Kikawada T
Hamamatsu Ear, Nose and Throat Surgicenter.
Nihon Jibiinkoka Gakkai Kaiho. 1993 Nov;96(11):1940-9. doi: 10.3950/jibiinkoka.96.1940.
Functional endonasal sinus surgery (FESS) is becoming the procedure of choice for the surgical treatment of chronic sinusitis. The operation has been made possible by the introduction of the endoscope to sinus surgery. The endoscope allows a more detailed observation of ethmoid lesions, and provides direct visual access to the paranasal region which is not visible through the anterior nares. A technique which involves the exclusive use of endoscopy, endoscopic sinus surgery, presents several problems however, especially in cases of polyposis or those with excessive bleeding. For ideal sinus surgery, tools must guarantee the greatest possible safety, ease, and accuracy. None of the currently available tools is independently able to fully satisfy all three of these requirements, not even the endoscope. The anatomical region being operated on determines which of these three requirements is most critical in each phase of the surgery. Ease is most important in the nasal cavity, which has no exceptionally dangerous regions to be operated on. The quickest and simplest operation is most expedient for minimizing blood loss in severe polyposis. To achieve this objective, macroscopic manipulation using a headlamp is most suitable. There is no need to use the endoscope or microscope to remove polyps in the nasal cavity. Because almost all of the risks in sinus surgery are encountered in the ethmoid region, operation in this area demands the safest method. For example if the ethmoid cavity is filled with massive polyps, it is sometimes difficult to endoscopically detect whether orbital fat has broken into the ethmoid. To discriminate between fat and a polypoid lesion or to distinguish dura from mucoperiost during surgery, the microscope is clearly the superior tool. In region where dead angles prevent accurate manipulation, use of the endoscope is essential. To optimize success in sinus surgery using the currently available tools, the author describes a combined macro-micro-endoscopic technique (COMMET) which effectively combines use of the headlamp, the microscope, and the endoscope according to the demands of each anatomical region.
功能性鼻内镜鼻窦手术（FESS）正成为慢性鼻窦炎外科治疗的首选术式。鼻窦手术因引入了鼻内镜而得以开展。鼻内镜能更详细地观察筛窦病变，并能直接观察经前鼻孔无法看到的鼻旁区域。然而，一种仅使用鼻内镜的技术——鼻内镜鼻窦手术，存在一些问题，尤其是在息肉病或出血过多的病例中。对于理想的鼻窦手术，工具必须保证尽可能高的安全性、简便性和准确性。目前现有的工具没有一种能独立完全满足这三个要求，即使是鼻内镜也不行。手术操作的解剖区域决定了在手术的每个阶段这三个要求中哪一个最为关键。在没有特别危险区域需要操作的鼻腔中，简便性最为重要。对于严重息肉病，最快最简单的手术最有利于减少失血。为实现这一目标，使用头灯进行宏观操作最为合适。在鼻腔中切除息肉无需使用鼻内镜或显微镜。因为鼻窦手术几乎所有风险都出现在筛窦区域，该区域的手术需要最安全的方法。例如，如果筛窦腔内充满大量息肉，有时很难通过鼻内镜检测眼眶脂肪是否已侵入筛窦。在手术中区分脂肪与息肉样病变或区分硬脑膜与黏膜骨膜时，显微镜显然是更优越的工具。在存在死角妨碍精确操作的区域，使用鼻内镜至关重要。为了利用现有工具优化鼻窦手术的成功率，作者描述了一种宏观 - 微观 - 内镜联合技术（COMMET），该技术根据每个解剖区域的需求有效地结合了头灯、显微镜和鼻内镜的使用。
