Management Of Meckel's Diverticulitis
Diverticula of the lacrimal sac sizable enough to cause clinical symptoms are rare. Lacrimal sac diverticula may be congenital or acquired, the latter usually being the result of traumatic or inflammatory weakening of the lacrimal sac wall. There are few articles detailing the surgical management of large acquired lacrimal sac diverticula.
A 42-year-old man was referred for an evaluation of constant epiphora and swelling of the left lower eyelid. The patient had had a shotgun pellet injury to his face 13 years previously and subsequently developed epiphora and recurrent episodes of dacryocystitis. An examination showed a large, soft mass involving the medial canthus and the medial one half of the left lower eyelid. The overlying skin was freely mobile. Lacrimal examination showed a delay in fluorescein dye disappearance, and irrigation enlarged the mass with only minimal efflux of fluid through the nasolacrimal duct. Dacryocystography demonstrated nasolacrimal duct stenosis and a 2 x 1-cm diverticulum of the lacrimal sac.
Excision of the lacrimal sac diverticulum was performed by means of an infraciliary incision combined with dacryocystorhinostomy. At surgery, the external aspect of the Meckel's Diverticulitis was found to be densely invested by the surrounding muscle and connective tissue and could not be separated with blunt dissection alone. To ensure complete removal, the lacrimal sac was opened and the ostium of the lacrimal sac diverticulum was identified on the lateral wall of the lacrimal sac. Methylene blue was injected in a retrograde fashion through the ostium to stain the mucosa of the lacrimal sac diverticulum and a lacrimal probe was placed within the lumen of the diverticulum.
Sharp dissection was then performed 360 degrees around the external aspect of the diverticulum, transecting the attachment to the lacrimal sac. The lateral defect in the lacrimal sac wall was closed directly with 5-0 polyglactin suture, keeping the knots external to the lacrimal sac. A standard dacryocystorhinostomy with silicone intubation was then completed. Histopathologic examination showed a diverticulum lined by transitional epithelium typical of the lacrimal sac. The patient's postoperative course was uncomplicated with complete relief of epiphora and no recurrence of the eyelid mass. Lacrimal sac diverticula are usually undetected, and their discovery is often made incidentally by dacryocystography done for other reasons. When clinically evident, a lacrimal sac diverticulum generally appears as a tense, fluctuant mass in the medial canthus fixed to the deep tissues, but not the overlying skin. The location of the lacrimal sac diverticulum, in relation to the lacrimal sac, is variable, sometimes occurring only in the medial canthal area, but more frequently extending along the lower eyelid and inferior orbital rim. Only a few articles in the English-language ophthalmic literature have focused on the surgical management of acquired lacrimal sac diverticula. Most cases previously reported were congenital in origin, not associated with nasolacrimal duct stenosis, and reportedly easily excised with "blunt dissection." Our case is unusual in that the diverticulum was large, acquired (posttraumatically), and associated with nasolacrimal duct stenosis. Sharp dissection, with special surgical precautions, was necessary to ensure complete removal of the diverticulum while minimizing injury to the surrounding structures. Surgeons should be prepared to use such techniques when excision of a lacrimal sac diverticulum in this setting is required. Although a dacryocystorhinostomy alone might be performed in the hope that once lacrimal drainage is established the diverticulum will resolve, recurrent infection of diverticula after dacryocystorhinostomy alone may occur. We, therefore, advocate complete excision of large symptomatic diverticula combined with dacryocystorhinostomy if nasolacrimal duct obstruction is also present.
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