The assistant surgeon passes a 20-gauge fiberoptic light probe through a canaliculus into the lacrimal sac; the area of maximal brightness isn't the center of the sac, it corresponds with the posterior end of the lacrimal sac where the overlying bone is thinnest.
Making a circular incision with the sickle knife through the lateral nasal wall mucosa down to bone 1 to 1.5 cm anterior to the base of the uncinate process. This mucosa is then ele¬vated with the Freer elevator. The underlying bone is carefully penetrated with a Kerrison rongeurs or drill.
As the bone is removed anteriorly, it becomes thickened and is best removed with a diamond burr. The removed mucous membrane and bone can be guided by the illumination of the sac, and extends posterior to approximate the ethmoid infundibulum or the most anterior of the infundibular cells, remove the uncinate process in the usual manner.
To confirm complete removal of the bone, a lacrimal probe should be inserted through the inferior punctum into the sac. In¬tranasally the sac will be tented by the probe. A 5- to 10-mm incision in the inferomedial wall of the sac should be made. Most of the medial wall of the sac should be carefully removed with the Weil-Blakesley forceps (Marsupialisation).
To confirm complete removal of the bone, a lacrimal probe should be inserted through the inferior punctum into the sac. In¬tranasally the sac will be tented by the probe. A 5- to 10-mm incision in the inferomedial wall of the sac should be made. Most of the medial wall of the sac should be carefully removed with the Weil-Blakesley forceps (Marsupialisation).
The stents are grasped with a Blakesley forceps, withdrawn from the nasal cavity, and cut from the tubing.
The silastic stents are either tied to each other or held together by a silk suture. The elevated mucosa from the egger nasi will rotated to flap the marsupialised sac anterior only (Flapping), by this way the tears flow will be directed posteriorly over the inferior turbinate, with wide posterior ostium.
Post-operative care and follow-up
Nasal irrigations with saline should be begun on the first postoperative day. These should be three times daily and gentle but thorough . Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing .
Silastic stents are removed 3 months after surgery . In revision cases where postoperative scarring has been a problem, stents may be left in place for 6 months or longer .
The major outcome was defined by the patients’ subjective assessment of improvement and by objective evaluation of patency by endoscopic examination of the internal ostium.
