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| ARTICLE |
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| Year : 1967 | Volume
: 15
| Issue : 3 | Page : 81-85 |
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Dacryocystorhinostomy - a new technique of suturing the flaps by using modified sewing machine needle
RN Mathur, PT Chakko, R Ebenezer, Gowri Kumar
India
| Date of Web Publication | 21-Jan-2008 |
Correspondence Address:
R N Mathur
India
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Mathur R N, Chakko P T, Ebenezer R, Kumar G. Dacryocystorhinostomy - a new technique of suturing the flaps by using modified sewing machine needle
. Indian J Ophthalmol 1967;15:81-5 |
Although lot of technical improvements have been achieved in dacryocystorhinostomy operation from the time of Toti (1904), still suturing the mucosal flaps offers difficulty and make this, otherwise simple operation, not quite so popular. Modified sewing machine needles of our design have simplified this suturing of the flaps. We would like to share our experience with a review of 255 D.C.R. operations done in 223 patients at the Schell Eye Hospital of the Christian Medical College, Vellore.
| Modified Sewing Machine Needles | |  |
These needles come in many sizes ranging from No. 9 to No. 25. We prefer No. 14 as adequate for our work. These can be modified very easily in any theatre. The lip is grinded short and resharpened. These are heated over spirit lamp or any flame and bent at 120˚ and 45˚ angles to make for posterior flaps and anterior flaps, respectively [Figure - 1]
These can be fixed on Elliots trephine holders [Figure - 2] or artery forecep. Capt. Subramaniyam of Madras had made a nice holder for these, like the one used for holding laryngoscope mirror. These needles combine the advantage of Reverdin's needle and Dupuy-Dutemps miniature aneurismal needles and Sarda's needle and at the same time laceration of even a fragile flap is infrequent. These are very cheap and locally available in all places.
Views about the earliest time one may do the operation have been modified ever since the time of Toti (1904) and Dupuy-Dutemps (1920). We feel that 2 years (Stallard-1958) is too young an age while we may operate at 3 years of age.
Today most types of lacrimal sac affections can be managed much better by D.C.R. and dacryocystectomy has very few indications.
Operative Technique:
In most patients the operation was performed under local anaesthesia, except in children where general anesthesia was administered by endotracheal route. Nose is packed with anethaine 1 with adrenaline before the operation. We premedicate our patients with Largactil 50 mg. 2 hours before operation.
Exposure of Sac:
We prefer to make the incision well forward, straight and boldly down to the bone in one sweep. (Hallum, 1943, 1948). A vertical incision is made 2 cm. long with its upper limit 1 mm. above the level of the inner canthus, and 1 cm. nasally. With a periosteal elevator the entire bony surface is exposed and soft tissues including the lacrimal sac arc retracted laterally. This exposes the lacrimal fossa upto the posterior lacrimal crest. Wound edges are retracted with sutures an4 clamped further forwards.
| Bone Resection | | |
Many methods are available using chisel and hammer (Jain, Sethi and Prakash, 1955) dental drill, hand and electric trephine or drill. We found it much simpler to break the lacrimal part of the fossa, which is very thin, by lacrimal curette. This makes the opening big enough to introduce Citelli's punch. Enlarging the same, an osteum measuring about 1.5 x I cm. is made. The nasal pack is removed.
Incision for making Flaps
A probe is passed through the inferior punctum and the canaliculus into the sac and pushed medially to elevate the medial sac wall. A stab wound is made in it with an used cataract knife and enlarged up and down with scissors, the ends being cut in "I" shape. This results in two window flaps in the medial sac wall. [Figure - 3].
The nasal mucous membrane flaps are made in the same way, the vertical cut being such that the anterior flap is bigger than the posterior. This may have to be modified according to individual case.
Suturing of Mucosal Panel Flaps:
This is the most difficult part of the operation. Movements of ordinary needles are difficult to manipulate in the depth and in this restricted area. We have modified a Singer sewing machine needle which has eased this otherwise difficult operation. [Figure - 1],[Figure - 2]
The posterior flap suturing needle has an obtuse angle of about 120° and anterior one of about 45 degree. We have been using these since 1960 and in no case we found difficulty. Laceration which occurs with the Dupuy-Dutemps miniature aneurismal needle and Reverdin's needle is absent. The posterior and anterior flaps of sac and nasal mucous membrane are sutured using 4 Zero silk or catgut as illustrated in [Figure - 4],[Figure - 5],[Figure - 6],[Figure - 7].
Closing of incision:
The wound is sutured in two layers. First the retracted periosteum, medial palpebral ligament and muscles are sutured, using few interrupted catgut stitches. The wound is dusted with sulfa powder. The skin wound may be closed by subcuticular continuous stitches using 000 black silk. Terramycin ointment is applied into the conjunctival sac. Gauze dressing is applied and the wound bandaged.
Postoperative Management:
Many surgeons recommend syringing the duct from the 4th day using steroids. In our experience it is not necessary. The bandage is removed after 48 hours and wound allowed to heal by leaving it open, cleaning every day with alcohol. On the 6th postoperative day sutures are removed and the first syringing is done. Next day the patient goes home with zinc adrenaline drops for home use.
Complications:
Hemorrhage from the skin incision was rare and incision being more medial, angular vein is hardly ever involved.
Fracture of the lacrimal bone which occurs during chiselling is absent using the punch technique in making the osteum.
Laceration of the nasal mucosa or the sac itself can occur if no care is taken to retract it while using the punch. Using these modified sewing needles laceration is infrequent while suturing.
| Results | | |
The followup of these cases are very difficult once they are discharged from the hospital. But surely they come back if any trouble persists. Hence our results are mainly seen postoperatively. Two cases were definite failures and excision of the remains of the sac was done. 8 cases had mild block which cleared with probing once and syringing for 3-4 days.
Skin wound becomes inconspicuous within 2-3 months of the operation.
| Discussion | | |
Although chronic dacryocystitis and mucocele with atonic sac offer the most favourable prognosis, with more and more experience good results with relief of epiphora may be obtained even in cases of chronic dacryocystitis with fistula and pseudo sac after dacryocystectomy. We had good results in 20 such cases in this series.
Obstruction in the common canaliculus was regarded in the past as contraindication, however Berrie Jones, Canaliculodacryocystorhinostomy and polyethylene intubation has improved the success rate in these cases. We used epidural tube in 10 cases with blocked lower canaliculus. 7 were reoperated cases, 2 injury and one pseudosac. The tube was left through the D.C.R. opening into the nose and removed after 3 months.
D.C.R. is not favoured in quite young children but even in them it is not contraindicated. (Stallard, 1958). 19 of our patients were under 15 years of age and youngest was 4 years. We think 2 years is rather too young an age but we have done D.C.R. in 3 year olds. The results are yet to be known, hence they are not included in this series.
[Table - 2] shows the relative age and sex incidence.
Youngest patient in this series is 4 years and oldest 78 years. There is a relatively higher incidence among females (69%).
A more medially placed incision (Hallum 1948) well forward (1 cm. medial to the inner can thus) made straight and boldly down to the bone has its advantage, that exposure of sac is best, angular vein is not cut, and Mongoloid folds (as reported by Keith-Lyle, Cross, Simpson and Frazer, 1946) are absent in a medially placed incision. As the skin incision and sutured flaps are at different levels, blockage by the development of scar tissue is infrequent. The success of operation largely depends upon correct apposition of the flaps, suturing of flaps without laceration which is facilitated by the use of these modified sewing machine needles. It is difficult to agree with Shuttleworth (1949) that the exact technique of operation does not affect the ultimate result.
Subcuticular skin stitches render the incision line inconspicuous and in our opinion a few deep catgut sutures go a long way towards producing a normal canthal appearance.[9]
| References | | |
| 1. | Dupuy-Dutemps, P.. and Bourguet. J. (1820). Ann. Oculist. (Paris) 157, 445.  |
| 2. | Hallum. A. V. (1943). J. Med. Ass. Georgia, 32, 186. |
| 3. | (1948), Trans. Amer. Ophthal. Soc., 46, 243. |
| 4. | Jain. N. S., Sethi, D. V., and Prakash, O. (1955). J. All. India Ophthal. Soc., 3, 13. |
| 5. | Keith-Lyle, T. Cross. A. G. Simpson. J. F., and Frazer, G. A. (1946). Brit. J. Ophthal. 30, 102. |
| 6. | Shuttleworth, F. N. (1949), Brit. J. Ophthal. 33, 183. |
| 7. | Stallard, H.B. (1958), "Eye Surgery", 3rd ed., p. 318 Wright, Bristol. |
| 8. | Sarda, R. P. Et al. Brit. Jn. Ophthal. (1961) 45, 138-143. |
| 9. | Toti, A. (1904). Clin. med. Pisa, 10, 385. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2]
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