RU2750547C1 - Method for formation of anastomosis between dacryocyst and the nasal cavity in external dacryocystorinostomy - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: resection of the bone of the nose sidewall is performed with the formation of a “window” with a diameter of 12 mm. An incision of the nasal mucosa is made with the formation of the outer lip of the nasal mucosa and the inner lip of the nasal mucosa. A longitudinal incision of the inner wall of the dacryocyst is made from the dome to the inlet to the naso-lacrimal canal with the formation of the inner lip of the dacryocyst and the outer lip of the dacryocyst. An amniotic membrane is placed between the inner lip of the dacryocyst and the inner lip of the nasal mucosa. The anastomosis in the form of a tube is formed by suturing the opposite flaps from the wall of the dacryocyst, from the nasal mucosa and the amniotic membrane. The edges of the bone tenderloin are covered by 360° by the anastomosis walls made in the form of a tube.

EFFECT: method reduces the number of relapses of dacryocystitis, accelerates the healing time of the surgical wound, and reduces the risk of inflammatory complications.

1 cl, 2 ex, 5 dwg

Description

The invention relates to medicine, namely to ophthalmology, and for the surgical treatment of dacryocystitis.

One of the first measures in solving this issue was cutting out of the mucous membranes of the lacrimal sac and the nasal cavity of opposite flaps of different widths in such a way that the formed posterior and anterior wall of the anastomosis did not come into contact and did not grow together along the incision line. A very important role in solving the problem of preventing anastomosis obliteration was played by the study of the causes and pathogenetic mechanisms of this process. V.N. Arkhangelsky (1928) found that the basis of the failure of the classical dacryocystorhinostomy is the proliferation of tissue from the periosteum and the edges of the connected mucous membranes of the lacrimal sac and the nasal cavity. Favorable conditions for the anastomosis are created when the anastomosis is insufficient in the first hours after the operation.

Analogs.

Various methods of forming an anastomosis between the lacrimal sac and the nasal cavity in external dacryocystorhinostomy have been proposed. The literature contains data on suturing the lips of the mucous membranes of the nasal cavity and lacrimal sac (Dupuy-Dutemps, Bourguet // Ann.d 'oculistique. - 1921. - Vol. 158. - P. 241-261) and intubation with various alloplastic implants ... A known method of forming an anastomosis during the operation of an external dacryocystorhinostomy using an insert-fixator of the mucous membranes for temporary intubation of the anastomosis, proposed by M.Yu. Sultanov and O.N. Nesterenko (1968) (Sultanov M.Yu.Dacryocystorhinostomy with temporary intubation of the anastomosis with an insert-fixator of the mucous membranes // Bulletin of Ophthalmology. - 1970. - No. 3. - P. 49-51). The Sultanov-Nesterenko mucous membrane fixative insert is made of Teflon, spongy silicone, silicone or rubber tube in the form of a half-ring with a concave outer surface. The end edges of the half-ring are stitched with a thread in the form of a loop for the purpose of subsequent removal of the liner through the nose for 7-10 days. The anastomosis is formed seamlessly, covering the bony window with a mucous flap of the lacrimal sac according to Taumi using the nasal mucosa, which is pressed by the half-ring of the liner implanted in the fistula. Half-ring dimensions: outer diameter 11-14 mm (outside the groove), width - 7 mm, wall thickness 1.0-1.5 mm.

A known method of forming an anastomosis during an operation of an external dacryocystorhinostomy using an implant for intubation of an anastomosis L.N. Kolesnikova and E.A. Pestova (Kolesnikova L.N., Pestova E.A. A new modification of the formation of an anastomosis during dacryocystorhinostomy // Bulletin of ophthalmology. - 1987. - No. 1. - S. 25-27). The Kolesnikova-Pestova implant for anastomosis intubation is a silicone tube with an outer diameter of 5 mm and a length of 20-25 mm, stitched from both ends around the circumference with one silk thread. The ends of the tube are bent outward of the tube, forming a bead with a larger diameter than the diameter of the tube itself. The rollers are designed to fix the implant in the anastomosis. The tube is placed in an anastomosis formed by cross-cut mucous membranes with incisions offset by 45 ° relative to each other. The thread from the upper end of the tube is taken out through the lower lacrimal canal, and from the lower end of the tube through the nasal cavity. Both ends of the silk thread are tied and fixed on the skin of the patient's face. When the tube is withdrawn in the postoperative period, pulling the ends of the thread helps to narrow the diameter of the implant in the places where the thread is applied and to remove it more quickly.

Criticism of analogues.

The use of the above methods is associated with a number of negative aspects. The Sultanov-Nesterenko fixation insert and the Kolesnikova-implant are not produced by the pestovoy industry. Making them yourself is a laborious process, which lengthens the operation time. The materials from which the implants are made can injure the surrounding tissue. In addition, the known implants do not take into account the anatomical features of a particular person due to the lack of the possibility of intraoperative modeling, and also have shapes that do not allow being in the anastomosis for a long time. The stabilization of regenerative processes in the area of the bone defect occurs at 4-5 weeks. It is for this period that it is desirable to leave the implant.

Invention prototype.

The prototype of this method is the classical dacryocystorhinostomy according to Dupuis-Dutan-Bourgue (Guide to eye surgery / Edited by M.L. Krasnova, V.S.Belyaev. - 2nd ed., Revised and added. - M .: Medicine , 1988. - S. 474-475). proposed in France in 1921. The essence of the prototype method is to create an anastomosis by suturing the opposite flaps from the wall of the lacrimal sac and from the nasal mucosa.

Criticism of the prototype.

Suturing the posterior lips of the nasal mucosa and lacrimal sac during the formation of the anastomosis is a laborious process because their total length is shorter than the distance between the lacrimal sac and the nasal mucosa. With the formation of an anastomosis between the nasal cavity and the lacrimal sac, only the outer and inner lips of the nasal mucosa and the lacrimal sac are formed and stitched, which cover the upper and lower edges of the bone notch, which leads to the growth of granulations from the periosteum of the uncovered edges of the bone notch and, as a result, to recurrence of dacryocystitis.

The purpose of the invention.

The aim of the invention is to improve the efficiency of the operation of external dacryocystorhinostomy and the prevention of relapses. This goal is achieved by forming a tubular fistula between the lacrimal sac and the nasal cavity using an amniotic membrane.

The essence of the invention.

The essence of the invention is illustrated in FIG. 1, where

Pos. 1 - outer lip of the lacrimal sac

Pos. 2 - inner lip of the lacrimal sac

Pos. 3 - outer lip of the nasal mucosa

Pos. 4 - inner lip of the nasal mucosa

FIG. 2, where

Pos. 2 - inner lip of the lacrimal sac

Pos. 4 - inner lip of the nasal mucosa

Pos. 9 - amniotic membrane

FIG. 3, where

Pos. 2 - inner lip of the lacrimal sac

Pos. 4 - inner lip of the nasal mucosa

Pos. 5 - lateral upper edge of the nasal mucosa

Pos. 6 - lateral lower edge of the nasal mucosa

Pos. 7 - lateral upper edge of the lacrimal sac

Pos. 8 - lateral lower edge of the lacrimal sac

Pos. 9 - amniotic membrane

Pos. 10 - the upper edge of the amniotic membrane

Pos. 11 - the lower edge of the amniotic membrane

FIG. 4 where

Pos. 1 - outer lip of the lacrimal sac

Pos. 3 - outer lip of the nasal mucosa

Pos. 10 - the upper edge of the amniotic membrane

Pos. 11 - the lower edge of the amniotic membrane

FIG. 5, where

Pos. 1 - outer lip of the lacrimal sac

Pos. 3 - outer lip of the nasal mucosa

Pos. 10 - the upper edge of the amniotic membrane

Pos. 11 - the lower edge of the amniotic membrane

The formation of a tubular anastomosis between the lacrimal sac and the nasal cavity with external dacryocystorhinostomy is carried out as follows.

Local infiltration anesthesia is performed with 2% lidocaine solution along the anterior lacrimal crest and in the area of the bony fossa, below the inner ligament of the eyelids towards the nasolacrimal canal and above the inner ligament of the eyelids to the periosteum. A gauze turunda moistened with 2% solution of lidocaine with 1-2 drops of adrenaline is introduced into the middle nasal passage. The skin incision is made 1.5 mm above the inner ligament of the eyelids 4 mm medial to the inner corner of the palpebral fissure, then the incision is continued in a straight line obliquely downward and outward along the anterior lacrimal ridge 15 mm long to the bone, with the exception of the lower section of the wound. The soft tissues are separated until the inner ligament of the eyelids appears. The edges of the wound are fixed with a retractor. The internal ligament of the eyelids at the site of its attachment to the bone is cut together with the periosteum along the anterior lacrimal crest along the entire length of the wound and separated from the bone with a raspor together with the lacrimal sac. Using a manual trepanor cutter, the bone of the lateral wall of the nose is resected to form a "window" with a diameter of 12 mm. The essence of the invention is as follows:

An incision is made in the nasal mucosa within the bone window with the formation of the outer lip of the nasal mucosa (Fig. 1, pos. 3) and the inner lip of the nasal mucosa (Fig. 1, pos. 4). Then, a longitudinal section of the inner wall of the lacrimal sac is carried out from the dome to the entrance to the nasolacrimal canal, with the formation of the inner lip of the lacrimal sac (Fig. 1, pos. 2) and the outer lip of the lacrimal sac (Fig. 1, pos. 1). Between the inner lip of the lacrimal sac (Fig. 2, pos. 2) and the inner lip of the nasal mucosa (Fig. 2, pos. 4), an amniotic membrane is placed (Fig. 2. Pos. 9). Sutures are applied to the inner lip of the lacrimal sac (Fig. 2, Fig. 3, pos. 2) and the amniotic membrane (Fig. 2, Fig. 3, pos. 9); sutures are applied to the inner lip of the nasal mucosa (Fig. 2, Fig. 3, pos. 4) and the amniotic membrane (Fig. 2, Fig. 3, pos. 9), thus forming the lower wall of the anastomosis (Fig. 3, pos. 4, item 9 item 2). Sutures are applied to the upper edge of the amniotic membrane (Fig. 3 pos. 10) and the lateral upper edge of the lacrimal sac (Fig. 3 pos. 7); sutures are applied to the upper edge of the amniotic membrane (Fig. 3, pos. 10) and the lateral upper edge of the nasal mucosa (Fig. 3, pos. 5); sutures are applied to the lower edge of the amniotic membrane (Fig. 3 pos. 11) and the lateral lower edge of the lacrimal sac (Fig. 3 pos. 8); sutures are applied to the lower edge of the amniotic membrane (Fig. 2, pos. 11) and the lateral lower edge of the nasal mucosa (Fig. 2. Pos. 6); sutures are applied to the outer lip of the nasal mucosa (Fig. 4, Fig. 5, pos. 3) and the outer lip of the lacrimal sac (Fig. 4, Fig. 5, pos. 1), thus forming the upper wall of the anastomosis (Fig. 5, pos. . 3, item 1). Sutures are applied to the upper edge of the amniotic membrane (Fig. 4 and Fig. 5, pos. 10) and the upper wall of the anastomosis (Fig. 4 and Fig. 5, pos. 3, pos. 1); sutures are applied to the lower edge of the amniotic membrane (Fig. 4, pos. 11) and the upper wall of the anastomosis (Fig. 4 and Fig. 5, pos. 3, pos. 1), thus forming the side walls of the anastomosis (Fig. 5, pos. 10 , item 11).

At the end of the operation, sutures are applied to the inner ligament of the eyelids and the soft tissues of the anterior lacrimal crest. Sutures are applied to the skin. A gauze turunda lubricated with tetracycline 1% ointment is introduced into the nasal passage. The edges of the wound are treated with a solution of brilliant green. Apply an aseptic pressure bandage to the area of the surgical wound. Turunda is removed on day 7. The stitches on the skin are removed on day 7.

Examples of specific execution of the method.

Clinical example No. 1

Patient A., 38 years old, was admitted to the GBU NPO "DCMG" on January 17, 2017 with a diagnosis of Chronic purulent dacryocystitis on the left.

From the anamnesis: Lachrymation on the left bothers about 2 years. For the last 7 months, there has been a purulent discharge from the inferior lacrimal opening, which increases with pressure on the area of the lacrimal sac.

Research methods: tubular and nasal tests are negative.

On January 18, 2017, an operation was performed according to the proposed method - external dacryocystorhinostomy on the left:

local infiltration anesthesia with 2% lidocaine solution along the anterior lacrimal crest and in the area of the bony fossa, below the inner ligament of the eyelids towards the nasolacrimal canal and above the inner ligament of the eyelids to the periosteum. A gauze turunda moistened with 2% solution of lidocaine with 1-2 drops of adrenaline was introduced into the middle nasal passage. The skin incision was made 1.5 mm above the inner ligament of the eyelids, 4 mm medial to the inner corner of the palpebral fissure, then the incision was continued in a straight line obliquely downward and outward along the anterior lacrimal ridge 15 mm long to the bone, except for the lower section of the wound. The soft tissues are separated until the inner ligament of the eyelids appears. The wound edges are fixed with a retractor. The internal ligament of the eyelids at the site of its attachment to the bone is cut together with the periosteum along the anterior lacrimal crest along the entire length of the wound and separated from the bone by a raspor together with the lacrimal sac. A manual trepanor cutter was used to resect the bone of the lateral wall of the nose with the formation of a "window" with a diameter of 12 mm.

An incision is made in the nasal mucosa within the bone window with the formation of the outer lip of the nasal mucosa and the inner lip of the nasal mucosa. Then a longitudinal section of the inner wall of the lacrimal sac is made from the dome to the entrance to the nasolacrimal canal, with the formation of the inner lip of the lacrimal sac and the outer lip of the lacrimal sac. An amniotic membrane is laid between the inner lip of the lacrimal sac and the inner lip of the nasal mucosa. Sutures were placed on the inner lip of the lacrimal sac and the amniotic membrane; sutures are placed on the inner lip of the nasal mucosa and the amniotic membrane, thus forming the lower wall of the anastomosis. Sutures were placed on the upper edge of the amniotic membrane and the lateral upper edge of the lacrimal sac; sutures are placed on the upper edge of the amniotic membrane and the lateral upper edge of the nasal mucosa; sutures are placed on the lower edge of the amniotic membrane and the lateral lower edge of the lacrimal sac; sutures are placed on the lower edge of the amniotic membrane and the lateral lower edge of the nasal mucosa; sutures are placed on the outer lip of the nasal mucosa and the outer lip of the lacrimal sac, thus forming the upper wall of the anastomosis. Sutures were placed on the upper edge of the amniotic membrane and the upper wall of the anastomosis; sutures are applied to the lower edge of the amniotic membrane and the upper wall of the anastomosis, thus forming the lateral walls of the anastomosis.

Sutures were applied to the inner ligament of the eyelids and the soft tissues of the anterior lacrimal crest. Stitches were applied to the skin. A gauze turunda was introduced into the nasal passage, lubricated with tetracycline 1% ointment. The edges of the wound were treated with a solution of brilliant green. An aseptic pressure bandage was applied to the area of the surgical wound. Turunda was retrieved on the 7th day. The stitches on the skin were removed on day 7.

Thus, the goal of the proposed invention to improve the efficiency of the operation of external dacryocystorhinostomy and the prevention of relapses is realized.

Clinical example No. 2

Patient J., 44, was admitted to the State Budgetary Institution of Nonprofit Organization "DCMG" on February 20, 2017 with a diagnosis of Post-traumatic dacryocystitis on the right.

From the anamnesis: About 1 year ago she received a nose injury. About what the rhinoplasty was performed. Last 6 months notes lacrimation and lacrimation on the right.

Research methods: tubular and nasal tests are negative. 02/21/2017, an operation was performed according to the proposed method - external dacryocystorhinostomy on the right:

local infiltration anesthesia with 2% lidocaine solution along the anterior lacrimal crest and in the area of the bony fossa, below the inner ligament of the eyelids towards the nasolacrimal canal and above the inner ligament of the eyelids to the periosteum. A gauze turunda moistened with 2% solution of lidocaine with 1-2 drops of adrenaline was introduced into the middle nasal passage. The skin incision was made 1.5 mm above the inner ligament of the eyelids, 4 mm medial to the inner corner of the palpebral fissure, then the incision was continued in a straight line obliquely downward and outward along the anterior lacrimal ridge 15 mm long to the bone, except for the lower section of the wound. The soft tissues are separated until the inner ligament of the eyelids appears. The wound edges are fixed with a retractor. The internal ligament of the eyelids at the site of its attachment to the bone is cut together with the periosteum along the anterior lacrimal crest along the entire length of the wound and separated from the bone by a raspor together with the lacrimal sac. A manual trepanor cutter was used to resect the bone of the lateral wall of the nose with the formation of a "window" with a diameter of 12 mm.

An incision is made in the nasal mucosa within the bone window with the formation of the outer lip of the nasal mucosa and the inner lip of the nasal mucosa. Then, a longitudinal section of the inner wall of the lacrimal sac is performed from the dome to the entrance to the nasolacrimal canal, with the formation of the inner lip of the lacrimal sac and the outer lip of the lacrimal sac. An amniotic membrane is laid between the inner lip of the lacrimal sac and the inner lip of the nasal mucosa. Sutures were placed on the inner lip of the lacrimal sac and the amniotic membrane; sutures are placed on the inner lip of the nasal mucosa and the amniotic membrane, thus forming the lower wall of the anastomosis. Sutures were placed on the upper edge of the amniotic membrane and the lateral upper edge of the lacrimal sac; sutures are placed on the upper edge of the amniotic membrane and the lateral upper edge of the nasal mucosa; sutures are placed on the lower edge of the amniotic membrane and the lateral lower edge of the lacrimal sac; sutures are placed on the lower edge of the amniotic membrane and the lateral lower edge of the nasal mucosa; sutures are placed on the outer lip of the nasal mucosa and the outer lip of the lacrimal sac, thus forming the upper wall of the anastomosis. Sutures were placed on the upper edge of the amniotic membrane and the upper wall of the anastomosis; sutures are applied to the lower edge of the amniotic membrane and the upper wall of the anastomosis, thus forming the lateral walls of the anastomosis.

Sutures were applied to the inner ligament of the eyelids and the soft tissues of the anterior lacrimal crest. Stitches were applied to the skin. A gauze turunda was introduced into the nasal passage, lubricated with tetracycline 1% ointment. The edges of the wound were treated with a solution of brilliant green. An aseptic pressure bandage was applied to the area of the surgical wound. Turunda was retrieved on the 7th day. The stitches on the skin were removed on day 7.

The aim of the proposed invention to improve the efficiency of the operation of external dacryocystorhinostomy and the prevention of relapses is implemented in this clinical example.

Features of the invention that differ from the prototype.

In the proposed method for external dacryocystorhinostomy:

- use the amniotic membrane, canned in 2% formalin solution, as an implant - form a tubular anastomosis

- the walls of the tubular anastomosis cover the edges of the bone notch 360 degrees.

According to the prototype method, the amniotic membrane is not used, the anastomosis covers the bone notch 180 degrees to the upper and lower edges of the bone notch.

The prototype method lacks essential features of the invention.

The technical result from the application of this method.

The technical result from the application of this method prevents the proliferation of tissue from the periosteum into the lumen of the bone notch due to the fact that the anastomosis has the shape of a tube that covers the edges of the bone notch 360 degrees.

The amniotic membrane has antibacterial, anti-inflammatory, antiproliferative properties. 12 months after the operation, 79 (98.75%) patients treated with the proposed method of external dacryocystorhinostomy were satisfied with the results of the operation. The lacrimation function and the lacrimal duct flushing test remained fully functional. Only in 1 patient (1.25%) during this period of postoperative observation, clinical symptoms reappeared, indicating the absence of lacrimation.

Thus, the proposed invention allows:

1. To carry out the prevention of recurrence of dacryocystitis

2. To speed up the healing time of the surgical wound by 5 days (the above are specific examples of the clinical implementation of the method.)

3. Reduce the risk of inflammatory complications.

Sources of information taken into account:

1. Bastrikov N.I. Diseases of the lacrimal organs. - Rostov-on-Don, 2007.

2. Volkov V.V., Sultanov M.Yu. External dacryocystorhinostomy. - L., 1975 .-- 104 p. -

3. Pole B.L. Essays on the pathology of the lacrimal passages Sat. scientific, works on ophthalmology. - L., 1947.

4. Shamkhalov Sh.A., Beloglazov V.G. Dacryocystitis. - Makhachkala, 1989.

5. Cherkunov B.F. Diseases of the lacrimal organs. - Samara, 2001.

6. Guide to eye surgery / Ed. M.L. Krasnova, V.S. Belyaeva. - 2nd ed., Rev. and add. - M .: Medicine, 1988. - S. 474-475). - prototype.

Claims (1)

A method of forming an anastomosis between the lacrimal sac and the nasal cavity with external dacryocystorhinostomy, which consists in creating an anastomosis by suturing the opposite flaps from the wall of the lacrimal sac and from the nasal mucosa, characterized in that the tube-shaped anastomosis is formed as follows: after resection of the bone of the lateral nasal wall with the formation of a "window" with a diameter of 12 mm, an incision is made in the nasal mucosa with the formation of the outer lip of the nasal mucosa and the inner lip of the nasal mucosa, a longitudinal section of the inner wall of the lacrimal sac from the dome to the entrance to the nasolacrimal canal, with the formation of the inner lip of the lacrimal sac and the outer lip of the lacrimal sac, between the inner lip of the lacrimal sac and the inner lip of the nasal mucosa, an amniotic membrane is placed, sutures are applied to the inner lip of the lacrimal sac and the amniotic membrane, sutures are applied to the inner lip of the nasal mucosa and amniotic membrane, forming a lower wall with mouth; sutures are applied to the outer lip of the nasal mucosa and the outer lip of the lacrimal sac, forming the upper wall of the anastomosis; sutures are placed on the upper edge of the amniotic membrane and the upper wall of the anastomosis, on the upper edge of the amniotic membrane and the lateral upper edge of the nasal mucosa, on the upper edge of the amniotic membrane and the lateral upper edge of the lacrimal sac, on the lower edge of the amniotic membrane and the upper wall of the anastomosis, on the lower edge of the amniotic membrane and the lateral lower edge of the nasal mucosa, on the lower edge of the amniotic membrane and the lateral lower edge of the lacrimal sac, the formed tube-shaped fistula walls cover the edges of the bone notch 360 °.

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