**4. Retrograde sialendoscopy**

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

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

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

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

Early complications are rare and include lingual nerve damage, hematoma, and gland swell-

A certain degree of postoperative stenosis is expected in the long term; however, the region of

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

6 weeks usually the maximum depending on the patients' tolerance.

with the addition of oral antiseptic solution local application after meals.

ing extrusion of the stent which are usually managed in a conservative way.

the hilum is large enough, and these strictures run usually as asymptomatic.

stones or strictures, etc.

122 Salivary Glands - New Approaches in Diagnostics and Treatment

removal.

**3.2. Follow-up assessment**

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

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

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 the length of the remained duct.

Contraindication of this procedure is the diffuse stenosis of the duct or severe strictures due previous trauma or surgery.

**Figure 6.** Retrograde sialendoscopy: insertion of the sialendoscope into Wharton's duct after removal of the submandibular gland. The duct is stretched with a silk suture.
