**3.1. Surgical technique**

Early complications such as hematoma, sialadenitis, wound infection, fistula, and obstructed and/or extruded stent have been rarely published and usually occur within the first postoperative month. In such cases, conservative management and removal of stent if needed are

**Figure 4.** (A) Fibrin glue and (B) absorbable sutures are used for the repositioning of the gland flap in cases of non-

**Figure 3.** Stent placement in a retrograde fashion via the surgical field. The left loop isolates the main duct, and the right

the facial nerve branch which run close to the ductal system.

120 Salivary Glands - New Approaches in Diagnostics and Treatment

Initially, one of the surgeons' concerns about the procedure was the potential postoperative stenosis at the site of the ductal incision. This fact is expected and was confirmed in our data, as 7 patients out of 12 had an endoscopically diagnosed postoperative stenosis [9]. However,

enough measures [9–11].

superficial stone location.

The procedure starts again with a sialendoscopy, and when the endoscope approximates, the stone then is fixed to the floor of the mouth or can be held steadily by an assistant.

Infiltration of the transilluminated area with xylocaine 2%-adrenalin 1% solution follows. The next step is an incision of the oral mucosa approximately 2 cm in length following the axis of Wharton's duct size just above the lighted area (**Figure 5A** and **B**). Caution should be taken at this point in order to avoid lingual nerve damage as it crosses Wharton's duct and this is the reason why some authors identify and isolate the nerve with a loop from the surgical field [8].

A useful surgical tip is the fact that the floor of the mouth can be pushed upward by external pressure at submandibular triangle below the patient's mandible, giving better access to the hilum area endorally.

hilum. This procedure offers equally good results although does not preserve the integrity of the ductal system. Moreover, when marsipulization of the main duct reaches the hilum, the endoscopic assessment of the residual ductal system becomes problematic due to leakage

Combined Approaches in Sialolithiasis of Major Salivary Glands

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In cases with parenchymal and especially multiple stones of the submandibular gland, an external approach with removal of the gland is indicated. However, some stones may slip into Wharton's duct during surgical manipulations causing symptoms at a later time. In a study by Milton et al., authors found that 5% of patients who underwent submandibular gland

For such cases a retrograde sialendoscopy is proposed through the surgical field after the removal of the gland [14]. A standard procedure of submandibular gland resection is performed with a transcervical incision. Identification and preservation of the lingual nerve from the gland at the area of submandibular ganglion follow along with careful dissection and skeletonization of the submandibular duct. Two stay sutures are placed on the opposing sides of the duct, proximal to the gland. After the removal of the gland, these sutures are used for stretching of the duct in order to facilitate placement of a large in outer diameter (1.4 or

In cases where residual stones or debris are identified, then they can be removed by wire basket or alternatively can be pushed by the endoscope into the oral cavity (retrograde) or into the neck with the endoscope coming from the oral cavity. At the end of the procedure, stay sutures help for duct traction into the neck and its ligation proximally in order to minimize

Contraindication of this procedure is the diffuse stenosis of the duct or severe strictures due

**Figure 6.** Retrograde sialendoscopy: insertion of the sialendoscope into Wharton's duct after removal of the subman-

removal had residual stones in the remaining duct, requiring further surgery [13].

1.6 mm) sialendoscope for retrograde inspection (**Figure 6**).

during saline irrigation.

**4. Retrograde sialendoscopy**

the length of the remained duct.

dibular gland. The duct is stretched with a silk suture.

previous trauma or surgery.

**Figure 5.** (A) Transillumination of the hilum area in a right submandibular gland intaraorally. (B) Incision and stone removal.

After the identification of the duct, silastic loops are positioned around the duct helping its traction and dissection. The stone is palpated by the finger or surgical instrument, and a straight incision above the stone at the axis of the duct is performed. Once the stone has been removed, an endoscopy of the ductal system behind the stone is mandatory for residual stones or strictures, etc.

The use of a stent at the end of the procedure is not universally accepted; however, it is the preference of the authors as it offers a stable floor for the ductoplasty. Its insertion through the papilla can be performed directly or with the use of the endoscope or a guide-wire for more safety especially when a precise placement to the posterior portion of the duct is required. The stent is then sutured and secured with a nonabsorbable suture to Wharton's papilla area. The time of stenting varies in the literature with a period of 3 weeks being the minimum and 6 weeks usually the maximum depending on the patients' tolerance.

#### **3.2. Follow-up assessment**

Patients receive the same instructions as in parotid stones for their diet postoperatively. Similarly, they take broad-spectrum antibiotic treatment for a week and analgesics if required with the addition of oral antiseptic solution local application after meals.

Early complications are rare and include lingual nerve damage, hematoma, and gland swelling extrusion of the stent which are usually managed in a conservative way.

A certain degree of postoperative stenosis is expected in the long term; however, the region of the hilum is large enough, and these strictures run usually as asymptomatic.

This procedure is not popular in the literature as the parotid one, because many surgeons prefer the endoral marsipulization of the duct to have access in stones at the region of the hilum. This procedure offers equally good results although does not preserve the integrity of the ductal system. Moreover, when marsipulization of the main duct reaches the hilum, the endoscopic assessment of the residual ductal system becomes problematic due to leakage during saline irrigation.
