solution of lidocaine), a direct skin incision is made in the area of the inner corner of the eye and soft tissues up to 10 mm long, starting 2-3 mm above the inner ligament of the eyelids. Put expanders. Soft tissues exfoliate in a blunt way, dissect the inner ligament of the eyelids. The medial wall of the lacrimal sac is separated from the periosteum and part of it is cut off. The lacrimal sac cavity is sanitized with a solution of hydrogen peroxide and furacilin 1: 5000-5-10 ml. Then the periosteum is separated on the side wall of the nose and in the area of the projection of the lacrimal sac a laser cut out a bone window with a diameter of 6-7 mm under endoscopic control of the corresponding half of the nose on the monitor. Laser coagulate the nasal mucosa in the projection of the bone "window". At the same time, the laser mode for the bone “window” is 7 watts, for the nasal mucosa 4-5 watts. To cool the tissues, the surgical field is irrigated with saline. The upper lip of the wound of the medial wall of the lacrimal sac is sewn to the periosteum with two interrupted sutures (Vikril 5/0) above the bone “window”. The operation is completed by the application of nodal sutures (Vikril 5/0) on the inner ligament of the eyelids and in layers on soft tissues. The skin wound is sutured with a continuous intradermal suture of Halstead (synthetic monofilament suture material). The wound is treated with a 1% alcohol solution of brilliant green. Gentamicin 40 mg is injected subcutaneously into the area of the lacrimal sac. Pressure bandage on the wound.

Indications for use of this method: relapses after transcanalicular laser endoscopic dacryocystorhinostomy, complicated dacryocystitis with the development of phlegmon and the formation of skin fistula, traumatic dacryocystitis.

Example 1

Patient P., 53 years old, was admitted with a diagnosis of left-sided chronic recurrent dacryocystitis. 5 months ago, a transcanalicular laser endoscopic dacryocystorhinostomy was performed. 1 month after the operation, she noticed an exacerbation, lacrimation and purulent discharge appeared on the left eye. Upon receipt, the lacrimal and nasal passages on the left are impassable. On the x-ray of the lacrimal-nasal passages, the contrast mass was determined in the area of the lacrimal sac 10 × 3.5 mm in size and the upper 2/3 of the lacrimal-nasal canal.

A reoperation was performed according to the method we developed: laser endoscopic dacryocystorhinostomy with external access. After local anesthesia with a solution of lidocaine 2% -5 ml with the addition of adrenaline (8-10 drops), a direct incision of the skin and soft tissues 10 mm long was made in the region of the inner corner of the eye, starting 2-3 mm above the inner ligament of the eyelids. Soft tissues were stratified in a blunt way, dissected the inner ligament of the eyelids. The medial wall of the lacrimal sac was separated from the periosteum and part of it was cut off. The lacrimal sac cavity was sanitized with a solution of hydrogen peroxide and furatsillin 1: 5000 - 5-10 ml. Then, on the side wall of the nose in the area of the projection of the lacrimal sac, the laser cut a bone window with a diameter of 6-7 mm under endoscopic control of the left half of the nose on the monitor. Laser coagulated the nasal mucosa in the projection of the bone "window". At the same time, the laser mode for the bone “window” is 7 watts, for the nasal mucosa 4 watts. The upper lip of the wound of the medial wall of the lacrimal sac was fixed to the periosteum with two interrupted sutures above the bone “window”. The operation was completed by applying interrupted sutures to the inner ligament of the eyelids and soft tissues in layers, and the continuous intradermal suture of Halstead was applied to the skin wound. The wound was treated with a 1% alcohol solution of brilliant green. Gentamicin 40 mg was injected subcutaneously into the area of the lacrimal sac. Pressure bandage on the wound. In the postoperative period, the tear-nasal canal was washed daily with a solution of gentamicin daily for 3 days after the operation, followed by the addition of dexazone. Patency of the tear ducts has recovered.

In the control after 9 months, the patency of the lacrimal and nasal passages was free, tubular and double collargol tests were positive. On radiography of the lacrimal and nasal passages, the contrast mass was determined in the nasal cavity.

Example 2

Patient S., 22 years old, was admitted for surgical treatment with a diagnosis of right-sided chronic purulent dacryocystitis with a skin fistula. Recurrent phlegmon of the lacrimal sac. When washing the lacrimal passages, there was no patency in the lacrimal-nasal canal, lavage fluid escaped through the skin fistula. On the R-graph of the lacrimal-nasal passages, the contrast mass was determined in the lacrimal tubules, in the area of the lacrimal sac 5 × 5 mm in size and exited through the skin fistula.

Laser endoscopic dacryocystorhinostomy with external access with revision and suturing of the skin fistula was made according to our developed method. In the postoperative period, for 3 days after the operation, the lacrimal and nasal canal was washed with a gentamicin solution, followed by the addition of dexazone. Patency of the tear ducts has recovered.

The patient was observed for 10 months. Patency of the lacrimal and nasal passages was free, tubular and double collargol tests were positive. On radiography of the lacrimal and nasal passages, the contrast mass was determined in the nasal cavity.

Claims (1)

The method of external dacryocystorhinostomy, including a skin incision, the implementation of the bone "window", the formation of a stoma on the nasal mucosa, partial removal of the medial wall of the lacrimal sac, suturing of the skin wound, characterized in that the skin incision is performed up to 10 mm long, the bone "window" and the stoma on the nasal mucosa is formed by a diode laser using a power mode of 7 and 4-5 W, respectively, the upper lip of the wound is sutured to the periosteum above the bone window, after which a continuous Halsted suture is applied to the skin wound.