Though various incisions have been described, the author prefers the commonly used curvilinear incision of about 10–12 mm in length, 3–4 mm from the medial canthus along the anterior lacrimal crest and along relaxed skin tension lines (Fig. 34.3). However, extension of this skin incision above the medial canthus can lead to scars and epicanthic folds. An alternate can be the use of a straight incision at the lateral surface of the nose, 8–10 mm from the medial canthus. In cases of malignant lacrimal sac tumors, the incisions may be much longer and at variable locations based on the size and adjacent spread of the lesion. For example, the Weber–Ferguson incision if lateral rhinotomy is additionally planned. The Ophthalmologist should follow a multidisciplinary approach as appropriate when managing lacrimal sac malignancies.

Blunt dissection is carried on to separate the subcutaneous tissues and orbicularis muscle and reach the periosteum (Fig. 34.4). A Freer’s elevator is used to separate the periosteum from the bone and reflect it laterally (Fig. 34.5). As the periosteum is being reflected laterally, the anterior limb of medial canthal tendon is noted attached to it just anterior to the anterior wall of the lacrimal sac (Fig. 34.6). The lacrimal fascia, which is contiguous with the periosteum is adherent near the medial canthal tendon and hence reflection of tendon aids in lacrimal sac dissection (Fig. 34.6). The tendon is cut at the suture of Notha and the medial wall of the sac is bluntly separated from the bones of the lacrimal fossa.

The lateral wall is separated with the help of Westcott scissors by separating it from the orbicularis oculi. The closed blades of the scissor are then directed downward between the lateral wall of the sac on one side and orbicularis and periorbita on the other. The common canaliculus needs to be severed from the sac during this step. To avoid perforation of sac as well as to detect inadvertent perforation intraoperatively, one can use fluorescein-stained viscoelastics or methylene blue [6, 8]. The sac needs to be filled with either of this material before the beginning of dissection. The superior wall and the posterior wall can be separated from the fascia with a Westcott scissor right up to the nasolacrimal duct (Fig. 34.7).

Once the sac is dissected all around and separated from its soft tissue attachments, the sac is amputated at its junction with the nasolacrimal duct (Fig. 34.8). In cases of lacrimal sac tumors, the amputation is carried at a point as far as possible toward the distal nasolacrimal duct. Occasionally, bony nasolacrimal duct along with a lateral rhinotomy or medial orbital wall excision is combined with dacryocystectomy depending on the extent of malignancy.

After the sac removal, the common internal canaliculus, nasolacrimal duct stump, and any remnant sac lining should be cauterized to prevent recurrences (Fig. 34.9). The canaliculi are cauterized separately using Ellman Surgitron needle (Ellman Int Inc, New York, USA) in a coagulation mode or with the help of a probe within the canaliculus. The punctum and the canaliculi show an immediate whitish discoloration following a successful cautery.

Once hemostasis is achieved, the orbicularis is sutured back with 6-0 vicryl followed by skin closure with 6-0 prolene or vicryl or silk based on surgeon’s preference.

Extended dacryocystectomy refers to complete extirpation of lacrimal sac along with any of the surrounding structures like nasolacrimal duct, overlying lacrimal fossa bone, frontal process of maxilla, ethmoids, lateral nasal wall, anterior part of medial orbital wall, and surrounding soft tissues (Figs. 34.10, 34.11, 34.12, 34.13, and 34.14). Extended dacryocystectomy is indicated in lacrimal sac tumors and the extent of tumor infiltration into surrounding structures determines the extent of the surgery [3–5].