DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Not dictated.
POSTOPERATIVE DIAGNOSES: Not dictated.
OPERATIONS PERFORMED:
1. Right external dacryocystorhinostomy with partial medial anterior turbinectomy and bicanalicular lacrimal micro intubation.
2. Repair of right lower eyelid ectropion and retraction utilizing AlloDerm posterior lamellar implant, malar face superomedial myocutaneous advancement and lateral tarsal suspension.
3. Partial carunculectomy, right eye
SURGEON: John Doe , MD
ANESTHESIA: Topical ocular, total intravenous, local infiltrative, topical nasal with monitored anesthesia care.
ANESTHESIOLOGIST: Jane Doe , MD
ESTIMATED BLOOD LOSS: Fifty mL.
SPECIMENS: Medial wall lacrimal sac; segment of caruncle, right side; segment of head of middle turbinate, right side.
INDICATIONS FOR SURGERY: This (XX)-year-old gentleman is noted to have complete nasolacrimal duct obstruction with canalicular stenosis associated with ectropion formation of the right lower lid with retraction and cicatricial changes of the malar face area. The patient was noted to have obstruction of the rhinostomy by the head of the middle turbinate necessitating partial middle anterior turbinectomy as well.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating room table. Previously, the skin surrounding the right eye was defatted with an alcohol pad, and a dacryocystorhinostomy incision line was placed in the nasoalar fold. The patient received appropriate preoperative sedation and monitoring, and a solution of 2% lidocaine with 1:100,000 epinephrine in a 50:50 mixture with 0.75% bupivacaine was instilled subcutaneously beneath the previously demarcated gentian violet line. In addition, the anterior lacrimal crest and lacrimal sac were infiltrated with the same solution. The lateral wall of the nose was also infiltrated with the same solution prior to packing the middle meatus of the nose and the lateral wall of the nose with 4% soaked cocaine gauze. The anesthetic agent was massaged into place. The surgeon performed a surgical scrub.
Upon his return, the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery. A hard corneoscleral shield was placed before the cornea of the right eye after a series of topical tetracaine drops had been applied. A #15 Bard Parker blade was used to incise the previously demarcated gentian violet line. The orbicularis fibers were then spread with a mosquito clamp. The sharp edge of the Freer periosteal elevator was used to strip the orbicularis muscle from the anterior lacrimal crest. The periorbita overlying the anterior lacrimal crest was incised with the sharp edge of the Freer periosteal elevator and the medial wall of the nasolacrimal fossa was exposed. The medial wall of the lacrimal sac was infiltrated with this same solution. A rhinostomy was formed with the Kerrison punch as well as the front biting Takahashi forceps, enlarging this to an area of 15 x 15 mm. Hemostasis was achieved during the entire case with direct digital pressure, Bovie cautery, and Gelfoam-soaked topical thrombin, as well as bone wax as necessary. The rhinostomy was noted to clear the internal common punctum by 5 mm on the superior side. The wound was packed with Gelfoam soaked in topical thrombin and the upper and lower canaliculi were dressed. A punctal dilator dilated the superior and inferior canaliculus. A #00 Bowman probe was then inserted through the canaliculus to tamp the medial wall of the lacrimal sac. This was then incised with a #11 blade and enlarged superiorly and inferiorly to posterior and anterior lacrimal mucosal flaps with sharp Westcott scissors. A biopsy of the lacrimal sac was taken and sent to the pathologist for analysis. The wound was again packed with Gelfoam soaked in topical thrombin, and attention was directed to the nasal mucosa. This was incised with a cutting cautery into both anterior and posterior directed H flap.
At this point, the head of the middle turbinate was noted to obstruct the superior and posterior portion of the rhinostomy necessitating partial middle anterior turbinectomy. Additional local infiltrative anesthesia was delivered submucosally along the length and breadth of the obstructing segment. A 3 mm upbiting 90-degree Kerrison punch was used to resect this segment of blocking tissue. Additionally, this problem was approached intranasally with front biting Takahashi-type forceps. Hemostasis was obtained with direct digital pressure packing, Bovie cautery as well as topical thrombin soaked Gelfoam. While the Gelfoam was placed through the rhinostomy and into the site of the turbinate resection, resection of the megalocaruncle was also performed. Additional local infiltrative anesthesia was delivered subconjunctivally into this area and a segment of caruncle, 1.3 cm, as an ellipse, was resected beginning laterally and continuing medially. This relieved the obstruction of the inferior punctum. The bicanalicular Guibor tube was then placed through the superior and inferior canaliculus through the rhinostomy to exit the left naris. The anterior lacrimal sac mucosa and the anterior nasal mucosa were then anastomosed with a 4-0 double arm chromic suture after the micro tubes had been tied upon themselves with a 6-0 nylon suture. The rhinostomy was packed with a small piece of Gelfoam soaked in topical thrombin and hemostasis was noted to be complete. The micro tube was then tied upon itself and the nose was allowed to retract. The rhinostomy site was inspected and noted to be of adequate dimension and location. The nose was then packed with a small Merocel nasal packing after the nasal packing had been trimmed to fit. The Merocel nasal packing was then soaked with the remaining topical thrombin. Tension was adjusted in the medial canthus. The hard corneoscleral shield had been removed after a series of topical tetracaine drops had been applied.
Attention was directed to the right lower eyelid. A #15 Parker-Bard blade was used to incise the previously demarcated gentian violet line along the lateral palpebral raphe. A sharp Westcott scissor was used to perform a lateral canthotomy and cantholysis. The inferior crus of the lateral canthal tendon was then isolated and lysed from its periorbital attachment utilizing the Ellman radiofrequency unit. Hemostasis was achieved during the entire case with direct digital pressure, packing, and Ellman radiofrequency unit cautery. The right lower lid was noted to swing freely after lysis of the inferior crus of the lateral canthal tendon. The hard corneoscleral shield was then removed after a series of topical 0.5% tetracaine drops had been applied to allow for estimation of lower lid laxity. The full thickness of the eyelid was notched with sharp Westcott scissors. Once the excessive lower lid laxity and lateral canthal tendon laxity was determined, the hard corneoscleral shield was replaced. The sharp Westcott scissors was used to perform a full thickness resection of the right lower lid and a tarsal block was fashioned by Ellman radiofrequency unit cautery resection along the posterior orbicularis fascia. This was to allow for formation of a tarsal block laterally. The inferior portion of the conjunctiva was cleansed with the #15 Parker-Bard blade, removing conjunctival cells to prevent a conjunctival occlusion cyst. The tarsal strip was then anastomosed to the orbital tubercle 5 mm posterior to the anterior face of the lateral orbital rim, utilizing a mattress style 4-0 double-arm Prolene suture. The lid level and contour was noted to be appropriate when compared to the other side. The lid margin was repaired in a standard three suture technique, anastomosing just anterior to the mucocutaneous junction, the lash line, and the gray line. The ends of the suture were left long and incorporated into the subsequent suture to prevent corneal irritation. The lateral palpebral raphe was closed with a running 6-0 fast-absorbing plain suture. The hard corneoscleral shield was removed, and the lid level and contour were again noted to be adequate.
The patient underwent implantation of the lamella of the posterior lamella implant utilizing the AlloDerm dermal implant. The implant was further aided in placement by using additional local infiltrative anesthesia and performing wide undermining of the malar face. This was suspended superomedial after development of flap formation to allow for reduction of the retraction of the lower lid, which was recurrent after even previous surgery. This was held in place with a series of interrupted deep buried 6-0 and 5-0 Vicryl sutures. The dermal implant was cut to a size of 26 x 11 mm in a narrow head shape and placed into the posterior lamella to expand the posterior lamella and reduce the ectropion formation. The eyelid level contour was noted to be appropriate. The rhinostomy was inspected with a 0 degree 4 mm endoscope and hemostasis was noted to be complete. Sponge, needle and instrument counts were correct at the end of the procedure. All the wounds were dressed with Maxitrol ointment. A cool moistened eye pad was placed. The patient tolerated the procedure well and was taken to the recovery area in stable condition.
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