RU2428150C1 - Method of restoring dacryocystorinostoma in case of its healing - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to ophthalmology and can be used in case if passability of lachrymal way, surgically formed earlier by means of dacryocystorhinostomy, is disturbed. Essence of method lies in intra-operation determination of scar healing characteristics by its outpouching into nasal cavity by means of transcanalicularly introduced instrument, dissection of healing, control washing of lachrymal ways and temporary intubation of lachrymal way. Operation is carried out under endonasal endoscopic control. As instrument, which is used to outpounch healing into nasal cavity, used is light conductor, healing being dissected by means of radiowave energy of modernised Javate tip, introduced transcanalicularly, whose working part lacks bent at 9 distal end, and straight working part of tip has at the end bend at angle 5 to longitudinal axis. Dissection is started from healing perforation in the thinnest place, then dissection is performed along edges of bone window by making overlapping each other perforations. ^ EFFECT: application of invention makes it possible to reduce risk of operation complications, reduce operation time, minimise recurring healings. ^ 1 ex, 2 dwg

Description

The invention relates to medicine, more specifically to ophthalmology, and can be used in case of violation of patency of the tear duct, which was previously surgically formed using the operation of dacryocystorhinostomy (DCR).

Dacryocystorhinostomy is a surgical intervention in the development of dacryocystitis, which can be performed endonasally, transcanalicularly using laser radiation or external access. The essence of each technique is the same - to form a dacryocystorhinostoma (in the information sources it is abbreviated as dacryostomy), i.e. create an anastomosis between the mucous membrane of the lacrimal sac and the nasal cavity with resection of the lacrimal bone. Unfortunately, often in practice over time, the formed anastomosis overgrows, i.e. dacryocystitis occurs again. According to the scientific literature, the recurrence rate of dacryocystitis after performing external DCR ranges from 9 to 23%, after endonasal DCR from 2 to 16%, and after transcanalicular laser DCR within 17.6%.

The elimination of the overgrowth of the formed anastomosis by repeated interventions using the above-mentioned technologies does not quite suit surgeons for the following reasons. Repeated DCR with external access is associated with great technical difficulties and the morbidity of the reoperation due to the presence of scar vascularized tissues. Restoring patency of the anastomosis by transcanalicular perforation of the fusion (scar membrane) with a probe with retrograde bougieurage or endonasal intubation is ineffective. Repeated transcanalicular laser DSB has the same disadvantages as the primary one: hyperthermic damage to surrounding tissues, healing with severe scarring and, as a result, a large percentage of relapses. Endonasally performed electrocautery (electric burning) of the scar membrane or elimination of fouling with a sickle-shaped metal knife or radio wave energy from the Surgitron is unsafe even with endoscopic monitoring in terms of damage to the posterior wall of the lacrimal sac and tarsoorbital fascia with loss of orbital fat.

There is a method that allows after surgery anastomosis to function again, protected by the patent - "Method of operation for relapses of dacryocystitis" (RF patent No. 2173125 - prototype). The essence of the method lies in the fact that the anastomosis is freed from infection by endonasal access, without endoscopic control. To do this, first pierce with a probe the fusion of the mouth of the lower lacrimal tubule and the bone window. Bulge out the area of the inflamed anastomosis into the nasal cavity. With an endonasal approach, the anastomosis and the bone window are cleaned of scar and granulation tissue using a sickle knife. Then, through the lower lacrimal tubule, a polyethylene tube is passed and taken out of the nasal cavity. A silicone sponge (sleeve) is put on the withdrawn end of the tube, with which the anastomosis is plugged. Starting from the 3rd day, the newly created lacrimal duct is woken up by moving the tube. Remove the tube with the sleeve on the 14-17 day after surgery.

The disadvantages of the method:

- insufficient visual control over the manipulations in the intervention zone, does not allow to perform manipulations delicately, atraumatically (optical, rather than endoscopic rhinoscopy is used);

- when opening a rough vascularized membrane (fusion) with a scalpel from the side of the nasal cavity, there is a danger of damage to the posterior wall of the lacrimal sac, lacrimal tubules, tarsoorbital fascia, orbital structures;

- the dosage opening of the scar membrane covering the anastomosis is not ensured; there is a danger of its chaotic rupture and the occurrence of bleeding from vascularized scar tissues.

The objective of the invention is to develop a more reliable method that allows you to restore the dacryostomy in case of its overgrowth more atraumatic under endoscopic control, using radio wave energy.

The technical result obtained as a result of solving this problem is to reduce operational complications, reduce the time of surgery, minimize re-infusions.

The specified technical result can be obtained if the method for restoring the dacryocystorhinostoma in case of its overgrowth, including intraoperative determination of the characteristics of cicatricial growth by protruding it into the nasal cavity using a transcanalicular instrument, excision of the growth, control washing of the tear ducts and temporary intubation of the tear duct, under endonasal endoscopic control, while as a tool that protrudes the fusion in the polo nose, they use a fiber, and they cut out the contamination with the help of the radio wave energy of the modernized Javat tip, transcanalicularly installed, the working part of which does not have a distal end bent at an angle of 90 °, and the straight working part of the tip has a bend at an angle of 5 ° to the longitudinal axis, and begin excision with perforation of the overgrowth in the thinnest place, and then excised along the edges of the bone window by performing overlapping perforations.

Among the essential features characterizing the method, the distinguishing ones are:

- the operation is carried out under endonasal endoscopic control;

- as a tool that protrudes the fusion into the nasal cavity, use a light guide;

- excision of contamination with the help of radio wave energy of the modernized tip of Javat, transcanalicular wound;

- the working part of the modernized Javat tip lacks a distal end bent at an angle of 90 °, and the straight working part of the tip has a bend at the end at an angle of 5 ° to the longitudinal axis;

- begin excision with perforation of the overgrowth in the thinnest place;

- then the excision along the edges of the bone window is excised by performing overlapping perforations.

Between the totality of essential features and the achieved technical result, there is a causal relationship.

Endonasal endoscopic control has come to the surgery of the lacrimal ducts in recent years and its advantages against optical rhinoscopy (prototype) are obvious. It is especially important at the initial stage of the operation to evaluate the infection: its location, whether the infection is adjacent to any structures, thickness, the thinnest place of infection, vascularization, etc. Such an assessment can be done qualitatively, with good visualization, with the help of an endonasal endoscope, when there is a protrusion protruding in front of the lens, and this distance is ensured by means of a transcanalicular optical fiber. The distal end of the fiber is simultaneously provided with a distance of fouling and its illumination. After a thorough intraoperative diagnosis, having studied the infection with the help of an endoscope, the surgeon has the opportunity to act delicately, efficiently, confidently during the release of the anastomosis from the infection. Membrane excision (fusion) begins with the thinnest spot identified during the examination. This eliminates the chaotic rupture of the membrane. It is proposed to use the radio wave energy of the upgraded Javat tip to the Surgitron DF-120 device, transcanalicularly wound for excision of the overgrowth. This method allows you to cut and coagulate soft tissue using high frequency radio waves (4 MHz) without tissue deformation. The standard radio wave tip of Javat has a L-shaped shape and is intended for the formation of a flap of the nasal mucosa in the intervention zone and excision of the walls of the lacrimal sac during its endonasal institution during endonasal dacryocystorhinostomy surgery. A feature of the modernized tip is that the working part does not have a distal L-shaped end bent at an angle of 90 °, and the straight working part of the tip has a bend at the end at an angle of 5 ° to the longitudinal axis. This design allows you to get the radio wave tip from the side of the lacrimal ducts to infect atraumatic (diameter of the working tip with insulation - 1.1 mm, which is comparable with the diameter of the enlarged lacrimal tubule). And bending the end of the working part of the tip by only 5 ° relative to the longitudinal axis makes it possible, by rotating the handle of the tip around its own axis (without tilting it), to end up the end working part of the tip at the point where it is necessary to destroy tissue with radio wave energy - along the edges of the bone window (window area on average 4 × 6 mm). The excision of the overgrowth of a radio-wave instrument, established transcanalicularly, is carried out quickly, efficiently and atraumatically. Earlier, we noted that when the Javat radio wave tip is used endonasally to excise the anterior wall of the lacrimal sac (with endonasal endoscopic dacryocystorhinostomy), there is a risk of damage to the posterior wall of the lacrimal sac, the mouth of the lacrimal tubules, tarsoorbital fascia, orbital structures. In this technology, excision of the growth is performed not towards the lacrimal sac, but from the lacrimal sac towards the nasal cavity, therefore, such an injury is excluded.

Thus, between the set of essential features and the achieved technical result, there is a causal relationship.

Figure 1 - shows a variety of standard Javat tips (all of them are L-shaped).

Figure 2 - shows a modernized Javat tip (there is no distal end bent at an angle of 90 °, and the direct working part of the tip has a bend at the end at an angle of 5 ° to the longitudinal axis).

The method is as follows.

An epibulbar drip anesthesia and local anesthesia of the nasal cavity are performed. Siekhel’s conical probes No. 1-3 expand the lower lacrimal opening, tubule, fill the lacrimal tubule and lacrimal sac with viscoelastic (known technique - patent No. 2335264). A light guide is transcanalicularly inserted into the lacrimal sac, illuminating the fusion with it. At the same time, a rigid endoscope connected to a video camera is inserted into the nasal cavity. Light pressure is applied to the scar membrane by the distal end of the light guide, its deflection into the nasal cavity is visualized, its boundaries, density, thickness, and vascularization are clarified. Then the light guide is brought out and in its place through the same lacrimal opening and tubule into the lacrimal sac to the scar membrane (fusion) a modified Javat tip is brought. The working part of the tip is covered with insulation, has a length of 23 mm and is slightly curved at the end, the bend is 5 ° to the longitudinal axis. The working part of the tip ends with a rounded, non-insulated working end. The radio wave tip protrudes the fusion into the nasal cavity and in the thinnest place under the control of the endoscope, in the “cutting + coagulation” mode, the scar membrane is perforated using a power of 10-12 watts (if necessary, the “cutting” and “coagulation” functions can be performed separately). Perforating the infestation in the thinnest place, the surgeon determines the magnitude of the power of the radio wave exposure, which he will use to perforate other, denser areas of infestation. Having opened the membrane, they begin to excise it. The membrane is sequentially excised along the edges of the bone window, by performing overlapping perforations. To advance the distal end of the tip along the contour of the tip, turn the handle of the tip around its own axis (the action is provided due to the constructive bending of the tip by 5 °). After complete excision of the growth, the selected tissue is removed to the outside or washed. Then carry out a control wash of the lacrimal passages and a temporary bicanalicular intubation with a standard silicone system for an average of 2-3 months. After 1 month, the patient is invited to a control wash.

Example. Patient T., b. 1936 In May 2009, he underwent endonasal endoscopic DCR on the left. At the appearance on June 22, 2009, there were no complaints, the intubation system occupied the correct position, and when washing the lacrimal passages, the fluid freely entered the nose. At the place of residence, the intubation system was removed on 08/20/2009. With the appearance of 10/19/2009 - complaints of lacrimation, when washing the lacrimal passages, the flushing fluid in the nose does not pass. Performed endoscopic rhinoscopy - revealed cicatricial infection of the dacryostomy. Diagnosis: recurrence of dacryocystitis on the left.

November 6, 2009, the patient underwent surgery according to the developed technology. That is, transcanalicular excision of the scar membrane was performed using the modernized Javat radio wave tip to the Surgitron DF-120 apparatus under endonasal endoscopic control. The modernization of the design of the tip consisted in the fact that the working part of the tip did not have a distal end bent at an angle of 90 °, and the straight working part of the tip had a bend at the end at an angle of 5 ° to the longitudinal axis. Initially, the characteristics of cicatricial fusion were determined intraoperatively using a transcanalicularly wound fiber, which protruded the fouling towards the nasal cavity, and an endoscope connected to the video camera. Characteristics of fouling: scar membrane 5 × 5 mm in size of uneven thickness, with single newly formed vessels. A weak (thin) place in the membrane was detected at 5 o'clock near the edge of the bone window. At this point, perforation perforation was carried out using the power of the radio wave tip equal to 12 W, as a result, the membrane was opened atraumatically. Then continued the excision of the growth along the edges of the bone window, by performing overlapping perforations, using a power of 14 watts. After complete excision of the membrane, a control washing of the tear ducts was performed. A temporary intubation with Bika was performed.

At the turnout of December 11, 2009, there were no complaints. The intubation system is in the correct position, the dacryostomy is 4 × 5 mm in size, the control rinsing of the tear ducts, the fluid freely passes into the nose and comes out.

01/25/2010 - the intubation system was removed, a control flushing of the restored lacrimal duct was performed, the fluid freely passes into the nose.

With the appearance of February 26, 2010, the tear duct works well, the patient has no complaints.

The inventive method in our center operated on 16 patients. All operations went without complications. The method has confirmed its reliability, allowing to restore dacryocystorhinostoma after its infection in all 16 patients. At the same time, less time was spent on the operation than with traditional technologies, the number of repeated infusions was minimized.

Claims (1)

A method for restoring a dacryocystorhinostoma in case of its overgrowth, including intraoperative determination of the characteristics of cicatricial growth by protruding it into the nasal cavity using a transcanalicular instrument, excision of the growth, control washing of the tear ducts and temporary intubation of the tear duct, characterized in that the operation is performed under the endonasal control at the same time, as a tool, which protrudes the fusion into the nasal cavity, they use a light guide, and a resection t is fouling with the help of radio wave energy of the modernized Javat tip, transcanalicularly installed, the working part of which does not have a distal end bent at an angle of 90 °, and the direct working part of the tip has a bend at an end of 5 ° to the longitudinal axis, and excision begins with perforation perforation in the thinnest place, and then excised along the edges of the bone window by performing overlapping perforations.

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