Introduction
Papilla crossing is one of the key points for sialendoscopy, especially in submandibular sialendoscopy. After the papilla has been crossed, the sialendoscopy can begin. Instead of papilla crossing, other approaches to the salivary duct may also be needed. For example, the retropapillary approach can replace the papillary crossing when this crossing is not feasible. However, when the lithiasis removal procedure is over, the surgeon must check for the absence of remaining lithiasis in combined approaches procedures; in such cases, a retrograde approach to the duct is helpful ( Fig. 15.1 ).
Usual papillary crossing is performed with probes of increasing diameter, as described by Marchal et al. In 20% of cases, usual papillary crossing does not work, giving place to another papilla crossing technique – the guided puncture technique.
Anterior Approaches to the Duct
Papillary Approach
The Classic Marchal Technique
The progressive papilla dilatation is performed with lacrimal or salivary probes of diameters from 0000 to 6. The main difficulty is that after each salivary duct probe change, the surgeon goes out of the papilla and can lose the papilla entrance. At each step of the dilatation, it becomes more and more difficult to find and enter the papilla again.
The Chossegros Guided Puncture Technique
After the smaller probe 0000 insertion and removal, the probe is directly replaced by a 0.6 mm guidewire, which is nearly the same diameter as the 0000 probe. This guide measures 50 cm long. The surgeon must take care not to enter too deeply into the duct, to avoid posterior lithiasis migration. After the guide is in place, a center-drilled bougie is inserted on it, allowing a slow and progressive dilatation of the papilla ( Fig. 15.2 ). Several diameters of bougies are available and the authors recommend starting with the 1 mm bougie, following with the 1.5 mm diameter bougie (and in rare cases, the 2.0 mm). The bougie penetrates the duct by its conic end. When the cylindric part of the bougie enters the duct easily, the papilla diameter is similar to the diameter of the bougie and to the diameter of the sialendoscope. To facilitate entering the duct, the authors recommend leaving the guidewire in the duct. The bougie is removed and the guidewire is inserted into the working channel of the sialendoscope ( Fig. 15.3 ). This technique reduces the operative time and the percentage of papilla entrance failure, especially for the submandibular sialendoscopy.
