This is a retrospective review of the management and outcomes of 14 malignant tumours of the lacrimal sac. All patients were operated on jointly by an orbital surgeon and a head and neck surgeon. There is a detailed description of their technique which involved en bloc removal of tumours via a combined lateral rhinotomy and medial orbitotomy approach, including all the bone surrounding the nasolacrimal duct and the lacrimal sac fossa. The resultant bony defect involved the antero-medial orbital floor and supero-medial maxilla, which was then repaired with titanium mesh and screws. The remnant of the medial canthal tendon was fixed to the mesh. Eight patients had postoperative radiotherapy, and another received it following further surgery for recurrent disease. Only half the patients had epiphora, and none developed diplopia. Two lost vision, one from radiation toxicity and one required evisceration following severe exposure and corneal perforation. Two, both with squamous cell carcinoma, developed local recurrence, including one who had regional spread. One of these was lost to follow and the other died of their disease. All others were disease-free after an average of 51 months follow-up including one who required a modified neck dissection for regional lymph node disease at 19 months. The paper develops the en bloc resection technique described in a series of 11 patients by Valenzuela in 2006. The authors stress the advantages of having an orbital and head and neck surgeon operating together, of intraoperative frozen section monitoring of surgical margins and the simultaneous reconstruction with titanium mesh. They preserved the canaliculi and puncta, as well as a stump of the medial canthal tendon, and none had a tumour recurrence at these sites. The authors discuss the role of adjuvant radiotherapy which was associated with a high incidence of wound breakdown and exposure of the titanium mesh, requiring a secondary pedicle flap. The paper is a useful review of the management of these difficult tumours, and provides further evidence that the en bloc technique is superior to more conservative methods such as dacrocystectomy.