- Patient preparation
- General anaesthesia or local with sedation if appropriate
- Supine position with neck extended and head turned slightly opposite to the affected side
- Mouth gag may be used to maintain exposure
- Identify and palpate the stone
- Use bimanual palpation (intraoral and submandibular) to confirm position
- Stone should be palpable intraorally along the course of Wharton’s duct
- Avoid procedure if stone is deep/hilar or gland is chronically infected—consider sialendoscopy or gland excision instead
- Can place a suture behind the stone to stop it sliding posterior
- Expose Wharton’s duct
- Retract tongue laterally using a tongue depressor or stay suture
- Identify the duct papilla near the lingual frenulum
- Trace the duct posteriorly toward the stone
- Use careful dissection with fine scissors or scalpel to isolate the duct
- Ductotomy
- Incise directly over the palpable stone, longitudinally along the duct
- Ensure not to transect the duct transversely or damage surrounding mucosa
- Stone extraction
- Gently express the stone by milking the duct
- If not freely mobile, carefully dissect around it with blunt instrument or mosquito forceps
- Avoid injury to adjacent lingual nerve, which crosses under the duct posteriorly
- Flush the duct
- Irrigate with sterile saline to ensure clearance of debris or smaller fragments
- Consider passing a lacrimal probe or sialendoscope to check for residual stones
- Duct management
- Typically left open to allow drainage
- Some surgeons marsupialise the duct by suturing mucosa to the duct wall
- Avoid primary closure to prevent restenosis
- Postoperative care
- Soft diet and good oral hygiene
- Salivary stimulation (sialogogues) to promote flow
- Antibiotics if significant inflammation present
- Monitor for recurrence or ductal stenosis