In external DCR, the authors reserve radiosurgery for skin incisions, creation of lacrimal sac and nasal mucosal flaps, and hemostasis. They recently introduced the mini-incision DCR [7] for better cosmetic results. The Javate DCR electrode (attached to the Surgitron unit, set in the cut mode) is used to make an 8–10 mm incision set about 7–8 mm below the lower lid margin (Fig. 9.2). It starts from at a point slightly inferior to the medial canthal tendon, extending just into the anterior lacrimal crest, and continuing laterally in a horizontal direction following the periorbital relaxed skin tension lines. This offers less bowstringing and postoperative scarring in contrast to incisions positioned 3–4 mm beneath the lower lid margin which can cause ectropion from wound contracture or orbital fat prolapse when incisions are placed just above the orbital septum [8]. Radiofrequency also provides excellent hemostasis since individual bleeding points are controlled by the electrodes. Tissue anatomy is not obscured by hemorrhage, thereby providing better visualization and shortened operative time. Patients wearing spectacles also report greater comfort immediately after mini-incision DCR surgery. This is not only due to less postoperative pain and inflammation but also the spectacle nose-pads usually do not rest on the resulting incision site. The rapid postoperative recovery allows an earlier return to normal daily activities and work.

Blunt scissors are then used to dissect down to the anterior lacrimal crest. Bleeders are coagulated to markedly decrease postoperative periorbital ecchymosis. The DCR electrode is then used to incise through the periosteum overlying the anterior lacrimal crest. After the osteotomy is created, the nasal mucosal flaps are made using the electrode set in coagulation mode.

The posterior flaps of the sac and nasal mucosa are apposed with one or two interrupted sutures using 6-0 polygalactin sutures (Vicryl). The suture is set in place with a backhand throw from the lacrimal sac to the nasal mucosal posterior flap.

Once the posterior flap is prepared, a bicanalicular silicone tube Crawford Bicanaliculus Intubation Set (S1-1270u, FCI, 20–22 rue Louis Armand, 75015 Paris, France) is needed to intubate the nasolacrimal fistulae (Fig. 9.3). The ends of the tube are secured in place by a series of two square knots followed by silk 5-0 sutures; after which, the ends are trimmed to appropriate length without extending beyond the nose orifices [5]. Recently, the FCI Nunchaku Self-retaining Bicanalicular Nasal Intubation (S1-1371 Nunchaku105mm, FCI, 20–22 rue Louis Armand, 75015 Paris, France) is used for bicanalicular silicone intubation. The FCI Nunchaku is a pushed silicone self-retaining bicanaliculus intubation stent that acts like a conformer, allowing tears to be drained by capillary. From a technical perspective, pushed nasolacrimal intubation is much simpler than the traditional pulled types of nasolacrimal intubation. The metallic guide is located inside the lumen, not as an extension of the stent as in conventional intubation sets (Fig. 9.4). The stability is guaranteed by the design of the silicone tubes. What’s great about it is no knots, sutures, or retinal buckles that collect dirt and form incrustation with mucoid material are needed at the end of the procedure (Fig. 9.5a, b) and no retrieval from the nose is needed.

Anastomosis of the anterior flaps created from the nasal mucosa and the lacrimal sac is performed using 5-0 polygalactin sutures (Vicryl). A 6-0 nylon suture is used for closure of the skin incision using either continuous running or subcuticular suturing.

A patient undergoing ERA-DCR is placed in a supine position with the head slightly elevated to decrease venous pressure at the operative site. Although local anesthesia is an option, general endotracheal anesthesia is preferred because of the copious volume of irrigation used to completely irrigate the mitomycin from the nasal passage. Nasal preparation includes packing with cotton soaked in 0.05 % oxymethazoline hydrochloride along the lateral nasal wall to initiate mucosal decongestion. A 4-mm 0° rigid Karl Storz Hopkins endoscope (Karl Storz GmbH and Co., Tuttlingen, Germany) is used for visualization as submucosal injection of 2 % lidocaine hydrochloride with epinephrine (1:100,000) is placed in the middle turbinate and the lateral nasal wall just anterior to the attachment of the turbinate. In some patients, the middle turbinate limits access to the lacrimal sac fossa. In such patients, the middle turbinate is infractured medially instead of removing its anterior portion. The entire procedure is performed with a video camera attached to the endoscope. The assisting surgeon is able to observe the surgery on a video monitor.