Advances in Nd:YAG Laser Surgery

Stephen N. Joffe and Yanao Oguro

Editors

Advances in
Nd:YAG Laser Surgery
With 230 Figures

Springer-Verlag
New York Berlin Heidelberg
London Paris Tokyo
Stephen N. Joffe, M.D., F.A.C.S., Yanao Oguro, M.D.
F.R.C.S. Head, Department of Internal
Professor of Surgery Medicine
University of Cincinnati Medical Center National Cancer Center Hospital
Cincinnati, Ohio, USA Tsukiji, Chuo-ku, Tokyo, Japan

Library of Congress Cataloging-in-Publication Data

Advances in Nd-YAG laser surgery.
Includes bibliographies and index.
\. Lasers in surgery. 2. Nd-YAG lasers.
I. Joffe, Stephen N. II. Oguro, Yanao. [DNLM:
\. Laser Surgery. WO 500 A244J
RD73.L3A38 1987 617' .05 87-20703
ISBN-I3: 978-1-4612-8322-5

<!l1988 by Springer-Verlag New York Inc.

Softcover reprint of the hardcover 1st edition 1988

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ISBN-I3: 978-1-4612-8322-5 e-ISBN-13: 978-1-4612-3728-0

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Preface

The Nd:YAG laser has finally become the multidisciplinary and muitispeciaity
tool of the 1980s. Primarily developed for gastrointestinal applications for
controlling bleeding, at present it is also used for endoscopic treatment of
gastrointestinal tumors, endobronchial cancer, and bladder and gynecological
lesions and finding applications in otorhinolaryngology and neurosurgery. De-
velopment of laser scalpels and focusing head-pieces has now allowed the
Nd:YAG laser to be used for open surgical procedures in general and plastic
surgery, head and neck surgery, urology, gynecology, dermatology, and neu-
rosurgery.
The rapid development in ceramic technology has led to contact surgery
allowing physicians a choice of excision, vaporization, coagulation, incision,
or combinations thereof by easily changing probes rather than having to select
new laser wavelengths. This technology is rapidly replacing the carbon dioxide
laser which currently has no adequate flexible waveguide for fiberoptic en-
doscopy, cannot be used in a water medium (e.g., bladder), and has poor
coagulation properties when compared to the Nd:YAG laser.
Future developments may see the Nd:YAG laser even replacing electro-
cautery in the operating room due to its greater safety and efficacy. Local
hyperthermia (laserthermia) with computer control, photodynamic therapy,
and ophthalmic applications make the Nd:YAG laser the most exciting tech-
nological advancement in medicine and surgery for the 1980s.
Cost containment, DRGs (Diagnosis Related Groups), alternative health
care delivery systems, rising costs, decreasing revenue, medical malpractice,
inflation, and unemployment are forcing physicians and hospitals to cut health
care costs. No economy can afford to spend over one billion dollars per day
on health care. Lasers lower the cost of patient treatment, improve the quality
of care, and significantly reduce the morbidity and mortality associated with
surgical procedures. The era of outpatient minimally invasive surgery is with
us and the Nd:YAG laser now provides the tool to accomplish these objectives.

Stephen N. Joffe and Yanao Oguro

Contents

Preface v
Contributors xi

Recent Advances in Laser Medicine and Surgery in Japan

Kazuhiko Atsumi

2 A Brief History of the Nd:YAG Laser 7

John C. Fisher

3 Noncontact Delivery Systems and Accessories for the

Application of the Nd:YAG Laser in Endoscopy and Surgery 10
Frank Frank

4 Contact Delivery Systems and Accessories 19

Norio Daikuzono

5 Clinical Applications in Gastrointestinal Bleeding 30

Stephen N. Joffe and Richard M. Dwyer

6 Laser Treatment for Advanced or Recurrent Cancer of the

Gastrointestinal Tract 42
Yoshiki Hiki, Tetsuhiko Yamao, and Hitoshi Shimao

7 Videoendoscopy 46
David E. Fleischer

8 Endoscopic Laser Therapy of Carcinoma of the Esophagus

and Gastric Cardia 53
Richard C. Ranard and David E. Fleischer

9 Endoscopic Laser Treatment of Gastrointestinal Tract Cancer

in Japan: Update 61
Yanao Oguro and Hisao Tajiri

10 New Modalities of Contact Nd:YAG Laser Endoscopy for

General Application in the Gastrointestinal Tract 65
Soutaro Suzuki, Jun Aoki, and Takeshi Miwa
VIII Contents

II Contact Nd:YAG Laser Treatment of Gastrointestinal Tract

Cancer 74
Hisao Tajiri and Yanao Oguro

12 Use of Lasers in Nonbleeding Gastrointestinal Lesions: A

European Experience 79
I.M. Brunetaud, V. Maunoury, I.P. Ancelin, D. Cochelard,
A. Cortot, and I.e. Paris

13 Nd:Y AG Laser Therapy for Intractable Gastric Ulcer 85

Kazumichi Harada and Masayoshi Namiki

14 Use of the Nd:YAG Laser in Cholangioscopic Surgery 91

Teruo KOliZu and Yoshikazu Yamazaki

15 Nd:YAG Laser Treatment of Bladder Tumors 96

A.G. Hofl·tetter

16 Contact Laser Treatment for Bladder Cancer 99

Hirota Washida

17 Endoscopic Nd:YAG Laser Treatment in Airway Lesions 104

Kenkichi Oho and Ryuta Amemiya

18 Developments in Bronchoscopic Nd: Y AG Laser Resection 110

I-F. Duman and B. Meric

19 Neurosurgical Applications of Laser Technology 118

William D. Tobler and Iohn M. Tew, II'.

20 The Use of Contact Lasers (Nd:YAG and Argon) in

Neurosurgery: Clinical and Experimental Data 131
Victor Aida Fasano

21 Fiberoptic Laser Endoscopy in Neurosurgery 139

P. W. Ascher

22 The Contact Nd: Y AG Laser in Neurosurgery 143

Hirotsugu Samejima, Satoshi Iwabuchi, and Nobuo Yoshii

23 Nd:Y AG Laser Surgery: Overview of Applications 150

Stanley M. Shapshay

24 Applications of the Nd: Y AG Laser in Otorhinolaryngology 156

Masaru Ohyama, Kouichi Yamashita, Shigeru Furuta, Takuo
Nobori, and Norio Daikuzono

25 Reconstructive Surgery for Head and Neck Tumors by

Contact Nd: Y AG Laser Technique 179
Goro Magi, Yuichi Kurono, and Issei Ichimiya
Contents ix

26 Laser Conization of the Uterine Cervix 183

Ryozo Totani, Tesuro Karasawa, and YolO Suzuoki

27 Endometrial Ablation 192

Theresa Zumwalt

28 Nd:YAG Laser Applications in Gynecology 200

Jack M. Lomano

29 Clinical Application of Nd:Y AG Laser in Dermatology and

Plastic Surgery 208
K. Arai and T. Sato

30 Study of the Benefits of the Nd:YAG Laser in Plastic Surgery 213

David B. Apfelberg and Teruko Smith

31 Prevention of Dental Caries and Treatment of Early Caries Using

the Nd:YAG Laser 227
Hajime Yamamoto and Teruo Kayano

32 Laser Therapy in Dental and Oral Surgery 235

Akinori Nagasawa

33 Laser Hemorrhoidectomy 247

M.Y. Sankar

34 Splenic Resection with the SLT Contact Nd:YAG Laser

System©: A Comparison of Contact N d: YAG with the CO~ Laser 256
John Foster, Tom Schroder, Kim A. Brackett, and
Stephen N. Joffe

35 Liver and Pancreatic Laser Surgery 266

Tom Schroder and Stephen N. Joffe

36 Contact Laser Applications in Ophthalmology 271

Jay L. Federman and Fumitaka Ando

37 The Short-Pulsed Nd:YAG Laser in Ophthalmology: A

Review of Current Clinical Techniques 275
Carmen A. Puliafito and Roger F. Steinert

38 General Anesthesia for Nd:YAG Laser Surgery 288

Kevin C. Moore

39 The Variable-Function Fiberoptic Laser Apparatus Using

Nd:YAG and Carbon Monoxide Lasers 294
Tsunenori Arai and Makoto Kikuchi

40 Computer-Controlled Contact Nd:YAD Laser System for

Interstitial Local Hyperthermia 302
Norio Daikuzono, Masaru Ohyama, Stephen N. Joffe, Soutaro
Suzuki, Hisao Tajiri, and Hiroshi Tsunekawa
x Contents

41 Safety Procedures for Nd:YAG Laser Surgery 311

R. James Rockwell, Jr.

42 Tissue Interactions of Carbon Monoxide and Carbon Dioxide

Lasers 330
Tsunenori Arai and Makoto Kikuchi

43 Tissue Interactions of Nd:YAG Lasers 336

Kim A. Brackett

44 Setting Up Ambulatory Laser Centers 344

Carolyn J. Mackety

45 The Laser Industry: Present and Future 353

Arthur A. Bertolero

Index 361
Contributors

R. Yuta Amemiya, M.D., F.C.C.P., Senior Instructor, Department of Sur-

gery, Tokyo Medical College, Nishi-shinjuku, Shinjuku, Tokyo, Japan

I.P. Ancelin, M.D., University of Lille, Centre Multidisciplinaire de Trait-

ment par Laser, H6pital Regional, Lille, France

Fumitaka Ando, M.D., National Nagoya Hospital, San-No-Maru, Naka-Ku,

Nagoya, Japan

lunAoki, M.D., Department ofInternal Medicine, Tokai University, School

of Medicine, Boseidai, Isehara-shi, Kanagawa, Japan

David B. Apfelberg, M.D., Director, Comprehensive Laser Center, Palo Alto

Medical Foundation, Palo Alto, California, USA

K. Arai, M.D., National Defense Medical College, Namiki, Tokorozawa-

shi, Saitama-ken, Japan

Tsunenori Arai, Ph.D., Assistant Professor, Department of Medical Engi-

neering, National Defense Medical College, Namiki, Tokorizawa-shi, Sai-
tama-ken, Japan

Peter Wolf Ascher, M.D., Department of Neurosurgery, University of Graz,

Graz, Austria

Kazuhiko Atsumi, M.D., Professor, Institute of Medical Electronics, Faculty

of Medicine, University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan

Arthur A. Bertolero, Director of Marketing, Surgical Laser Technologies,

One Great Valley Parkway, Malvern, Pennsylvania, USA

Kim A. Brackett, Ph.D., Research Associate Professor of Surgery, Depart-

ment of'Surgery M.L. SSB, University of Cincinnati College of Medicine,
Cincinnati, Ohio, USA

lean-Marc Brunetaud, M.D., Associate Professor of Medicine, and Chief,

Laser Center, University Hospital, Lille, France
xii Contributors

D. Cochelard, M.D., Biomathematics Laboratory, School of Pharmacy,

University of Lille, Lille, France

A. Cortot, M.D., University of Lille, Gastroenterology Department, H6pital

Regional, Lille, France

Norio Daikuzono, M.Sc .. Surgical Laser Technologies, Japan Co., Ltd., lid-
abashi, Chiyoda-ku, Tokyo, Japan

J.F. Duman. M.D .. Service d'Endoscopie Thoracique, H6pital Salvator,

Marseille, France

Richard M. Dwyer, M.D .. Associate Clinical Professor, Harbor UCLA

Medical Center, Los Angeles, California, USA

Victor AIda Fasano, M.D., Ph.D .. Director, Institute of Neurosurgery, Uni-

versity of Turin, Torino, Italy

Jay L. Federman, M.D., Co-Director Research, Research Department, Wills

Eye Hospital, Philadelphia, Pennsylvania, USA

John C. Fisher, Sc.D., Heart and Lung Institute of Wisconsin, and St. Luke's
Hospital, Milwaukee; Consultant in Laser Medicine and Surgery, Bradenton,
Florida, USA

David E. Fleischer, M.D., Chief, Endoscopy Unit, Division of Gastroen-

terology, Georgetown University, Washington, DC, USA

John Foster, M.D., Resident in Surgery, University of San Francisco, San

Francisco, California, USA

Frank Frank, Ph.D., MBB Medizintechnik, GmbH Application and Research

Munich, FRG

Shigeru Furuta, M.D., Assistant Professor, Department of Otolaryngology,

Faculty of Medicine, Kagoshima University, U suki-cho, Kagoshima, Japan

Kazumichi Harada, M.D., The Third Department of Internal Medicine,

Asahikawa Medical College, Nishi-kagura, Asahikawa-shi, Hokkaido, Japan

Yoshiki Hiki, M.D., Kitazato University, Kitazato, Sagamihara-shi, Kana-

gawa, Japan

Prof, Dr. med. A.G. Hofstetter, Director, Urology Clinic, Medical University
of Lubeck, Lubeck, FRG

Issei Ichimiya, M.D., Department of Otolaryngology, Medical College of

Oita, Hazama-cho, Oita, Japan

Satoshi Iwabuchi, M.D., Department of Neurosurgery, Ohashi Hospital,

Toho University, School of Medicine, Ohashi, Meguro-ku, Tokyo, Japan
Contributors xiii

Stephen N. Joffe, M.D., F.A.C.S., F.R.C.S., Professor of Surgery, Uni-

versity of Cincinnati Medical Center, Cincinnati, Ohio, USA

Tetsuro Karasawa, M.D., Department of Obstetrics and Gynecology, Nagoya

National Hospital, Samlomaru, Naka-ku, Nagoya-shi, Aichi, Japan

Teruo Kayano, Department of Oral Pathology, Faculty of Dentistry, Tokyo

Medical and Dental University, Yushima, Bunkyo-ku, Tokyo, Japan

Makoto Kikuchi, Ph.D., Professor, Department of Medical Engineering,

National Defense Medical College, Namiki, Tokorozawa-shi, Saitama-ken,
Japan

Teruo KOIlZll, M.D., Assistant Professor, Second Department of Surgery,

Chiba University, School of Medicine, lnohana, Chiba-shi, Chiba Pref., Japan

Yllichi KlIrono, M.D., Department of Otolaryngology, Oita Medical College,

Hazama-cho, Oita-gun, Japan

Jack M. Lomano, M.D., Director for Educational Development and Co-

Director of Grant Laser Center, Grant Hospital Medical Center; and Clinical
Assistant Professor, The Ohio State University, Columbus, Ohio, USA

Carolyn J. Mackety, R.N., M.A., Vice President, Laser Centers of America,

Inc., Columbia Plaza, Cincinnati, Ohio, USA

V. Maunoury, M.D., University of Lille, Centre Multidisciplinaire de Trait-

ment par Laser, Hopital Regional, Lille, France

B. Meric, M.D., Service d'Endoscopie Thoracique, Hopital Salvator, Mar-

seille, France

Takeshi Miwa, M.D., Department oflnternal Medicine, School of Medicine,

Tokai University, Bohseidai, lsehara, Kanagawa, Japan

Goro Mogi, M.D., Professor and Chairman, Department of Otolaryngology,

Medical College of Oita, Hazama-cho, Oita, Japan

Kevin C. Moore, M.B., Ch.B., F.F.A.R.C.S., D.A., Consultant Anesthetist,

Department of Anesthesiology, Oldham General Hospital, Rochdale Road,
Oldham, Lancashire, UK

Akinori N agasawa, M.D., Department of Oral Surgery, Metropolitan Hiroo

General Hospital, Tokyo, Ebisu, Shibuya-ku, Tokyo, Japan

Masayoshi Namiki, M.D., The Third Department oflnternal Medicine, Asa-

hikawa Medical College, Nishi-kagura, Asahikawa-Shi, Hokkaido, Japan

Takuo Nobori, M.D., Associate Professor, Department of Otolaryngology,

Faculty of Medicine, Kagoshima University, U suki-cho, Kagoshima,
Japan
xiv Contributors

Yanao Oguro, M.D., Head, Department ofInternal Medicine, National Can-

cer Center Hospital, Tsukiji, Chuo-tau, Tokyo, Japan

Kenkichi Oho, F.e.e.P., Professor, Department of Surgery, Tokyo Medical

College, Nishishinjuku, Shinjuku-ku, Tokyo, Japan

Masaru Ohyama, M.D., Professor and Chairman, Department of Otolar-

yngology, Faculty of Medicine, Kagoshima University, Usuki-cho, Kago-
shima, Japan

J.e. Paris, M.D., University of Lille, Gastroenterology Department, Hopital

Regional, LilIe, France

Carmen A. Puliafito, M.D., Director, Laser Research Laboratory, Massa-

chusetts Eye and Ear Infirmary; Assistant Professor of Ophthalmology, De-
partment of Ophthalmology, Harvard Medical School, Boston, Massachu-
setts, USA

Richard C. Ranard, M.D., Gastroenterologist in Private Practice, McLean,

Virginia, USA

R. James Rockwell, Jr., President, Rockwell Associates, Inc. Cincinnati,

Ohio, USA

Hirotsugo Samejima, M.D., Department of Neurosurgery, Ohashi Hospital,

Toho University, School of Medicine, Ohashi, Meguro-ku, Tokyo, Japan

M. Y. Sankar, M.D., F.R.e.S., Assistant Professor of Surgery, Department

of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA

T. Sato, M.D., National Defense Medical College, Namiki, Tokorozawa-

shi, Saitama-ken, Japan

Tom Schroder, M.D., Ph.D., Associate Professor, Fourth Department of

Surgery, University of Helsinki, Kasarminkatu, Helsinki, Finland

Stanley M. Shapshay, M.D., F.A.e.S., Chairman, Department of Oto-

laryngology-Head and Neck Surgery and Director, Eleanor Naylon Dana
Laser Research Laboratory, Lahey Clinic Medical Center, Burlington, Mas-
sachusetts, USA

Hitoshi Shimao, M.D., Kitazato University, Kitazato, Sagamihara-shi, Kana-

gawa, Japan

Teruko Smith, P.A.e., R.N., Laser Specialist, Palo Alto Medical Foundation,
Department of Plastic and Reconstructive Surgery and Comprehensive Laser
Center, Palo Alto, California, USA

Roger F. Steinert, M.D., Assistant Clinical Professor, Harvard Medical

School, Associate Surgeon in Ophthalmology, Massachusetts Eye and Ear
Infirmary, Laser Research Laboratory, Boston, Massachusetts, USA
Contributors xv

Soutaro Suzuki, M.D., Instructor, Gastrointestinal Endoscopy, Department

of Internal Medicine, School of Medicine, Tokai University, Bohseidai, Is-
ehara, Kanagawa, Japan

Yozo Suzuoki, M.D., Department of Obstetrics and Gynecology, Nagoya

National Hospital, Sannomaru, Naka-tu, Nagoya-shi, Aichi, Japan

Hisao Tajiri, M.D., Medical Staff of the National Cancer Center, Department
of Internal Medicine, National Cancer Center Hospital, Tsukiji, Chuo-ku,
Tokyo, Japan

John M. Tew, Jr., M.D., Professor and Chairman, Department of Neuro-

surgery, University of Cincinnati, College of Medicine, Cincinnati, Ohio,
USA

William D. Tobler, M.D., Assistant Professor, Department of Neurosurgery,

University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA

Ryozo Totani, M.D., Department of Obstetrics and Gynecology, Nagoya

National Hospital, Sannomaru, Naku-ku, Nagoya-shi, Aichi, Japan

Hiroshi Tsunekawa, Meitetsu Hospital, Japan

K. Tsutsumiuchi, M.D., Department of Otolaryngology, Kanazawa Medical

College, Uchinada, Ishikawa, Japan

Hiroto Washida, M.D., Chief Doctor of Urology, Department of Urology,

Anjo Kosei Hospital, Miyukihonmachi, Anjo, Japan

Hajime Yamamoto, M.D., Department of Oral Pathology, Faculty of Den-

tistry, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo,
Japan

Tetsuhiko Yamao, M.D., Kitazato University, Kitazato, Sagamihara-shi,

Kanagawa, Japan

Kouchi Yamashita, M.D., Department of Otolaryngology, Kanazawa Medical

College, Uchinada, Ishikawa, Japan

Yoshikazu Yamazaki, M.D., Second Department of Surgery, Chiba Uni-

versity, School of Medicine, Inohana, Chiba-shi, Chiba, Japan

Nobuo Yoshii, M.D., Department of Neurosurgery, Ohasi Hospital, Toho

University, School of Medicine, Ohashi, Meguro-ku, Tokyo, Japan

Theresa Zumwalt, M.D., Assistant Clinical Professor, Department of

Obstetrics and Gynecology, University of California at Irvine, Irvine, Cal-
ifornia, USA
1
Recent Advances in Laser
Medicine and Surgery in Japan
Kazuhiko Atsumi

The emission of a "laser" beam-first success- of Laser Medicine and Surgery has organized
fully achieved using a synthetic ruby by T.H. an international symposium biannually; so far,
Maiman in 1960-is one of the greatest discov- these symposia have been held in Dallas, Graz,
eries of this century. Tokyo, Detroit, Jerusalem, and Munich (see
Unlike ordinary light, a laser beam is coher- Table 1.1). At the same time, many international
ent, monochromatic, focusable, and directable. symposia and conferences concerned with laser
Since 1961, when the ruby laser was first used medicine and surgery were organized by phy-
to photocoagulate a detached retina, laser med- sicians and engineers for the exchange of infor-
icine has become firmly established, with suc- mation on laser technology, medical applica-
cessful applications in many clinical specialties tions, education, and so on.
and basic research, including plastic surgery, Many kinds of lasers have been used in med-
neurosurgery, otolaryngology, gynecology, and icine, but, at present, the three used most often
other fields. are carbon dioxide, Nd:YAG, and argon lasers.
At the present time, the field of laser surgery These laser applications require the use of high
can be divided into five levels according to their power to attain the desired thermal effects on
maturity-from the veteran ophthalmology to biologic tissues. Recently, however, the ten-
the fledgling cardiovascular surgery (Figure 1.1). dency of laser applications in medicine has been
In 1975, the First International Symposium on changing toward the use of low energy and short
Laser Surgery was organized by Dr. I. Kaplan pulses (Figure 1.2).
in Tel Aviv. Since then, the International Society

Current Status of Laser Surgery

I Ophthalmolagy and Medicine in Japan
ENT In 1965, a ruby laser unit for medical use was
IT Gastroenterology developed at the University of Tokyo, and the
Obstetrics & Gynecology
first clinical case of skin cancer was treated in
ill Dermatology & Plastic Surgery 1967.
Neurology
Since 1970, scientific meetings on laser med-
Urology icine were organized annually by Japanese re-
N Thoracic search groups, and in 1980 the Japanese Society
General Surgery
of Laser Medicine and Surgery was formally or-
Oncology
Orthopedics
ganized. At the present time, 800 members are
V registered with the Society, covering various
Dental
Cardiovascular clinical fields as well as basic medical research
and engineering. I By October 1984, 500 lasers
FIGURE 1.1. Maturity of laser surgery. were installed in medical facilities in Japan. This
2 Kazuhiko Atsumi

TABLE 1.1. Symposia and Congresses of the International Society for Laser Medicine and Surgery
No. of No. of
Date Symposium or Congress President Place Participants Papers
1975 (Nov. 5-6) I st International Dr. 1. Kaplan Tel Aviv 150 34
Symposium on Laser (Israel)
Surgery
1977 (Oct. 23-26) 2nd International Dr. B. Aronoff Dallas 250 37
Symposium on Laser (USA)
Surgery
1979 (Sep. 24--26) 3rd International Dr. F. Heppner Graz 350 138
Congress on Laser (Austria)
Surgery
1981 (Nov. 25-27) 4th Congress of the Dr. K. Atsumi Tokyo 800 292
International Society (Japan)
for Laser Surgery
1983 (Oct.7-9) 5th International Dr. T. Fuller Detroit 850 318
Congress of Laser (USA)
Medicine and Surgery
1985 (Oct. 13-18) 6th Congress of the Dr. 1. Kaplan Jerusalem 700 334
International Society (Israel)
for Laser Medicine
and Surgery
1987 (June 22-26) 7th Congress of the Dr. W. Munich 476 302
International Society Waidelich (West
for Laser Medicine Germany)
and Surgery

included 180 CO 2 , 180 Nd:YAG, 40 argon, and Recent Developments in Medical

25 argon-dye lasers. Laser Instruments
Figure 1.3 shows the classification of the las-
ers used in medicine, as reported at the annual
meetings from 1983 to 1985. The Nd:YAG laser Many of the medical lasers were developed in
was used most often, followed by the CO2 , Ar- Japan. For example, the world's smallest port-
gon-dye and diode lasers have been used in- able CO 2 laser scalpel of lOW, and nontoxic
creasingly each year for photodynamic therapy halide fibers to deliver the CO2 laser beam, were
and for low-energy applications. developed in Japan, and also the widely used
Figure 1.4 shows the medical areas in which contact Nd:YAG laser. The recent advance-
lasers are applied most frequently, in the fol- ments in medical laser instruments in Japan are
lowing order: Photodynamic therapy, gastroin- shown in Table 1.2.
testinal endoscopy, dentistry, biostimulation, The wavelength of the carbon monoxide laser
and medical diagnosis. beam, 5 "",m, is half that of the carbon dioxide

Coagulation
I High Energy I Vapo
Carbonization (Thermal Effect)
r Izat! on
I
Short Laser Application
Pulsed In - ?
Medicine & Surgery
ragmentatlon
ssure Effect] J
sma Effect
I Low Energy I FIGURE 1.2. Biostimulation (non-
thermal effect).
1. Laser Medicine and Surgery in Japan 3

CO2
CO
Hcl-YAG
Al"llon
He-Ne
Krypton
Ruby 0---01983
DIOCIe Gl-------<ll 1984
Na-Gloss ••- -__
. 1985

Argon-Dye
YAG-ll\Ie
N2-DYe
Gold-Vooor-
Dve
Exclmer-ll\Ie
Optica l Fiber
IS 20 25 35 50 55

FIGURE 1.3. Classification of laser use . (From the papers presented at the annual meeting of the Japan Society
for Laser Surgery and Medicine, 1983-1985.)

laser. Therefore the CO laser beam is more eas- vapor lasers in clinical photodynamic therapy
ily delivered through an optical fiber as com- for cancer cases is increasing. Argon-dye lasers
pared to the CO 2 laser beam. The CO laser sur- were manufactured in Japan and first used there
gical unit was constructed by Dr. Kikuchi and for the diagnosis and treatment of cancer.
an As 2 S3 fiber was used as the delivery system. Recently, MIT! started a national project to
The application of argon-dye, N 2 , and gold- develop cancer diagnostic and treatment sys-

Bas I e Resea rch

Genero I Surg,
Plast Ie Surg, 1983

Denoota logy 1984

Neuro Surgery _ - -•• 1985

Oohtholfoology
-Dental (Orol)
Oto I aryngo I 09Y
Cardiovascular
Choledocho -
Hepatic

Endoscopy (GI) I ,..Fi"i::;;;:;;:::::::....------"'~--

Gynecology tl1
UrOlogy

PDT
Blost Irrulat Ion
FIGURE 1.4. Frequency of use oflasers Dlognos I s
by medical specialty. (From papers
Ins t mrent
presented at the annual meeting of the
Japan Society for Laser Surgery and MIscellaneous
Medicine, 1983-1985.) 5 10 IS 20 25
4 Kazuhiko Atsumi

TABLE 1.2. Recent developments in medical laser TABLE 1.4. The 6th International Congress of Laser
instruments in Japan Surgery and Medicine (Jerusalem, October 13-18, 1985)
CO laser surgical scalpel No. of No.
1.32-fLm Nd:Y AG laser Fields applications Lasers used lase
Photodynamic therapy with N,-dye laser
Photodynamic therapy with gold-vapor laser Basic research 2 CO, 165
Cancer diagnostics and treatment with argon-dye laser General surgery 25 Helium-neon 10
Cancer diagnostics and treatment with excimer-dye laser Neurosurgery 29 Nd:YAG 72
Semiconductor Ga-Al-As laser Ophthalmology 21 Argon 45
Otolaryngology 28 Argon-dye 22
Dental and oral surgery 13 Diode 9
Thoracic surgery 5 Excimer
terns using the excimer laser. In these systems, Cardiovascular surgery 29 Krypton 2
Plastic surgery 9 Gold-vapor 2
a tunable excimer laser is used-405 nm for di- Dermatology 20 Copper-vapor
agnosis and 630 nm for cancer treatment. Gynecology 33 Ruby 2
Diode lasers for biostimulation were also de- Urology II Optical fiber 5
veloped. Orthopedics 3 Miscellaneous 0
Endoscopy J3 359
Photodynamic therapy 24
Low-energy laser 24
Recent Advancement in Instrument 16
Laser Therapeutics Miscellaneous 29
334
Recent advancements in laser therapeutics are
shown in Table 1.3. Microvascular anastomosis
has been achieved by using a special low-energy ,
5-80 mW, CO 2 laser developed by Dr . Hayashi. stimulation, pain relief, and vascular anasto-
Choledocholithotripsy has been performed mosis (Figure 1.5).
with excellent results by use of the contact With this background, the First International
Nd:YAG laser with a new ceramic endoscopic Symposium on Low Energy Laser Surgery and
tip attachment designed by Dr. Kouzu. With this Medicine was held in Tokyo in June 1986.
technique he succeeded in destroying stones in The definition of low laser energy has not yet
92% of the cases, but in only 66% were suc- been clarified; however, there are some general
cessfully removed without the laser. agreements.
Low-energy laser applications is one of the A low-energy laser has a power output of less
main investigations in laser medicine and sur- than 100 mWand an energy density of less than
gery. The 6th International Congress of Laser 50 mW/cm 2 • The biologic effects of the low-en-
Surgery and Medicine was held in Jerusalem in ergy laser are considered to be as follows: ac-
October 1985. Table 1.4 shows the applied fields tivation of biochemical substances, stimulation
and lasers used by the participants at the con- of biologic tissues, and denaturation of biologic
gress. Low-energy laser applications was one proteins, as shown in Figure 1.6.
session among the major applications in medi- In our laboratory, in cooperation with Dr.
cine. This included use in wound healing, bio- Ohshiro, the low-energy diode laser, with a
wavelength of 830 nm and a power output of 60
mW, has been used for pain relief. The clinical
TABLE 1.3. Recent advancements in laser
data for our study of pain were obtained by the
therapeutics
patients' responses in a double-blind test and by
Microvascular anastomosis by CO, laser the use of thermographic imaging. In 70% of pa-
Choledocholithotripsy by contact Nd:Y AG laser with new
ceramic probes tients there was relief of pain, with diode laser
Ureterolithotripsy by contact Nd: Y AG laser with new treatment, although 40% obtained similar pain
ceramic probes relief (placebo) without laser irradiation. Further
Pain relief by semiconductor laser studies are therefore necessary to analyze the
Laser endoscopy treatment for ectopic pregnancy pain relief mechanisms induced by laser stim-
Selective vagotomy by CO, laser
ulation.
1. Laser Medicine and Surgery in Japan 5

Vascular Anastomosis
Wound Tissue Nerve Anastomosis
PDT Healing Welding Skin Suture

Blostlmulatlon Acupuncture

Low Energy Laser

In

Pain
Relief
Medical
Diagnosis

DentistrY Orthoped I cs Sports

Medicine

FIGURE 1.5. Applications of the low-energy laser in medicine and surgery.

Recent studies are seeking how to use short- increasing for doctors, nurses, and technicians.
pulsed lasers effectively for highly precise re- For this purpose, educational curricula, teach-
moval of small volumes of tissue and their frag- ers, and facilities are required.
mentation. An example of the short-pulsed laser To meet the requirements of the researchers
is the excimer laser, which has a promising fu- and clinical users of laser medicine, the. first
ture in cardiovascular surgery for laser angio- Laser Hospital in the world-Nanasato High-
plasty or in combination with balloon angio- Tech Medical Center-was built in Omiya City,
plasty. Research is also being carried out on the 30 miles north of Tokyo, and opened in 1985.
very short pulse excimer pumped-dye laser with In this hospital, the laser instruments-
metal-copper and gold-vapors and on the Nd:YAG, argon, argon-dye-are installed in a
long-pulsed flash-lamp pumped-dye lasers. The central room. The laser beams are delivered
longer pulsed laser can be used in the fragmen- through optical fibers into the two surgical op-
tation of kidney stones. eration rooms and the seven outpatient rooms.
The laser selection, output, and time are con-
trolled by a central computer (Figure 1.7). Over
Education and the Laser Hospital 100 cases have to date been treated. The laser
In consequence of the rapid progress of laser hospital will be expected to contribute not only
medicine and surgery, educational problems are to the community's care but also to the edu-

Activation Stimulation Denaturation Coagulation Vaporization

of r- of f- of _ of _ of
Biochemical Biological Biological Biological Biological
Substances Tissues Proteins Tissues Tissues
Photodynamic Electro- Thermal Thermal Thermal
Effect MagnetiC Effect Effect Effect
Effect (Low) (Moderate) (High)
I I I

Low Energy Application High Energy Application

Laser Output : < 100 mW Laser Output : 20 - 120 W

Energy Density<SO mW/cm 2 Energy Density>SO - 100 W/cm 2

FIGURE 1.6. Biologic effects of laser energy irradiation.

6 Kazuhiko Atsumi

Surgica l Opergtlon Rooms

A B C 0
0 0 6- 0 0 6-

11 I 0: Nd-YAG
CO2 (SOW X 1> 0: Argon
CO2 (30W X I) 6- : Argon-Dye

~LUL I
Central
Wi 11 II
Endoscopy
Supply
-- - ---------------- Pl astl c
Surgery
Gynecology
"
Urology "
O1olar-
yn<]ology Surgery
Ophthal-
,., logy
Nd- YAG (lOOW x 2)
Argon (lW x 1) o 06. 00 6. 006. 006. 006. 0 6.
0 0 6- Argon- Dye
(1.5Wx 1)
Argon Photo
~o'9ulator (I
Nd-YAG (I OOW X 1) C02 (30W x \)
Outpatient R
ooms

FIGURE 1.7. Arrangement of the medical laser system in the Nanasato High-Tech Medical Center (Japan).

cation oflaser surgeons and technicians, as well 9. Medical data processing by optical fibers
as provide international information on devel- 10. Medical data bank and networking by laser
opments in laser medicine. z.3 communication
Laser medicine will mark a revolutionary
The Future of Laser Medicine change in traditional medical and surgical pro-
In the future, the diagnostic and therapeutic op- cedures leading to new medical research and
tions not previously available will include: new horizons in the treatment of patients.
1. Noninvasive, bloodless surgery
2. Precise diagnostic and selective treatment of References
cancer 1. Atsumi K: Overall research and development of
3. Ultramicrosurgery laser medicine and surgery in Japan. New Frontiers
4. Laser genetic engineering Laser Med Surg 13:19-38, 1983.
5. Specific diagnosis by laser immunology 2. Atsumi K: New designed, central supplied laser
6. Subcellular biomedical research hospital. Abstracts, 6th Congress of the Interna-
7. Sensitive diagnosis by laser doppler flow- tional Society of Laser Surgery and Medicine, Je-
metry rusalem, 1985.
8. Online, three-dimensional imaging of the 3. Atsumi K, et al: The new laser hospital. Tech-
whole body by x-ray holography nological and clinical aspects. Lasers Surg Med
6(2):213, 1986.
2
A Brief History of the N d: YAG Laser
John C. Fisher

The successful operation of the first working Bessis and his associates8 in France in 1962
laser by Theodore Maiman l in 1960 was lik~ the described the use of the ruby laser to irradiate
key to a locked chest full of other types of laser, the constituents of living cells. In that same year,
just waiting to be discovered. Only six years Koester, Snitzer et al. 9 wrote of experimental
later, working prototypes of gas, liquid, solid, retinal coagulation by ruby laser. In 1965, Min-
and semiconductor lasers had been constructed ton, Zelen, and Ketcham 10 described the use of
by several groups of investigators, spurred on ruby and pulsed Nd:glass laser lasers on the
by Maiman's achievement. By the end of that Cloud man S-91 mouse melanoma. In 1971,
decade, hundreds of materials had been found James Fidler ll in Cincinnati reported his use of
capable of laser action. a 100-W Nd:YAG laser with a Nath fiber to in-
In December of 1961, Elias Snitzer2 reported cise canine livers, and in that same year, Mus-
achieving laser action in barium crown glass sigang and Katsarosl 2 in West Germany used a
doped with neodymium ions. His work un- 25-W Nd:YAG laser to study its effects on ex-
doubtedly stimulated Geusic, Marcos, and Van cised tissues.
Uitere to pursue the development of the The first clinically significant application of
Nd:YAG laser, which they announced in 1964, the Nd:YAG laser to surgery was Peter
together with laser action in other neodymium- Kiefhaber'sl3 use of it in West Germany to con-
doped garnets. trol massive gastrointestinal bleeding in humans.
All of these scientists, of course, were the ul- In 1978, Alfons Hofstetter and Karlheinz
timate intellectual beneficiaries of the legacy of Rothenberger l4 tried coagulation of tumors of
Albert Einstein,4 whose 76-year lifespan ended the bladder wall, transmitting the laser beam
in 1955, just five years too soon for him to see through an optical fiber inserted via the urethra.
the fulfillment of his inspired prediction, in 1917, In 1979, L. Toty et al. I5 in France reported the
of the possibility of stimulated emission of ra- endoscopic treatment of tracheobronchial le-
diation. However, he did survive long enough sions by the Nd:Y AG laser. In the hands of
to witness the construction of the first masers Jean-Francois Dumon and his colleagues l6 in
by Gordon, Zeiger, and Townes 5 in the United Marseille, by 1983 the Nd:YAG laser had be-
States, and by Bassov and Prokhorov6 in the come the preferred modality for palliative treat-
Soviet Union, in the year 1954. ment of obstructing malignant tumors ofthe air-
The early medical experimenters who saw way. _
potential value in lasers as surgical tools began In 1973, in Paris, Daniele Aron-Rosa 17 had
their trials, often haphazard and unscientific, not begun her long search for an ultrashort-pulsed
long after Maiman' s first firing of the ruby laser. laser to do intraocular surgery, which culmi-
Perhaps prophetically, G. Meyer-Schwickerath7 nated in 1980 in the use of a mode-locked, pi-
in Germany had reported the first surgical use cosecond-pulsed Nd:YAG laser to cut vitreous
oflight in 1954, the year of the maser, to prevent strands. Concurrently, Franz Fankhauser l8 in
retinal separation. Bern was developing the ophthalmic applica-
8 John C. Fisher

tions of the Q-switched, nanosecond-pulsed well overshadow the purely surgicaI applications
Nd:YAG laser in collaboration with the firm of the Nd:YAG laser in the next decade.
Lasag, A.G. of Thun, Switzerland. By 1978 he
had performed iridectomies in 102 eyes, using
the multimode Lasag Microrupter 1 laser. At this
writing, short-pulsed Nd:YAG lasers have be-
References
come standard tools of the ophthalmologist, 1. Maiman TH: Report in Phys Rev Lett 4:564, 1960.
performing posterior caps ulotomies and other 2. Snitzer E: Optical maser action of Nd3+ in barium
rrecise intraocular procedures that are difficult crown glass. Phys Rev Lett 7:444-446, 1961.
or impossible to do by means of the argon-ion 3. Geusic JE, Marcos HW, Van Uitert LG: Laser
laser or other modalities. oscillations in Nd-doped yttrium aluminum, ytt-
In 1984, in Cincinnati, Stephen Joffe and his rium gallium, and gadolinium garnets. Appl Phys
Lett 4:182, 1964.
associates 19 introduced sapphire tips for quartz
4. Einstein A: On the quantum theory of radiation.
optical fibers to the United States, following a Phys Z 18:121, 1917.
collaborative development with Norio Daiku- 5. Gordon JP, Zeiger HJ, Townes CH: Molecular
zono and his associates in Japan. These shaped microwave oscillator and new hyperfine structure
waveguides, attached to the standard quartz fi- in microwave spectrum ofNH 3 • Phys Rev 95:282-
bers used for transmission of Nd:YAG laser 284, 1954.
beams, are placed in contact with the surgical 6. Bassov NG, Prokhorov AM: Article in J Exp
target, and permit precise cutting of soft tissue Theor Phys (USSR) 27:431, 1954.
with excellent first-pass hemostasis of transected 7. Meyer-Schwickerath G: Lichtkoagulation: Eine
vessels, but without the extensive thermal dam- Methode zur Behandlung und Verhutung der
age characteristic of Nd: Y AG beams delivered Netzhautablosung. Graefes Arch Ophthalmol
156:2, 1954.
by noncontacting fibers. I was a scientific re-
8. Bessis M, Gires F, Mayer G, Nomarski G: Ir-
viewer of Joffe's paper for the journal Medical radiation des organites cellulaires a l'aide d 'un
Instrumentation, and I was impressed by the el- laser a rubis. Compt Rend Acad Sci 225: 1010,
egant simplicity of this concept, which has 1962.
opened the whole field of thoracic and abdom- 9. Koester CJ, Snitzer E, Campbell CJ, Ritter MC:
inal surgery to the Nd:Y AG laser, formerly Experimental laser retinal coagulation. J Opt Soc
thought to be useless for precise cutting and va- Am 52:607, 1962.
porization. 10. Minton JP, Zelen M, Ketcham AS: Experimental
Today the Nd:YAG laser has become a stan- results from exposure of Cloud man S-91 mouse
dard instrument in general laser surgery, com- melanoma in the CDBA/2F hybrid mouse to neo-
plementing the CO 2 , which originally dominated dymium or ruby laser radiation. Ann N Y Acad
Sci 122:758, 1965.
the field. Its applications extend to bronchology,
11. Fidler JP: Personal communication to Stanley
gastroenterology, dermatology, gynecology, Stellar et al., 1971.
ophthalmology, neurosurgery, urology, and 12. Mussigang H, Katsaros W: Lasers in operative
vascular surgery. There is probably no part of surgery with possibilities of transmission by flex-
the human body that cannot be surgically treated ible light conductors. Bruns Beitr Klin Chir
in an effective manner by the Nd:Y AG laser in 218(8):746--763, 1971.
one form or another. 13. Kiefhaber P, Nath G, Moritz K: Endoscopic con-
With the use of nonlinear optical materials, trol of massive gastrointestinal hemorrhage by ir-
such as potassium titanyl phosphate and others, radiation with a high power neodymium: YAG
it may be possible in the near future to build a laser. Prog Surg 15:140-145, 1977.
frequency-quadrupled Nd: YAG laser to produce 14. Hofstetter A, Rothenberger K, Keiditsch E, et
al: The efficiency of the neodymium:YAG laser
a wavelength of 266 nm for the precise surgery
in urinary bladder treatment. Proceedings of the
now being done experimentally with various 4th Congress of the International Society for
excimer lasers. Perhaps the most important ap- Laser Surgery, 1981. Laser Tokyo 10: 18-20, 1981.
plications of all will be in the field of bios tim- 15. Toty L, et al: Utilisation d'un faiscean laser YAG
ulation, where Abergel and his associates 20 have a conduction soup Ie pour Ie traitement endo-
demonstrated the ability of rays at 1064 nm to scopique des certaines lesions tracheo-bron-
lyse collagen in keloids. Uses of this kind may chiques. Rev Fr Mal Respir 87:57-69, 1979.
2. History of the Nd:YAG Laser 9

16. Dumon JF, Meric B: Handbook of Endobronchial OphthalmicMicrosurgery. Appleton-Century-

YAG Laser Surgery, Marseille. Privately pub- Crofts, Norwalk, CT, 1983, pp 101-146.
lished by Dumon & Meric, 1983. 19. Joffe S, Daikuzono N: Artificial sapphire probe
17. Aron-Rosa D, Griesemann JC: Pulsed ultrarapid for contact photocoagulation and tissue vapori-
Y AG neodymium laser. Section of vitreous zation with the Nd:YAG laser. Med Instrum
strands and cyclitic membranes in the manage- 19:173-178,1985.
ment of retinal detachment. Conferenza Intemaz 20. Abergel RP, Meeker CA, Thomas SL, et al: Con-
suI Distaco di Retina, Rome, 29 Sept-l Oct, 1980. trol of connective tissue metabolism by lasers:
18. Fankhauser F: The Q-switched laser: Principles Recent developments and future prospects. J Am
and clinical results. In Trokel SL (ed): YAG Laser Acad DermatoI1l(6):1l42-1l50, 1984.
3
Noncontact Delivery Systems and
Accessories for the Application of the
N d: YAG Laser in Endoscopy and Surgery
Frank Frank

The almost explosive development of numerous action is of primary importance. The degree and
laser systems has led to a wide spectrum of ap- extent of the thermal effect depend on the optical
plications. Among the earliest suggested appli- and the thermal properties of the tissue, the ge-
cations were those employed in material pro- ometry of the laser beam, and the energy of the
cessing, such as cutting, drilling, and welding, incident light.
and applications in medicine. The properties of The most important optical parameter is the
the laser beam, such as monochromaticity and wavelength-dependent absorption of the laser
coherence, are utilized primarily in the field of light by biomolecules. The transitions of the
medical diagnosis. The small divergence of laser biomolecules are equivalent to the wavelengths
light or, rather, the resulting possibility of con- shorter than about 280 nm. In this region, only
centrating a very high light intensity at the focal few, mostly low-power, lasers are available at
point of a lens, is of fundamental importance for present.
therapeutic purposes. All applications in surgery The much more molecule-specific vibrational
and -associated fields utilize the conversion of and rotational absorption bands are all within
laser light into heat within the tissue, and the the range of wavelengths larger than 1000 nm.
reactions thus produced, for cutting and coag- With a few exceptions, visible radiation is vir-
ulating tissue. tually not absorbed by biologic objects. Among
The Nd:YAG laser has become a coagulation the major exceptions to this rule are the hemo-
instrument, which has found acceptance in in- globin in the red blood cells, and the pigment
terdisciplinary surgery. Due to the low absorp- melanin. Here, marked absorption in the green
tion and high scattering in tissue, the radiation visible spectrum occurs.
of the Nd:YAG laser leads to a deep and ho- The high water content of most tissues leads
mogeneous coagulation effect. The noncontact to a very marked absorption of infrared radia-
treatment and the fact that blood and lymphatic tion. This leads to an extremely efficient con-
vessels are coagulated and closed have led to version of energy, and heating of tissue when
successful applications, especially with regard irradiating with lasers employing these wave-
to tumor surgery. lengths.
Apart from absorption, a further important
optical tissue parameter that has to be consid-
Biophysical Considerations ered is scattering. Biologic tissue is highly
structured, so that a beam of light directed into
For a consideration of the interactions between it undergoes a considerable change in spatial
the laser light and biomolecules, for example, distribution owing to reflection, refraction, and
in cells and tissue, the parameters of the biologic diffusion effects. Scattering occurs mainly when
objects must be related to the physical param- absorption is low.
eters of laser radiation. The thermal properties of tissue are its thermal
For surgical applications, the thermal inter- capacity and thermal conductivity. This is often
3. Noncontact Nd:YAG Laser Treatment in Endoscopy and Surgery 11

thought to be equivalent to water. This as- veins of up to 3 mm in diameter can be closed

sumption is incorrect as it is often difficult to rapidly and reliably.2
estimate the transmission of energy by thermal Also of importance for the form and nature
conduction, when layers of tissue of highly dif- of tissue damage by Nd:YAG laser is surface
fering structure and complicated geometry are cooling. The main advantage of the Nd:YAG
involved. For example, the wall ofthe stomach, laser is the possibility of coagulating without
the retina, the wall of the bladder-or in the vaporization. When the surface of the tissue is
presence of blood vessels, with usually irregular cooled with gas, the extent of the necrosis is
blood flow through them leads to a very het- clearly marked on the surface. With water cool-
erogeneous dissipation of energy. Furthermore, ing, which is possible only at the 1064-nm
during irradiation, phase transitions, such as wavelength, a deep, drop-shaped necrosis de-
vaporization or carbonization, which alter the velops, the surface of the tissue hardly being
optical and thermal properties of the tissue, fre- injured. Initially, the coagulation volume ex-
quently occur. pands with increasing irradiance, but is then
limited by backscatter from the blanched sur-
face. If carbonization occurs on the surface, ab-
Effect of Nd:YAG Laser sorption increases and the tissue is vaporized.
Light on Tissue If the surface of the tissue is cooled with water,
the blanching effect is delayed, carbonization
The Nd:YAG laser emits light in the near-in- avoided, with the result that deep coagulation
frared range at 1064 and 1318 nm. At 1064 nm occurs.3
absorption in tissue is very low. Optical scat- A comparison of the coagulation effect of
tering is therefore very pronounced, resulting in electrocautery and Nd: YAG laser light reveals
uniform distribution of the radiation in tissue. marked differences. This difference is particu-
Slow heating of a large tissue volume around larly noticeable in multilayered tissue such as
the point of impingement of radiation occurs, the wall of the bladder. With comparable surface
followed by a deep, slowly progressing coagu- necrosis, the coagulation zone produced by
lation. electrocoagulation is shallow, with rough, ir-
The tissue volume covered by the laser light regular lateral and deep boundaries. Nd:YAG
is heated, which results in delayed destruction lasing results in a laterally sharply delineated
of the tissue, with no noticeable structural dam- necrosis involving all the layers of the bladder
age. The low absorption leads to coagulation wall. In parenchymatous organs, such as, liver
depths of d.own to 6 mm. Finally, protoplasm tissue, the coagul;:ttion effect of an electric cur-
vaporizes at the tissue surface, leading to rent is much shallower than that of the N d: YAG
marked shrinking, although the tissue surface laser. 4.5
itself is hardly damaged. The surface of the tis- The deep coagulation effect of the Nd:YAG
sue is covered with only a thin layer of fibrin. I laser also leads to the temporary sealing of
Particularly in multilayered tissue, for example, lymph vessels. This effect can be clearly dem-
the wall of the stomach, the depth of the necrosis onstrated experimentally. Dye is injected into
depends on the blood circulation. the apex of a rat bladder. If a transmural necrosis
The effects at the surface of the tissue are, is produced by laser irradiation around the re-
for the most part, influenced by the power den- sulting weal, it can be seen that the lymph flow
sity applied on irradiation. The focused Nd:YAG stops at the lasered zone for 3 to 4 weeks. After
laser beam, 1064 nm, power density approxi- electrocoagulation, however, dye is deposited
mately 10 kW/cm 2 , ruptures the tissue surface in the lymph nodes-proof enough that the
and leads to a wide, conical coagulation lesion. lymph vessels are not properly closed by elec-
Defocused delivery-power density approxi- trocautery .6
mately 200 W/cm 2-leads to a shallow coagu- The absorption coefficient of water and saline
lation effect, with sealing of the vessels under is approximately 10 times higher at the Nd:YAG
the surface. Blood vessels are sealed by the laser wavelength of 1318 nm than at 1064 nm.
combined effect of shrinkage and uniform co- This results in more efficient conversion of en-
agulation of tissue. Arteries of up to 2 mm and ergy into heat in tissue at 1318 nm. The extinc-
12 Frank Frank

tion coefficient in blood at 1318 nm is only one- sults in the occlusion of blood and lymph ves-
third of that at 1064 nm.7 This results in less heat sels. 9
dissipation by blood and deeper penetration in The first continuous wave Nd:YAG laser,
tissue at 1318 nm. working on the 1064-nm wavelength, was intro-
Especially in tissue with a high water content, duced in the medical field in 1973. Since then a
a marked loosening of the necrotic tissue is ob- number of different systems with power ranges
tained with laser light of 1318-nm wavelength from 40 to 120 W have been developed (Table
with ablation. However, it is by no means to be 3.1, Figure 3.1). All these instruments have
compared with the well-known precise incision similar construction characteristics. The essen-
obtained with a 1O,600-nm CO 2 laser. Unlike the tial component is the laser head, which accom-
CO 2 laser incision, tissue ablation with the modates all the optical elements of the Nd:YAG
Nd:YAG laser at 1318 nm is distinguished by a laser: crystal, pump lamps, and resonator mir-
clear and effective coagulation zone along the rors, as well as a pilot laser within the visible
borders of the incision. 8 .9 spectrum. The pilot light is emitted by a helium-
neon laser in the milliwatt range, and is con-
centric with the main invisible Nd: Y AG laser
N d: Y AG Laser Systems and beam. Both are transmitted to the operative field
Accessories via a flexible quartz fiber light guide. The pilot
light marks the target point of the therapeutic
Through use of targeted non contact irradia- beam.
tion with the Nd:YAG laser pathological tissue Early in the development of the medical
can be destroyed. The marked depth effect re- Nd:YAG laser, it became apparent that laser

TABLE 3.1. Commercial continuous wave Nd:YAG laser systems for endoscopic and
surgical use with date of clinical introduction
Power Launched
Company Model (on tissue) (year)
Aloka LMY 1001 100 W 1985
Cilas YM 575 50W 1980
YM 100 100 W (quasi-cw) 1981
YM 101 85 W 1985
Cooper Laser Sonics 8000 100 W 1978
(Molectron Medical) 4000 50 W 1985
6000 80W 1986
8900 120 W 1986
ML 880 100 W (1.06 fLm), 45 W (10.6 fLm) 1984
Fujinon FYLMI toO W 1984
Laser Industries 2100 100 W 1986
MBB-Medizintechnik mediLas toO W 1973
(MBB-AT) mediLas 2 120 W 1979
mediLas 40 N 40 W 1986
mediLas 60 N 60W 1987
NIlC 130YZ toO W (1.06 fLm), 30 W (10.6 fLm) 1983
IS tol toO W 1986
Olympus MYL-I 100 W 1984
Osada Nd:YAG 60 W 1985
Pentax SLY-I toO W 1984
Pilkington Medical Fiberlase toO toO W 1982
(Barr & Stroud)
Surgical Laser Technologies SLT CL60 60 W 1986
3. Noncontact Nd: YAG Laser Treatment in Endoscopy and Surgery 13

FIGURE 3.1. Examples of clinical Nd:YAG laser systems. Model mediLas 2 (120 W) with separate laser head
and model mediLas 40 N (40 W) with integrated laser (MBB-Medizintechnik GmbH).

radiation is only as useful as the available ac- divergence ranges from 6° to 24° and can be
cessory instruments. The surgeon needs appro- compensated by adjusting the irradiation dis-
priate instruments to take full advantage of the tance or by the use of appropriate lenses.
efficient properties of the Nd:YAG laser. Var- Gas-cooled or liquid-flushed light guide sys-
ious instruments have been developed for rou- tems are available. The gas is introduced into
tine clinical use, following the philosophy that the light guide at the optical coupling. A suitable
they should be as similar as possible to instru- nozzle at the distal end provides efficient irri-
ments that are already familiar to the user. gation and cooling. The rinsing solution is either
introduced in the same way or more often di-
rectly connected to the endoscope or handpiece,
Flexible Laser Light Guides which is used together with the light guide. The
fiber tip can easily be repaired if damaged. Sys-
Transmission of the laser beam via flexible light
tems from 1 to 2.6 mm in diameter are available.
guides is based on the total reflection occurring
at the interface between two media with different
refractive indices. The light is propagated within Instrumentation for Endoscopic
the optically denser medium. The light wave
Application
being repeatedly totally reflected along the
length of the light guide. The transmission takes Of the various indications for the use of the
place in quartz glass fibers. Nd: YAG laser in medicine, applications in the
Commercially available quartz optical fibers endoscopic field have reached essential impor-
with a strong Teflon covering (fiber diameter tance. For the well-known endoscopic indica-
0.2-0.6 mm) fulfill all the requirements relating tions in gastroenterology, pulmonology, and
to mechanical stability and high flexibility. Laser urology, the common instrumentation has been
light is introduced at the proximal end by means modified for laser use. 10- 28 New endoscopic
of lens systems whose focal point is adjusted to techniques for special endourologic interven-
the fiber core diameter. The transmission effi- tions, gynecology, ENT, and neurosurgery have
ciency of these fiber systems is 90%. The exit led to developments of suitable systems. 29- 38 In
14 Frank Frank

this section a choice of typical endoscopic sys- Because of the exceptionally good vision it
tems using different technical principles are de- affords, some operators use a rigid endoscope
scribed (Figure 3.2). in the treatment of esophageal varices. The light
In gastroenterology all routine diagnostic in- guide, together with the telescope, is introduced
struments are used without any modification. into the shaft, which is provided with an aspi-
The light guide is passed directly through the ration channel. By angulating the light guide it
working channel and can be advanced distally is possible to irradiate the esophageal wall per-
as far as desired. pendicularly. The instrument has a diameter of
The noncontact application of the Nd:YAG 14 mm, which limits its application.
laser in gastroenterology is suitable for stanching Also in pulmonology, all routine flexible di-
bleedings from esophageal varices, ulcers, and agnostic instruments can be applied. Two-chan-
Mallory-Weiss tears. The treatment of tumors nel instruments have the advantage that one
in the upper and lower gastrointestinal tract, channel is available for aspiration while the fiber
palliative elimination of stenosing tumors, cur- is in place. Most of the interventions to recan-
ative radiation of sessile neoplastic polyps and alize endobronchial and endotracheal stenoses
benign intestinal and esophageal stenoses, are are performed under outpatient conditions.
additional indications, which are rapidly be- In complicated cases of bronchial tumor re-
coming more important than hemostasis. section, an operating technique is required in
With the endoscopic application of the which aspiration and ventilation can be per-
N d: YAG laser in gastroenterology a triconical formed simultaneously. For this purpose a mul-
quartz-glass fiber was used initially. The sub- tichannel rigid bronchoscope is available. The
stantially lower 4° divergence of this fiber makes light guide is introduced, together with the tel-
the power density at the site of exposure largely escope, through the sheath containing the as-
independent of variations in the irradiation dis- piration and ventilation channels. By angulating
tance. An operating distance of up to several the light guide, it is possible to irradiate the
centimeters is possible without any appreciable bronchial wall perpendicularly. The instrument
reduction in the power density required for co- has a diameter of 13 mm, which limits its ap-
agulation. The 0.3- or 0.2-mm quartz glass fiber plication (Figure 3.2).
is loosely mounted in a Teflon tube, which In another multichannel rigid bronchoscope,
makes it extremely susceptible to mechanical a diameter of 11 mm has been obtained by omit-
damage. The use of this light guide requires ting the angulation mechanism. The channels for
modified gastroscopes. The operating channel the aspiration catheter and the light guide are
is sealed at the distal end by a window . If the identical, adjacent, and interchangeable. The
tip is damaged, the whole light guide must be smoke generated during tissue vaporization can
replaced. be aspirated through another channel to ensure

FIGURE 3.2. Examples of different rigid laser endoscopes for noncontact application of the Nd:YAG laser:
cystoscope, bronchoscope, neurosurgical endoscope (Karl Storz, GmbH & Co.).
3. Noncontact Nd: YAG Laser Treatment in Endoscopy and Surgery 15

good vision. The rotatable anesthetic attachment the part of the system that will be introduced
ensures optimal irradiation conditions with sim- into the ureter.
ple operation. For the irradiation of tumors in the pelvis and
For treating tumors in the genitourinary sys- the calices of the kidney, a flexible endoscope
tem, such as multicentric tumors or colonizing with an outer diameter of only 4 mm can be
tumors of the urethral, vesical, and ureteral mu- used. The light guide and rinsing fluid are passed
cosa, and tumors in the pyolocaliceal area, sev- through the working channel.
eral endoscopic laser instruments are available. Owing to the homogeneous coagulation effect
The standard laser cystoscope for outpatient the Nd:YAG laser is also successfully applied
treatment of small bladder tumors, stage TIS and to tubal sterilization in the gynecologic field. The
Tl, consists of a conventional cystoscope sheath laparoscopic sterilization by partial coagulation
of 19-21 French, an observation telescope with of the oviducts improves the chances of future
variable viewing angles, and a special laser cys- refertilization. This laparoscope insert is
toscope insert, similar to a normal Albarran in- equipped with distal forceps to ensure a per-
sert. The light guide is passed through the manent obturation of the ovular tuba. The
working channel. The distal end of the light gas-cooled light guide is combined with the for-
guide can be flexed to up to 80° with the aid of ceps insert. The forceps are so constructed that
the modified Albarran lever. In addition, the fi- the laser beam always remains within the
ber tip can be moved distally to permit exact branches. This prevents damage to the sur-
adjustment of the distance from the area to be rounding tissue.
irradiated (Figure 3.2). A rinsing solution is in- For laparoscopic application of the Nd:YAG
troduced onto the attachment and led to the dis- laser in gynecology, such as in the treatment of
tal end, so that, with circulating rinsing, the vol- endometriosis, the laser light guide with a coax-
ume can easily be kept constant. Practically all ial gas flow can be adapted to the routine op-
regions of the bladder can be irradiated perpen- eration laparoscopes using a special laser insert.
dicularly. The distal flexibility permits exact and safe ir-
For clinical interventions on larger tumors and radiation of the area to be treated.
for laser irradiation of the tumor bed after elec- A laser hysteroscope is applied for the en-
troresection, a 24 French resection sheath with doscopic treatment of uterine hemorrhage and
an oblique tip and a central cock is used instead coagulation of tumors and lesions in the uterus.
ofthe sheath described above. The greater rins- The rigid optic permits laser treatment under di-
ing effect that can be achieved with this ar- rect visual control. The mobility of the distal
rangement permits efficient laser irradiation fiber end guarantees efficient irradiation. The
even when bleeding occurs. continuous irrigation system ensures adequate
For the combined treatment of electroresec- cooling.
tion and laser irradiation in one session, the light A laser laryngoscope as well as a laser tra-
guide is attached directly to the electrotome but cheoscope operate on the same principles as the
the distal fiber end cannot be bent. bronchoscopes described previously. Distal il-
Interventions within the urethra, in the treat- lumination and the flexible gas-cooled light guide
ment of urethral carcinomas and condylomas, allow optimal, targeted irradiation.
allow the use of a system with a modified sheath New neurosurgical indications for the endo-
of 20 French and an additional overall reflux scopic noncontact application of the Nd:YAG
sheath. There is no need for the Albarran lever, laser are the treatments in cases of hydroceph-
since the fiber is passed directly through the alus, cystic brain tumors, or massive bleeding.
laser insert with the observation optic. Any A laser encephaloscope that permits controlled
possible damage to the urethral mucosa is thus movement of the distal end of the flexible fiber
avoided. has been created for the endoscopic Nd:YAG
A ureterorenoscope of 9 French has been de- laser interventions in the ventricle system, for
signed for tumor treatment within the lower part perforating brain cysts and vaporizing the neo-
of the ureter. An inspection insert with a bougie plastic tissue in the cyst wall. With the special
channel facilitates the introduction of the in- viewing obturator, the 15 French sheath can be
strument. Fiber and telescope are inserted into introduced under visual control. Rinsing and fi-
16 Frank Frank

ber movement is done in the same manner as not impair vision (Figure 3.3). In addition to the
with the urologic endoscopes. standard shapes, such hand applicators with
For the atraumatic aspiration of hematomas flexible tubes enable the surgeon to reach oth-
in the cervicocranial region the laser neuro- erwise inaccessible regions.
surgical endoscope with a simultaneous rinsing
and suction mechanism is available. The inte-
grated light guide allows a directed microcoa- Integration with the Microscope
gulation of bleeding vessels (Figure 3.2). For operations in extremely restricted access
areas, such as in neurosurgery and ENT, or for
Instrumentation for Open Surgery microsurgical laser-assisted anastomosis in
connection with the 1318-nm Nd:YAG sys-
For all external applications in dermatology, tem,46,47 an operating microscope adapter is
urology, and gynecology, and for interventions available.
on exposed areas in neurosurgery or in general The optical elements of the micromanipulator
surgery39-45-with or without the operating mi- are the fiber coupler, the main optics, and a
croscope-various handpieces have been de- movable mirror, controlled by a joystick. A
signed for unrestricted, free-hand manipulation safety filter at the top protects the eyes against
(Figure 3.3). reflected radiation. A window at the bottom
The focusing handpiece is equipped with an protects the optics against dust and smoke. The
interchangeable optic. Focus points as small as micromanipulator is mounted on the operating
0.4 mm diameter can be achieved. By altering microscope firmly by a dovetail joint. The di-
the irradiation distance, both the power density ameter of the laser beam can be adjusted on the
and the diameter of the treated area can be var- micromanipulator between 0.9 and 5.0 mm. The
ied (Figure 3.3). aiming beam and the high-power Nd:YAG beam
For operations that have to be performed un- are guided coaxially through the optics of the
der microscopic control, hand applicators of microscope, so that the focal plane coincides
various designs have been developed that permit with the focal plane of the microscope. The
free, three-dimensional working. Both gas- beam can be moved within the operating field
cooled and liquid-flushed systems are used. The precisely by the joystick. The sensitivity of the
small, 3 mm, diameter of these instruments, does joystick is adjustable to the size of the visual
field, determined by the magnification setting of
the microscope. It is limited exactly to the di-
ameter of the visual field, avoiding any acci-
dental pointing of the laser beam outside the op-
erative field 48 (Figure 3.3).

Conclusions
Apart from many and various Nd:Y AG laser
applications in medicine, approved and estab-
lished, there is a definite perspective of other
successful laser applications, especially in the
field of tumor surgery. The laser is a valuable
supplement to other auxiliary tools in modern
medicine. Consequently, its application is jus-
tified whenever the therapeutic outcome
achieved with this technology is superior to that
FIGURE 3.3. Examples of hand-held devices for non-
contact application of the Nd:YAG laser (MBB- obtained using other methods.
Medizintechnik GmbH) and an operating microscope The endoscopic applicability of the Nd:YAG
adapter for Nd:YAG laser (Manufactured by Carl laser warrants special mentioning, as it leads to
Zeiss, West Germany.) considerably less morbidity on the patient, as
3. Noncontact Nd:YAG Laser Treatment in Endoscopy and Surgery 17

well as reduction of prolonged hospitalization 11. Sander R, Posl H, Spuhler A, Frank F: Neodym-
and subsequent expenditures. YAG-Laser mit CO 2 -jet-stream Erfahrungsbe-
The applicability and the value of contact richt. F ortschr Gastroenterol Endosk Vol. II: 105-
Nd:YAG laser surgery is currently under in- 108, 1979.
vestigation. Experimental and clinical results 12. Sander P, Posl H, Spuhler A, Hitzler H: Der
Neodym-YAG Laser: Ein effektives Instrument
indicate that for special indications contact sur-
fiir die Stillung lebensbedrohlicher Gastrointe-
gery is feasible. Similar to the initial areas of stinalblutungen. Leber Magen Darm 11:31-36,
application in Nd:YAG laser surgery, an anal- 1981.
ysis and optimization for this new method will 13. Hochberger J, Ell Ch, Lux G: Protective tips for
be necessary before routine clinical practice. . endoscopes used in laser therapy. Endoscopy
18: 163, 1986.
14. Dumon J-F, Reboud E, Garbe L, et al: Treatment
References of tracheobronchial lesions by laser photoresec-
tion. Chest 81:278-284, 1982.
1. Hofstetter A, Frank F [unter Mitarbeit von Biilow 15. Dumon J-F, Shapshay S, Bourcereau J, et al:
H] Halldorsson Th, Keiditsch E: Der Neodym- Principles for safety in application of neodymium-
YAG-Laser in der Urologie. Editiones Roches, YAG laser bronchology. Chest 86: 163-168, 1984.
Basel, 1979. 16. Dierkesmann R, Huzly A: Technik der endo-
2. Beck OJ, Wilske J, Schonberger JL, Gorisch W: bronchialen Laser-Behandlung. Prax Klin Pneu-
Tissue changes following application of lasers to mol 6:211-256, 1983.
the rabbit brain. Results with CO 2 and Nd:YAG 17. Staehler G, Hofstetter AG, Schmiedt E, et al:
lasers. Neurosurg Rev 1:31-36, 1979. Zerstorung von Blasentumoren durch endosko-
3. Landthaler M, Brunner R, Haina D, et al: The pische Laser-Bestrahlung. Dtsch ArztebI75:681-
neodymium-YAG laser in dermatology. MMW 686, 1978.
126:1108-1112, 1984. 18. Hofstetter AG, Frank F: Ein neues Laser-En-
4. Keiditsch E, Maiwald H, Hofstetter AG, et al: doskop zur Bestrahlung von Blasentumoren.
Comparison of the effects of the neodymium-YAG Fortschr Med 97:232-234, 1979.
laser and electrocoagulation in experimental an- 19. Frank F, Hofstetter AG, Bowering R, Keiditsch
imal research. In Kaplan I (ed): Laser Surgery E: Endoscopic application of the Nd:YAG laser
III, Part II. Tel Aviv, 1979, pp 185-193. in urology. Biophysical fundamentals and instru-
5. Keiditsch E, Hofstetter AG, Rothenberger K, et mentation. SPIE Proc 211:36-40, 1979.
al: Comparative morphological investigations of 20. Rothenberger K, Pensel J, Hofstetter AG, et al:
the effects of the neodymium-YAG laser and Transurethral laser coagulation for treatment of
electro-coagulation in experimental animal re- urinary bladder tumors. Lasers Surg Med 2:255-
search. In Bellina JH (ed): Gynecological Laser 260, 1983.
Surgery. Plenum, New York and London, 1981, 21. Frank F, Bailer P, Beck OJ, et al: Instrumentation
pp 327-336. for the surgical application of the Nd:YAG laser.
6. Zimmermann I, Stern J, Frank F, et al: Intercep- SPIE Proc 405:105-109, 1983.
tion of lymphatic drair.lage by Nd:YAG laser ir- 22. Frank F, Bailer P, Beck OJ, et al: Instrumente
radiation in rat urinary bladder. Lasers Surg Med fiir die chirurgische Anwendung des Nd:YAG
4:167-172,1984. Lasers. In Waidelich W (ed): Optoelektronik in
7. Stokes LF, Auth DC, Tanaka D, et al: Biomedical der Medizin. Springer-Verlag, Berlin, 1984, pp.
utility of 1.34 fLm Nd:YAG laser radiation. IEEE 39-45.
Trans Biomed Eng BME-28:297-299, 1981. 23. Frank F: Multidisciplinary use of the Nd:YAG
8. Beck OJ, Frank F, Keiditsch E, Wondrazek F: laser. SPIE Proc 658: , 1986.
Klinische und experimentelle Untersuchungen zur 24. Hofstetter AG, Frank F, Keiditsch E: Laser
Erweiterung der Nd: YAG-Laseranwendung in der treatment of the bladder: Experimental and clin-
Neurochirurgie. Laser 1:13-18, 1985. ical results. In Smith JA (ed): Lasers in Urologic
9. Frank F, Beck OJ, Hessel S, Keiditsch E: Com- Surgery. Year Book, Chicago and London, 1985,
parative investigations of the effects of the pp 63-81.
Nd: YAG laser at 1.06 fLm and 1.32 fLm on tissue. 25. Frank F: Biophysical fundamentals, technical
Lasers Surg Med 6:546-551, 1986. prerequisites, and safety aspects for the appli-
10. Kiefhaber P, Nath G, Moritz K: Endoscopical cation of the neodymium-YAG laser in urology.
control of massive gastrointestinal hemorrhage by Eur Urol 12:3-11, 1986.
irradiation with a high-power neodymium-YAG 26. Frank F: Technical prerequisites and safety con-
laser. Prog Surg 15:140-155, 1977. siderations for the use of the Nd:YAG laser in
18 Frank Frank

gastroenterology. Endoscopy 18(Suppl 1):6-9, 38. Frank F, Halldorsson Th, Hofstetter AG, et al:
1986. Neue Instrumente und Sicherheitsuntersuchungen
27. Frank F: Biophysical aspects, instruments and zur Anwendung des Neodym-YAG-Lasers. Ver-
safety in the use of the Nd:YAG laser in pul- handlungsber Dtsch Ges Lasermed I: 165-176,
monology. Tumor Diagn Ther 7:5-9, 1986. 1982.
28. Malloy TR: Urologic neodymium:YAG laser sur- 39. Hofstetter AG, Staehler G, Keiditsch E, Frank
gery. Surg Clin North Am 64:905, 1981. F: Lokale Laser-Bestrahlung eines Peniskarzi-
29. Hofstetter AG, Bowering R, Keiditsch E, Frank noms. Fortschr Med 96:369-371, 1978.
F: Zerstorung von Uretertumoren mit dem Neo- 40. Frank F, Bailer P, Beck OJ, et al: Instrumentation
dym-YAG-Laser. Fortschr Med 101(14):619-664, and safety aspects for the surgical application of
1983. the Nd:YAG laser. In Joffe SN, Muckerheid M,
30. Hofstetter AG, Bowering R, Keiditsch E, Frank Goldman L (eds): Neodymium-YAG Laser in
F: ZerstOrung von Uretertumoren mit dem Neo- Medicine and Surgery. Elsevier, New York, 1983,
dym-YAG-Laser. Verhandlungsber Dtsch Ges 205-214.
Lasermed I: 136-138, 1982. 41. Beck OJ, Frank F: ND-YAG-Laser in der Neu-
31. Malloy TR, Schultz RE, Wein AJ, Carpiniello VL: rochirurgie. Munch Med Wochenschr (or) MMW
Renal preservation utilizing neodymium:YAG 126:109-113, 1984.
laser. Urology 27:99-103, 1986. 42. Oeckler RCT, Beck OJ, Frank F: Erfahrungen
32. Bailer P: Tubensterilisation durch Laser-Koagu- mit dem N d-Y AG-Laser in der chirurgischen Be-
lation. Fortschr Med 43:1977, 1983. hand lung intra- und supraselliirer Tumoren.
33. Lomano JM: Photocoagulation of early pelvic Fortschr Med 102:218-220, 1984.
endometriosis with the Nd: YAG laser through the 43. Frank F: Biophysical basis and technical requi-
laparoscope. Reprod Med 30:77-81, 1985. sites for the use of the N d-YAG laser in neuro-
34. Karduck A, Richter H-G: Lasermikrochirurgische surgery. Neurosurg Rev 7:145-150, 1984.
Behandlung gutartiger Stimmlippenveriinderungen 44. Beck OJ, Frank F: The use of the Nd-YAG laser
und ihre funktionellen Ergebnisse. Laryngol in neurosurgery. Lasers Surg Med 5:345-356,
Rhinol Otol 58:764-769, 1979. 1984.
35. Beck OJ, Gorisch W, Frank F: Endoskopische 45. Landthaler M, Brunner R, Haina D, et al: First
selektive Plexuskoagulation mittels Laser, ein experiences with the Nd:YAG laser in dermatol-
denkbarer Weg zur Behandlung des Hydroceph- ogy. In Joffe SN, Muckerheid M, Goldman L
alus? In Kaplan I (ed): Laser Surgery III, Part II. (eds): Neodymium-YAG Laser in Medicine and
Tel Aviv, 1979,75-78. Surgery. Elsevier, New York, 1983, pp 175-183.
36. Auer LM, Ascher, PW, Holzer P: Endoscopic 46. Ulrich F, Bock WJ, Schober R, Wechsler W: Re-
. evacuation of intracerebral haemorrhage. High- pair of the carotid artery of the rat with the
Tech Surgical Treatment-A New Approach to Nd:YAG laser. First Congress ofLANSI, Fuschl,
the Problem? 1st International Symposium on 26-30 September, 1984.
Lasers in Cardiovascular Diseases, BadenlVi- 47. Schober R, Ulrich F, Sander T, et al: Laser-in-
enna, 26-28 June, 1986. duced alteration of collagen substructure allows
37. Frank F, Hofstetter AG, Keiditsch E: Experi- microsurgical tissue welding. Science 232: 1421-
mental investigation and new instrumentation for 1422, 1986.
Nd: YAG laser treatment in urology. In Bellina 48. Ulrich F, Nicola N, Bock WJ, et al: A micro-
JH (ed): Gynecologic Laser Surgery. Plenum manipulator to aid microsurgical removal of in-
Press, New York and London, 1981, pp 345- tracranial tumours with the N d-YAG laser. Lasers
356. Med Sci 1: 131-133, 1986.
4
Contact Delivery Systems and Accessories
N orio Daikuzono

Contact Laser Probes offer a completely new density. Approximately 30 to 40% of the beam
method of delivering Nd:YAG energy to tissue, energy can be lost to backscatter, and a portion
and overcome many of the limitations encoun- of the rest is expended on nontargeted healthy
tered with the conventional noncontact medical tissue due to inaccurate focusing and beam
laser systems. Using less than 25 W of power, scattering. SLT Contact Laser Probes® create
Contact Laser Probes will cut, coagulate, va- a well-defined localized region of high-power
porize, or administer low levels of interstitial ir- density right at the tip of the probe, which is
radiation. They can be attached to a variety of placed precisely against the target tissue. The
handles for use in open surgical procedures, or problem of focusing is completely eliminated.
can be affixed to a standard optical fiber and Spot size and power density are under accurate
passed through any rigid or flexible endoscope and precise control. Energy loss to backscatter
for use in an ever-increasing range of endoscopic is cut to less than 5%, and the overall laser out-
applications. put power needed to achieve a given therapeutic
SLT Contact Laser Probes® 1 are made of a effect is 75 to 90% lower than would be needed
specially selected, physiologically neutral syn- in a noncontact procedure. Since less total ener-
thetic sapphire crystal with great mechanical gy is delivered to the site, damage to healthy neigh-
strength, low thermal conductivity, and a high boring tissue is greatly reduced (Figure 4.1).
melting temperature (2030 to 2050°C) (Table 4.1). The Nd:Y AG laser is ideally suited for use
They are used in direct contact with tissue, with SLT Contact Laser Probes®. The Y AG is
which allows precisely controlled manipulations not limited by its absorption spectrum to any
and restores the tactile feedback that was lost particular tissue type. It is the best available
in conventional laser techniques. Due to the op- thermal coagulator, has good penetration, and
tical properties and geometric design of each its drawbacks in the noncontact mode-poor
probe, SLT Contact Laser Probes® shape the cutting, excessive backscatter, inaccuracy, and
power density to deliver the optimal laser energy excessive tissue damage-are precisely elimi-
intensity and distribution for each type of pro- nated by SLT Contact Laser Probes®. Since 25
cedure. By selecting the appropriate probe and W is the maximum power used with SLT Con-
laser power, not only can the user determine tact Laser Probes® in any therapeutic situation,
the precise spot size and power density, but he a compact, low-cost Nd:Y AG laser unit will
can also control the shape and volume of thermal meet every procedural requirement. A single
effect. This is not possible with any noncontact portable laser system can be used in inpatient
laser or with other thermal techniques (Table or outpatient operating rooms, the endoscopy
4.2). A conventional, noncontact YAG laser de- suite, or the physician's office, providing an ex-
livery system emits a diverging beam of grad- tremely versatile and cost-effective addition to
ually increasing size and diminishing power any hospital or clinic (Table 4.3).
20 Norio Daikuzono

TABLE 4.1. Comparison of single crystal synthetic sapphire and quartz

crystal
Property Sapphire Quartz
Melting point 2030-2050°C 1600°C
Thermal conductivity
(g-ca!-<:m"'sec) at 40°C 0.0016-0.0034 9.0158-0.0299
Coefficient of thermal expansion
(10- 7 x cmJ°C) 50-67 80
Elastic coefficient
(10- 6 x kg/cm") 5.0 0.78
Specific gravity 4.0 2.2
Hardness (mho) 9 7
Compressive strength (kg/cm") 28,000 2000
Tensile strength 2000 900-1200
Refraction index 1.76 1.54
Absorption of water 0.00 0.00
Chemical characteristics Acid- and base-proof Acid- and base-proof
Appearance Clear Clear
Crystal form Hexagonal Hexagonal
Transmission of Nd: YAG laser >90% >90%

Clinical Evaluations tween cutting and coagulation. The noncontact

Nd: Y AG laser beam produced excessive smoke
Both experimental and clinical studies with SLT at high powers, requiring evacuation, whereas
Contact Laser Probes® have produced remark- smoke was not a problem at any of the powers
able results. 2 Resection of rat liver could be ac- needed in the contact situation. Most significant,
complished at 5 W with a Contact Laser Scalpel, however, is the difference in tissue necrosis be-
whereas noncontact Nd: YAG laser powers be- tween the two techniques. The noncontact re-
low 20 W invariably resulted in fatal bleeding section caused up to 3 mm of lateral necrosis
complications. The resection was performed depending upon the laser power. The contac~
much more quickly with the low-power contact procedure, on the other hand. did not cause liver
probe than was possible with a noncontact Y AG necrosis of more than 0.5 mm under any cir-
beam (Figure 4.2). cumstance. This was true both immediately
Blood loss was significantly less in the contact postoperatively and at 15 days after surgery,
surgery group because of the SLT. Laser Scal- implying more rapid healing following contact
pel's® unique ability to control the balance be- laser surgery (Figures 4.3 and 4.4).
In clinical applications SLT Contact Laser
Probes® demonstrate parallel advantages:
Contact procedures are better controlled and
TABLE 4.2. Comparison of power densities: less traumatic than conventional non contact
Contact vs noncontact Nd:YAG laser laser techniques. In endoscopic procedures in
Laser power (W) required to achieve particular, SLT Contact Laser Probes® have
given power density at the tissue proved to be dramatically effective, and so ver-
surface
satile that they lend themselves to treatments
Contact Noncontact Power density never possible with noncontact lasers or with
Nd:YAG Nd:YAG (W/cm")
any other techniques. Damage to adjacent
1 12 700 healthy tissue is reduced by up to 75%, and there
;; 62 3,500 is consequently much less sloughing of necrotic
10 124 7,000
15 185 10,500 tissue and less incidence of subsequent infec-
20 247 14,000 tion. The depth of the thermal effect is carefully
25 309 17,500 controlled, which lowers the risk of perforation
Assumes typical noncontact Nd:YAG laser spot size of
when working in hollow viscera, and reduces
1.5 mm and 0.4 mm diameter SLT Contact Laser Scalpel.® pain because the thermal effects do not penetrate
Power indicated is that detected after exiting fiberoptic. through to the serosal surface (Figure 4.5).
4. Contact Delivery Systems and Accessories 21

FIGURE 4.1. Nd: YAG laser energy

distribution in tissue and loss
through backscatter.

: . : . .:''',, ,.>:
, ~ . '. ... .

Non-Contact Contact

Contact Probes homogeneously distributed laterally as well as

along the vertical axis.
SL T (Surgical Laser Technologies) Contact
Laser Probes® are designed to serve four gen-
eral medical functions: cutting, vaporization, SLT Contact Delivery Systems@
coagulation, and delivery of interstitial irradia-
tion (Figure 4.6). Each of these functions results SL T Contact Laser Probes® can be used not
from the induction of a thermal effect of given only with gas delivery but also with water, which
intensity in a certain tissue volume. Cutting re- can bring several advantages to clinical appli-
quires intense, highly localized heat to vaporize cation, for example, cooling adjacent normal
small tissue volumes rapidly, creating a con- tissue, reducing fumes, and eliminating gaseous
trolled incision with little damage to adjacent distension of the stomach. The SLT Contact
areas. For vaporization of fairly large tissue Laser® can deliver water by the simple control
volumes, an intense but broader thermal effect of a foot switch. SLT Contact Laser Probes®
is needed. Coagulation requires milder temper- are designed in a variety of configurations that
atures in yet larger volumes. For interstitial ir- produce power density distributions well suited
radiation, where a probe is inserted into the tis- to these specific therapeutic tasks. The synthetic
sue, one needs a fairly mild effect that is sapphire probes are available in two formats:

TABLE 4.3. Comparison of surgical laser system features

Nd:YAG
Feature CO, Argon Noncontact Contact
Beam easily deliverable to any part of the body No Yes Yes Yes
Beam transmissible through t1uids No Yes Yes Yes
Convenience in providing any required power density Moderate Low Moderate High
Precisely controllable focal point No No No Yes
Degree of damage to healthy tissue Low Moderate High Low
Smoke generation High Moderate High Low
Tactile feedback No No No Yes
Laser power requirements High High High Low
Laser maintenance requirments Moderate High Low Low
Delivery system maintenance requirements Moderate High High Low
22 Norio Daikuzono

200

1\
~

ISO
/
V \
time
"- V Con act

" '"
N O ll

/
" "
(seconds) 100
~
Con act
50

o
10 IS 20 25 30 40 SO 60 70 80 90 100

power (watts)

FIGUR E 4.2. Time required for ra t liver resec tion as a funct ion of laser powe r

d eath

severe 1\
1\
Non - _onra t

moderate

mild 1\ 1\
1\ 1\
,--ont ct

nil ~ ~

10 IS 20 25 30 40 50 60 70 80 90 100

power (watts)

F IG RE 4.3 . Blood loss as a function of laser powe r.

se vere
.....-
V
Non- _o nta

/
/~
moderate ./
/'f'

r--- L.--
ro ltact

nil
10 IS 20 30 40 50 60 70 80 90 100

power {wmts}

FIGURE 4.4. Amount of s moke as a function of lase r power.

4. Contact Delivery Systems and Accessories 23

DayO

-
3.0 /

r--V ........... /
depth of 2.0
....../
...-- / Non- ~uma (

net rosis
(mOl)

1.0
( umac[
~ ........

10 20 30 10 50 60 70 80 90 100

power (wa((s)

D~y 15
.L ~

"
3.0
I-- / '
r-........ ,/'
I l\.'V/ Non-( :ontat

.J
depth of 2.0
necrosis
(mm)

1.0

::oma(
-
10 20 30 10 50 60 70 80 90 100
power (w:l((s)

FIGURE 4.5. Depth of tissue necrosis as a function of laser power.

o o o o

Lase r Co nical Chi el R ounded Flat Frosted

Sca lpel Probe Probe Probe Probe Pro be
fo r open for f ine fo r incisi on , fo r fo r for coagulation
surgery incision excisio n a nd va porization coa gulat ion and intersti tial
va poriza t ion irradia tion

FIGURE 4.6. Contact Laser Probes and their energy distribution patterns.
24 Norio Daikuzono

(1) incising probes, called SLT Laser Scalpels®, below 25 W, and in some applications at power
used exclusively as hand-held instruments in as low as 2-3 W. It transforms the Nd:YAG into
open surgery for many specialties; and (2) var- a multidisciplinary, multipurpose surgical laser
ious small SLT Contact Laser Probes ® used that cuts as cleanly and precisely as the CO 2 la-
predominantly in endoscopic applications, but ser, yet retains the coagulative properties of the
which can also be used in open procedures con- noncontact Nd:YAG.
nected with hand-held instruments (Figure 4.7). SL T Contact Laser Probes ® are designed
All SLT Contact Laser Probes®, handpieces, primarily for use in endoscopic procedures.
and optical fiber for endoscopy can be used with They screw onto a metal Universal Connector
stable Nd:YAG lasers at low output powers, that fastens to 1.8 or 2.2 mm OD optical quartz
such as the SLT Contact Laser® (Figure 4.8). fiber (Figure 4.10), and will pass through rigid
The selection of interchangeable SL T Laser endoscopes or the biopsy channel of any stan-
Scalpels® have distal tip diameters ranging from dard flexible fiberoptic endoscope. Different
0.2 to 1.2 mm, and screw into a variety of han- probe geometries shape the laser energy distri-
dles that fit directly on the end of standard op- bution into appropriate configurations for va-
tical quartz fibers (Figure 4.9). SLT Laser Scal- porization, coagulation, cutting, or interstitial
pels® are used with the Nd: YAG laser at powers irradiation. The user can, if desired, change

Oral
'1
2. 2mm dlamete(

Laparoscopy

Conization

Nasal

Neurosurger y

General surgery

FIGURE 4.7. Optical fibers with

Laryngology handle.
4. Contact Delivery Systems and Accessories 25

cooled, and in most applications coaxial water

cooling can be used, eliminating the discomfort
and dangers of gaseous distension of the patient.
Due to the physical characteristics of the syn-
thetic sapphire crystal, SLT Contact Laser
Probes® can be used in direct contact with tis-
sue or blood without danger of melting. Once
the Universal Connector® has been affixed to
the fiber, there is no need for subsequent re-
cleaving or polishing. The direct contact tech-
nique makes possible more accurate targeting
of the laser effect, even on moving tissues, and
permits coaptation of bleeding vessels for sim-
pler and more rapid hemostasis.

General Medical Functions

Cutting with the SLT Laser Scalpel®
and the Conical® and Chisel Probes®
SLT incision probes provide simultaneous cut-
ting and coagulation, while causing minimal
damage to adjacent healthy tissue. Cutting can
be accomplished with any of the SL T Laser
Scalpels® in open surgery or with the SLT
Chisel ® and SLT Conical Probes® in endo-
scopic procedures. The geometric and optical
FIGURE 4.8. SLT Contact properties of the synthetic sapphire probes are
Laser. such that the Y AG beam is brought to a tight
focus and very high-power density exactly at the
probes during a procedure simply by withdraw- tip of the probe. Power density then drops off
ing the fiber from the endoscope, unscrewing rapidly at short distances from the tip, giving an
one probe, and screwing on another (Figure extremely localized and accurately controlled
4.10. thermal effect (Figure 4.12). In other words,
SLT Contact Laser Probes® are used with " what you see is what you get." Cutting takes
the Nd:YAG laser at powers under 25 W. The place at the tip, not in adjacent tissue. When the
Y AG beam is effective in water or at sites of probe is removed from the tissue, cutting ceases.
active bleeding, and provides exceptional co- This is not the case with the noncontact Y AG
agulative abilities. SLT Contact Laser Probes® beam. Moreover, since the thermal effects in
give complete control of energy penetration and contact cutting are so carefully circumscribed,
dispersion, minimizing unwanted damage to the invisible subsurface tissue damage that can
healthy tissue. Since very low laser powers are occur in noncontact Y AG procedures is reduced
used, there is minimal backscatter and virtually by over 80%.
no smoke. Significantly less heat is generated The diameter of the distal tip of the SLT Laser
around the target tissue. SLT Contact Laser Scalpel ® defines the spot size of the laser beam
Probes® are designed to be either gas- or water- when the Scalpel is in contact with tissue. Dif-

FIGURE 4.9. Contact Laser

Scalpel. Opt ical Fiber Laser Sca lpel Hand le Laser Scalpel
26 Norio Daikuzono

FIGURE 4.10. Optical fiber for

2.2 or 1. 8 mm diameter endoscopy.

ferent Laser Scalpel tip diameters give the sur- SLT Laser Scalpel crystal® channels beam en-
geon the ability to select either greater cutting ergy directly along its longitudinal axis, with
or greater coagulation. The choice of scalpels virtually no lateral irradiation, the cutting effect
depends upon the tissue texture and vascularity. is somewhat greater as the orientation ap-
Smaller tip diameters, for example, can be used proaches perpendicular. At the initial incision,
for an initial clean incision, whereas when the Laser Scalpel® may appear to cut more
working with soft, highly vascular tissue such slowly than a steel scalpel or the CO 2 beam.
as the liver or spleen, larger tip diameters pro- Over the course of an entire procedure, how-
vide better hemostasis. The maximum power ever, the Laser Scalpel is considerably quicker,
required is 25 W, though precise cutting can be since it efficiently cauterizes as it cuts. When
achieved at substantially lower power levels. In working with highly vascular tissue, there is no
general, the smaller the tip diameter, the lower need to stop to ligate or clip most bleeding ves-
the power level needed to produce a given tissue sels . Vessels with the almost same diameter as
effect. The SLT Laser Scalpels® screw easily the tip of the scalpel can be cut and sealed simply
onto the various handles, and the surgeon can by moving the Laser Scalpel® slowly across
quickly change tips as circumstances require. them. If necessary, one can go back and co-
While holding the tissue under tension, the SLT agulate bleeding spots, without changing instru-
Laser Scalpel® should be drawn lightly across ments, by dabbing lightly at the area with the
the surface of tissue, not used mechanically to scalpel. For larger vessels, light dabbing or
separate or tear. It is the laser energy rather than stroking with the Laser Scalpel® along each side
physical pressure of the probe that is creating of the vessel will create edema, after which the
the incision. Incision depth is determined by a vessel can be cut. The Laser Scalpel uses power
combination of tip diameter, laser power, and levels 75-90% lower than those needed by non-
the speed of movement across the tissue. contact lasers to accomplish a given surgical ef-
The SLT Laser Scalpel® should be held in a fect. There is minimal backscatter, a constant
comfortable and natural position, much as one and well-defined spot size, and less energy is
would hold a pencil, although at a slightly put into the tissue. The result is far less damage
steeper angle to the tissue surface. Since the to adjacent healthy tissue, as seen from histo-
logic studies of incision sites. Operating time and
blood loss are greatly reduced, resulting in an
~_ ___~~ijL=-________ overall decrease in postoperative complications.
Two different SLT Contact Laser Probes®
offer a choice of endoscopic cutting styles.
Contact Universal Powers below 15 Ware sufficient for most ther-
Laser probe connector apeutic situations, and some operations can be
performed at much lower powers. Users should
FIGURE 4.11. Contact Laser Probe. realize, however, that recommended power set-
4. Contact Delivery Systems and Accessories 27

FIGURE 4.12. Power

density vs distance
from tissue.

,
~ med ica lly
effective
,~ power levels

...........
Non-( o ntac

"
distance (ro m tissue
......... Can act

----------------------~.

tings are of less importance than the actual ob- Probe®, and is effective for quick preliminary
served tissue effects, and changes in the tissue work when there is no danger of perforation. To
texture and color are the only reliable indications achieve optimal cutting and greatest depth con-
of the laser effect. The SLT Conical Probe® trol, the SLT Chisel Probe® should be held with
provides a power density distribution pattern one of the flat faces nearly parallel to the tissue.
very similar to that of the SLT Laser Scalpel®
and is used in much the same way to create fine Coagulation with SLT Flat®,
incisions. Since the tip of the SL T Conical
Probe® should ideally be moved laterally across
Frosted®, and Hollow Probes®
the tissue surface, rather than pressed against Hemostasis is accomplished by heating tissue
it, the use of a rigid endoscope offers certain sufficiently to produce edema and protein co-
advantages, since once the probe has been ori- agulation. For this purpose one needs a power
ented against the tissue, the entire delivery sys- density distribution that creates a milder,
tem can be gently shifted to guide the incision. broader, and deeper thermal effect than is re-
The SLT Chisel Probe® will cut directly through quired for cutting or vaporization. The Nd: Y AG
tissue, although its primary use, as its shape and laser is generally the instrument of choice for
name suggest, is to shave off thin layers of tis- coagulation because its beam penetrates fluid
sue. The SLT Chisel Probe® vaporizes and co- and tissue to a depth sufficient to seal, rather
agulates as it cuts, providing a clean and blood- than merely cap, bleeding vessels . The noncon-
less site. Used with a rigid or flexible fiberoptic tact Y AG requires 60--100 W of power for co-
endoscope , this probe can be pressed to the tis- agulation, however, which causes a certain
sue surface and pushed lightly across it. It is degree of uncontrolled tissue damage and oc-
ideal for recanalization of a totally or partially casionally precipitates severe bleeding as a re-
obstructing carcinoma of the esophagus, bron- sult. SLT Contact Laser Probes®, on the other
chus, or colon. It removes tissue more rapidly hand, safely and effectively seal vessels up to 3
than vaporization with the SL T Rounded mm in diameter using powers below lOW.
28 N orio Daikuzono

All SLT Contact Laser Probes® provide a cer- tages to the true vaporization delivered by the
tain measure of coagulative ability, but the SLT Rounded Probe®. For endoscopic esoph-
physical shape and power density distributions ageal cancer removal, for example, the conven-
of the SLT Flat® and Frosted Probes® are best tional noncontact technique involves coagulating
suited to this purpose. The Flat Probe is the in- to some depth below the surface, causing ne-
strument most often used for general coagula- crosis, waiting 48-72 hours for the blanched
tion. At power settings between 8 and lOW it layer to slough off, and then repeating the pro-
provides much more rapid hemostasis than other cess as necessary until the tumor has been re-
laser or thermal methods, with minimal necrosis moved. Until sloughing has taken place, it is not
in adjacent tissue. The Frosted Probe, which clear how deep tissue damage extends, and one
was designed primarily for use in interstitial ir- must therefore proceed cautiously, layer by
radiation, can also be used for deep coagulation. layer, over the course of three to eight treatment
By pressing this probe into mucosal tissue up sessions. The results still may not be altogether
to its flange, and using very low power and satisfactory, since the procedure is limited by
longer durations, less than 7 Wand 9 seconds, the danger of thermal or necrotic perforation.
it provides effective coagulation of vessels sev- The SLT Rounded Probe®, on the other hand,
eral millimeters below the tissue surface. Be- actually removes layers of cells, and can va-
cause the power is low and the probe is embed- porize tissue to an arbitrary depth in the course
ded in the tissue, neither air nor water cooling of one or two sessions. The probe is simply
is needed with this technique. dabbed, stroked or painted across the target site,
and vaporization is indicated by a slight dark-
ening of the tissue. Because the power density
Vaporization with the SL T Rounded is localized at the rounded surface of the probe,
Probe® there is less danger of immediate thermal per-
Vaporization requires higher power density and foration or of later complications due to necrosis
temperature than coagulation, and a broader of underlying tissue, and one can confidently
energy delivery than is needed for cutting. The work closer to the mucosal wall. Water delivery
SLT Rounded Probe® allows rapid removal of is sufficient to cool the probe during endoscopic
thin layers of tissue for controlled debulking of vaporization, which eliminates the discomfort
large tissue volumes. The SLT Chisel Probe®, and danges of patient distension, and further re-
as described in the previous section on "cut- duces the small quantities of smoke generated
ting," can also be used for a cruder and quicker by debulking procedures. Since there is less un-
combination of shaving and vaporization in areas controlled heating of deep tissue layers, contact
where there is little risk of perforation. When vaporization is also less painful to the patient.
the Nd:YAG laser is used in the noncontact
mode, vaporization is generally performed at 70-
100 Wand produces a mixed effect of coagu-
Interstitial Irradiation
lation and vaporization with significant bleeding The primary present function of the SLT Frosted
and subsurface tissue damage. In endoscopic Probe® is to provide deep coagulation, but its
application, where the precise distance of the chief future application will be in the adminis-
fiber from the target tissue and the angle of beam tration of local hyperthermia and photodynamic
incidence are difficult to control, the power therapy. The SLT Frosted Probe® is pushed
density and thermal effect at and below the tis- into the tissue up to its flange and delivers Y AG
sue surface vary greatly and unpredictably. The power density and thermal energy in a hemi-
SLT Rounded Probe®, on the other hand, de- spherical volume of2 to 3 cm radius. With pow-
livers approximately the same power density as ers of 5-7 W the SLT Frosted Probe® coagu-
an 80-W non contact Y AG beam using only 15 lates, but at powers in the 1- to 3-W range it
W of power, and produces true vaporization provides local hyperthermia. For the treatment
with minimal subsurface effects yet with suffi- of areas more than 2 to 3 cm in size, multiple
cient coagulation to limit bleeding. Vaporization probes can be implanted. A feedback system for
takes place only when the probe is in direct temperature, using a computer, probes con-
contact with the tissue. There are many advan- nected with multiple distribution delivery sys-
4. Contact Delivery Systems and Accessories 29

terns, and thermocouples, allows far more ac- performing endoscopic procedures. The patient
curate control of treatment sites than current should be given complete protection. Care
methods. should be taken to avoid the use of combustible
gases or inflammable materials in the vicinity of
the laser. Use nonreflective instruments and
Safety Precautions equipment to avoid specular reflection of the
When employing SLT Laser Scalpels® and laser beam. Above all, even with SLT Contact
Contact Laser Probes®, observe all regulations Laser Probes® the power density of the beam
and safety guidelines governing the Nd:Y AG drops off very quickly at short distances from
laser. Though the use of lower power levels and the probe, the laser should be activated only
the reduction in backscattered energy make the when the probe is directed at the surgical site.
contact method safer than conventional non- These recommendations are not to be taken as
contact techniques, any medical laser can cause a definitive list of safety precautions. Refer to
harm if improperly handled. Warning notices the manual of the particular laser being em-
must be posted at all entrances to any room ployed.
where the laser will be used, and precautions
should be taken to avoid accidental entry while
the laser is in operation. Access should be re- References
stricted to personnel who have been suitably in-
1. Daikuzono N, Joffe SN: Artificial sapphire probe
formed about the relevant safety measures. for contact photocoagulation and tissue vapori-
Protective eyewear, equipped with sideguards zation with the Nd:YAG laser. Med Instrum
and rated as suitable for use with the Nd:YAG 19(4):Jul-Aug, 1985.
laser, must be worn by all personnel present in 2. Joffe SN, et al: Liver resection with the Neodym-
the room during a laser operation, and appro- ium:YAG laser. Surg Gynecol Obstet 163:437-442,
priate protective eyepieces must be used when 1986.
5
Clinical Applications in
Gastrointestinal Bleeding
Stephen N. Joffe and Richard M. Dwyer

As recently as 1981, fewer than 12 medical cen- acute and chronic studies of photocoagulation,
ters in the United States were using lasers in the penetration, and perforation of the Nd:YAG
treatment of gastrointestinal (GI) disease. By laser in the treatment of experimental canine
1984, 200 hospitals were using lasers for this gastric bleeding. According to their study,
purpose/ and by the end of 1986/ there were Nd:YAG laser photocoagulation was an effec-
approximately 1,000. The reasons for such pro- tive method of controlling experimental bleed-
liferation include increased applications of the ing. Energy densities (W/cm2) three times that
use of lasers in GI problems, the relative ease required to achieve control of bleeding were
with which they can be used, and the recent rul- necessary to cause the serious complication of
ing by the Food and Drug Administration that perforation. Johnston et al. \0 compared efficacy
the Nd:YAG laser is safe and effective and is and histologic damage caused by monopolar and
therefore no longer considered to be an inves- bipolar electrocoagulation to that of argon and
tigational device. Furthermore, lasers provide a Nd: YAG laser photocoagulation when applied
multidisciplinary and multispecialty modality as endoscopically to control bleeding from standard
well as therapeutic options where such choices canine gastric ulcers. They indicated that more
did not exist or were limited previously. 3 More energy and greater power was required with
importantly, they have been found to be safe, each method to treat bleeding ulcers efficiently
efficient, and cost-effective in most cases. through endoscopy than at laparotomy. They
concluded that each method was 93% effective
in stopping the bleeding, but the lasers were
Experimental Studies easier to use. Furthermore, the argon laser and
bipolar electrocoagulation caused less tissue in-
In 1979 Goodale et al. 4 first reported control of jury.
bleeding from gastric erosions using a CO 2 laser Laser-related tissue injury was generally pre-
with a rigid gastroscope. In 1973 Nath et al. 5 dictable and correlated with total energy ad-
described the transmission of a laser beam ministered and gastric distension. A quantifiable
through a fiberoptic flexible gastroscope, and in arterial bleeding gastric ulcer was produced in
1975 Dwyer6 reported laser-induced hemostasis dogs by McLeod et aI., 11 by suturing the splenic
in an animal model. In 1979 Silverstein et al. 7 artery to the base of the ulcer. The main artery
and Waitman et al. 8 compared the effects of the blood flow rate varied from 50 to 120 mllmin.
argon laser to the Nd:YAG laser in the treatment The Nd:YAG laser, via the flexible endoscope,
of experimentally induced bleeding in canine successfully arrested bleeding in all dogs. It was
gastric ulcers. Each came to the conclusion that noted that coaxial CO 2 allowed adequate visu-
both types of lasers were effective in achieving alization of the spurting blood vessel and that
hemostasis, and, since argon produced less tis- the helium-neon laser provided a satisfactory
sue damage, it was considered safer. In the same aiming beam.
year Dixon et al. 9 published their results of the The histologic changes following Nd:YAG
5. Clinical Applications in Gastrointestinal Bleeding 31

laser photocoagulation of canine gastric mucosa mortality rate of 10%. Widespread availability
were studied by Kelly et al., 12 who concluded of flexible fiberoptic endoscopy in the early
that exposure of the dog stomach to Nd:YAG 1970s provided adequate visualization of the
laser produced tissue changes varying from mild bleeding site, and the door was opened for the
mucosal edema to cell vaporization. Thermal possibility of endoscopically controlling such a
contraction was the primary hemostatic mech- situation. In an effort to achieve this goal, many
anism, with thrombosis occurring only as a sec- techniques were tried, including electrocoagu-
ondary effect. lation, injection of vasoactive substances and
The effect on gastric acid secretion following sclerosant solutions, tissue adhesives, heater
intragastric Nd:YAG laser application to the probes, and thrombotic sprays (Table 5.1). With
lesser curve and the pyloric mucosa of the technical advances represented by coupling las-
stomachs of rats has been studied. This tech- ers to flexible fiberoptic endoscopes, the next
nique of intragastric vagolysis produced a sta- priority was the development of a technique for
tistical reduction in acid secretion maintained safe photocoagulation of the large variety and
over several weeks.13 number of bleeding lesions found in the gas-
trointestinal tract. Of all the endoscopic mo-
dalities for treating UGI bleeding, the greatest
Endoscopic Applications of amount of information is available about lasers.
Lasers Tens of thousands of patients have now been
treated. With the exception of injection sclero-
Upper gastrointestinal (UGI) hemorrhage ac- therapy, the Nd:YAG laser is the only device
counts for approximately 200,000 admissions to used to treat both variceal and nonvariceal le-
acute-care hospitals annually, making it a major sions. 14
health issue. Fiberoptic endoscopes can help to The clinical applications of lasers for GI
determine the precise cause of the bleeding in bleeding are shown in Table 5.2 and refer pri-
more than 90% of cases. Duodenal ulcers (24%), marily to use of the continuous wave Nd: YAG
gastric erosions (23%), and esophageal varices laser with a fiberoptic delivery system.
(10%) account for the bleeding in the vast ma-
jority of cases.
Therapeutic endoscopy, using the laser, re-
quires a change in approach to GI bleeding. To TABLE 5.1. Endoscopic methods of treating GI
become a therapeutic laser endoscopist requires bleeding
changing from a simple diagnostic procedure Injection therapy
into a new therapeutic arena under emergen- Variceal scierosants
cy and often adverse circumstances. By using Ethanol
Topical therapy
the laser, the amount of blood transfused and
Tissue adhesives
the overall morbidity and mortality of GI bleed- Clotting factors
ing can be decreased. It is important to have Collagen
a well-trained team to achieve the goals of ear- Ferromagnetic tamponade
ly endoscopic diagnosis and laser therapy, es- Mechanical therapy
Sutures
pecially in the management of critically ill pa-
Balloons
tients. Hemociips
The application oflasers to the problem of GI Thermal therapy
bleeding was first conceived by the University Electrocoagulation
of Washington group, Silverstein and Rubin, Monpolar
Electrohydrothermal
Kiefhaber of the University of Munich, Dwyer Bipolar (multipolar)
and the Los Angeles group, and the Joffe group Heater probe
at the University of Glasgow. Therapeutic en- Laser
doscopy developed because of a lack of any Argon
consistently effective alternate method between Nd:YAG
Noncontact (air fiber)
the extreme of ice water lavage through a na- Contact (sapphire)
sogastric tube and laparotomy with an overall
32 Stephen N. Joffe and Richard M. Dwyer

TABLE5.2. GI endoscopic applications of the cise, tips burn out if they touch blood or tissue,
Nd:YAG laser and fibers break and are expensive. If the quartz
Coagulation tip touches tissue or blood, it absorbs heat and
Acute hemorrhage melts. Then the delivery system must be re-
Active bleeding moved, the polyethylene catheter and Teflon
Recent bleeding (e.g., visible vessel, fresh blood clot)
Stigmata of recent hemorrhage (SRH)
cover cut back, the quartz fiber cleaved and
Potential bleeding polished, and a new metal tip inserted. This can
Angiodysplasia take 10 to 30 minutes and may have to be re-
Varices peated during a procedure. Contact endoscopic
Hemorrhoids surgery with endoprobes made of synthetic sap-
Vaporization
Neoplastic disease
phires allow direct surgery with greater precision
Palliation and safety. 15
Curative
Ancillary (e.g., placement of esophageal prosthesis)
Benign stricture or web
Biliary disease
A Laser Endoscopy Suite
Strictures
Fracturing gallstones The small examining room that is usually avail-
Cutting able for diagnostic endoscopy purposes may be
Tumor excision (polyps) inadequate. The room should be sufficiently
Sphincteroplasty large to house a procedure table, a cart with
Stricture·
Cyst drainage
materials for resuscitation, cardiac monitoring
devices, and suction.
The laser equipment requires proper electric
supply sources with special wiring, running-
water facilities for cooling the high-powered
Laser Fiberoptic Delivery lasers, and space for the stretcher. The room
Systems preferably should not have multiple entry doors,
and a warning light with laser signs should be
Present fiber delivery systems are composed of installed outside. Patients being considered for
fibers with a quartz core surrounded by a sili- laser photocoagulation invariably have consid-
cone rubber cladding and a Teflon cover. The erable blood loss and may be actively bleeding.
quartz core, cladding, and Teflon cover are en- These patients are at risk of aspiration and may
closed within a polyethylene catheter. The require longer periods of endoscopy. Protective
catheter provides protection for the fiber, per- glass filters can be fixed to the viewing end of
mitting gas or water to flow between the fiber the flexible endoscope to prevent eye damage
and catheter to cool and clean the fiber tip and when the laser is activated. Videoendoscopy
the treatment site. Fibers can range from 50 to now allows a totally closed system for laser util-
1000 fLm in diameter; the production size is 400 ization, and, with the fiber placed into the en-
to 600 fLm. The divergence angle of the laser doscope, no eye protection is required.
beam at the tip of the catheter is typically be- In patients with UGI bleeding, gastric lavage
tween 8° and 12°. with saline or water is initially carried out with
Fibers are flexible and can be used in con- a larger bore tube until the effluent is clear. Al-
junction with endoscopes or attached to micro- ternatively, if not contraindicated, vasopressin
scopes. Flexible fibers are easily inserted into is given intravenously; this assists in causing
commercial endoscopes. The endoscope man- gastric emptying and may diminish the bleeding,
ufacturers such as Olympus, Fujinon, Pentax, which aids proper visualization of the bleeding
and ACMI provide endoscopes with biopsy sites during endoscopy. A forward- or end-
channels that accept the fiber without modifi- viewing endoscope with two- or single-channel
cations being required. endoscopes can be used. With the latter, it is
Current delivery systems have major limita- preferable to use a separate polyethylene tube
tions: they cannot be sterilized adequately, of adequate size with distal side holes attached
noncontact surgery is often difficult and impre- to the endoscope for proper evacuation of coax-
5. Clinical Applications in Gastrointestinal Bleeding 33

ial gas and smoke known as "laser plume," reduced from 58% with gastric resection to 23%
which is produced during noncontact laser sur- using the laser, and from 15% for vagotomy to
gery. Coaxial water with the contact endoprobes 0% using the laser. 18 Reasons for failure include
avoid this problem and prevent gaseous abdom- coagulopathies, especially those associated with
inal distension. Endoscopy is peIformed using platelet abnormalities and technical difficulties,
a local anesthetic and an adequate amount of which included a bleeding site inaccessible to
intravenous Demerol and diazepam. General the laser beam.
anesthesia is administered only when patients Many centers in the United States and Europe
are uncooperative and when proper airway con- are now using the Nd: YAG laser for the treat-
trol is required. ment of GI bleeding. Results are variable, de-
The power and duration, as well as the coaxial pending on multiple factors, not least of which
gas or water flow, are adjusted on the laser ma- is the training and learning experience of the
chine, and the laser fiber is inserted through the users of these endoscopic methods and their
biopsy channel of the endoscope. If the laser ability to undertake emergency endoscopy ef-
fiber is kept 0.5 to 1.5 cm away from the mucosa, ficiently, safely, and with accuracy in deter-
it is known as noncontact or air-fiber photo- mining the bleeding lesion before the laser is
coagulation. Touching tissue or blood with the even used. Use of the argon laser has virtually
bare quartz fiber when the laser is activated been discontinued for treatment of GI bleeding,
causes' damage to the tip of the fiber, which will as it appears adequate only in stopping super-
subsequently melt. In the same way, the fiber ficiallesions such as erosions.I9-21
tip should be kept well outside the distal end of
the endoscope; otherwise it will damage the en-
doscope when the laser is activated. There are Controlled Studies
several methods of treating the bleeding lesion, The efficacy and safety of laser therapy for GI
including peripherally, circumferentially, or Z- hemorrhage have been evaluated in controlled
pattern photocoagulation. trials 22- 30 and reviews published. 31 Although sci-
entific evaluation of any new modality requires
a randomized and controlled study to resolve
Clinical Results in Upper GI uncertainty, variations in design, size of study
populations, and interpretations of data may
Hemorrhage Treated with prevent a definitive answer. Studies need to be
Noncontact (Air-Fiber) Nd: YAG precisely assessed with regard to which bleeding
Laser Technique patients were studied. To date, nine studies have
been performed using the Nd:YAG laser with
Uncontrolled Studies the noncontact technique, of which eight relate
to non variceal bleeding. 22-29
In 1973 in Munich, Nath and Kiefhaber 5 first The following sections summarize details of
described the passage of Nd:YAG laser radiation these controlled randomized clinical trials per-
down an endoscopic waveguide. Two years lat- formed to evaluate safety and effectiveness of
er, the first patients with gastrointestinal bleed- the Nd:YAG laser in the treatment ofUGI hem-
ing were treated by this group with the Nd:YAG orrhage. In each of these studies, patients pre-
laser, and, by 1979, Kietbaber l6 reported treating senting with acute UGI bleeding were allocated
459 patients with 94% permanent hemostasis. to either a control or a laser-treatment group.
Subsequently, the number of un selected patients
treated by Kiefhaber l7 . 18 increased to 852.
London Study
Bleeding was treated successfully in 92% of the
1092 acute bleeding episodes. In bleeding In the London multicenter Nd:YAG study25.32
esophageal varices, the mortality was reduced recently completed, 527 consecutive patients
from 70% to 36% by using sclerotherapy follow- were admitted with UGI hemorrhage. At emer-
ing laser photocoagulation. Comparing the re- gency endoscopy, the 260 patients with peptic
sults of laser treatment versus surgery, the mor- ulcer and the 138 cases of stigmata of recent
tality rate from bleeding acute ulcers was hemorrhage (SRH) were included in the trial as
34 Stephen N. Joffe and Richard M. Dwyer

TABLE 5.3. London study of Nd:YAG laser in upper duction in bleeding and in the requirement for
GI bleeding emergency surgery. No perforations were re-
Treatment ported, and the mortality rate following surgery
group Total Rebleed Surgery Died was a high, but commonly reported, 25% in the
Laser 70 7 7 1 non-laser-treated patients (Table 5.5).
Contol 68 27 24 8
p < 0.001 p < 0.005 p < 0.05 Belgium Study
In the Belgium study /2 388 consecutive cases
being accessible to laser therapy. Of this group, with bleeding peptic ulcers were admitted. Of
26 patients had inaccessible lesions for laser these, 152 patients were included in the trial (129
treatment and 97 had no SRH. The laser-treated ulcers). Patients were divided into two bleeding
patients had a significant reduction in rebleeding groups: patients who had active arterial bleeding
(p < 0.001), requirement for emergency surgery and patients who had active, but nonpulsatile,
(p < 0.05), and mortality (p < 0.05). Notably, bleeding at the time of endoscopy. The results
only 10% of the laser-treated patients required in the ulcer group combine recurrent and con-
emergency surgery, compared to 35% in the tinued bleeding as rebleeding (Table 5.6).
control group, of whom 33% died postopera- The rebleeding rate in Group 2 was signifi-
tively (Table 5.3). cantly reduced (p < 0.005) in the laser-treated
Stratification of the different endoscopic ap- group. This trial had a major disadvantage, in
pearances of the bleeding lesions showed the that the ethical committee refused to allow ran-
importance of treating visible vessels with the domization of the highest-risk patients with
laser (p < 0.01) (Table 5.4). spurting vessels to a control group.
In the first group, although the initial hemo-
Glasgow Study stasis achieved with the Nd:YAG laser was 87%,
there were episodes of rebleeding, thereby low-
The criteria for entry into the Glasgow single-
ering the figures of permanent hemostasis to
blind controlled study26 were a major UGI bleed
45%. In the second group, the initial hemostasis
(at least 3 pints of blood, hemoglobin < 10 g/dl,
was achieved in 100% and an incidence of 5%
shock or postural hypotension), and at the time
rebleeding was noted.
of emergency endoscopy a lesion had to be vis-
ualized. From a consecutive pool of 698 patients
Other Studies
admitted with acute non variceal UGI hemor-
rhage, 184 patients were found to have gastric In four additional studies23.24.27.28 it was con-
or duodenal ulceration as a cause for the bleed- cluded that the laser-treated group did no better
ing; 16 patients were found to have a visible than the control groups with regard to continued
vessel, either bleeding or not bleeding, and were bleeding, need for surgery, or mortality. In the
subsequently randomized to active laser treat- study of Rohde et al. 27 only active bleeders were
ment or to act as a control. Only those patients included, and the authors did not believe laser
who would have been considered for emergency therapy was of value. In two other studies 23 .24
surgery were included. the features of the design may have made it dif-
This study, which was the first prospective ficult to ascertain a laser benefit, if one actually
randomized investigation into the therapeutic existed.
effect of the Nd:YAG laser, also showed a re- Krej s28 recently assessed the Nd:YAG laser

TABLE 5.4. Lesions found on emergency endoscopy

Visible vessel SRH Overlying clots
Treatment
group No. Rebleeding No. Rebleeding No. Rebleeding
Laser 39 6 17 0 13
Control 43 23 13 1 11 2
p < 0.01 NS NS

SRH, stigmata of recent hemorrhage; NS, not significant.

5. Clinical Applications in Gastrointestinal Bleeding 35

TABLE 5.5. Glasgow study of Nd:YAG in upper GI tients with active esophageal variceal bleeding
bleeding into a laser-treatment group and a control group.
Treatment In this small study, initial hemostasis was sig-
group Total Rebleed Surgery Died nificantly greater in the laser-treated group, but
Laser 8 2 I 0 the variceal incidence of rebleeding was high.
Contol 8 8 8 2 Laser therapy may be useful for acute variceal
p < 0.001 p < 0.001 NS bleeding and may be of interim benefit, but it
N S, not significant. does not represent definitive therapy. A similar
conclusion was reached by Kiefhaber et al. 18 in
a larger uncontrolled series. They were suc-
in a 30-month randomized, controlled trial. Ac- cessful in stopping variceal hemorrhage in 160
tively bleeding patients (18 laser, 15 control) and or 174 episodes of bleeding, but, because of a
patients who had recently bled and stopped but moderately high incidence of rebleeding, they
had stigmata of recent hemorrhage (64 laser, 69 recommended that sclerotherapy be performed
control) were studied. The laser conferred no early for more definitive treatment.
benefit to either group. The study must be fault- In summary, the Nd:YAG laser is effective
ed, as the most severely ill patients, those who in stopping active UGI bleeding and reduces the
could not be transported to the laser, were ex- need for emergency surgery. The rebleeding
cluded. Furthermore, the laser treatment was from spurting arteries or new lesions can be
often carried out by rotating residents in training managed successfully by repeated laser photo-
who probably did not have sufficient skill or ex- coagulation. Perforations have not been a prob-
perience. lem. The argon laser, in randomized studies, has
Trudeau et al. 29 evaluated the Nd:YAG laser been shown to have no effect on the rate of re-
for patients with endoscopic stigmata of recent bleeding, necessity for operation, or mortali-
bleeding with visible vessels. In the 33 patients ty.19,20

studied, the Nd:YAG laser reduced the number

of rebleeding episodes, reduced the need for ur-
gent surgery, and improved survival. Clinical Results in Other GI
A point to be noted is that there was not a Bleeding Conditions
single perforation in any of these eight studies
where the laser was used to treat nonvariceal Colonic Hemorrhage Due to
bleeding in severely ill patients. The evidence
is thus overwhelming in the truly scientifically
Benign Lesions
performed studies that the Nd:YAG laser is ef- Colonic lesions can be treated with the Nd:YAG
fective in UGI bleeding, and there can be no laser, bearing in mind the thinness of the dis-
argument regarding its safety. tended colonic wall. Lesions such as bleeding
The study of Fleischer 3o ,31 randomized pa- diverticulae and arteriovenous malformations

TABLE 5.6. Belgium study of Nd:YAG in upper GI

bleeding
Type of
Group bleeding Total Rebleed Surgery Died
Spurting
Laser 23 14 14 7
Control No Controls
2 Nonspurting
Laser 38 2 6
Control 32 12 4 5
3 Stigmation -
Recent Bleed
Laser 14 3 2 2
Control 22 7 5 3
36 Stephen N. Joffe and Richard M. Dwyer

may be coagulated by using 60- to 70-W power istration no longer classifies the laser as an ex-
and an exposure time duration of 0.1 to 0.3 sec- perimental device for any gastrointestinal ap-
onds, with noncontact and 8- to 12-W with ex- plication. There are more controlled and
posure time of 2 to 3 seconds with the contact uncontrolled data suggesting the safety and ef-
endoprobe and coaxial water. Coaxial water ficacy of the laser than are available for any
avoids distension and reduces the risk of per- other endoscopic method of treatment, whether
foration, and, by combining it with lower laser by thermal means or not.
energy, it reduces thermal damage. Previously, the laser had two inherent dis-
advantages. One was portability, and this prob-
Nonbleeding Benign GI Lesions lem is being addressed. The newer medium-
powered Nd:YAG lasers require single-phase
The Osler-Weber-Rendu syndrome may exhibit 208 to 220 V and are air cooled. This is opposed
as single or multiple, small or large vascular to three-phase electrical and special water
malformations. Following successful laser ther- hookups of the high-powered lasers. Mobility is
apy, new lesions might appear in different sites. now much less of a problem. The cost of lasers
This requires "harvesting" of gastric and colonic is approximately 5 to 20 times higher than that
lesions on a periodic basis to prevent further of other endoscopic hemostatic methods. This
bleeding episodes. Other lesions that may bleed means that if a physician or hospital does not
include benign polyps in the stomach, duoden- plan to use the laser for purposes other than the
um, or colon, which can be both photocoagu- treatment of bleeding, it is unlikely to be cost-
lated and vaporized. effective, unless the volume of cases to be
treated is at least one per week. However, the
Malignant Lesions of the GI Tract Nd:YAG laser has other applications in GI, such
as recanalization of obstructing carcinomas of
Laser therapy has been used to control bleeding the esophagus, stomach, and colon, as well as
in malignant lesions of the gastrointestinal tract, treatment of polyps and other tumors. In 1986,
which either helps to prepare the patient for de- more than 500 medical centers worldwide, about
finitive surgery or obviates the need for further 300 of which are in the United States, are using
surgical intervention in an incurable situation. lasers to treat gastrointestinal disease. 14
The various methods of endoscopic therapy
of UGI bleeding in humans has been reviewed
Current Status by Fleischer l4 (Table 5.7). The amount of in-
formation that exists from rigorously controlled
Lasers are readily available in the United States, scientific studies is small. Equally disturbing is
Europe, and Japan. The Food and Drug Admin- the minimal information published on studies

TABLE 5.7. Evidence that endoscopic therapy is beneficial in upper GI bleeding

Efficacy established
Bleeding from varices Bleeding from ulcers
Anecdotal Uncontrolled Controlled Anecdotal Uncontrolled Controlled
Method None report series trial None report series trial
Topical X 0 4 0
Injection 6 10 4 0
Mechanical X 0 0
Thermal
Monopolar X 0 0 3 I
Bipolar X 0 0 2 2
Heater probe X 0 0 3 0
Laser 3 6

Number indicates number of published papers.

Adapted and updated from Fleischer D: Endoscopic therapy of upper gastrointestinal bleeding. Gastroenterology 90:22
234, 1986.
5. Clinical Applications in Gastrointestinal Bleeding 37

that compare the different modalities for treating Water irrigation applied coaxially at a low flow
the same lesion in humans. Some comparative is adequate for cooling the fiber-to-probe junc-
information exists for animal models, which tion. Contact laser probes can be applied directly
cannot always be translated into the clinical sit- to the tissue, which provides tactile feedback
uation. Experimentally induced ulcers are path- during YAG laser procedures, and allows tam-
ologically, histologically, and hemodynamically ponading of vessels for more effective hemo-
different from those found in humans. stasis.
The flat probe is the instrument most often
used for coagulation. The technique employed
Contact Nd:YAG Laser is similar to that used in the noncontact method
Photocoagulation of laser photocoagulation. Rosettes are formed
around the periphery of the bleeding vessel to
Daikuzono and Joffe 15 recently developed a initiate edema. When bleeding visibly decreases,
synthetic sapphire crystal attached to the end which may take up to 30-45 seconds, the probe
of the quartz fiber using a universal metal con- can be used mechanically to coapt and seal the
nector that allows contact Nd:YAG laser pho- vessel with short pulses of energy.
tocoagulation. The geometric shape of these To prevent heat dissipation of the absorbed
synthetic sapphires provides the desired endo- Nd:YAG laser energy in a spurting blood vessel,
scopic effects of coagulation for bleeding and and to create a sufficiently deep thrombosis,
vaporization or excision of tumors. The power laser powers under 10 W, administered in 0.5-
density (W/cm 2 ) is directly related to the dis- to 3-second pulses, are most effective. With the
tance of the probe from tissue. The contact power off, the flat probe can be pressed directly
probes prevent the backscattering of light, re- onto the tissue. Firing the laser in pulses pro-
duce the depth of tissue damage, and allow for duces a high temperature change in the tissue
much lower powers of laser energy to be used. (160-250°C), which, when applied to vessel
Several centers in Europe, Japan, and the walls, induces a glue-like adhesion, providing
United States 33 are currently evaluating the coaptation and coagulation of the vessel.
contact endoprobes in both upper and lower GI When properly employed, the contact laser
surgery. endoprobe will not melt and can be reused.
Physical compress~on of the vessel walls al- However, if the laser is activated for more than
lows a more effective form of closure with co- 2 seconds while a probe is not in contact with
agulation, known as coaptation. The noncontact tissue-especially at higher powers-the probe
Nd: YAG laser may be less effective than either may turn white and change shape. If this hap-
of the other techniques, as pressure cannot be pens, the probe's optical and geometrical prop-
applied to tissue without burning and melting erties are irreversibly altered, and the probe
the fiber tip, making coaptation impossible. In must be replaced. The user should not deactivate
order to stop bleeding from moderately large the laser before removing the probe from the
vessels, substantial amounts of energy must be tissue or it may adhere. If sticking does occur,
applied to the tissue with the non contact meth- the probe should not be pulled off, but instead
od, causing significant damage and occasionally a short laser pulse should be given while gently
even precipitating further bleeding. Moreover, withdrawing the probe from the tissue. Coaxial
the noncontact laser technique produces smoke water irrigation further reduces the possibility
that requires special evacuation, and the coaxial of adhesion.
gas flow creates problems of patient distension, During the circumferential treatment of a
which increases risk of perforation and gas em- bleeding site, one establishes a simple repetitive
bolization. pattern. By setting the laser for 2- to 3-second
The conventional noncontact method is typ- intervals, the probe is placed on the tissue, the
ically used for endoscopic coagulation at powers foot pedal pressed, the probe lifted off, and the
in the 60- to 100-W range. Contact laser probes foot pedal released. Alternatively, the laser is
safely and efficiently seal vessels 1 to 3 mm in set in the continuous mode and the probe is
diameter, using powers below 10 W. Because "walked" around the bleeding site, touching the
of the low overall power and the reduction in tissue for 0.5- to 2.0-second intervals at each
scattered energy, there is virtually no smoke. spot. It is important when using contact endo-
38 Stephen N. Joffe and Richard M. Dwyer

probes that the laser provide a stable output in sion occurs, the power should be adjusted down
a low power range, as sudden uncontrollable (under 10 W), and with the laser activated, the
power bursts will not only damage the tissue probe can be gently disengaged from the tissue.
being treated but will also cause irreversible When there is massive bleeding from a vessel,
damage to the probes. the flat probe can be pressed directly against
Techniques may have to be altered, depending the vessel and the laser activated at 8-10 W for
on the type of tissue, the lesion being treated, 2 to 3 seconds. This will slow bleeding suffi-
blood flow, and numerous other factors. The ciently to allow circumferential treatment.
only true indication of coagulation is cessation
of bleeding or blanching around the treatment
site. Individual users with experience develop
Bleeding Erosions
their own methods of treatment. Bleeding erosions have several punctate bleed-
Each type of bleeding lesion must be identified ing points from arteriolar and capillary vessels
and evaluated independently. Prior to endos- at the edges or in the base of the erosion. Using
copy, if the patient is actively bleeding and/or the flat probe, these can be directly photoco-
there are blood clots in the stomach, the stomach agulated. If there is a diffuse ooze, the Z-shoot-
must be emptied for adequate visualization of ing technique is used. With laser power on, the
the bleeding site. This can be performed in one probe is moved back and forth over the tissue
of several ways. The preferred technique is to surface in a zigzag fashion. This coagulates the
pass a large-bore tube (Ewald) and irrigate the vessels feeding into the bleeding area. The
stomach with cold saline continuously until the bleeding points within the triangular areas are
effluent is minimally pink-stained and there are then directly treated.
no further blood clots. If the endoscope is passed
and blood clots are still found in the stomach,
Bleeding Esophageal Varices
the procedures should be repeated. An alter-
native or supplementary method is to give in- Bleeding is decreased using a vasopressin in-
travenous injection of metoclopramide (Reglan) fusion and an inflated Sengstaken-Blakemore
and a bolus of vasopressin (20 units over 10 tube inserted 4 hours before the procedure. In
minutes), provided that there are no contrain- a manner similar to the circumferential treat-
dications. Endoscopy is performed in a standard ment, the flat probe is used to coagulate parallel
manner under sedation. If the patient is actively lines on either side of the varix, either starting
bleeding and there is risk of aspiration, then en- distally and working proximally or vice versa,
dotracheal intubation should be performed. but avoiding direct treatment of the varix. The
At the end of the procedure, all lesions are procedure is repeated, working closer and closer
gently washed off and observed for a minimum to the varix until adequate vasoconstriction is
of 3 to 5 minutes to make sure that the bleeding obtained. Only when bleeding has decreased is
has stopped completely. Fresh frozen plasma the probe placed on the varix itself to coapt the
and blood are given as required. Clotting defects vessel proximal to the bleeding site. If the varix
are corrected and antacids, H 2-receptor antag- is bleeding actively during the procedure, a gas-
onists, and cytoprotective agents are prescribed. tric balloon is inflated and pulled up tightly to
In the event of rebleeding, the procedure can the cardioesophageal junction to decrease blood
be repeated. flow.
For a bleeding varix in the stomach, the feed-
ing vessels around the bleeding site are coapted
Bleeding Gastric and Duodenal Ulcers and waiting for 30-45 seconds to allow edema
with a Visible Vessel and coagulation ofthe feeding vessels to occur.
The flat probe is applied circumferentially
around the rim of the ulcer. Subsequently, the
Bleeding Mallory-Weiss Tear
probe can be applied directly to the vessel for
final coagulation and coaptation. If the probe The flat probe is applied around the bleeding
sticks to the vessel, the laser power is set too site, which coagulates the blood vessels sup-
high, producing vaporization of tissue. If adhe- plying the bleeding point. Once bleeding has di-
5. Clinical Applications in Gastrointestinal Bleeding 39

minished, the bleeding point itself can be co- to its flange, adjacent to a bleeding site, either
agulated. variceal or nonvariceal, it delivers a power den-
sity and thermal energy in a hemispherical vol-
ume up to a 2-cm radius. With powers of 5-7
Lower GI Bleeding W, it coagulates and can be moved circumfer-
Although there are many causes of lower GI entially around the bleeding site. More clinical
bleeding, angiodysplasia is the condition for experience is required. A comparison of endo-
which the Nd:YAG laser, particularly when used scopic hemostatic techniques, listing advantages
in conjunction with contact probes, has dem- and disadvantages, is given in Table 5.8, and
onstrated the clear advantages. features of contact and non contact laser effects
Contact photocoagulation with the flat probe is given in Table 5.9.
is performed circumferentially around the an- Currently, the endoscopic method of contact
giodysplastic lesion in an attempt to seal off the laser photocoagulation has been used in over 200
feeding vessels. Immediately upon coagulation patients with a success rate of over 90% in stop-
and coaptation of the feeding vessels, bleeding ping bleeding without any complications or per-
stops. foration. A randomized prospective study would
More recently we have been evaluating a hol- help in its definitive evaluation, but this is most
low cylindrical contact probe at low power. The unlikely at present.
probe is used only with coaxial saline to prevent
air embolization. The thermal effect simulates
the noncontact high-powered laser, producing Conclusions
an effect on tissue at greater depth, but with the
added advantage of coaptation. This endoprobe Endoscopic laser therapy for GI bleeding should
may be especially useful in the very actively be considered as one. approach in the broad
bleeding visible vessel, such as arterial spurters. range of therapeutic possibilities. During emer-
The frosted interstitial probe provides inter- gency endoscopy for GI bleeding it is wise to
stitial irradiation with deep coagulation. Al- anticipate that laser therapy may be required.
though primarily used in local hyperthermia and If possible, the endoscopist should be prepared
photodynamic therapy, it may have a place in to deliver treatment, if appropriate, at the time
GI bleeding. Pushed directly into the tissue up he embarks on the diagnostic endoscopy. In

TABLE 5.8. Comparative endoscopic hemostatic techniques

Heat Noncontact Contact
Characteristic Monopolar Bipolar probe Argon YAG YAG
Efficacy with major
arterial bleeding High Sometimes High Low Moderate High
Tamponade during
coagulation Limited Limited Yes No No Yes
Coagulation through
desiccated tissue No Poor Yes Yes Yes Yes
Controlled coagulation
depth No No Yes No No Yes
Tissue erosion potential Yes Yes No Yes Yes No
Risk of perforation High High Low Low High Low
Adjacent tissue damage Yes Yes Yes No Yes No
Coaxial irrigation possible Yes Sometimes Yes No No Yes
Gas insufflation required No No No Yes Yes Yes
Nonsticking probe No No Yes N/A N/A Yes
Large-channel endoscope
needed Yes Sometimes Yes No No No
Interference with
electronic equipment Yes Yes No No No No
Ability to cut and vaporize No No No No Poor No
40 Stephen N. Joffe and Richard M. Dwyer

TABLE 5.9. Contact versus noncontact Nd:YAG

characteristics
Characteristic Noncontact Contact
Power levels
Coagulation 60-100 W lOW
Vaporization 70-100 W 8-15 W
Blood loss High Low
Smoke generation High Low
Width and depth of 3-5 mm 0.2-1.0 mm
thermal damage
Energy lost to backscatter 30-40% 5%
Tamponading of bleeding vessels No Yes
Fiber maintenance requirement Frequent Infrequent
Tactile feedback No Yes
Pain to patient Moderate Low
Risk of perforation High Low

many instances, the treatment chosen will be 2. Joffe SN: The Nd:YAG laser-Past, present and
dictated by the availability of therapeutic mo- future perspectives. Proceedings of the Interna-
dality and the skill of the operator. tional Nd:YAG Laser Society, Tokyo, Japan,
For variceal bleeding, only sclerotherapy and 1986.
Nd:YAG laser treatment are options at present. 3. Joffe SN, Muckerheide MC, Goldman L: Neo-
dymium-YAG Laser in Medicine and Surgery.
For nonvariceal bleeding, injection therapy,
Elsevier, New York, 1983.
electrocoagulation, laser photocoagulation, and
4. Goodale R, Okaka A, Gonzales R, et al: Rapid
the heater probe are reasonable considerations. endoscopic control of bleeding gastric erosions
The overwhelming evidence, however, points to by laser radiation. Arch Surg 101:211, 1970.
the success of the Nd:YAG laser in this area. 5. Nath G, Gorish W, Kiefhaber P: First laser en-
Contact laser photocoagulation combines the doscopy via a fiberoptic transmission system.
coagulating properties of the Nd: Y AG laser with Endoscopy 5:203, 1973.
the tactile feedback and coaptive features of the 6. Dwyer R, Havirback B, Bass M, Cherlow J: Las-
contact endoprobe. It provides safe, rapid, ef- er-induced hemostasis in the canine stomach.
fective hemostasis. Accurately targeted low- JAMA 231:486, 1975.
power Nd:YAG laser energy causes less surface 7. Silverstein F, Auth D, Rubin C: Argon vs.
Nd:YAG laser photocoagulation and experimen-
damage and lateral necrosis than other thermal
tal canine gastric ulcers. Gastroenterology 77:491,
techniques, yet offers a controlled penetrating 1979.
thermal effect. Moreover, with a single versatile 8. Waitman AM, Grant DZ, Debeer R, Chryssanthou
instrument, one has the ability not only to co- C: Endoscopic laser photocoagulation: Compar-
agulate, but to cut and vaporize for other path- ison of argon and Nd:YAG. Gastrointest Endosc
ologic conditions. 25:52, 1979.
The mUltidisciplinary applications of the 9. Dixon JA, Berenson MM, McCloskey DW:
Nd:YAG laser system make it a universal tool Nd:YAG laser treatment of experimental canine
in the armamentarium of therapeutic endoscopy gastric bleeding. Gastroenterology 77:647-652,
and open surgery. The incorporation of mini- 1979.
mally invasive surgery, cost containment, and 10. Johnston JH, Jensen DM, Mautner W: Compar-
ison of endoscopic electrocoagulation and laser
improved quality of patient care will expand its
photocoagulation of bleeding canine gastric ulcers.
applications in the health care industry. Gastroenterology 82:904-910, 1982.
11. MacLeod lA, Bow DR, Joffe SN: A quantifiable
bleeding gastric ulcer in dogs for assessing the
neodymium YAG laser. Endoscopy 14:9-10, 1982.
References 12. Kelly DF, Bown SG, Calder BM, et al: Histo-
I. Fleischer D: Endoscopic laser therapy for gas- logical changes following Nd:YAG laser photo-
trointestinal diseases. Arch Intern Med 144:1225- coagulation of canine gastric mucosa. Gut 24:916--
1230, 1984. 920, 1983.
5. Clinical Applications in Gastrointestinal Bleeding 41

13. Joffe SN, Sanker MY, Brackett K: Effect of In- copic Y AG laser treatment in massive UGI
tragastric Vagolysis on Acid Secretion. Elsevier, bleeding. Scand J Gastroenterol 16:633-640, 1981.
Optoelectronics, Munich, 1983. 24. Escourrou J: Nd:YAG laser therapy for acute
14. Fleischer D: Endoscopic therapy of upper gas- gastrointestinal hemorrhage. In Atsumi K ,Nim-
trointestinal bleeding. Gastroenterology 90:217- sakul N (eds): Laser Tokyo 1981. Tokyo Inter-
234, 1986. group Corp., 1981.
15. Daikuzono N, Joffe SN: Artificial sapphire probe 25. Swain C, Brown S, Salmon P, et al: Controlled
for contact photocoagulation and tissue vapori- trial of Nd:YAG laser photocoagulation in bleed-
zation with the Nd:YAG laser. Med Instrum ing peptic ulcers. Lasers Surg Med 3:111, 1983.
19:173-178, 1985. 26. MacLeod lA, Mills PR, MacKenzie JF, et al:
16. Kiefhaber P: International experience with lasers Neodymium yttrium aluminium garnet laser pho-
for gastrointestinal bleeding. Proceedings of the tocoagulation for major haemorrhage from peptic
International Laser Congress, Detroit, MI, 1979. ulcers and single vessels in a single blind con-
17. Kiefhaber P, Kiefhaber K, Huber F, Nath G: En- trolled study. Br Med J 286:345-348, 1983.
doscopic applications of neodymium YAG laser 27. Rohde H, Thon K, Fischer M, et al: Results of a
radiation in the gastrointestinal tract. In Joffe SN defined therapeutic concept of endoscopic neo-
(ed): Neodymium-YAG Laser in Medicine and dymium-YAG-Iaser therapy in patients with upper
Surgery. Elsevier, New York, 1983, pp 6-14. gastrointestinal bleeding. Br J Surg 67:360, 1980.
18. Kiefhaber P, Kiefhaber K, Huber F, Nath G: En- 28. Krejs GJ, Little KH, Westergaard M, et al: Laser
doscopic neodymium: YAG laser coagulation in photocoagulation for the treatment of acute peptic
gastrointestinal hemorrhage. Endoscopy 18(Suppl ulcer bleeding: A randomized controlled clinical
2):46-51, 1986. trial. NEJM 316, 1618-1621, 1987.
19. Vallon AG, Cotton PB, Laurence BH, et al: Ran- 29. Trudeau W, Siepler JK, Ross K, et al: Endoscopic
domized trial of endoscopic argon laser photo- neodymium:YAG laser photocoagulation of
coagulation in bleeding peptic ulcers. Gut 22:228- bleeding ulcers with visible vessels. Gastrointest
233, 1981. Endosc 31:138, 1985.
20. Swain CP, Storey DW, Northfield TC, et al: 30. Fleischer D: Endoscopic Nd:YAG laser therapy
Controlled trial of argon laser photocoagulation for active esophageal variceal bleeding. A ran-
in bleeding peptic ulcers. Lancet ii: 1313-1316, domized controlled study. Gastrointest Endosc
1981. 31:4-9, 1985.
21. Jensen DM, Machicado GA, Tapia JF, et al: En- 31. Fleischer D: Endoscopic laser therapy for upper
doscopic argon laser photocoagulation of patients gastrointestinal tract disease. SUfV Dig Dis 1:42-
with severe gastrointestinal bleeding. Gastrointest 53, 1983.
Endosc 28:151, 1982. 32. Swain CP, Kirkham JS, Salmon PR, et al: Con-
22. Rutgeerts P, VanTrappen G, Broekhaert L: Con- trolled trial of Nd:YAG laser photocoagulation in
trolled trial of neodymium YAG laser treatment bleeding peptic ulcers. Lancet i: 1113-1116, 1986.
of upper digestive hemorrhage. Gastroenterology 33. Joffe SN: Contact neodymium:YAG laser surgery
83:410-416, 1982. in gastroenterology: A preliminary report. Lasers
23. Ihre T, Johansson C, Seligsson U, et al: Endos- Surg Med 6:155-157, 1986.
6
Laser Treatment for Advanced or
Recurrent Cancer of the Gastrointestinal
Tract
Yoshiki Hiki, Tetsuhiko Yamao, and Hitoshi Shimao

In 1973, Nath et al. 1 were the first to publish arotomy was performed in 25 cases (23%), and
the medical application of laser endoscopy. The gastrointestinal endoscopy was performed in 76
trials for treating diseases of the digestive organs cases (70%) (Figure 6.1). In 64 patients, endo-
endoscopically began around 1975. Friihmorgen scopic Nd:YAG laser therapy was performed,
et aI., 2.3 Kiefhaber et al., 4 Dwyer et aI., 5 and first for hemostasis, followed by direct appli-
Waitman et a1. 6 published the results of their ex- cation to the tumor.
perimental and clinical studies on the use of laser Benign tumors were treated in 25 patients:
endoscopy in hemostatic therapy for digestive esophageal submucosal tumor, gastric polyp,
tract hemorrhage. gastric submucosal tumor, atypical cell tumor,
In Japan, reports on laser endoscopy appeared rectal adenoma, and anal polyp. Malignant tu-
in 1979, and at the Congress of the International mors were present in 39 patients, namely, 22
Laser Association held in Tokyo in 1981, the cases of early cancer (1 esophagus, 18 stomach,
use of the laser for gastrointestinal tumors was 3 rectum) and 17 cases of advanced and recur-
discussed, in addition to its application for hem- rent cancers (3 esophagus, 7 stomach, 7 colon)
orrhage. (Figure 6.2).
At present, digestive tract tumors are treated
endoscopically by two procedures. One pro-
cedure is radical treatment with the high-energy Method
Nd:YAG laser, which, by thermal action, co-
agulates, degenerates, and disperses the tumor. In our study we used a laser-oscillation system,
The other procedure is the photodynamic ther- Molectron Model 8000 Nd:YAG laser and NIIC
apy of the low-energy argon-dye laser, which 130YZ. Intermittent radiation was performed
destroys the tumor photochemically in reaction under the following conditions of tip power out-
with a hematoporphyrin derivative previously put: noncontact type, 50-70 W of power for 0.5-
injected into the tumor. 7-10 In this chapter we 1.0 second and contact type, 15-20 W of power
will report our treatment of advanced and re- for 0.5-2.0 second.
current cancers of the digestive organs using the
Nd:Y AG laser with endoscope attachment.
Efficacy-Evaluating Criteria for
Subjects Laser Therapy of Advanced and
Recurrent Cancer
At Kitazato University, the N d: Y AG laser has
been used in clinical applications since 1979. In In judging the therapeutic efficacy of cancer
our study, radiation therapy was administered treatment, longevity must be the primary cri-
209 times to 108 patients. Among them, abdom- terion in the case of radical surgery, while treat-
inal surgery was performed in 7 cases (7%), lap- ment of early cancer, with fewer clinical symp-
6. Laser Treatment for Cancer of GI Tract 43

Results
In 18 of the 22 patients treated with the Nd:YAG
laser for early cancer, the tumor was eliminated
and histologic examination was negative. Of the
remaining 4 patients, 2 received radiotherapy
during surgery, 1 required hemostasis, and 1
died from the disease. The tumors ranged from
0.5 to 4.0 cm, and radiation was administered
from 1 to 5 times. Some cases were treated by
repeated radiation for depressed lesions and
larger tumors. No recurrent symptoms appeared
for 56 months.
The efficacy of laser treatment was observed
in 11 of 17 patients with advanced and recurrent
cancers. Symptoms were mitigated in cases of
gastrointestinal cancer aggravated by hemor-
FIGURE 6.1. Nd: YAG laser treatment. rhage and in cases of rectal esophageal stenosis.
Moreover, tumors were reduced in combined
use with local immunotherapy, and longevity
toms, may be judged by the result of histologic was seen in some cases. In one case of Borrm-
examination and the eradication of the tumor. ann type I stomach cancer, the tumor was erad-
In those cases of advanced and recurrent cancer icated after four doses of radiation and histologic
that preclude surgical treatment, symptoms such examination was negative. There was no recur-
as intermittent flare-ups, pain, hemorrhage, or rence after 7 months. In another case of the same
exudation should be relieved conservatively. diagnosis, there was local recurrence after rec-
When longevity is the therapeutic goal, a stan- toto my (perineal-type rectal cancer). This pa-
dard for efficacy is needed. Therefore, we have tient suffered from exudation and hemorrhage;
established the criteria shown in Table 6.1. however, after 10 local laser treatments in 6

I
esophagus submucosal 01
c:::::J 2
~----------------'112
benign 25 stomach ::ucosal
atypical cell L--_ _ _ _ _ _- I 16
polyp c:::::J 2
rectum & anus {
adenoma c:::::J 2
esophagus []1
[]1
IIa E:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::q 10

early ca. stomach lIc I::::::::::::::::::::::::::::::! 4

IIa+ lie 00 1
IIc+1II (::::::;:;:;::12

I
rectum 1::::::::::::::::::::::13

esophagus (::\\:::::::::::::::13
advanced
stomach I::::::::::::::::::::::::::::::::::::::::::::::::::::) 7
ca.
colon-rectum I::::::::::::::::::::::::::::::::::::::::::::::::::::) 7

FIGURE 6.2. Endoscopic laser treatment for gastrointestinal tumor [n = 64 (157)].

44 Yoshiki Hiki, Tetsuhiko Yamao, and Hitoshi Shimao

TABLE 6.1. Criteria of laser effect

Tumor Evaluation Criterion
Malignant Excellent Tumor is destroyed and pathohistologic
(palliative examination is negative.
cases) Good Tumor size is reduced over half and
clinical courses are improved.
No change Tumor size is same as before and
clinical courses are not improved.
Worse Tumor becomes big and clinical
courses are getting worse.
Benign Complete remission Tumor is vanished.
Partial remission Tumor size is reduced as before.
Stable Tumor size is same as before.

months, the ninth biopsy was negative. Then the apy is indicated for these latter patients. How-
injury became a clear granular wound. No ever, the purpose and procedure may vary for
change was seen in 4 cases: in one case where early cancer and advanced or recurrent cancer.
there was no improvement of colonic cancer
with longer stenosis; in two cases where there
was tracheal infiltration of esophageal cancer;
Early Cancer
and in one case of stomach cancer where the For early cancer, radical treatment is the goal,
hemorrhage was not controlled (Table 6.2). but, as cancer is a systemic disease, lymphatic
metastasis is always a problem.
Lymphatic spread and depth of the cancer-
Therapy for Cancer "m" (mucosal) and "sm" (submucosal) was re-
viewed in those cases treated with surgery for
At present, the basic therapy for cancer is re- early cancer. Simultaneously, cancer size was
sectional surgery. Systemic chemoimmuno- also surveyed. As a result, it was found that no
therapy is mainly given for those cases impos- lymphatic metastasis occurred when the cancer
sible to excise or in those cases where surgery "m" depth was less than 2 cm. Therefore, a
is contraindicated by being medically unfit, se- radical cure of early stomach cancer can be
rious complications, or age. Today, laser ther- achieved by the laser alone, if it is an m-cancer

TABLE 6.2. Results-recurrent or advanced cancer (N = 17)

Organ Case (times) Type Indication Excellent Good No change
Esophagus 3 (5) Stenosis Obstruction I x
Tracheal Obstruction I x
invasion
Stenosis Obstruction I x
Stomach 7 (23) Hc + III-like Tumor
reduction I
IIa + lIc-like Tumor x
reduction I
Borrmann I Tumor x x
reduction 2
Borrmann H Tumor x
reduction I
Borrmann III Bleeding I x
Post operative Obstruction I X
recurrence
Colon-rectum 7 (42) Post-LAR Recurrence 3 XX X
Post-Miles Recurrence 2 X X
Borrmann III Obstruction 2 X X
6. Laser Treatment for Cancer of GI Tract 45

smaller than 20 m without an ulcer. In this case, A radical cure may be effected by repeated
the premise is the exact identification of cancer radiation for the advanced cancer. However, in
depth with endoscopic diagnosis including the most cases, the laser is used for the relief of
biopsy. These results should be considered when stenosis, relief of pain, or to obtain hemostasis.
the choice of cancer therapy is the laser alone. For the distinct lesion with residual cancer after
radiation, including early cancer of the de-
pressed type, local therapy in combination with
Advanced and Recurrent Cancer OK-432 may induce better results. Frequent
Use of the laser for local radical cure is con- observations should be made over time with
servative therapy. However, the laser can in- histologic examination following biopsy. For
crease longevity by palliating the symptoms of therapy with the endoscopic laser, especially the
patients with advanced and recurrent cancer, Nd:YAG laser, it is necessary to cut the lesion,
who complain of bleeding, pain, or exudation. therefore the exact range of the lesion must be
Of course, advanced cancer is not necessarily in focus, as compared with the argon-dye laser's
complicated by lymphatic metastasis, in which photodynamic therapy, for which it is important
case the tumor may be disintegrated by repeated to keep the front of the lesion in view. The ther-
laser radiation. Also, the judgment of radical apeutic approach must be fully understood to
cure can be made by the results of this therapy select appropriate laser equipment.
over time. In comparison with the photodynamic therapy
of the argon-dye laser, the Nd:YAG laser can
be used simply and easily for retreatment of
Discussion cancer residue after initial therapy, in a short
treatment time. Also, it is useful for controlling
When laser radiation is indicated for digestive the patients' symptoms or the side effects of he-
tract tumor, consideration should be given to matoporphyrin derivative.
the necessity of combined treatments, and to the
selection of endoscopic devices for the lesion
site, size, depth, and tissue type.
References
The laser can be used as direct therapy for I. Nath G, et al: First laser endoscopy via a fiber-
raised, epithelial lesions such as adenomas, optic transmission system. Endoscopy 5:208,
types I and IIa, whereas the larger masses, such 1973.
as polyps, should first be reduced by high-fre- 2. Friihmorgen P, et al: Experimental examination
quency polypectomy, and then the laser can be on laser endoscopy. Endoscopy 6: 116, 1974.
applied. Polypectomy of type lIb (flat lesion) is 3. Friihmorgen P, et al: The first endoscopic laser
coagulation in the human GI tract. Endoscopy
performed by injecting physiologic saline solu- 7: 156, 1975.
tion into the submucosa, so-called strip biopsy, 4. Kiefhaber P, et al: Endoscopical control of mas-
and applying laser radiation to the excised end. sive gastrointestinal hemorrhage by irradiation
In radical laser therapy for the depressed type with a high-power neodymium-Yag laser. Prog
of early cancer (IIc, IIc + III, III + IIc), it is Surg 15: 140, 1977.
essential to grasp the full range of the lesion. 5. Dwyer RM, et al: Laser-induced hemostasis in
Irradiation should be executed from the periph- the canine stomach. JAMA 231:486, 1975.
eral site of the lesion. Radiation from the center 6. Waitman AM, Grant DZ, Debeer R, Chryssanthou
may cause edema in the peripheral site, which C: Endoscopic laser photocoagulation: compari-
would make the range of the lesion indistinct, son of argon and Nd:YAG. Gastroint Endoscopy
resulting in insufficient radiation and, concom- 25:52, 1979.
7. Itoh K, et al: Endoscopic laser therapy for stom-
itantly, a residue of cancer at the peripheral site.
ach tumor. Gastroenterol Endosc 23:1517, 1981.
Of course, a cancer residue may remain under 8. Atsumi K: Challenge to the future medicine by
the necrotic ulcer caused by the laser after ra- laser. J Jpn Laser Med Assoc 3: 1-4, 1982.
diation of deep sm-cancer. In such cases, re- 9. Kasugai T, et al: Laser-endoscopic therapy for
peated-but not excessive-radiation should be early stomach cancer. J Jpn Nippon Rinsho (Jap-
administered in order to minimize the danger of anese Clinic) 42:2282, 1984.
perforation that may occur in high-power one- 10. Hiki Y: Laser endoscopy. Jpn Text New Med Ser,
time radiation treatment. yearly ed 84-A:51-60, 1984.
7
Videoendoscopy
David E. Fleischer

Fiberoptic endoscopy has revolutionized the

management of gastrointestinal diseases. Since
Component Parts of the
its advent, in the late 1950s, endoscopy has al- Videoendoscopic System
tered both the diagnosis and management of nu-
merous medical problems. It provided the first The component parts of the videoendoscopic
nonsurgical option for examining the digestive system are the (1) videoendoscope, (2) video-
tract in vivo and also provided the opportunity processor, (3) display monitor, and (4) acces-
for biopsy with histopathologic evaluation and sories (Figure 7.3).
therapy. A wide variety of therapies can now A videoendoscope is somewhat similar in ap-
be carried out endoscopically; for example, en- pearance to a fiberoptic endoscope, though it
doscopic laser therapy for bleeding lesions and need not be. The control head is shown in Figure
gastrointestinal neoplasms is commonplace. 7.4. No viewing eyepiece is required, since the
The key innovation in flexible endoscopy was physician looks at a television monitor. Suction
the use of the fiberoptic bundle to transmit light and air/water buttons are shown in the figure.
for the visual image. In 1983, Sivak and Cabled knobs control movement at the distal
Fleischer l reported the first use of the videoen- part of the tip. Intubation is performed through
doscope, using equipment developed by Welch- the mouth or the anus, as with routine fiberoptic
Allyn, Inc. The videoendoscope looks similar endoscopy.
to the fiberoptic endoscope, but there are nu- Information is then carried to a videoproces-
merous differences (Figure 7.1). The physician sor (Figure 7.5). The videoprocessor converts
looks at the video monitor rather than through the information from the CCD which is an an-
an eyepiece. The image is transmitted electron- alogue device to discrete numerical values. Once
ically rather than through fiber bundles. This the information is converted from an analogue
means that several observers can watch. the system to a digital system, the data can be
procedure simultaneously (Figure 7.2). Elec- translated to a binary code that can feed into
tronic transmission opens up numerous options computers. Therefore, television images can be
for both display and analysis. transmitted from one room of the hospital to an-
The key to the development of the electronic other, from one medical area to another many
endoscope was the charge-coupled device miles away, or even, via a satellite communi-
(CCD), invented in 1969 by Boyle and Smith. cation system, over very far distances. Also,
The CCD is generally referred to as a chip, and once the information exists in a binary language,
it was first incorporated into gastrointesti- the videoendoscopic system can be interfaced
nal endoscopes by Welch-Allyn, Inc. Sivak 2 with computers and a wide variety of analytic
has presented a detailed and lucid description functions can be carried out. In addition, the
of the CCD and its application with videoendo- endoscopic images can be stored for retrieval at
scopes. a later date.
7. Videoendoscopy 47

review at a later date. Photographic systems can

be utilized that present an instant picture, a 35-
mm slide, or a hard copy (Figure 7.7). A storage
retrieval system, for example, using a laser disk,
can be hooked up to the system for storage of
a large number of video pictures . Additional
monitors can be placed so that more persons in
more sites can view the image. Finally, perhaps
most importantly , a computer interface can be
established so that the potential for analysis of
the video image can be realized. This new and
exciting area holds great promise for videoen-
doscopy and will be discussed in detail later in
this chapter.

New Developments with

Videoendoscopy
FIGURE 7.1. Videoendoscope (Welch-Allyn).
Videoendoscopy offers several opportunities
The display monitor can be a standard tele- that did not exist with standard fiberoptic en-
vision or a computer monitor. In addition to the doscopy. Some of these that currently exist are
visual images, information about the patient and (1) video advantages, (2) advantages for per-
the procedure can be typed into the picture with sonnel and patients , (3) specific advantages dis-
a standard keyboard (Figure 7.6). tinct from fiberoptic instruments, and (4) doc-
A wide variety of accessories can be matched umentation.
to the videoendoscopic system . Avideotape re- The first apparent video advantage is that
corder can be used to record the proceedings to high-quality images can be projected for mUltiple

FIGURE 7.2. With videoendoscopy , the image is displayed on a monitor. Several observers can watch the
procedure.
48 David E. Fleischer

FIGURE 7.3. Component parts of the videoendoscopic system include the videoendoscope , videoprocessor ,
display monitor, and accessories.

viewers to observe in the same room. A teaching better coordination occurs between the endos-
attachment is not required and verbal discus- copist and the gastrointestinal assistant, since
sions can take place among multiple observers. they are both observing the same procedure si-
If a record is to be made of the procedure, an multaneously. The gastrointestinal assistant
additional television camera system is not re- finds the procedure more enjoyable because he
quired. The obvious video advantage of docu- can glance at the television monitor as well as
mentation will be discussed below. at the patient. Since the assistant does not have
There are certain advantages that are obvious to hold a lecture scope to his eye , his hands are
to health personnel and patients. The endos- now free to assist with the procedure or the pa-
copist experiences less eyestrain when viewing tient. Coordination between the assistant and the
the procedure through a monitor as opposed to physician is logically better if the assistant has
through an eyepiece. It is also apparent that better use of his hands. Initially, there was con-

FIGURE 7.4. The control section of the videoendoscope is similar to the fiberoptic endoscope. Suction and air/
water buttons are seen.
7. Videoendoscopy 49

FIGURE 7.5. The videoprocessor serves as the light source , but also processes information received from the
videoendoscope.

cern that it may be frightening for the patient to with the patient at a later date is often of much
observe the procedure while it is being carried value.
out, which is possible with the television mon- The videoendoscope has numerous potential
itor.However, most patients prefer to see the benefits, in contrast to fiberoptic instruments.
procedure, and those who choose not to look Obviously, there will be no fiber breakage , since
can "tune out" during the procedure. The phy- the electronic endoscope does not employ fibers.
sician naturally uses discretion as to when ob- It is possible that the cost of both the instrument
servation by the patient is appropriate. The and the repair will be reduced when electronic
ability to have a record that can be reviewed endoscopes are used more extensively. Also, as

FIGURE 7.6. Keyboard (character generator) of the Welch-Allyn videoendoscopic system.

50 David E. Fleischer

Limitations of Videoendoscopy
Technological advancement usually carries with
it some tradeoffs. Currently, videoendoscopic
systems are more expensive than routine fiber-
optic endoscopic systems. Videoendoscopic
systems have more component parts and they
are larger; therefore operational space and stor-
age of the equipment is of some concern. They
are less portable than the current fiberoptic sys-
tem, so that if an emergency procedure is re-
quired, for example, in an intensive care unit,
transporting the system is awkward.
There is a learning period for physicians who
are accustomed to the fiberoptic endoscope.
FIGURE 7.7. Photography from a videoendoscopic When these physicians confront the videoen-
system can be instant, 35 mm, or hard copy. doscopic system for the first time, they need to
observe and participate in five to ten procedures
before they become comfortable with its use.
the chips become smaller, the potential for Currently, videoendoscopes exist for standard
smaller endoscopes and larger channels will ex- upper endoscopy and colonoscopy. There are
ist. few specialized instruments. Although some
Perhaps the most obvious immediate advan- duodenoscopes do exist, these are not com-
tage of videoendoscopy is in the area of docu- monly employed at the present time.
mentation. Here there are important opportun- Another concern about videoendoscopy is the
ities for teaching. During the actual endoscopic rapidity with which the technology is changing.
procedure the teacher, the trainee, and other Therefore, there tends to be a real concern on
related observers can all view the activity si- the part of the purchaser that he may be pur-
multaneously. It presents an opportunity for the chasing a system that will be outdated in a few
trainee to review the procedure after it has been months or years.
carried out and to glean some information about None of these problems is insurmountable,
how the examination was performed. Since the but they indicate some of the limitations of vi-
videotape is potentially available immediately deoendoscopy at the present time.
after the procedure, it can be used at confer-
ences on the same day, as well as on other days.
The existence of a videotape means that the The Future of Videoendoscopy
only record of an endoscopic procedure is no
longer just a dictated description. Instead, the The videoendoscopic system, as described,
videotape can be reviewed by other physicians represents an important advancement. Several
who will be seeing the patient-much like an x- of the advantages have been cited. However, it
ray film is reviewed. There is the opportunity is my opinion that if videoendoscopes are to re-
for preoperative review by the surgeon. Long- place fiberoptic systems (and I believe that they
distance live consultations could be carried out will), it will be new developments that allow
while the procedure is being performed or at a them to do so. I think that the two areas that
later date. This videotape record of the proce- will determine the future of videoendoscopy are
dure permits comparisons with other endosco- the computer interface and the analytic poten-
pies. Since the information can be stored and tial. Since it is the computer interface that is
retrieved, records from a single patient can be likely to enhance the analytic potential, the two
compared much like x-ray records. The fact that areas actually are one. With computer interface,
the procedure is documented also lends potential the electronic image can be evaluated in several
for quality control and other means of accessing fashions. Computerized image enhancement will
performance and management. be possible with edge enhancement evaluation.
7. Videoendoscopy 51

Increased enhancement of the topography of the tions that are not currently apparent may be
gastrointestinal tract can provide hitherto un- highlighted. The videoendoscope is not limited
available data useful for diagnostic interpretation to the light spectrum visible to the human eye,
(Figure 7.8). Magnification of electronic images therefore, infrared and ultraviolet sensing may
is also possible, whereby an area can be enlarged be possible. Endoscopic thermography may al-
and evaluated in greater detail. The potential for low us to distinguish small differences in tem-
color evaluation and manipulation is reasonably perature, and this may have diagnostic benefits.
straightforward. The gastrointestinal polyp that At the present time thermography is used in the
we see as a pink excrescence may contain mul- evaluation of normal and abnormal medical
tiple colors. It may be that normal cells are one conditions. Of course, with a computer inter-
color, and pathologic areas are another. By face, the generation of an endoscopic report,
varying the color and manipulating it, distinc- even including pictures, is within easy reach.
The techniques described above greatly en-
hance the potential for analysis. It may be pos-
sible to determine blood flow with videoendo-
scopes. A more precise measurement of the size
of the lesion-depth and height as well as length
and breadth-can be obtained. Currently, ultra-
sonic endoscopy is used to determine the depth
of lesions. The density of a lesion, as determined
by computerized tomography, may be assess-
able with the videoendoscope, and this could
give important information about the nature of
the lesion. Ideally, the distinction between ma-
lignant and nonmalignant lesions might some day
be made with a videoendoscope.

Application of the
Videoendoscope for Use
with Lasers
Some of the potential advances discussed above
would be important for laser application. With
regard to the management of gastrointestinal
bleeding, if blood flow could be determined be-
fore and after laser therapy, one could get abet-
ter idea of both the hemodynamic nature of the
lesion being treated and the efficacy of the ther-
apy. One limitation of laser treatment of gas-
trointestinal neoplasms is in the pathologic
evaluation of the lesion. In contrast to a snare
polypectomy for the treatment of a gastrointes-
tinal polyp, laser ablation does not allow for the
delivery of the entire specimen to the patholo-
gist. However, if videoendoscopy allowed for
histologic interpretation, pathologic analysis
would not be as critical. Also, the laser endo-
scopist often does not know how deep the laser
FIGURE 7.8. Small lesion in duodenum before image therapy should be delivered, since he does not
enhancement (top) and after (bottom). know the depth of the tumor in the gastrointes-
52 David E. Fleischer

FIGURE 7.9. Welch-Allyn videoendoscope adapted for from the aiming light, which could overwhelm the
laser use. The white tip reflects the Nd: YAG beam. CCD and reduce the quality of the picture when the
A filter at the tip protects (CCD) and reduces return white aiming light is present.

tinal wall. If the depth of the lesion could be employed with lasers is that special protective
ascertained, a more precise delivery of the laser eyeglasses are not required for the endoscopist
energy would be possible, and, in fact, the sur- or the other health personnel, since the laser
geon could determine whether or not curative beam is not observed directly through the eye-
therapy with the laser was possible. This would piece of the endoscope, but rather the endos-
have an immediate application for the manage- copy team watch the procedure on a television
ment of early gastric cancer and the possibility monitor.
of the laser as a means of curative therapy.
Some modifications of endoscopes are nec-
essary for use with lasers. The white aiming light Conclusion
from the laser fiber will overwhelm the CCD
(chip) with its bright intense light. Therefore, Videoendoscopy represents a revolutionary ad-
the filter must be placed either into the laser or vance in the evaluation and management of pa-
at the tip of the endoscope so that the video pic- tients with gastrointestinal diseases. In its cur-
ture will not be wiped out. Additionally, this fil- rent form, it is an interesting and appealing
ter provides some protection for the chip. The alternative to fiberoptic endoscopy. However,
videoendoscopic system by Welch-Allyn em- the key to the future is in its analytic potential,
ploys such a filter (Figure 7.9). The Welch-Allyn and, when this is fully realized, videoendoscopes
instrument also has a white tip on the endo- will completely replace fiberoptic instruments.
scope, which is more apt to reflect than to ab-
sorb the beam from the most commonly em-
ployed Nd:YAG laser, which is the one most References
commonly employed. An enlarged biopsy chan- 1. Sivak MV Jr, Fleischer DE: Colonoscopy with a
nel also is important in endoscopic laser therapy videoendoscope: Preliminary experience. Gas-
because it permits the exhaust of gas from the trointest Endosc 30:1-5, 1984.
laser fiber. It should be mentioned again that an 2. Sivak MV Jr: Videoendoscopy. Clin Gastroenterol
added advantage of the videoendoscope when 15:205-234, 1986.
8
Endoscopic Laser Therapy of Carcinoma
of the Esophagus and Gastric Cardia
Richard C. Ranard and David E. Fleischer

In the United States, the largest experience with cinoma of the esophagus in the United States is
laser treatment of neoplasms of the gastrointes- less than 6 months. Palliation, with minimization
tinal tract is with carcinoma of the esophagus. of morbidity and duration of hospitalization, is
The great majority of these lesions are squamous often the goal for patients with esophageal car-
cell carcinomas, although adenocarcinoma of the cinoma who have limited survival.
esophagus occurs in 3 to 7% of cases. The en- In recent years, the medical community has
doscopic laser therapy (ELT) of these lesions, witnessed the emergence of ELT for the pallia-
as well as of adenocarcinomas of the gastric tion of cancers of the esophagus and gastric car-
cardia, is effective in the palliation of these too- dia. ELT, however, must be reviewed in the
often incurable diseases. context' of the available alternatives. Radiation
The incidence of cancer of the esophagus is therapy, surgery, chemotherapy, bougienage
increased in blacks, males, and the socioeco- with or without prosthetic stent placement, and
nomically disadvantaged. It is postulated that gastrostomy or pharyngostomy all are used in
this is partly because the two major risk factors the palliation of cancer of the esophagus a~d/or
for carcinoma of the esophagus, cigarette gastric cardia, but each has specific limitations.
smoking and alcohol ingestion, are more prev- Radiation therapy, with a full course of 6000
alent in these groups. The risk of esophageal rad or more delivered to the mediastinum, is the
carcinoma is increased geometrically when both most common modality employed in the treat-
of these factors are present. Washington, DC is ment of carcinoma of the esophagus. It is often
one of the several areas in the United States employed in patients with locally advanced or
where there is an increased incidence of esoph- widespread disease, and in those with other
ageal carcinoma. This is where investigation of medical problems that lessen the chance for a
ELT of esophageal carcinoma was initiated. 1 good surgical outcome. Although short-term re-
Patients most commonly present with symp- lief of symptoms is common, prolonged control
toms of obstruction or bleeding. They have often of local disease is rare. Most patient have celiac
experienced considerable weight loss as a re- axis node involvement or distal metastases at
flection of their poor nutritional status. Dys- the time of autopsy. No controlled trials com-
phagia, the most common presenting symptom, pare radiation therapy to surgery for squamous
almost always reflects advanced disease, where cell carcinoma of the esophagus, but survival
cure is seldom possible. The average time in- rates are similarly poor. In a comprehensive re-
terval between onset of dysphagia symptoms view by Earlam and Cunha-Mel0 2 of collective
and the diagnosis is over 3 months. The esoph- radiotherapy results on esophageal cancer, a 1-
agus is distensible and surrounded by a rich year survival of 18% and a 5-year survival of
lymphatic system. This permits extensive tumor approximately 6% were reported. These rates
growth before symptoms occur, allowing little are similar to that of surgically treated patients.
possibility for cure. Median survival time from Compilation and evaluation of numerous sur-
presentation with advanced squamous cell car- gical studies by Earlam and Cunha-Mel0 3 de-
54 Richard C. Ranard and David E. Fleischer

termined that, of every 100 patients with cancer Georgetown University Hospital, investigating
of the esophagus, 58 will be operative candidates chemotherapeutic intervention with continuous
and 42 will not be operative candidates. Of those infusion 5-FU and intermittent cis-platinum
58, 39 will have the tumor resected and 19 will preoperatively and postoperatively, with con-
be unresectable. Of those 39 who come to op- current ELT for palliation of obstruction or
eration, 13 will die in the hospital and 26 will bleeding as indicated. Despite some suggestions
leave the hospital with the tumor excised. Of of increased response rates, incomplete re-
these 26, 18 will live 1 year, 9 will live 2 years, sponses and significant morbidity in patients
and only 4 will live 5 years. Given these figures, with limited survival will continue to restrict the
the authors point out that an informed patient use of chemotherapy in the palliation of carci-
might ask about alternative treatment. noma of the esophagus.
Both radiation therapy and surgery for cancer Bougienage, with or without prosthetic stent
of the esophagus have limitations apart from placement, is relatively safe and efficacious, and
poor survival. Radiation therapy may take sev- provides symptomatic relief in many patients.
eral weeks to provide symptomatic relief. It Reported complication rates vary widely. Heit
cannot be administered for recurrences after the et al. 7 reported improvement in 24 of 26 patients,
maximum dose has been reached. Its effect is with only one perforation. Cassidy et al. 8 re-
not organ-specific. Nausea, malaise, pulmonary ported on 154 patients with malignant strictures
fibrosis, and spinal cord lesions leading to para- undergoing more than 1300 individual dilata-
plegia, as well as radiation-induced esophageal tions, with only three serious complications-
strictures can occur. two perforations, and one massive hemor-
Surgery is limited because the location of the rhage-although 15% of the patients required
lesion or the condition of the patient make most peroral prosthesis placement to maintain a pat-
lesions unresectable at presentation. Many in- ent lumen. Mean survival after prosthesis in-
stitutions consider surgery only with lesions of sertion was 4.5 months. Graham et al. 9 reported
the distal third of the esophagus, reserving ra- one perforation and one fatal hemorrhage in 18
diation therapy for proximal lesions. Surgical patients, 5 of whom were dilated prior to pros-
morbidity is high. Surgical mortality in patients thetic stent placement for esophagorespiratory
considered operable is reported as high as 29%3 fistulas.
although mortality in the range of 10% is more Bougienage may be unworkable if the stricture
commonly reported. is too tight to allow clinically significant dila-
Past results have generally been disappoint- tations. Although successful initially, the pro-
ing, but encouraging data are emerging on cedure often becomes increasingly difficult and
chemotherapeutic intervention in squamous cell painful, and intervening periods of improved
carcinoma of the esophagus. Single-agent ther- symptoms are of progressively shorter duration.
apy has not been effective, with brief responses While patients with stenosing tumors of the gas-
at rates usually in the range of only 15-20%.4 tric cardia are often afforded temporary symp-
More encouraging results have occurred with tomatic benefit, dilatation is technically more
combination chemotherapy, often with cis-plat- difficult because the narrowed area often di-
inum-based regimens. Response rates up to 53% verges at a sharp angle from the esophageal lu-
or more with prolongation of survival are re- men.
ported. 5 Prospective randomized trials originat- Atkinson's grouplO reported satisfactory res-
ing at the National Cancer Institute indicate that toration of swallowing in 121 patients with en-
patients responding to preoperative and post- doscopic insertion of prosthetic tubes. There
operative combination chemotherapy have were 5 fatal and 10 nonfatal perforations, thirty-
longer disease-free and overall survival-more three of 121 patients survived for 6 months or
than 3 years. However, the failure to stratify more. Den Hartog Jager et al. 11 reported gen-
nutritional factors may have affected these re- erally good palliation, with restoration of food
sults. 6 These findings, and favorable results with passage, in 200 patients with esophagogastric
short-term continuous infusion of 5-fluorouracil malignancies after endoscopic placement of
(5-FU) instead of the traditional bolus infusion, plastic prostheses. Complications included 16
have led to the recent initiation of trials at perforations with 1 death, obstruction of the
8. Laser Treatment of Cancer of Esophagus and Gastric Cardia 55

prosthesis in 35 patients, and tube migration in exception of lesions extending up to the crico-
44 patients. Seventeen percent of patients sur- pharyngeus, ELT is applicable to lesions any-
vived more than 6 months. where in the esophagus. Surgery with general
Restrictions on prosthetic stent placement are anesthesia and its attendant morbidity are
technical in some cases. Many investigators feel avoided. Symptomatic relief is gained in a rel-
that stents are contraindicated for treatment of atively short time with often dramatic improve-
lesions in the proximal esophagus if the stent is ments in quality of life. Most patients are able
adjacent to the cricopharyngeus, or for lesions to leave the hospital.
in the distal esophagus if the prosthesis crosses In the evaluation of a patient for palliation
the gastroesophageal junction. Occasionally, a with ELT, a CBC, coagulation parameters,
malignant stricture cannot be dilated to accom- multiple chemical analyses, chest x-ray, and
modate stent placement, although in patients barium swallow, as well as chest and abdominal
with malignant obstruction and fistulae, ELT has computerized tomographic (CT) scans are ob-
been reported to establish a lumen sufficient to tained. Consensus can be sought from the sur-
allow prosthesis placement. Some patients have geons, radiation oncologists, and medical on-
required general anesthesia. Besides the major cologists that curative treatment is not possible.
complications of bleeding, perforation, obstruc- Many patients have had recurrence after prior
tion, and severe gastroesophageal reflux, some radiation therapy or surgery. Others are unable
reports have associated stent placement with to tolerate radiation therapy and a few are po-
premature mortality. 9 tentially curable, but nutritional or medical sta-
Gastrostomy, jejunostomy, and pharyngos- tus precludes surgery. Once a course of ELT is
tomy provide effective relief from obstructing chosen, the radiographic studies are reexam-
esophagogastric malignancies. The patient's ined. They will affect technical decisions and
dignity, however, is too often compromised help gauge the number of treatments required.
during his final days. The basic pleasure of eat- A CT scan, for example, can define the extent
ing is forfeited and the patient's self-esteem is of disease. It may show if the wall at an anas-
hindered when it should be fostered. These pro- tomotic site is thick enough to allow ELT with
cedures, as well as the other modalities for a low risk of perforation. Alternatively, it may
palliation of esophagogastric cancer, can each reveal lesions outside the esophagus.
be beneficial in selected cases. Shortfalls and The patient is fasted for 12 hours before each
restrictions, however, have led to the descrip- session. He is reminded that dysphagia may
tion and critical evaluation of ELT as an effec- worsen before it improves, secondary to the lo-
tive adjunct in the palliation of these malignan- cal inflammation and swelling that follows ELT.
cies. These factors make the maintenance of an often
A study by Fleischer et al. 1 only 5 years ago, impaired nutritional status problematic during
was the first to describe the safe and effective long courses of ELT. Based on pretreatment
use of ELT for palliation of carcinoma of the nutritional status, initial lumen diameter, and
esophagus. Their pilot study has formed the ba- tumor length, a judgment is made on the pa-
sis of a much larger experience, so that the Fed- tient's ability to ingest oral feeding during ther-
eral Food and Drug Administration no longer apy. If it is anticipated that ELT will take longer
classifies ELT for obstructing carcinoma of the than 1 week, parenteral nutrition is sometimes
esophagus as an experimental procedure. initiated.
Treatment is almost always initiated as pallia- A screening examination with a small-diam-
tion. Most commonly, symptoms are related to eter endoscope is generally done by the thera-
obstruction or bleeding. The majority of patients peutic endoscopist at an earlier session or just
treated with ELT have undergone previous ra- before the first endoscopic laser treatment. The
diation therapy or surgery. In some cases, ELT point of maximum obstruction is discerned, with
is the only course left, short of feeding gastros- the smallest luminal diameter used as a reference
tomy-jejunostomy. After appropriate instruction point. It is determined where the tumor is,
and experience, ELT is technically easy to per- whether it is predominantly mucosal or sub-
form. The endoscope gives direct visualization mucosal, and if there is a large polypoidal com-
at the margin of the tumor. With the possible ponent, better debulked by polypectomy snare
56 Richard C. Ranard and David E. Fleischer

than by ELT. It is important to know the course treatment to a 180°-270° arc because of the in-
of the lumen just below the area being treated creased risk of postlaser stricture and perfora-
to help guide the laser beam appropriately. tion. The laser beam is fired with the fiber at a
ELT can be performed in a conventional en- 1.0-cm distance from the tumor. Tissue contact
doscopy suite, although practical modifications is avoided with noncontact probes, and it is often
optimize logistics. Optimally, one assistant at- necessary to withdraw the fiber to clean the fiber
tends the patient and assists with the equipment, tip.
and a second assistant records medical obser- Recently, newly developed sapphire tips that
vations. Several commercially produced lasers attach to the distal fiber allow the laser to be
are available. We use a Nd:YAG laser (Cooper used as a contact device. Different tip shapes
LaserSonics or Lasers for Medicine) with a alter the effect so that coagulation, vaporization,
power output of 10-100 W. The Nd:YAG beam and/or excision can be better achieved. With
is preferred to the argon beam. Although the these contact fibers, the laser energy is concen-
latter is more superficial, theoretically reducing trated at the point of interaction between the
the risk of perforation, it does not produce the probe tip and the tissue. Since the energy density
deeper tissue effect and subsequent sloughing will be very concentrated at the tip, much lower
of the Nd:YAG laser, which enables an in- energies can be applied to achieve coagulation
creased volume of tumor to be destroyed at each (8-12 W). There are many appealing aspects to
session. this technique. Its actual role in the endoscopic
Laser energy is preselected and conveyed by therapy of esophageal malignancies is not, as
a quartz waveguide through the biopsy channel yet, fully defined. 13
of a therapeutic endoscope. Fleischer usually The first tissue reaction is a white circular
uses 90-100 W in 2.0- to 2.5-second pUlses. burn where the beam hits tumor tissue. After
Lower powers (40-50 W) have been advocated initial treatment, the tissue will be coagulated
by some physicians who believe that effective and whitish-yellow. With continued treatment
tissue damage can be accomplished at these the tissue is vaporized and blackened. Cavitation
powers and that there is less smoke and de- occurs ifthe laser beam is continuously focused
bris to interfere with vision. Coaxial gas flow on the same site and if the fiber is close « 1.0
serves to cool the fiber tip and clear it of de- cm) to the tissue and the power is high (90-100
bris. The coaxial gas can overdistend the stom- W). As it is not possible to control tissue tem-
ach, causing patient discomfort and vasovagal peratures with currently used endoscopic lasers,
responses, unless the gas can be exhaust- the endoscopist must use visual clues and his
ed. Therefore, rates (20 cc/second) are recom- own experience to determine the tissue effect
mended. of the laser.
The patient is prepared with topical anes- The treatment of tumors of the gastric cardia
thetic, and intravenous meperidine and mida- is similar to treatment of esophageal tumors,
zolam sedation. Secretions may be controlled with some technical differences. The tumor is
with an anticholinergic agent when completely more likely to distort the anatomy, with the lu-
obstructing lesions or extremely proximal le- men more apt to diverge from the vertical axis
sions are present. The patient is placed in the of the esophagus at an acute angle, increasing
standard left lateral decubitus position. the technical difficulty. Functional improvement
In the original technique described by is potentially lessened because food must pass
Fleischer and Kessler, 12 the endoscope is ad- through a rigid aperistaitic, horizontal segment
vanced to the proximal tumor margin. The without the advantage of gravity.
quartz waveguide carrying the laser beam is If the lumen of the malignant stricture of the
passed out and initially directed centrally, aiming esophagus or gastric cardia is markedly de-
at tumor closest to the lumen, then circumfer- creased, a biopsy forceps, ERCP cannula, or a
entially around the luminal opening. The circle laser-resistant guidewire can be passed to act as
of treatment is widened concentrically toward, a probe to map out the luminal pathway. If the
but never directly to, the esophageal wall. If lumen is completely occluded, the treatment is
there is a short submucosal segment, however, more difficult, with increased risk of perforation.
circumferential treatment is avoided, limiting However, as long as tumor protrudes into lumen
8. Laser Treatment of Cancer of Esophagus and Gastric Cardia 57

and lumen can be visualized distal to the treat- effective to just push treated tissue distally with
ment site, the margin of error is wide and the the endoscope or a dilator.
risk of complications lessened. After evacuation of necrotic tissue, subse-
Usually, the first session is completed when quent treatment of tumor is performed. Laser
the superior margin is treated with the cross- treatment is continued until the lumen can per-
section of tumor vaporized. However, if the lu- mit passage of an II-mm endoscope into the
men is wide enough to pass a scope, treatment stomach, or until the patient can eat solid foods.
can be continued at various levels distally during Passage of an ll-mm endoscope usually cor-
the first session. Unfortunately, proximal edema relates clinically with the ability to ingest many
with swelling at the superior margin often pre- solid foods, although the correlation is poor in
cludes this approach. patients with cervical tumors. In his cumulative
Alternatively, ELT may be initiated at the experience, Fleischer required a mean of 3.3
distal tumor margin. The advantage is that when sessions per course of treatment for patients
edema from treatment ensues at the treatment with esophagogastric cancer (unpublished data).
site, the endoscope can be withdrawn proximally Squamous cell carcinoma has required a mean
and treatment can be continued on a longer ver- of 3.6 treatments and adenocarcinoma, primarily
tical segment of tumor. Unfortunately, the lu- arising in the gastric cardia, required 2.8 treat-
men can often accommodate only a single- ments on average.
channel endoscope with its limited capability to Dilatation is performed when necessary 1 to
exhaust smoke and coaxial gas flow. Sometimes, 2 days after the last laser treatment. This may
when the luminal narrowing is marked, there is stretch the lumen still further and may aid in
no option because even the smallest endoscope debridement. Tapered polyvinyl dilators are
cannot traverse the tumor, even with the aid of preferred. They are firmer than Maloney dila-
a guiding device. tors, and may be safer and easier than Eder-
Mter the initial session, succeeding sessions Puestow dilators. 13 A barium swallow is helpful
are carried out at 48- to 72-hour intervals. This after a course of ELT to document improvement
allows a convenience Monday - Wednesday - relative to baseline radiographs and to reveal any
Friday schedule of treatments. This time frame unsuspected perforation.
seems to allow maximal tumor necrosis and is Pietrafitta and Dwyee 4 have reported success
readily tolerated by patients. When the treated in obtaining a patent 13 - to 20-mm diameter
area is observed at 48 hours, it is whitish-yellow, esophageal lumen with a single-session treat-
soft, and necrotic. Serial treatment at less than ment in five patients. After widening the lumen
48-hour intervals does not allow for maximal to 15 mm with Savary-Guillard dilators over a
sloughing of necrotic tissue, and longer intervals guidewire, they advance a 9.8-mm endoscope
unnecessarily prolong the full course oftherapy. into the stomach. Then, retracting the endo-
Before treatment is begun on underlying, pre- scope, starting at the distal tumor margin, they
viously untreated tumor, it is necessary to apply ELT to the entire length of the tumor, us-
evacuate destroyed tumor from the prior treat- ing a Nd:YAG laser with a power setting of 85
ment. Large biopsy forceps, polyp graspers, and Wand a pulse duration of 0.5 seconds. Subse-
polypectomy snares can be employed to remove quently, vigorous debridement is performed with
necrotic tissue, but the softness of the tissue af- biopsy forceps. Four patients tolerated a regular
ter laser therapy limits their utility. Sometimes, diet after a single treatment. One patient re-
endoscopy cleaning brushes and Water Piks are quired two subsequent treatments.
helpful. Multiple retrievals can be anticipated In the first full series on ELT of esophageal
when multiple levels of the tumor have been carcinoma by Fleischer and Kessler,12 14 pa-
treated in one session. In this circumstance, and tients for whom no curative therapy was possible
when the chunks of tissue are too large to be were treated with the Nd:YAG laser. An arbi-
withdrawn through the biopsy channel, an ov- trary grading system to quantitate dysphagia,
ertube can be passed to facilitate removal and odynophagia, and chest pain was used to com-
reduce trauma to the pharynx and cricophar- pare symptoms before and after ELT. All 14 pa-
yngeus. Often, no one method is entirely ade- tients had clinical, endoscopic, and radiographic
quate, and, sometimes, it is quickest and most improvement. All patients could eat solid food
58 Richard C. Ranard and David E. Fleischer

after treatment, while only four could do so be- prognosis for ambulatory patients in comparison
fore treatment. Mean survival was 14 weeks. with the bedridden and anorectic patients who
Although survival compared favorably with fared worse.
other treatments, it must be noted that many Tumor location and length were important
patients treated with ELT had recurrence of tu- determinants of outcome. Outcome was better
mor after surgery or radiation therapy or were for tumors in straight segments of the mid-
not considered suitable for these modalities. For esophagus or distal esophagus, particularly if
many, even dilatation was either no longer ef- they were less than 5 cm in length. Tumors that
fective or was technically impossible. recurred at the anastomotic site after a previous
In a similar group of patients, using historical esophagogastrectomy were particularly easy to
controls, Mellow et al. 15 evaluated the effect of treat and afforded the most dramatic relief be-
ELT on the survival of patients with carcinoma cause the obstructed segment was short. If ob-
of the esophagus. They reported a longer du- struction occurred in a sharply angulated, an-
ration of time free from dysphagia and prolonged atomically distorted site at an anastomosis or
survival when the laser-treated group was com- near the gastroesophageal junction, both the
pared to similar patients treated with radiation technical difficulty and the probability of per-
therapy. They also documented the efficacy of foration were increased. The outcome tended
re-treatment after tumor reocclusion, a mean of not to be as good. Such horizontal, aperistaltic
10 weeks after the initial course of ELT was fin- segments would require food to cross without
ished. the aid of gravity, thereby increasing the like-
In a study by Fleischer and Sivak,16 15 pa- lihood of obstruction.
tients with advanced adenocarcinoma of the Tumors of the cervical esophagus had the
gastric cardia were treated with endoscopic poorest outcome. When the proximal tumor
Nd:YAG laser therapy. Seven patients had been margin is within 3 to 4 cm of the cricopharyn-
explored, but palliative surgery was not believed geus, it can be difficult to know where to deliver
to be possible, and four patients had recurrence treatment. The lumen may not be clearly defined
after prior surgery. All patients had clinical and the maneuverability of the endoscope is
benefit in terms of increased food intake, and lessened, making it difficult to aim the laser
most could eat all foods. On one or two later beam. Risk of aspiration is also greater with
occasions 3 of 15 patients received ELT for re- cervical tumofs. Also, with cervical tumors, it
current tumor reobstructing the lumen, and the is not unusual to have little or no improvement
response to therapy was similar to that of initial in swallowing after ELT, even though stan-
therapy. Mean survival was in excess of 5 dard endoscopes readily pass through the laser-
months, and again similar to that of other treat- treated area.
ments reported in the literature. This exemplifies the difference between tech-
Certain parameters affect the initial outcome nical and functional success, later examined by
of ELT of esophagogastric cancer. Fleischer and Mellow and Pinkas. 18 In their series, 30 consec-
Sivak l7 examined the affect on outcome of tumor utive patients with advanced carcinoma of the
histology and endoscopic appearance, clinical esophagus and gastroesophageal junction
performance status, and tumor location. No dif- underwent palliative ELT. Functional·success
ference in response was discerned between was not an implicit sequela for the 97% of pa-
squamous cell carcinoma and adenocarcinoma tients for whom luminal patency was achieved.
of the esophagus. This is not surprising, as both Functional success as they defined it-the ability
are thermally destroyed. Outcome was better for to ingest all necessary calories and leave the
treatment of mucosal tumors than of submucosal hospital for home-was possible for 70% of pa-
or extrinsic tumors, although the distinction is tients. These figures mirror the experience of
not always precise. The former tend to be ex- Fleischer and his cumulative series of 120 pa-
ophytic and polypoid and, therefore, technically tients with esophagogastric cancer, where 95%
easier to treat. Luminal closure and scarring may had technical success, while 73% had functional
occur more rapidly if the treated tumor is sub- success (unpublished data). This schism was
mucosal. Performance status conferred better greater for adenocarcinoma than for squamous
8. Laser Treatment of Cancer of Esophagus and Gastric Cardia 59

cell carcinoma, probably reflecting the greater evidence of bacteremia or aspiration pneumonia,
percentage of adenocarcinomas involving the suggesting that tissue inflammation and necrosis
gastroesophageal junction. In addition to loca- are the etiologies for these findings.
tion of tumor in the cervical esophagus or gas- While severe pain during ELT is unusual, pain
troesophageal junction, reasons for poor func- can infrequently make patients uncomfortable
tional success are radiation-induced pharyngeal enough to temporarily halt treatment. Pain is
dysphagia, anorexia, painful tumor load, debil- much more common in patients with submucosal
ity, and treatment complications. disease in whom it is necessary to burn through
Procedure-related death and perforation are normal mucosa than in patients with mucosal
the major complications of EL T of the eso- tumor. Additional intravenous meperidine in-
phagogastric lesions. Procedure-related death is variably relieves the pain, but some patients may
rare and was not encountered in Fleischer's cu- benefit from pretreatment with 2% xylocaine
mulative series. In that 120-patient series, there delivered through a sclerotherapy needle. Mild
were 7 (6%) perforations. This is in line with pain after the procedure is handled with a mild
data reported at the Washington Symposium on analgesic. Infrequently, more severe pain may
ELT in April 1985, where 13 investigators re- last for up to 1 week before resolving sponta-
ported perforation rates of 0 to 4%, and 13 in- neously.
vestigators reported rates of 5 to 10%.19 Erosion Minor bleeding can be expected with the de-
of laser-treated necrotic tissue can cause me- struction of friable, malignant tissue during
diastinal or abdominal perforation and tra- EL T. It occurs in approximately 50% of pa-
cheoesophageal fistula. It can occur days to tients, but is easily managed and usually stops
months after ELT. It is often difficult to solely spontaneously. If not, laser coagulation at a
implicate ELT in the etiology of perforations, lower power setting is usually satisfactory. Un-
given that a previous course of radiation therapy , controlled bleeding secondary to ELT was not
or dilatation can also be responsible and that observed in the 120 patients in Fleischer's cu-
they also can occur spontaneously without any mulative series.
treatment. The potential for perloration is higher Gastric overdistension before opening the
when the laser damages the luminal wall, as can esophageal lumen may cause discomfort, va-
be expected with endoscopists inexperienced in sovagal response with bradycardia, or respira-
ELT, or when technical difficulty is great, as tory distress in approximately 12% of patients. 17
when treating the cervical esophagus. Such per- Frequent evacuation of air and turning down the
foration can be avoided by focusing the beam coaxial gas flow can quickly reverse this com-
on the central luminal area, and avoiding, as plication. Aspiration was unusual and was sus-
much as possible, treatment of tumor adjacent pected in only 5 of 120 patients in Fleischer's
to esophageal wall. Conservative treatment with series.
fasting, parenteral nutrition, and antibiotics
often suffices. Tracheoesophageal fistulas re-
quire prosthetic stent placement. Summary
Occasionally, perforation is suspected clini-
cally, as when free intraperitoneal air is seen on Cure of obstructing tumors of the esophagus and
routine postlaser x-rays, but no perforation is gastric cardia is rare. Mter the possibility of cure
found at surgical exploration. This benign pneu- is ruled out, palliation is the primary goal. ELT
moperitoneum may be due to the passage of provides effective palliation with minimization
coaxial gas through necrotic laser-treated tumor of morbidity and mortality. With proper training,
tissue. Therefore, a barium swallow is recom- the technique is easily learned by experienced
mended to confirm suspected perforations. endoscopists. The place of ELT versus modal-
Minor complications that are not uncommon ities for palliative therapy is not as yet fully de-
include low-grade temperature elevations and fined. The focus of further investigation should
milk leukocytosis. In most patients, both resolve be on how these modalities can interface in a
without treatment in less than 24 hours. Blood complementary manner and in what situations
cultures and chest x-rays typically reveal no one treatment is truly preferable to another.
60 Richard C. Ranard and David E. Fleischer

References esophagogastric malignancy by endoscopic posi-

tioning of a plastic prosthesis. Gastroenterol-
1. Fleischer D, Kessler F, Haye 0: Endoscopic ogy 77: 1078, 1979.
Nd:Y AG laser therapy for carcinoma of the 12. Fleischer D, Kessler F: Endoscopic Nd:YAG
esophagus: A new palliative approach. Am J Surg laser therapy for carcinoma of the esophagus: A
143:280, 1982. new form of palliative treatment. Gastroenter-
2. Earlam R, Cunha-Mel0 JR: Oesophageal squa- ology 85:600, 1983.
mous cell carcinoma: II. A critical review of ra- 13. Joffe SN: Preliminary clinical applications of the
diotherapy. Br J Surg 67:457, 1980. contact surgical rod and endoscopic microprobes
3. Earlam R, Cunha-Melo JR: Oesophageal squa- with one Nd:YAG laser. Gastrointest Endosc
mous cell carcinoma: I. A critical review of sur- 31:155,1985.
gery. Br J Surg 67:381, 1980. 14. Pietrafitta J, Dwyer R: Endoscopic laser therapy
4. Kelsen D: Chemotherapy of esophageal cancer. of malignant esophageal obstruction. Arch Surg
Semin Oncol 11: 159, 1984. 121:395, 1986.
5. Kelsen D, Coonley C, Hilaris B, et al: Cisplatin, 15. Mellow MH, et al: Endoscopic therapy for
vindesine, and bleomycin combination chemo- esophageal carcinoma with N d: YAG laser: Per-
therapy of local, regional, and advanced esoph- spectiye evaluation of efficacy, complications,
ageal carcinoma. Am J Med 75:639, 1983. and survival. Gastrointest Endosc 29:165, 1983.
6. Roth J: Personal communication, M.D. Anderson 16. Fleischer D, Sivak MV: Endoscopic Nd:YAG
Hospital, Houston, TX. (1986) laser therapy as palliative treatment for advanced
7. Heit HA, Johnson LF, Siegel SR, Boyce HW: adenocarcinoma of the gastric cardia. Gastroen-
Palliative dilatation for dysphagia in esophageal terology 87:815, 1984.
carcinoma. Ann Intern Med 89:629, 1978. 17. Fleischer D, Sivak MV: Endoscopic Nd:YAG
8. Cassidy DE, Nord HJ, Boyce HW: Management laser therapy as palliation for esophagogastric
of malignant esophagus strictures. [Abstract]. Am cancer: Parameters affecting initial outcome.
J Gastroenterol 76:173, 1981. Gastroenterology 89:827, 1985.
9. Graham DY, Dobbs SM, Zubler N: What is the 18. Mellow MH, Pinkas H: Endoscopic laser therapy
role of prosthesis insertion in esophageal carci- for malignancies affecting the esophagus and gas-
noma? Gastrointest Endosc 29: 1, 1983. troesophageal junction: Analysis of technical and
10. Ogilvie AL, Dronfield MW, Ferguson R, Atkinson functional efficacy. Arch Intern Med 145: 1443,
M: Palliative intubation of oesophagogastric neo- 1985.
plasms at fiberoptic fibreoptic endoscopy. Gut 19. Fleischer D: The Washington Symposium on En-
23: 1060, 1982. doscopic Laser Therapy. April 18-19, 1985. Gas-
11. den Hartog Jagar FCA, Bartelsman JFWM, Tyt- trointest Endosc 31: 397, 1985.
gat GNH: Palliative treatment of obstructing
9
Endoscopic Laser Treatment of
Gastrointestinal Tract Cancer in Japan:
Update
Yanao Oguro and Hisao Tajiri

Owing to the recent advances in gastroente- being performed, especially for gastrointestinal
rologic endoscopy, it has become possible to cancers. The addresses were obtained from for-
treat radically some types of early gastric cancer mer studies, from papers presented in selected
by endoscopic procedures. In 1973, we were the symposia, and from laser companies in Japan.
first in Japan to treat an elevated type of early Answers were collected from 75 institutions in
gastric cancer by endoscopic polypectomy. November 1985. The response rate was 56.4%.
Since then, 12 cases of such lesions have been Of these 75 institutions, endoscopic laser equip-
treated by this method, without surgery, in our ment for use in gastroenterology was available
hospital. Of these patients, 11 have been alive in 66 hospitals.
for more than 5 years, and one died from renal
cancer, independent of the gastric malignancy
treated 6 years ago.) Results of the Studies
In 1978, we began to study laser endoscopy
in the radical treatment of early gastric cancer Endoscopic Laser Equipment
and the recanalization of obstructions of the Available for Gastroenterology
gastrointestinal tract. Endoscopic laser treat-
ment for these malignancies has now been per- In November 1985 there were 82 endoscopic
formed in many hospitals and medical institutes lasers in use for gastroenterology in Japan, of
in Japan. which 63 were Nd:Y AG lasers (Table 9.0.
In April 1981, the Laser Endoscopy Com- Compared with the June 1984 study, there was
mittee of the Japan Society for Gastroenterol- an increase of 20 lasers: 19 Nd:YAG and one
ogical Endoscopy (Chairman: Yanao Oguro) N 2 -dye. The number of argon and/or argon-
began a study of the current status of laser en- dye lasers, remained the same 15 in both stud-
doscopy, especially for the treatment of gas- ies.
trointestinal cancers, throughout Japan. 2 Sub-
sequent studies were performed in November Endoscopic Laser Treatment for
1982/ in June 1984, and in November 19~5. The
results of the last study is reported here, com-
Gastrointestinal Cancers
paring it to former studies. As of November 1985, 1558 cases of gastroin-
testinal cancer had been treated by laser en-
doscopy in Japan, an increase of 569 cases since
Method of the Studies the June 1984 study. Radical treatment was per-
formed in 1076 cases (an increase of 311 cases),
Questionnaires were mailed to 133 hospitals and of which, 963 cases were gastric cancer. Symp-
institutes, where endoscopic laser systems were tomatic and/or palliative treatment was admin-
available and endoscopic laser treatment was istered in 482 cases (an increase of 228), and, of
 62 Yanao Oguro and Hisao Tajiri

TABLE 9.1. Laser apparatus in digestive endoscopy these, recanalization was peIformed in 327 cases
No. of (Table 9.2).
Type of laser Manufacturer Units
Nd:YAG MBB 30 Radical Treatment with Laser
Molectron 25
Olympus 3 Endoscopy for Early Gastric Cancer
Aloka 3 and Its Lymph Node Metastasis
Pentax
Fujinon Endoscopic laser treatment for early gastroin-
subtotal 63
testinal cancers may be indicated for the follow-
ing two conditions: (1) absence of lymph node
Argon or Argon dye Spectra Physics 6
Lexe1
or distant pletastasis, and (2) complete vapori-
3
Coherent Radiation 4 zation of the cancerous lesion by laser irradia-
Cooper Medical 2 tion. As shown in Table 9.3, we studied the fre-
subtotal 15
quency of lymph node metastasis in early gastric
cancer cases after radical laser irradiation, in
Krypton Spectra Physics 2
which there was no residual carcinoma in the
N2-dye Molectron surgically removed stomach. Of 68 patients who
Cooper Medical
had been surgically treated for early gastric
Total 82 cancer, there were 3 cases (4.4%) with lymph
November 1985, Japan. node metastasis, all being the type IIc early gas-
tric cancer. These three cases give a 7.7% in-
cidence for the group of 39 cases of IIc having
TABLE 9.2. Laser treatment for gastrointestinal lymph node involvement. According to these
cancer results, the frequency of lymph node metastasis
Treatment Site No. of cases is higher in IIc with an ulcer or ulcerous scar
Radical (Curative) purpose Esophagus 54
(VI), than a IIc without ulceration. Therefore,
Stomach 963 the indication for radical laser endoscopy treat-
Colon 52 ment for IIc type with VI should be determined
Others 7 carefully.
Subtotal 1076 According to our pathologic study on the sur-
Palliative, symptomatic Bleeding 102 gically operated cases with early gastric cancer, I
Stenosis 327
Others
there was no lymph node metastasis nor distant
53
metastasis in the following four types:
Subtotal 482
1. Pedunculated polypoid type (type I) of early
Total 1558 gastric cancer, restricted to the mucosal layer
November 1985, Japan. only

TABLE 9.3. No residual carcinoma in surgically removed organs, after

radical irradiation with laser endoscopy
No. Lymph node Percentage of
Type of of metastasis (+) lymph
Site carcinoma cases (+) (- ) node metastasis
Esophagus Superficial 2 2 0
Stomach 4 4
lIa 19 19
lIa + IIc 2 2
lIc 39 3 36 3/39 = 7.7%
lIc + III 4 4
Total 68 65 3/68 = 4.4%
Colon 2 2 0

November 1985, Japan.

9. Endoscopic Laser Treatment of GI Cancer in Japan 63

TABLE 9.4. Radical endoscopic lasar treatment of early gastric

cancer
No. of patients in each group
Group Group Group Total
Laser A* B** Ct patients
Nd:YAG 325 88 349 762
Argon 9 2 0 II
Argon + HpD 1 0 4 5
Argon-dye + HpD 28 2 50 80
Others 3 5 9
Total 364 95 408 867
Percent 42.0 11.0 47.0 100.0
November 1985, Japan.
HpD = hematoporphyrin derivative.
*Negative biopsy more than 1 year after treatment.
**Positive biopsy I year after treatment.
tEvaluation pending-less than 1 year follow-up.

2. IIa type of early gastric cancer, less than 3 Results of Endoscopic Laser
cm in diameter Treatment for Early Gastric Cancer,
3. Gastritis-like early gastric cancer, less than 2 for the Purpose of Radical Therapy
cm in diameter
4. Focal cancer
Without Surgery
As shown in the Table 9.4, 867 patients with
The first lesion in the list would be managed early gastric cancer were treated with radical la-
more effectively by endoscopic polypectomy serirradiation without surgery. Among them, 762
than by laser irradiation. However, radical las- cases were treated by Nd:YAG laser, 80 cases
er irradiation is indicated for the remaining by argon-dye laser, 5 cases by argon laser, and
three types of early gastric cancer. Laser irra- 9 cases by the other lasers. More than 1 year
diation with endoscopy can be performed as posttreatment, 364 patients (42.0%) had negative
radical therapy for almost any type of early biopsy (Group A in Table 9.4). In the same se-
gastric cancer, in those patients with other ries, 95 patients (11.0%) showed positive biopsy
serious diseases, those whose advanced age after 1 year (Group B in Table 9.4). Evaluation
prohibits surgery, and those who simply refuse was pending at the time of this writing in ,another
surgery. 408 cases (47.0%) because follow-up was less

TABLE 9.5. Symptomatic endoscopic laser treatment for gastrointestinal

cancers
Symptom Effective Noneffective Total Effectiveness (%)
Bleeding 76 26 102 74.5
Stenosis 64.6
Esophagus 41 28 69
Cardia 55 19 74
Pylorus 35 36 71
Stoma 44 8 52
Others 42 28 70
Subtotal 217 119 326
Tumor reduction, etc. 33 II 44 75.0
Total 326 156 472 69.1
November 1985, Japan.
64 Yanao Oguro and Hisao Tajiri

TABLE 9.6. Complications resulting from accidents, endoscopic laser irradiation

gastrointestinal cancers
Type of treatment Pyloric Death Total no. of
for accident Bleeding Perforation stenosis by laser accidents
Laser hemostasis 4 4
Nonsurgical 19 19
Surgery 6 8
Ethanol injection 2 2
Others 2
Total 32 2 0 35
Total treated cases 1558
Percent 2.0 0.1 0.1 0 2.2
November 1985, Japan.

than 1 year (Group C in Table 9.4). The high tion we experienced 35 complications. The most
percentage of pending results attests to the re- frequent complication was bleeding encountered
cency of laser treatment for early gastric cancer. in 32 cases (2.0%). There were two cases of
pyloric stenosis and one perforation. Most of
the complications were treated nonsurgically;
Result of Symptomatic Treatment with a few required surgery, laser hemostasis, eth-
Laser Endoscopy for Gastrointestinal anol injection, or other methods (Table 9.6).
Cancers There were no deaths as a result of a complica-
tion.
As shown in Table 9.5, laser photocoagulation
was performed in 102 cases of cancer-related gas-
trointestinal bleeding with 74.5% success. Laser
endoscopy for obstruction caused by cancer
ofthe esophagus, cardia, pylorus, stoma, and oth-
er sites was performed in 326 cases, with 64.6%
success overall. Laser endoscopic irradiation
References
for the purpose of tumor reduction, and so on, 1. Oguro Y, et al: Endoscopic treatment of early gas-
was performed in 44 cases, with 75.0% success. tric cancer:polypectomy and laser treatment. Jpn
J Clin Oncol 14(2):271-282, 1984.
2. Oguro Y, et al: Collective studies on gastroenter-
Complications of Endoscopic Laser ologicallaser endoscopy in Japan. Prog Dig Endosc
Irradiation for Gastrointestinal 19:62-64, 1981.
3. Oguro Y, et al: Present status of laser medicine
Cancers
and laser endoscopic treatment for cancers of gas-
In our series of 1588 patients with gastrointes- trointestinal tract in Japan. Prog Dig Endosc
tinal cancer treated by endoscopic laser irradia- 26:152-157, 1985.
10
New Modalities of Contact Nd:YAG Laser
Endoscopy for General Application in the
Gastrointestinal Tract
Sohtaro Suzuki, Jun Aoki, and Takeshi Miwa

It is generally recognized that fiberoptic endos- Contact Irradiation with SLT

copy has both diagnostic and therapeutic uses (Surgical Laser Technologies Inc)
and is one of the most common procedures in
clinical gastroenterology. In the last decade, Endoprobes®
several endoscopic modalities for the treatment
of gastrointestinal hemorrhage and neoplasms Properties of Endoprobes
have been applied clinically. They include laser Newly developed SLT contact endoprobes are
irradiation, 1-5 electrocoagulation,6 topical injec- made of a ceramic obtained from Al 20 3 powder
tion, sclerotherapy, thermoprobes,7 and intu- (Surgical Laser Technologies Melvel, PA and
bation of prosthesis. 8 All of these procedures Japan Co. Ltd,). Many of the physical charac-
naturally have both advantages and disadvan- teristics of aluminum oxide are advantageous for
tages. Laser endoscopy is an unique procedure. medical equipment: high melting point, low
Since the middle 1970s, Nd:Y AG lasers have thermal conductivity, high mechanical strength,
been applied using the noncontact method with hardness, and good transmission of the Nd:YAG
the optical quartz fiber. 1-5,8.9 There are distinct laser beam compared to that of the quartz fiber.
disadvantages of noncontact irradiation, such as It is easy to produce several different probe
the difficulty in keeping a constant distance from shapes to get a number of divergent angles and
the tip of the quartz fiber to the lesion, allowing power densities with this transparent new ce-
reliable tissue changes to occur related to the ramic material (Figure 10.1). These endoprobes
applied power. Furthermore, the quartz tip will can be screwed into a metal universal connector
be damaged when it comes into contact with tis- attached to the tip of a quartz fiber. The outer
sue or blood, To overcome these disadvantages, diameter of the tip is 2.2 mm, and so is able to
the SLT contact method® with SLT endo- pass through the biopsy channel of a standard
probes® directly connected to the quartz fiber upper gastrointestinal fiberscope (Figure 10.2),
was developed following reports of experimental
research with the surgical probe, which was Histologic Findings with Contact
made of new ceramic materials,I{}-12 We initiated
experimental and clinical studies of endoscopic
Endoprobes
Nd:YAG laser therapy, comparing the new SLT One to two weeks after Nd: Y AG laser exposure,
contact ceramic endoprobes with the single the canine stomach was removed and fixed in
noncontact quartz fiber endoprobes, in order to 10% formalin. Each irradiated lesion was sec-
evaluate the histologic effects and safety of each tioned into 5-mm slices to select the central area
method. In this chapter, we discuss the possi- of deepest injury for histologic examination. The
bilities of the clinical application of SLT contact histologic findings were studied by hematoxylin-
endoprobes as a new endoscopic modality in the eosin staining and Elastica-van Gieson staining 13
gastrointestinal tract. 13-16 (Figure 10.3),
66 Sohtaro Suzuki, Jun Aoki , and Takeshi Miwa

(1) Rat Probe (2) Rounded Probe (3) Conical Probe (4) Frosted Probe (5) Chisel Probe

(photocoagulation) (vaporization)
( Interstitial )
Irradiation (hyperthermia) Iincision)
excision

quartz
fiber
L--.rJ
0

,-0 ~
8= 80' - 100'

FIGURE 10.1. Contact method of laser endoscopy: type and beam divergence of endoprobes.

Effects with the SLT Flat Probe® and the duced transmural damages and might lead to
SLT Rounded Probe® excessive penetration and perforation of the
gastric wall.
The histologic examination of the canine gastric
wall showed that photocoagulation and vapor-
Effects with the SLT Chisel Probe®
ization through the mucosal layer to the sub-
mucosal layer occurred from contact irradiation Irradiation with the chisel probe at a power of
with the flat probe and the rounded probe, with 20 Wand a duration of 1.0 to 2.0 s.econds can
less than 20 W power and a short pulse (1.0 to incise the mucosal surface with less hemorrhage.
2.0 seconds) duration. We reported earlier 13 that This procedure may be applied for the recanal-
high-power contact irradiation->30 W-with ization of benign or tumorous strictures, and
continuous pulse (>3.0 seconds) duration pro- mucosal incision or excision for complete biopsy

I 2
IIII II J I FIGURE 10.2. Contact en-
doprobes.
10. Contact Nd:Y AO Laser Endoscopy for 01 Tract 67

(1) Flat Probe (2) Rounded Probe (3) Conical Probe (4) Frosted Probe (5) Chisel Probe
(photocoagulation) (vaporization) [ Interstitial ) (hyperthermia)
Irradiation (incision)

m
~----------~~------

FIGURE10.3. Histologic effects on canine gastric wall with contact method ofNd:YAO laser. m, mucosa; sm,
submucosa; pm, proprial muscle.

of submucosal tumor in the gastrointestinal sis in the submucosal layer, mucosal edema
tract. and hyperemia (Figures 10.4 and 10.5).

Effects with the SLT Frosted Probe®

Clinical Application
Interstitial irradiation with the frosted probe l4
effectively stops bleeding and reduces local Photocoagulation with the flat probe is easier
hyperthermia (laserthermia) with lower power and safer to use than the noncontact endoprobes
«5 W) and longer continuous duration (5 to 20 for controlling the irradiation depth and area in
minutes). Among the remarkable histologic relation to the exposed power and duration.
changes after low-power interstitial irradiation Therefore, the flat probe may be indicated for
were intravascular coagulation and thrombo- all types of gastrointestinal diseases, such as

..... ,.- ..
,
~

'
~" ... ..... ""_. ~ .,...
: ..""
-
'. . • , .... f.

: !,"'• • • •.
, ..
...... ..
"--.J.:.. ~

FIGURE 10.4. Soon after laserthermiafor 5 minutes, mucosal edema and hyperemia were apparent. (Hematoxylin
and eosin, x 20).
68 Sohtaro Suzuki, Jun Aoki, and Takeshi Miwa

- ...:
'- .. -. ...
- .. ". '"' '"'t-
--'.
-'-."
.- - -:-'"
.... -.
... " .... ~ .... -~-;. . --~.

.... "
~

~': '.
-~.
.'
'"- ' ....

FIGURE 10.5. Soon after laserthermia, intravascular coagulation in the submucosal layer without ulceration was
seen. (EVG, x 112).

depressed or protruded lesions. Vaporization a case of gastric ulcer hemorrhage caused by

with the rounded probe can reduce the tumor stress.
mass. From August 1980 to June 1986, we treat-
ed 50 patients-63 lesions-with the Nd:Y AG
endoscopic laser as initial therapy. These pa-
tients had contraindications for surgery because
Endoscopic Laserthermia®
of associated diseases. Noncontact irradiation
According to S.G. Bown,17 Nd:Y AG laser hy-
was administered to 30 of the lesions: 2 esoph-
perthermia can be induced by placing a bare
ageal superficial cancers, 10 adenomas, and 9
quartz fiber into the tumor tissue. We have been
early gastric cancers. In this group, 21 lesions
studying Nd:YAG laser hyperthermia (Laser-
(70.0%) were effectively cured. In another group
thermia®) with the SLT contact endoprobe,
of 19 lesions-l superticial esphageal cancer, IS
which has a conical shape and diffused laser
adenomas, and 3 early gastric cancers-irradi-
beam on its surface, at a low-power density of
ated with contact endoprobes, 16 lesions (84.2%)
about 0.05 W/cm 2 for I W of total irradiated
were cured. The local curative rate by the con-
energy.
tact endoprobe method was 14.2% higher than
the curative rate by the conventional noncontact
method. Computer-Controlled Laserthermia
Other clinical benefits of this new modality of
the contact method are as follows: One case of
System@
pyloric stricture due to a peptic ulcer and four We developed the computer-controlled endo-
cases of a submucosal tumor in the middle scopic contact N d: Y AG laser systems for lo-
esophagus were treated and diagnosed by ex- cal interstitial hyperhermia. 14 This system is
cisional procedures with the chisel probe, and shown in Figures 10.6 and 10.7. The measur-
interstitial irradiation with the frosted probe in ing of the tissue temperature with the thermo-
10. Contact Nd:Y AG Laser Endoscopy for GI Tract 69

FIGURE 10.6. Computer-controlled

Nd:Y AG laserthermia system. (-)
.Ir----
Keyboard
--,.
I
.
Nd:YAG laser system; (---) control and
monitor system. (- - - - -) computer
L-._+ __ ,
---1

system.
r------, 1'--+----, r--' - '-'
i- . ~
Printer CPU t-- -.....; Display i
L _____ --i L--T- .J L __ .__ -.i

~
r-- -------
I
-----------------, ,

Interface :

,
I ,

L - - - -I - - - - - - - - - - - - - -l- - - -- ~
,I

Nd- VAG laser

r---------, r----!.----,
, I
: ON/OFF : A/D converter :
controller ,
L _________ J
:...----f----~

!
I

,,
I
I

I
r - - _ .. .L - - - - ,
Laser power High speed
optical : Thermosensor :
attenuater : amplifier :
shutter L __ ______ .. _J

i,
I
,.. ____________ J

Interstitial Contact Probe Thermosensor

Mucosa

couple was confirmed by comparative studies appeared in the submucosal layer. Two weeks
of simultaneous measurements from the thermo- after the procedure the mucosal surface was
couple and the thermogram showed no inter- covered with thin regenerating epithelium, and
ference during the low-power Nd: Y AG laser fibrosis and thrombosis was seen in the sub-
irradiation. mucosal layer around the irradiated area, about
The control mode for temperature with laser 1.0 cm in width (Figure 10.9).
delivery is shown in Figure 10.8. For the first
stage of irradiation by laserthermia, laser energy Application to an Experimental
was delivered continuously from the basal tem-
perature of the subject until the "lower control
Gastric Tumor
temperature" of 42.0 or 43.0°C was reached. The computerized laserthermia system was ap-
When the tissue temperature reached the "upper plied to an ENNG-induced gastric tumor in
control temperature" of 43.5°C, it stopped de- Beagle dogs. Thermal control of this system was
livering laser energy. During the laserthermia stable and safe with a power of 3 W for a du-
treatment, this control pattern was carried out ration of 20 minutes (Figure 10.10). Laserther-
in the operating mode. mia was repeated at 2-week intervals. Each ses-
sion was performed for 20 minutes at
temperatures between 43.0 and 43.SOC with a
Histologic Findings
laser power of 3 Wand 0.5-second pulse du-
For 5 to 10 minutes after laserthermia, wide su- ration. The size of the tumor reduced during
perficial mucosal edema and hyperemia (Figure these procedures, eradicating the largest tumor
10.4) developed, and intravascular coagulation which was 3.0 cm in diameter after four sessions.
70 Sohtaro Suzuki, Jun Aoki, and Takeshi Miwa

FIGURE 10.7. Computer system with Nd:YAG endo-

scopy .

/
•

Laser delivery ~ I"""

, ON :OFF:
ON :OFF: ON :OFF: ON :
Continuous' I ~ 1--, ~
Pulse :
_________ ..JI
~
I
.. __
I
~ ~__ ..
I
__
I
~ ~

(O . I-5.0sec.):

t
Temp 48
50
Upper abnormal temp.
----.:...:...
ee) 46
Upper control temp.
Lower control temp.

36
34 Lower abnormal temp.

Time_

FIGURE 10.8. Control method for temperature with laser delivery.

10. Contact Nd:Y AG Laser Endoscopy for GI Tract 71

FIGURE 10.9. After 2 weeks , laserthermal irradiation for 5 minutes, 42 .0 ::t J .oce, showed thin regenerating
epithelium and submucosal fibrosis. (Hematoxylin and eosin, x 12).

Date:S5 ~03~lS Sta.Time:l7:1 9:44 End Time : 17 :39 :54

Pat.Num. :053 Name:SG-S24 Bir . :S 61 03 18 Sex :Male
Doc . :S.Suzuk i J.Aoki H.Ma kuuchi Nur.: ....... .. . .. . . ........ .. .. . .
In. Pow. (w)= 3.0 Tot.Jou . (j) =10000 .0 Tot.T ime(m)=20.00 Pul.on=0.5s~off=0.5s
Upper Temp.=43.5°C Lower Temp.=43.0° C Ab .Upp . Temp . =55 .0°C Ab.Low.Temp.=35.0°C
Temp. (0 C) Jou 1e (Xl 0000)
~ 1

50

45 ... : -:_ ~ • . ,·"~'d;~""", . .. , r. . ;'!' .; .:," J'~.'...-.:.<-. .:::.. ~';:'.: •.'!.:.-_,., ... .....:.~ ~ ' , ,-.';"- .. ' • ,,-.,_, .• ~:;....... - ........-., . '.' ,' .... . ," ,'. :_"" -" 0' '-;'-~" '"' ' _" ' •.
.5
./'.:/','\ . . .... ..
:I.!.::--'f. ,'.::.'.-:'[."'., . ...~\••::. (:':~,:. ,:::.;) ~..;.':;...:':,'" : . :.. ~';:;,..-.~./_ '''_~':....:'.:', :....:::.:.~,: ~:.:.\:~ _~;....:::-"- ~.'-!.:.~ ...~~.~ -:;;,..,.: -~.':J; :-~;.:..~: ~. .~-~_._~:.,:;:'~'i;''''''. .,': :'7:);::.:': ~ : ~"¥' .~., ~ -.~ ~.::w-~.
~:~.~':';,.'! ........~,....;~...-(..-:;~.~~ ..;.":'.. :"'-..-"'7-'::J.-....f"".,'..!---.«..~•.~ ......'(,.•.; . ..:;,~ ~-':'.;.; '"!,,-"''fr'!'·:~'~.':I::;;'-=-. ·_·",!·~~·,!~iI.~t',,,:,,;-:~::'·.·:%:'~".):I:-~.~..~v.,,\·4Il.::"_:~:......~_'_~_":'J.,";;.~· ",W.A.::-;·~~~'_~_~~.~"-'
.' .

--~---------~ - --
------ ,--,-_ ... - - -------------- --- ---- -----
~+-~-=-~-·~-~-~~--
-----
- ---+------------~------------~~-----------40
o 5 10 15 Time(min.)
Ela.T ime:20m 05 Res.T ime: 0m 05 Sum Jou . = 1090. 5 Rem.Jou.= 8909 .5

FIGURE 10.10. Computer-controlled Nd: Y AG laserthermia of an experimental gastic tumor.

72 Sohtaro Suzuki, Jun Aoki, and Takeshi Miwa

Discussion erthermia®) with the SLT contact frosted en-

doprobe® as a local curative treatment.
Since the middle of the 1970s, the noncontact It is suggested that wider areas of histologic
N d: YAG laser method with a single quartz fiber damage from the mucosal layer to the middle
has been applied to clinical endoscopy. Although layer of the gastric wall by Nd:YAG laserth-
the Nd:YAG laser for therapy of acute upper ermia with the computer control system will be
gastrointestinal bleeding was effectively he- better able to treat mucosal malignant tumors
mostatic, it was technically more difficult to use in the gastrointestinal tract. As for new modal-
and potentially could cause complications. 1-5 ities of endoscopic laser therapy, the SLT con-
Only 70 to 80% of the patients studied were he- tact method with the various endoprobes makes
mostatically controlled. This was discussed in it possible for applying interstitial irradiation
detail at the symposium "Problems of Hemo- mucosal incision or excision, and local laser-
static Procedures" at the 25th annual meeting thermia either alone or in combination. In ac-
of the Japan Society of Gastroenterological En- cordance with the advance of modern technol-
doscopy (JSGE) in May 1983. There were no ogy, the contact method with endoprobes will
differences reported in the clinical results of the not only make progress in endoscopic modalities
various hemostatic procedures for upper gas- but will also encourage the reduction of price of
trointestinal hemorrhage, whether H 2-recepter the laser equipment leading to even greater util-
antagonists, secretin, laser irradiation, electro- ization.
coagulation, topical injection of absolute ethanol
or epinephrine, and sprays of thrombin or fi-
brinogen were used. Several reasons that no in- References
creased benefits were reported from laser ther-
apy, compared to other endoscopic modalities, 1. Dwyer RM, Haverback BJ, Bass M, Cherlow J:
may be that the noncontact method requires the Laser-induced hemostasis in the canine stomach.
JAMA 231:486-489, 1975.
quartz tip to be at least 1.0 cm from the lesion.
2. Kiefuaber P, Nath G, Moritz K: Endoscopical
About half of the applied energy is lost by the control of massive gastrointestinal hemorrhage by
noncontact irradiation by back scattering . irradiation with a high-power neodymium-Yag
Therefore, a large amount of energy is required laser. Prog Surg 15:140-155, 1977.
for endoscopic noncontact Nd: YAG laser ther- 3. Silverstein FE, Protell RL, Gilbert DA, et al: Ar-
apy. In addition, the tip of the quartz fiber can gon vs. neodymium YAG laser photocoagulation
be damaged upon contact with tissue, blood or of experimental canine gastric ulcers. Gastroen-
fluid during laser exposure. terology 77:491-496, 1979.
It was demonstrated in our studies that the 4. Rutgeerts P, Vantrappen G, Broeckaert L, et al:
SL T contact endoprobes® made of synthetic A new and effective technique of Yag laser pho-
tocoagulation for sever upper gastrointestinal
sapphire, in reference to their various physical
bleeding. Endoscopy 16:115-117, 1984.
properties, including beam divergence and ther- 5. Fleischer D: Endoscopic laser therapy for upper
mal conductivity, have been more effective than gastrointestinal tract disease. Surv Dig Dis 1:42-
the conventional noncontact method with a 53, 1983.
quartz fiber. Deeper histologic effects by low- 6. Sugawa C, Shier M, Lucas CE, Walt AJ: Elec-
power Nd:YAG laser irradiation may be pro- trocoagulation of bleeding in the upper part of the
duced by concentrating the power density and gastrointestinal tract. Arch Surg 110:975-979,
decreasing the backscatter. 11-13 1975.
Although clinical results of endoscopic con- 7. Bate CM, Aziz LA: Electrohydrothermoprobe-
tact laser therapy with SLT contact endo- A simple alternative to laser therapy in the man-
probes® has improved, there are still some re- agement of acute gastrointestinal hemorrhage. Gut
26:477-480, 1985.
sidual areas of tumor tissue after irradiation. It 8. Ogilvie AL, Dronfield MW, Ferguson R, Atkinson
is still difficult to treat certain local lesions cur- M: Palliative intubation of oesophagogastric neo-
atively even if contact irradiation is superior to plasms at fiberoptic endoscopy. Gut 23: 1060-1067,
the effects of the noncontact method. This has 1982.
now led to endoscopic local hyperthermia (Las- 9. Fleischer D, Silvak MV: Endoscopic Nd:YAG
10. Contact Nd:YAG Laser Endoscopy for GI Tract 73

laser therapy as palliative treatment for advanced clinical applications. Gastrointest Endosc 33:282-
adenocarcinoma of the gastric cardia. Gastroen- 286, 1986.
terology 87:815-820, 1984. 14. Suzuki S, Aoki J, Shiina Y, et al: Endoscopic local
10. Joffe SN: Contact Neodymium:YAG laser surgery hyperthermia with Nd-YAG laser-Experimental
in gastroenterology: A preliminary report. Laser study and development of computed thermo-
Surg Med 6:155-157, 1986. system. J Soc Laser Med (in Japanese) 6:347-
11. Suzuki S, Shiina Y, Miura T, et al: Effects of Nd- 350, 1986.
YAG laser radiation on the gastrointestinal mu- 15. Symposium: Problems of hemostatic procedures
cosa. 6th report: Experimental studies with a new Gastroenterol Endosc (in Japanese) 25:1593-1629,
contact type of the YAG laser rod. Gastroenterol 1983.
Endosc (in Japanese) 26:705-710, 1985. 16. Halldorsson TH, Rother W, Langerholc J, Frank
12. Daikuzono N, Joffe SN: Artificial sapphire probe F: Theoretical and experimental investigations
for contact photocoagulation and tissue vapori- prove Nd: YAG-Iaser treatment to be safe. Int
zation with the Nd:YAG laser. Med Instrum Med Laser Symp. 29:3-31, 1979.
19:173-178, 1985. 17. Bown SG: Tumor therapy with the Nd-YAG laser.
13. Suzuki S, Aoki J, Shiina Y, et al: New ceramic In Joffe SN, Muckerheide M, Goldman L (eds):
endoprobes for endoscopic contact irradiation Neodymium-YAG Laser in Medicine and Sur-
with Nd: YAG laser: Experimental studies and gery. Elsevier, New York, pp 59-70, 1983.
11
Contact N d: YAG Laser Treatment of
Gastrointestinal Tract Cancer
Hisao Tajiri and Yanao Oguro

Although general surgery is probably still the contact endoprobe (provided by Surgical Laser
usual modality for most clinicians in the man- Technologies Japan Co., Ltd.) was therapeuti-
agement of gastrointestinal cancer, recent re- cally administered to 31 patients. The clinical
finements in endoscopy have stimulated support details are given in Tables 11.1 to 11.3.
for this tool. Laser endoscopy, in particular, has The treatment performance of the Nd:YAG
become widely used, with excellent results. This laser with contact endoprobe required a power
usage has sharpened an awareness of its indi- output of 10 to 30 W, with a duration of 1 to 2
cations and problems. J seconds. The types of endoprobes used for case
Since 1980, when laser endoscopy was clin- studies 1 to 27, except case 7, were the SLT
ically adopted at our hospital, the number ofpa- Rounded Probe (most frequently used), Flat
tients selected for this therapeutic course for Probe, or Hollow Probe. The frequency of ra-
gastrointestinal cancer has been increasing diation ranged from 100 to 600 times, depending
yearly. As laser endoscopy is still in the stage on the size of the lesion. Case 7 received pho-
of early development, progressive features ap- todynamic therapy with the Frosted Probe for
pear from time to time, and just recently we coagulation and interstitial irradiation. In this
adopted the new synthetic savphire contact en- case, hematoporphyrin derivative (HpD) in a
doprobe. 2 . 3 This chapter reports our study of the dose of 2.5 mg/kg was given intravenously 72
relative advantages of the contact endoprobe hours before the therapy. The argon-dye laser,
(contact method), in contrast to the traditional 300 m W, was radiated at six points on and
noncontact method. around the lesion, 7 minutes each, for a total of
42 minutes. We attempted to treat three cases
of stenosis of postsurgical anastomosis with the
Patients and Methods contact endoprobe after operations on esopha-
geal cancers. We also attempted histologic di-
From 1980 to April 1986 at our National Cancer agnoses of submucosal tumors.
Center Hospital (Tokyo), 81 patients with gas-
trointestinal cancer have undergone treatment
with the use of the endoscopic laser. The types Results
of cancer we encountered were as follows: 8 pa-
tients with superficial esophageal cancer, 55 pa- We used the SLT contact Nd:YAG laser system
tients with early gastric cancer (23 type IIa and to treat 26 of 27 cases of early gastric cancer.
32 type lIc), 15 patients with advanced gastric Photodynamic therapy was administered to one
cancer, and 2 patients with colon cancer. We case in this group (Case 7). All 27 patients had
used the Nd:YAG laser (Medilas, MBB) in 59 macroscopic cancers: 18 cases of type IIc and
cases, the HpD + argon-dye laser (Lexel Model 9 cases of type IIa. The cancers were small-
504) (photodynamic therapy) in 15 cases, and less than 2 cm in diameter (Figure 11.1). Most
a combination of both lasers in 7 cases. The of these patients were elderly, 78% were 65 or
11. Contact Nd:Y AG Laser Treatment of GI Tract Cancer 75

TABLE 11.1. Clinical details of patients with early gastric cancer treated by the
contact method: Resected cases and follow-up cases after more than one year
Age Macroscopic Size Period following
Case no. (years) Sex type Location (cm) therapy (prognosis)*
84 M IIa Corpus post. 1.0 Operation (L)
2** 65 M IIc Remnant 4.0 Operation (L)
stomach
3** 73 M lIa Antrum post. 2.0 16 m (died of heart
failure)
4 57 F IIc Angle less. 1.5 20 (L)
5 77 F IIc Antrum less. 1.0-2\0 19 (L)
6 83 F lIc Angle less. 4.0 18 (L)
7t 85 M IIc Antrum great. 1.5 16 (L)
8 56 M lIc Angle less. 1.0 \3 (L)
9 65 M IIa Corpus less. 1.5 12 (L)
10 72 M lIa Angle ant. 2.0 12 (L)
11 88 F IIa Antrum post. 1.5 12 (L)
12** 65 M IIc Antrum great. 1.0-2.0 12 (L)

May, 1986, National Cancer Center Hospital, Tokyo.

*L, living.
**Both the contact and the non contact methods were used.
tPhotodynamic therapy was used with the Frosted Probe.

older, with various coexisting complications, apparent. However, residual cancer in the sub-
such as heart disease and liver disease, which mucosa was detected in Case 2. The remaining
made them unfit to undergo surgical treatment. 25 cases were followed up as outpatients with
Two patients were subsequently treated by endoscopy and multiple biopsies. More than 1
surgery after the laser treatment, and the re- year had passed since the initial laser treatment
sected specimens were examined histopatho- for 10 of the 25 patients (Cases 3 to 12). With
logically. For Case 1, no cancer residue was the exception of Case 3, there was no recurrent

TABLE 11.2. Clinical details of patients with early gastric cancer treated by the
contact method: Follow-up cases for less than one year
Age Macroscopic Months following
Case no. (years) Sex type Location Size (cm) therapy (prognosis)*
\3 77 F IIc Antrum less. 0.5 1O(L)
14 84 F IIc Angle post. 2.0 9 (L)
15 74 M IIa Corpus great. 1.5 8 (L)
16 74 M IIc Corpus ant. 2.0 7 (L)
17 81 M IIa Corpus post. 1.5 6 (L)
18 65 M IIc Antrum post. 4.0 5 (L)
19** 69 M lIc Remnant 2.0 4 (L)
stomach
20 76 M IIa Antrum less. 1.0 4 (L)
21 57 M lIe Antrum less. 1.0 3 (L)
22 52 M IIc Angle ant. 1.0 3 (L)
23 75 M lIe Antrum less. 1.0 3 (L)
24 63 M lIa Corpus great. 1.5 2 (L)
25** 60 M IIc Corpus post. 1.5 2 (L)
26** 79 F lIc Corpus post. 4.0 I (L)
27** 69 M lIc Corpus post. 4.0 I (L)

May, 1986, National Cancer Center Hospital, Tokyo.

*L, living,
**Both the contact and the non contact methods were used.
 76 Hisao Tajiri and Yanao Oguro

TABLE 11.3. Clinical details of patients administered palliative therapy with the contact Nd:YAG laser
method.
Condition
Age Macroscopic Purpose (power x second
Case no. (years) Sex type Location of therapy x pulse) Result
72 F Borrmann 3 Cardia Alleviation of 15-20 W x 1.5 s x 324 Effective
stenosis
2 61 M Borrmann 3 Cardia Alleviation of 30 W x 1.5 s x 400 Effective
stenosis
3 77 F Borrmann 2 Cardia Alleviation of 30 W x 1-1.5 s x 353 Effective
stenosis
4 74 M Borrmann 3 Cardia Alleviation of 20-25 W x 1-1.5 s x 420 Effective
stenosis
5 88 M After Middle Alleviation of 10-15 W x I s x 40 Effective
operation of esophagus stenosis
esophageal
cancer
6 71 M After Middle Alleviation of 10-15 W x I s x 83 Ineffective
operation of esophagus stenosis
esophageal
cancer
7 40 M After Middle Alleviation of 10-15 W x I s x 67 Ineffective
operation of esophagus stenosis ~ operation
esophageal
cancer
8 40 M Submucosal Antrum Histologic 15 W x 2 s x 5 Confirmed
tumor post. diagnosis (glomus
tumor)

May. 1986, National Cancer Center Hospital, Tokyo.

cancer. For 5 of the remaining 15 cases, less mucosal tumor was done. This was the first at-
than 1 year-after the initial laser treatment, tempt using this method, and for confirmation
residual or recurrent cancer persisted, and the of the histopathologic diagnosis, a local excision
treatment was followed up more than twice. was performed. The tumor was confirmed to be
All of these were the depressed type of can- a glomus tumor, 3 x 3 x 2 cm.
cer. The Chisel Probe and Frosted Probe were
The results of palliative treatments, using the used to treat the stenosis of the anastomosed
contact Nd:YAG laser method, are shown in portion that resulted from the treatment of
Table 11.3. Cases 1 to 4 underwent treatment esophageal cancer in Cases 5 to 7 in Table 11.3.
in order to alleviate the stenosis that extended The recovery of case 5 from the stenosis symp-
from the lower part of the esophagus to the car- toms after the treatment was excellent and it was
dia due to the advanced gastric cancer (Figure not necessary to see him at the hospital for 3
11.2). Total obstruction was imminent. At least months.
one month following the treatment, these 4 pa- Cases 6 and 7 also underwent incision for
tients were freed from intravenous hyperali- treating the stenosis. However, in these cases
mentation (IVH) and were eating normally. Case the stenosis recurred 2 to 4 weeks after therapy.
1 was even released from the hospital and thus In Case 6 the stenotic portion was resected, and
became an outpatient. The Rounded Probe was he is still healthy. Case 7 died of metastatic car-
used for vaporization of this lesion. The treat- cinoma after 3 month~ of this therapy.
ment was successful and excessive tissue dam- When we first used these probes, sometimes
age and other adversities were avoided. In Case we observed mechanical problems between the
8, 1.0 cm of the mucosa around the submucosal probe and its metal sleeve. However, owing to
tumor was cut for histopathologiac diagnosis, the recent improvements in this instrument, no
and a biopsy of the submucosal tumore was more damage has occurred, regardless of the
done. This diagnosis, and a biopsy of the sub- number of times it is used.
11. Contact Nd: Y AG Laser Treatment of GI Tract Cancer 77

of cancers that can be treated most effectively,

focusing mainly on gastric cancers. I. Techni-
cally, since we have clinically adopted a new
material, a synthetic sapphire for the contact
endoprobe, it is possible to state that we have
approached a new stage of progress. 4 . 5 A com-
parison of the contact and the noncontact treat-
ment methods will demonstrate the superior
advantages of the former: (1) reproducible
radiation on the lesion was possible, (2) damage
to the blood or mucous membrane by the tip of
the fiber was avoidable, (3) the time period
needed for treatment was shortened, (4) the
thermal efficiency was high due to less back-
scattering of the beam and low thermal con-
ductivity, thereby reducing the need for high
power, and (5) pain and abdominal distension
was reduced by the use of water delivery instead
of gas.
In order to maintain the low power output
necessary for laser endoscopy, inexpensive and
stable laser generators are now available, for
example, the SLT Contact Laser. In the treat-
ment of early gastric cancers, those portions that
were especially difficult to irradiate with the
traditional noncontact method-for example, the
antrum and the upper part of the corpus or the
cardia, which were radiated in aU-turn tech-
nique-can now be treated with ease.
FIGURE 11 . 1. Type IIa of early gastric cancer (Case 20 Another important accessory is the power at-
in Table 11.2). (Top) Before Nd:Y AG therapy. (Bot- tenuator, which controls the instability of the
tom) After 4 months of therapy . laser and assures the low power, Jess than 10 W
from the Nd:Y AG laser, needed for endoscopic
laser therapy.
According to a nationwide investigation by the
Discussion Laser Endoscopic Committee for the Japanese
Society for Gastroenterological Endoscopy, of
The laser generator was introduced in Japan for the 66 Japanese institutions that treat gastric
use with laser endoscopy in 1978, and from that cancers, 25 have already adopted the contact
time on, much research has been conducted, method as routine, and it has proved to be very
especially on its use for the treatment of gas- effective. 6
trointestinal and bronchial cancers. At our hos- In conclusion, the contact method has many
pital, many patients have recovered from su- advantages over the noncontact method. For
perficial esophageal cancers and early gastric this reason, it should be more widely used for
cancers by laser endoscopy. For some of these laser endoscopic treatment. However, there still
patients , 5 years have passed without the re- remains a need for further improvements con-
currence of cancer. cerning (1) the problems of adhesion of the tissue
However, in regard to the endoscopic laser to the contact laser Tip (or Rod) during the
treatment, there still remain problems concern- treatment and (2) the most appropriate condi-
ing the instrumentation itself, the technique, and tions, such as the precise power and duration,
the selection of materials that will achieve the for this technique. Furthermore, we are now in
best results. Earlier, we reported on the types the process of seeking a highly effective and safe
78 Hisao Tajiri and Yanao Oguro

FIGURE 11.2. Palliative therapy for advanced gastric cancer of the cardia (Case 2 in Table 11.3). (Left) Before
therapy. (Right) After 1 week of therapy.

method for radiation into the tissue and of its contact type of the Y AG laser rod. Gastroenterol
clinical adoption, such as local laser hyperther- Endos. 26:705-710, 1984.
mia using a low-power Nd:Y AG laser. 7 4. Tajiri H, Oguro Y, Hirot'! T, et al: Present status
and problems of photoradiation therapy for gas-
trointestinal cancer. Jpn Soc Laser Med 5:119-124,
1985.
References 5. Tajiri H, Oguro Y, Shiotani H, et al: Laser en-
doscopic treatment of gastrointestinal cancer-A
1. Oguro Y, Tajiri H, Hirashima T: Endoscopic new approach to treatment by using contact probe.
treatment for gastric cancer. Stomach Intest J Jpn Soc Laser Med 6:549-522, 1986.
19:855-863, 1984. 6. Oguro y, Tajiri H, Takemoto T: Present status of
2. Daikuzono N, Joffe SN: Artificial sapphire for laser medicine and laser endoscopic treatment for
contact photocoagulation and tissue vaporization cancers of gastrointestinal tract in Japan. Laser
with the Nd:YAG laser. Med Instrum 19: 173-178, Optoelectronics in Medicine. p.323-327, 1985.
1985. Springer-Verlag (Berlin, West Germany)
3. Suzuki S, Shiina Y, Miura T, et al: Effects ofNd- 7. Tajiri H, Saito D, Ohkura H, Oguro Y: A study
YAG laser radiation on the gastrointestinal mucosa, on local interstitial hyperthermia using low power
the sixth report: Experimental studies with a new . Nd:YAG laser. Oncologia 17:161-163, 1986.
12
Use of Lasers in Nonbleeding
Gastrointestinal Lesions: A European
Experience
J.M. Brunetaud, V. Maunoury, J.P. Ancelin, D.Cochelard, A.Cortot,
and J.C. Paris

Lasers were developed in gastrointestinal (GI) rectosigmoid cancer) or until the lesions (rec-
endoscopy for their hemostatic properties. They tosigmoid villous tumor or rectal polyposis) were
are now used increasingly for tumor destruc- completely destroyed. Then patients with cancer
tion.1. 2 From December 1979 to April 1986, we were re-treated every month, and patients with
treated 409 patients with a GI tumor at the Lille benign lesions were followed up and re-treated
Laser Center. The lasers were used (1) for pal- if new lesions appeared or if there was a recur-
liation of esophagogastric (esophagus or gas- rence of lesions.
troesophageal junction) or rectosigmoid cancers
in nonsurgical patients, (2) for a curative effect
in selected patients with a rectosigmoid villous
Laser Treatment Modalities
adenoma, and (3) for the destruction of small Two types of laser were used for GI endoscopic
sessile polyps in patients with a familial poly- treatment: an argon laser and a Nd:YAG laser.
posis after total colectomy and ileorectal The argon laser was a 770 Lasersonics (Santa
anastomosis. Finally, for a few nonsurgical Clara, California) with a 10-W maximum power
patients with a small esophagogastric or rec- output. The argon wavelength is well absorbed
tosigmoid cancer, the purpose of the laser treat- by the tissue; it was used for vaporization of
ment was to completely destroy the lesion and superficial tumoral zones (until a flat surface was
to obtain negative biopsies. Small lesions were obtained, as delayed necrosis is negligible) at a
defined as a tumor less than 3 cm in length, with power of 8 W, a spot size of 1 mm (power den-
a circumferential extension of the base less than sity: 1000 W/cm 2) with a continuous beam. The
one-third of the circumference, without signs of Nd:YAG lasers were the YM 100 and 101 CI-
infiltration, and primarily exophytic without ul- LAS (Marcoussis, France) with an 80-W max-
ceration. imum power output. The Nd: YAG wavelength
is less absorbed by the tissue than the argon
wavelength. The volume of delayed necrosis
Patients and Methods occurring after noncontact Nd: YAG vaporiza-
tion can be difficult to predict from the mac-
Methods of Treatment roscopic aspect of the tissue during the treat-
ment. 3 Therefore the Nd: YAG laser was used
Patient Preparation
only for coagulation (blanching) of the tumor and
Patients were treated on an outpatient basis, an interval of 3 days to 1 week between two
without anesthesia or sedation. Patients with a treatments allowed the coagulated parts of the
low GI tumor were prepared with a small enema tumor to slough off. Reproducible effects with-
at the Laser Center and no special diet was re- out unexpected necrosis were obtained at 70 W,
quired before the treatment. Treatment was ad- 2-mm spot size (2000 W/cm 2), and 0.7-second
ministered once or twice a week until there was exposure time.
functional improvement (esophagogastric or Only the exophytic parts of the tumor were
80 J. M. Brunetaud et al.

treated by laser. In case of obstructing lesion, a small lesion without dysphagia. Table 12.1
the treatment was preferentially performed from gives the localization of the lesions, and Table
the distal part to the proximal part. For esoph- 12.2 gives the circumferential extension of the
agogastric tumors, when the endoscope was un- tumor bases. C 1 indicates less than one-third of
able to pass through the stenosis, dilatation was the circumference, C2 between one-third and
performed the day before the laser treatment. two-thirds, and C3 more than two-thirds.
In the rectosigmoid, a snare resection was used
to debulk the most exophytic parts of the tumor
121 Patients with a Rectosigmoid Cancer
before laser treatment.
The average age was 79 years (range 51 to 93
years). An advanced tumor was treated in 106
The Laser Fibers patients. Reasons for treatment, localization,
A 200-J.Lm core optic fiber was used for argon and circumferential extension are given in Ta-
laser transmission and a 400 J.Lm (YM 100) or a bles 12.3, 12.4, and 12.5. The main symptom at
600 J.Lm (YM 101) were used for Nd:YAG. In the beginning of the treatment was abnormal
both cases the fiber was protected by a Teflon rectal discharge in 88 patients and obstructive
catheter; the external diameter of the laser probe symptoms in 18. A small lesion was found in 15
was 1.6 mm for upper GI endoscopy and 2.2 patients. The reason for treatment and locali-
mm for lower GI endoscopy. Nitrogen gas was zation are given in Tables 12.3 and 12.4.
injected at a flow rate of 2 liters/minute to pro-
tect the fiber tip. For upper GI endoscopy, 192 Patients with a Rectosigmoid
coaxial gas escaped through the 2.2-mm biopsy
Villous Adenoma
channel of the endoscope, which was maintained
open. For lower GI endoscopy a cannula was The average age was 74 years (range 40 to 93
introduced in the rectum along the endoscope. years). The indications for laser treatment were
In a few cases where the conventional fiber nonsurgical patients (74), a small tumor requiring
reached an esophageal lesion tangentially and major surgery (57), recurrent tumor after a pre-
was difficult to use, a special contact probe with vious nonlaser treatment (56), and patient's re-
a synthetic sapphire (Surgical Laser Technol- fusal of surgery (5). Localization and circum-
ogies, (Melvern, PA, USA) was used with the ferential extension of the tumor base are given
Nd:YAG laser at 15 W. in Table 12.6.

Seventeen Patients with a

Patient Population
Rectal Polyposis
Seventy-Nine Patients with an
The average age was 29 years (range 11 to 48
Esophagogastric Cancer
years). Twelve patients had a familial polyposis
The average age was 71 years (range 46 to 95 and 5 had Gardner syndrome. All patients
years). Sixty-eight patients had an advanced le- underwent colectomy with an ileorectal anas-
sion (60 with dysphagia, 8 without), and 11 had tomosis before rectal treatment.

TABLE 12.1. Localization of the esophagogastric

lesions TABLE 12.2. Circumferential extension of the
Advanced lesions esophagogastic lesions
Advanced lesions
With Without
Localization dysphagia dysphagia Small lesions Circumferential With Without
extension dysphagia dysphagia Small lesions
Upper third 11 0 5
Middle third 6 5 3 CI «,/,) 3 3 11
Lower third 16 3 1 C2 (\rj-"I,) 11 3 0
Cardia 27 0 2 C3 (>"1,) 46 2 0
12. Lasers in Nonbleeding Gastrointestinal Lesions 81

TABLE 12.3. Reasons for treatment in patients with advanced and

small rectosigmoid cancers
Reasons for treatment Advanced lesions Small lesions
Nonsurgical without metastasis 65 II
Nonsurgical with metastasis 15 I
Colostomy and abnormal discharge 16 0
Recurrence after surgery 7 I
Refusal of surgery 3 2

the lesion. In the last patient acute gastric dil-

Results atation occurred during the first treatment,
which required a gastrostomy.
In the 8 patients with an advanced lesion
Results in Esophagogastric Cancers
without dysphagia, 4 died without dysphagia af-
Of the 60 patients with dysphagia, 47 (78%) were ter an average of 3 months, 3 were lost to follow-
improved. The average duration of the initial up, and 1 required a gastrostomy after 1 year.
treatment was 13 days. In 43 ofthe 47 improved Eight of the 11 patients with a small carci-
patients the treatment was ended and the av- nomas had negative biopsies after the treatment.
erage duration of improvement (ADI) after the However, one tumor recurred 6 months later.
initial treatment to recurrence of obstructions In 2 patients negative biopsies could not be ob-
could be recorded. The ADI was 110 days (range tained with treatment, and they were treated by
10 to 886) in these 43 patients. The ADI was 141 radiation therapy. The last patient with a small
days (range 13 to 886) in the 26 patients with an lesion is still under laser treatment.
adenocarcinoma, and 63 days (range 10 to 253) Complications occurred only in the group of
in the 17 patients with a squamous cancer. The patients with dysphagia. This included 2 fistula,
ADI was 48 days for upper third lesions, 44 days 1 fatal hemorrhage, and 1 acute gastric dilata-
for middle third, 95 days for lower third and 149 tion.
days for lesions of the cardia. The ADI was 156
days for a C2 tumor and 94 days for a C3. Thir-
teen patients (22%) presenting with dysphagia Results in Rectosigmoid Cancers
were not improved. In 12 patients the lack of
success was related to a very advanced stage of Of the patients with an advanced lesion, 89%
were improved after an average duration of 18
days for the initial treatment. Treatment was
TABLE 12.4. Localization of advanced and completed in 65 patients and the ADI was 9.4
small rectosigmoid cancers months (0.1 to 38.2). Using life table analysis
Advanced Small 39% ofthe patients are alive at 1 year, with 82%
Localization lesions lesions of them remaining improved. The improvement
Rectum 71 II . rate was higher in surviving patients with initial
Rectosigmoid junction 21 I abnormal rectal discharges (95% at 6 months)
Sigmoid 14 3
than in those with obstructive symptoms (60%).

TABLE 12.6. Localization and circumferential

extension of the 192 villous tumors
TABLE 12.5. Circumferential extension of
Villous Circumferential
the advanced rectosigmoid cancers Localization tumor extension
Circumferential extension Advanced lesion
Lower rectum 51 Cl «Y3) : 87
Cl «IiJ) 15 Middle rectum 71 C2 (11,-%) : 80
C2(y3-2/3) 40 Rectosigmoid junction 38 C3 (>%) : 25
C3 (>%) 51 Sigmoid 32
82 1.M. Brunetaud et al.

Patients with a C 1 tumor did much better than biopsy for carcinoma. However, only 6 had a
the other groups. The 11% failure rate depended true adenocarcinoma. One patient could not be
on the circumferential extension of the tumor: successfully treated. He had a circumferential
no failure in the 15 C1 patients, 1 failure in the lesion previously treated by electrocoagulation,
40 C2 patients, and 11 (22%) in the 51 C3 pa- which resulted in a very tight stenosis. Only a
tients. diverting colostomy could be performed.
Two of the 15 patients with a small rectosig-
moid cancer are still under treatment. Negative
biopsies were obtained in all the 13 others after
Results in Rectal Polyposis
an average treatment duration of 3.7 months. No rectal carcinoma was observed in the 12 pa-
However, 1 patient who had metastasis before tients with familial polyposis. Eleven were reg-
the treatment died 8 months later. The average ularly treated at the Laser Center with an av-
follow-up of the 12 patients with negative biop- erage follow-up of 8.5 years (range 1 to 15 years)
sies is 18.2 months (8-43.3). after the colectomy. One patient was lost to fol-
Three complications occurred in the group of low-up 10 years after the colectomy. Among the
patients with advanced rectosigmoid carcinoma. 5 patients with Gardner's syndrome, 2 were lost
This includes perforation at the rectosigmoid to follow-up 1 and 1.5 years after colectomy, 2
junction which proved fatal, 1 perirectal abscess, have been regularly followed for 2 years, and
and 1 rectovaginal fistula. the last patient required a proctectomy 5 years
after the colectomy for an adenocarcinoma. No
complication occurred in this group of patients.
Results in Rectosigmoid Villous
Adenomas
Treatment was incomplete in 52 patients, 8 pa- Discussion
tients were lost to follow-up, 14 died from an-
other etiology during the treatment and 30 are Our technique of using both argon and Nd:Yag
still under treatment. The treatment was suc- lasers is rather unique. The use of the argon laser
cessful for 131 patients, with an average of 22.6 in GI endoscopy is not common, probably be-
months follow-up (0.2 to 61.6). Among them, 12 cause the purchase of a second laser is found
had a recurrence after an average period of 7.9 too expensive by most of the gastroenterolo-
months, which was easily re-treated, .and 7 had gists. The mUltidisciplinary use of lasers 4 is a
a stenosis. However, only 2 stenoses were symp- solution in sharing the expenses with other spe-
tomatic and required dilatations. No perforation cialties, and to have the appropriate laser wave-
or massive hemorrhage occurred. The circum- length for each particular lesion. In fact, those
ferential extension was the main factor that in- who have access to an argon laser5 appreciate
fluenced the duration of treatment and the fre- the absence of delayed effects, risk of perfo-
quency of recurrence and stenosis (Table 12.7). ration, and thermal stenosis.
In 8 ofthe 192 patients with a villous adenoma, The method of using the noncontact N d: YAG
treatment was discontinued because of a positive laser is also controversial. Some vaporize the
tissue with a very high-power density (over
10,000 W/cm 2).6 We prefer to coagulate with a
TABLE 12.7. Influence of the circumferential lower power density (between 1500 and 2000 WI
extension of the tumor base on the treatment cm2) and wait until the coagulated areas slough
duration and on the percentages of recurrences and off. Others7 ,8 have an intermediate position; they
stenosis in patients with rectosigmoid villous coagulate the small lesions with the Nd:YAG
adenomas and vaporize the larger ones.
Treatment Our ambulatory treatment without special diet
duration Recurrences Stenosis
(5)
or medications is well adapted to our population
Extension (months) (%)
of elderly patients. Among the 409 patients of
CI 3.1 8.6 2.9 this study, only 16 (4%) were lost to follow-up
C2 5.3 6.3 4.2
C3 9.2 23.1 23.1 during the treatment. Our treatment technique
(association of argon and Nd:YAG lasers, and
12. Lasers in Nonbleeding Gastrointestinal Lesions 83

limitation of the Nd:YAG laser effects to co- suIts were reported by others. II - 14 However,
agulation is also safe. Major complications oc- possible local or regional spread of these tumors
curred in only 9 of our 409 patients (2.2%). They cannot be detected, and their endoscopic treat-
consisted of 5 perforations (3 fistulas, 1 peri- ment is limited to nonsurgical patients.
rectal abscess, and 1 free perforation), 1 hem- A large proportion of patients with a villous
orrhage, 2 stenoses, and one complication from adenoma were difficult cases with 55% having
the gas insufflation (acute gastric dilatation). a large lesion (C2 and C3) and 30% had a re-
Two complications (0.5% of the patients) were currence after previous nonlaser treatment.
fatal due to a free perforation and hemorrhage. However, all patients (except one) with a suc-
The major complications occurred only in ad- cessfully completed treatment were cured by the
vanced cancers or large villous adenomas. The laser treatment. These results are slightly better
complication rate was 6% for esophagogastric than those from Mathus-Vliegen and Tytgat, 5
cancers, 3% for the rectosigmoid cancers, and who have only a 40% cure rate in almost the
1% for the rectosigmoid villous adenomas. The same type of lesion. Six malignancies (3%) oc-
complication rate for esophagogastric treatment curred in our series. Mathus-Vliegen had also
is similar to that of Fleischer and Sivak9 or to a the same problem with a higher rate of 20% of
European survey of 326 patients. 10 The compli- malignant degeneration. Therefore it is impor-
cation rate for rectosigmoid cancers or villous tant to get adequate histology before tumor
adenomas is smaller than the 10% reported by treatment, using a large snare biopsy or resec-
Mathus-Vliegen and Tytgae· 8 tions. We also select our patients and we limit
The 78% immediate success rate in palliation the indications as mentioned above in the pa-
of obstructive esophagogastric cancer is similar tients' population paragraph.
to that of Fleischer and Sivak's study.9 The av- The management of patients with a previous
erage duration of improvement is short (110 resection and ileorectal anastomosis for familial
days), but it parallels the patients' survival, and polyposis is more difficult. The risk of malig-
gastrostomy could be avoided for most patients. nancy, even in patients regularly treated, is not
Radiation therapy was combined with the laser negligible. One patient developed a carcinoma
treatment of squamous cancers whenever it was 5 years after colectomy. Laser treatment has the
possible. However, in contrast to Fleischer's same limitations as electrocoagulation in this
experience, our results are better in adenocar- type of condition. Its main advantage over elec-
cinomas (ADI: 141 days) than in squamous can- trocoagulation is the excellent quality of healing
cers (ADI: 63 days). without scarring, as demonstrated by Mathus-
The 89% immediate success rate in palliation Vliegen and Tytgat. 8
of advanced rectosigmoid cancers was not sig-
nificantly dependent on the initial symptoma-
tology. However, at 6 months, 95% of surviving
Conclusions
patients with previous abnormal rectal discharge
Endoscopic laser treatment is a safe and effec-
and 60% of those with obstructive symptoms
tive technique for the treatment of sessile GI
remained improved. Mathus-Vliegen and Tytgaf
tumors. The main disadvantage of the lasers re-
and Escourou and co-workers lO ,1I have, respec-
mains their higher price, which can be lowered
tively, an immediate success rate of 93% and
by a multidisciplinary use. In the future, newer
100% in hematochesia and 83% and 67% in ob-
techniques like the large multipolar probe l5 may
structive symptoms. The laser treatment appears
be available for tumor destruction. However,
to be somewhat more effective for patients with
endoscopic laser therapy is the most feasible
predominant hematochesia than for those with
technique for treatment. Its safety and efficacy
obstructive symptoms.
having been proven in many studies including
A complete local destruction with negative
our own results in 409 patients.
biopsies of small esophagogastric os rectosig-
moid cancers can be achieved by endoscopic
laser treatment. This result was obtained by in References
7 of 9 upper gastrointestinal lesions and in all 1. Jensen DM: Lasers in the GI cancer war and other
the 13 lower gastrointestinal lesions. Similar re- fronts. Gastroenterology 87:974-976, 1984.
84 J .M. Brunetaud et al.

2. Fleischer D: Lasers and colon polyps. Technology ation of its safety, usefulness, and efficacy. Gas-
and pathology: The courtship continues. Gastro- troenterology 90: 1865-1873, 1986.
enterology, 90:2024-2025, 1986. 9. Fleischer D, Sivak M: Endoscopic ND:YAG laser
3. Brunetaud JM, Mosquet L, Houcke M, et al: Vil- therapy as palliation for oesophagogastric cancer.
lous adenomas of the rectum: Results of endo- Gastroenterology 89:827-831, 1985.
scopic treatment with argon and Nd:Yag lasers. 10. Delvaux M, Escourou J: Complications observees
Gastroenterology 89:832-837, 1985. au cours du traitement par laser des tumeurs du
4. Brunetaud JM, Mosquet L, Bourez J, et al: Or- tractus digestif superieur Acta Endosc 15: 13-17,
ganization of a multidisciplinary laser center. In 1985.
Fleisher D, Jensen D, Bright-Asare P (eds): 11. Escourou J, Delvaux M, Frexinos J, et al: Traite-
Therapeutic laser endoscopy in gastrointestinal ment du cancer du rectum par Ie laser neodyme
disease. Martinus Nijhoff, Boston, 1983, pp 167- Y AG. Gastroenterol Clin BioI 10: 152,...157, 1986.
172. 12. Patrice T, Jutel P, Le Bodic L: Traitement par
5. Dixon JA, Burt RW, Roetering RH, McCloskey laser des cancers intra-muqueux de l'oesophage
DW: Endoscopic argon laser photocoagulation of chez des patients inoperables. Gastroenterol Clin
sessile polyps. Gastrointest Endosc 28: 162-165, Bioi 4:374, 1985.
1982. 13. Oguro Y, Hiroshima T, Tagiri, et al: Endoscopic
6. Naveau S, Poitrine A, Poynard T, et al: Traite- treatment of early gastric cancer, polypectomy
ment palliatif des cancers de I' oesophage et du and laser treatment. Jpn J Clin On col 14:815-820,
cardia par Ie laser Y AG neodyme (essai preli- 1985.
minaire non contr61e) Gastroenterol Clin BioI 14. Lambert R, Sabben G: Photodestruction par laser
8:545-550, 1984. des tumeurs colorectales: resultats precoces.
7. Mathus-Vliegen EM, Tytgat GN: Nd: YAG laser (Abstract). Gastroenterol Clin Bioi 7:59A, 1983.
photocoagulation in gastroenterology: Its role in 15. Johnston J, Quint R, Petruzzi C, Namihira Y:
palliation of colorectal cancer. Laser Med Sci Development and experimental testing of a large
1:75-80, 1986. probe for palliative treatment of obstructing
8. Mathus-Vliegen EM,. Tytgat GN: Nd: YAG laser esophageal and rectal malignancy. (Abstract).
photocoagulation in colorectal adenoma. Evalu- Gastrointest Endosc 32:9, 1986.
13
YAG Laser Therapy for Intractable
Gastric Ulcer
Kazumichi Harada and Masayoshi Namiki

At present a number of excellent therapeutic treatment irrespective of an in- or out-patient

agents including Hz-blocker antagonists have status were handled as cases of intractable gas-
been developed for peptic ulcers. As a result, tric ulcer. The study subjects comprised 30 in-
so-called intractable gastric ulcers have come to dividuals, 23 males and 7 females. Twenty-seven
be encountered less frequently, though there are patients showed relapsed ulcer, whereas 3 had
still some cases of gastric ulcer with repeated had no previous history of ulcer. The patients
relapse and recrudescence that follow an in- ranged from 48 to 70 years of age with a mean
tractable clinical course. We have been applying of 55 years. As to the site of gastric ulcer, the
endoscopic local injection therapy for the treat- lesion was found in the angulus area in IS pa-
ment of intractable gastric ulcers for 20 years. tients, lower corpus area in 6 patients, middle
U sing this therapy, which consists of an injec- corpus area in 3 patients, and upper corpus area
tion of steroid solution and 0.5% Alantoine so- in 6 patients.
lution into the ulcer edge area and base, we have
obtained favorable results. In the present study
we used Y AG laser irradiation in lieu of the in- Methods
jection of steroid solution for the treatment of
intractable gastric ulcer and observed healing in For irradiation of the laser, the YAG laser Model
all cases. In the following, our procedures are 8000 (produced by former Molectron Co., now
described, with a presentation of the cases. incorporated into Cooper Co., USA) was used.
The laser was initially irradiated at a power
of 50 W, which was recently increased to 30 W,
Subjects for I second to several sites (3 to 5 sites) of the
ulcer edge from a distance of I to 2 cm (Figure
In this study, gastric ulcers not showing scarring 13.1). In addition, using an apparatus by which
after more than 3 months of pharmaceutical the laser can be irradiated in contact with the

H, ,H 2 stage A, ,A 2 stage 5 , stage

fi br osis t issue
• points of ir ra diation

FIGURE 13.1. Scheme ofYAG laser treatment for intractable gastric ulcer. No contact method: 30 W, 1 second
per site at 1-2 cm distance. Contact method (by microrod): 10 W, 1 second per site.
86 Kazumichi Harada and Masayoshi Namiki

1.8m/m
2.2m/m

FIGURE 13.2. (Top) SMRP-3. (Bottom) MRP-3. (SLT, Japan).

mucosa, a micro rod (Figure 13.2, SLT, Japan) of the H 2-blocker antagonist, scarring of the ul-
laser was irradiated at 10 W for 1 second to sev- cer was obtained in a mean period of2.6 months
eral sites of the ulcer edge. Use of this microrod after our laser therapy.
has made it possible to apply irradiation to the In 2 cases the ulcer relapsed, indicating that
specific site more precisely. recurrence of the ulcer cannot be prevented even
In most cases, favorable results were obtained with laser treatment. It is considered important
with only 1 day's treatment with the laser. In to take psychological precautions in addition to
only 2 cases was it required to give laser therapy local therapy in order to prevent a relapse. In
twice. none of the cases were any complications that
With respect to antiulcer drugs, the same drug may be associated with local therapy including
as a rule was used before and after laser therapy. laser irradiation therapy observed.

Results Case 1
The left portion of Figure 13.3 shows the case
In all 30 cases of intractable gastric ulcer which of a 65-year-old male who had an intractable ul-
could not achieve ulcer healing despite endos- cer with a marked rand wall in the posterior wall
copic local injection therapy or administration of the upper gastric body. The right portion is

FIGURE 13.3. Endoscopic findings of the intractable gastric ulcer. (Left) Before injection of dye. (Right) After
injection of dye.
13. YAG Laser Therapy for Intractable Gastric Ulcer 87

FIGURE 13.4. Endoscopic find-

ings of the intractable gastric
ulcer. (Left) During laser
treatment. (Right) Four days
after treatment.

a view using the dye contract method which case which was obtained from the edge of the
makes the rand wall more apparent. ulcer before laser irradiation. This manifested
The left portion of Figure 13.4 shows an en- extensive inflammation accompanying fibrosis
doscopic view of laser irradiation with 50 W/ and regeneration of the epithelium. The lower
second on 3 sites of the edge of the ulcers. The portion of Figure 13.8 shows the histology of a
right portion shows an endoscopic view 4 days biopsied specimen which was obtained from the
after irradiation in which the elevated ulcer edge same site 4 days after laser irradiation in which
became lower but the ulcer became larger in the the mucosa manifested marked edematous al-
active stage. terations. This allows the inference that a new
The upper left portion of Figure 13.5 shows healing process might have been initiated for the
an endoscopic view 6 weeks after irradiation and mucosa around the ulcer.
the upper right portion is of 8 weeks after ir-
radiation. The lower portion of Figure 13.4
shows a view 10 weeks after irradiation in which
cicatrization of the ulcer developed. This case
took the longest time in our study but still the
patient recuperated within 3 months.

Case 2
Figure 13.6 shows the case of a 43-year-old male
who had an intractable ulcer in the lesser cur-
vature at the gastric angle. He had no particular
subjective symptoms. The upper left portion of
Figure 13.7 shows the ulcer after laser irradiation
on 4 sites of the ulcer edge with 50 W/second/
site in which the irradiated sites discolored to
white. The right upper portion of Figure 13.7
shows an endoscopic view 4 days after irradia-
tion in which the ulcer became larger and shifted
to the active stage. The left lower portion of
Figure 13.7 was taken 5 weeks after irradiation
in which the ulcer is markedly healed. Eight
weeks after irradiation, cicatrization of the ulcer
developed as shown in the right lower portion FIGURE 13.5. Endoscopic findings of the intractable
of Figure 13.7. gastric ulcer. (Top left) Six weeks after treatment.
The upper portion of Figure 13.8 shows the (Top right) Eight weeks after treatment. (Bottom) Ten
histology of a biopsied specimen of the previous weeks after treatment.
88 Kazumichi Harada and Masayoshi Namiki

FIGURE 13.6. Endoscopic findings

of the intractable gastric ulcer
Small ulcer is seen in the angle.

Case 3 in the active stage. The lower right comer shows

the ulcer 11 weeks after treatment in which a
The upper left comer of Figure 13.9 shows the
scar developed.
case of a 50-year-old man who had an intractable
ulcer in the lesser curvature at the gastric angle.
The upper right comer was taken after laser ir-
radiation on 4 sites of the ulcer edge with 10 WI Discussion
second per site by using microrod. The lower
left comer of Figure 13.9 is the view I week As a treatment for chronic intractable ulcers,
after irradiation in which the ulcer became larger we have employed endoscopic local injection

FIGURE 13.7. Endoscopic findings

of the intractable gastric ulcer. (Top
left) Immediately after laser treat-
ment. (Top right) Four days after
treatment. (Bottom left) Five weeks
after treatment. (Bottom right)
Eight weeks after treatment.
13. YAG Laser Therapy for Intractable Gastric Ulcer 89

FIGURE 13.8. Histological

findings of the biopsy
specimen. (Top) Before
laser treatment. (Bottom)
Four days after laser
treatment.

therapy for 20 years. Two factors are thought turned into a fresh new ulcer for which a new
to contribute to the intractability of these ulcers, healing process can be expected. For this pur-
i.e., general factors including psychosomatic and pose, we injected a steroid hormone to lessen
local factors . In treating ulcers, it is necessary the hardness of the fibrinoid tissue and also in-
to deal pertinently with these two factors. En- jected 0.5% alantoine to facilitate favorable
doscopic local injection therapy is one means of granulation formation.
treating the local factors. After clinical application of the laser began 1.2 ,
In chronic intractable gastric ulcers, the heal- we had the idea to utilize the laser instead of
ing process appears to be hindered by extensive steroids although we have had satisfactory re-
fibrinoid tissue around the edge and extending sults from the local injection therapy. We ex-
to the base. We thought that we could expect pee ted to facilitate the healing process follow-
favorable healing by removing these hard fibri- ing the formation of a fresh new ulcer by laser
noid tissues. This means that a chronic ulcer is irradiation. Generally speaking, ulcers engen-
90 Kazumichi Harada and Masayoshi Namiki

FIGURE 13.9. Endoscopic findings of

the intractable gastric ulcer. (Top
left) Before treatment. (Top right)
Immediately after laser treatment
using microrod. (Bottom left) One
week after treatment. (Bottom right)
Eleven weeks after treatment.

dered by laser irradiation heal within a short pe- the edges of the ulcer was that the edge is the
riod, so our speculation seemed to be rational. site of epithelial regeneration.
In most of the cases of intractable peptic ulcer Studies describing the efficacy of some types
the lesion is relatively small in size (about 5 to of acupuncture laser therapy at low power for
10 mm) and at the healing stage (HI, H 2 ). There- cutaneous ulcer and oral aphta have increasingly
fore, endoscopic observation at 1 week after been published. It is assumed that Y AG laser
laser therapy on our cases revealed that the ulcer also plays a role as a stimulator in addition to
became a fresh one of a little larger diameter the role of providing energy. We are going to
and at the active stage (AI, A 2 ) following treat- investigate further the power of the laser, time,
ment with a mere irradiation by laser to several site of irradiation, etc.
marginal sites of the ulcer. These findings in-
dicate that the laser irradiation may playa role
in the debridement of the old ulcer which has
hardened with fibrosis. As one of the causes to Summary
prevent healing of the peptic ulcer, a decrease
in gastric mucosal blood flow has been enum- A total of 30 cases of intractable gastric ulcer
erated. When the gastric mucosal blood flow at were treated with Y AG laser at a relatively low
the edge of an intractable gastric ulcer was de- power, scarring the ulcer in a mean period of
termined by the H 2-gas clearance method before 2.6 months after irradiation in all cases. We be-
and after laser therapy, it was found that the lieve our method is valuable as a new clinical
blood flow at 1 week after laser irradiation was application of the endoscopic Y AG laser.
increased as compared to the pretreatment val-
ue. This circumstance is also considered ad-
vantageous for the healing process of peptic ul- References
cers. 1. Harada K et al.: YAG laser treatment for intract-
We have described laser treatment for chronic able gastric ulcers. Gastroenterol Endosc 23: 1752-
intractable gastric ulcers for which the healing 1758, 1981.
process was hindered by local factors. The rea- 2. Mizushima K et al.: Laser endoscopy and its clin-
son why we restricted the area of irradiation to ical application. Asian Med J 25:575-595, 1982.
14
Use of the Nd:YAG Laser in
Cholangioscopic Surgery
Teruo Kouzu and Yoshikazu Yamazaki

In recent years cholangioscopy has become a choledoco drainage (PTCD) fistulous tract. We
widely used technique. By the introduction of insert the cholangioscope after having dilated the
the Nd:YAG laser this procedure has come to PTCD fistula to the size of 18 French. We pro-
be used not only in endoscopy but has been ag- ceed to extract small stones that can be seen
gressively applied in the treatment of biliary tractunder the endoscope using the conventional
diseases. In this chapter we focus on the treat- Fogarty catheter, basket forceps, and alligator
ment of biliary tract calculi, using the Nd: Y AG forceps. However, in cases where large stones
laser. In the treatment of hepatolithiasis, the and stones are impacted within the bile duct
most important point to be observed is that with which absolutely refuse to yield and cannot be
whatever method of treatment used, bile duct removed even though graspable by the basket
calculi should leave no residual. As a means for forceps, lasers are used in the performance of
attaining this goal various methods are reported: the lithotripsy. The Medilas YAG laser was used
(1) lithotomy using a wire under fluoroscope l ; in our study. The method oflithotripsy is to first
(2) treatment by various tools used in lithotomy2; make a fistula through the surface of the calculus
(3) lithotomy by Dormia catheter3 ; and (4) lith- by applying the laser. If and when the direction
otomy by steel catheter. 4 There are also many of the stone can be altered we proceed to pro-
reports on lithotomy under direct observation duce multiple holes from a number of angles. In
endoscopy.5-7 In endoscopic lithotomy, the goal a case where we cannot move the stone and can
is to crush impacted calculi and calculi larger only open a single hole on facet, the laser beam
than the diameter of the fistula from which they is used to gradually enlarge the defect that has
are to be extracted and to extract these stones already been made. Then, having enlarged the
without any trauma. Since 1980 we have used hole sufficiently and grasping firmly with the al-
the Nd:YAG laser as a means for lithotripsy ligator forceps, the stone that was so hard it
in cholangioscopic lithotomy and previously could not be crushed previous to the laser ir-
reported on its value and safety. 8 This chapter radiation can now easily be broken into small
discusses recent progress in use of this meth- fragments. We proceed to extract fragments as
od. in the conventional manner. With fragments too
large to be removed, we once again apply added
laser irradiation to the surface and extract the
Method now smaller fragments in the same manner.
There are at the present time two laser irra-
Cholangioscopy is performed while perfusing diation methods: N oncontact irradiation and
with a saline solution or distilled water. In post- contact irradiation. In the noncontact irradiation
operative cases, the route for inserting the cho- method, allowing for a space of 3 to 5 mm be-
langioscope into the bile duct is through the tween the fiber tip and the surface of the cal-
T-tube tract. In a preoperative case or a case of culus, we perform high-power irradiation. In this
recurrence we use the percutaneous transhepatic method we previously constructed a quartz
92 Teruo Kouzo and Yoshikazu Yamazaki

fiber-tip device, but at present we use a digestive and clinical application in gallstone lithotomy
tract fiber tip from which the metal nozzle has and lithotripsy.
been removed. In the noncontact irradiation
method, a 70 W, O.5-second repeated irradiation
for calcium bilirubinate stone and a 70 to 80 W, Results
2-second repeated irradiation for cholesterol
stone are the laser settings used for irradiation. From 1974 to April 1986 cholangioscopic lith-
Contact irradiation is a method in which a syn- otomy was performed in 106 cases. Of these,
thetic SLT contact probe is fitted directly to the there were 27 cases of lithotripsy by laser, 13
quartz fiber tip, when placed in contact with the cases of hepatolithiasis postoperative residual
surface of the calculus, it directly irradiates it. calculi, 5 cases of hepatolithiasis with nonsurg-
As to the shape ofthe contact probe (Surgical ical history, 5 cases of retained stones in the
Laser Technologies, Japan), we learned through common bile duct, and 4 cases of gallbladder
an initial study that the bullet-shaped type is lithotomy.
most suitable for lithotripsy (Figure 14.1). Fur- The cholangioscope is inserted through the
thermore, the shape and size of the probes can T-tube tract. In many cases however, we used
be easily changed. When this contact probe is the PTCD route through the dilated tracts. The
used we can produce a sufficient opening leading success rate of complete cholangioscopic lith-
to a hole in cholesterol stones with irradiation otomy using the Nd:YAG laser was 91.5% (54
of as little as 15 W at pulsed intervals of 1 sec- of 59 cases). Using one of the forceps tech-
ond. This probe's endurance is relatively good, niques, the success rate for complete lithotomy
but with long use it degenerates. When this oc- was only 66% (31 of 47 cases). This indicates
curs, this probe is simply changed and a new that laser gallstone lithotripsy is a much more
one inserted. The SLT laser now used is very successful technique in our institution when both
stable at low power outputs, and we believe it methods were being evaluated simultaneously.
will lead to greater use in the field of research
Case 1
The patient was a 39-year-old man (Figure 14.2).
Upon being diagnosed 4 years ago as a case of
hepatolithiasis, the patient underwent a chole-
cystectomy, a cholodochotomy, and an intra-
operative lithotomy. After the operation, the
T-tube inadvertently slipped out. He was ob-
served as an outpatient, postponing the planned
cholangioscopic lithotomy. Recently, hospital-
ized with pyrexia and abdominal pain, a PTCD
tube was inserted into the right and left hepatic
ducts. In the left duct, several stones were iden-
tified. In addition there was cystic duct dilation
and a large stone in a right hepatic ductule. Di-
lation of the right and left PTCD fistulas was
performed for reaching the right and left hepatic
duct. Laser lithotripsy of the large calculus al-
lowed a complete removal of all stones by cho-
langioscopy over a total of 22 procedures. After
the lithotomy, the right hepatic duct dilation re-
turned to a normal size over time. Insertion of
the cholangioscope into the common duct was
easy. Also, the area thought to be a severe ste-
FIGURE 14.1. The contact rod made from ceramics for nosis before lithotomy, has returned to normal
lithotripsy. after lithotomy.
14. Nd:YAG Laser Use in Cholangioscopic Surgery 93

FIGURE 14.2. (Left) Arrows indicate stones in right and left lobe ofliver before treatment. PTCD = percutaneous
transhepatic choledoco drainage. (Right) After stone extraction by endoscopic lithotomy by Nd: YAG laser
irradiation.

Case 2 and extracted from the gallbladder. During lith-

otomy, part of the fragments passed into the
The patient was a 59-year-old woman (Figure common duct and accumulated in the distal end
14.3). Complaining of pain in the hypochon- failing to pass into the duodenum and an en-
drill urn, she was hospitalized with a diagnosis doscopic papillotomy was added to the proce-
of cholelithiasis. Past history included an ap-
dure. With a total of nine cholangioscopic
pendectomy at the age of 20 years, an explor-
lithotomies and one endoscopic papillotomy
atory laporotomy at 30 years , a reexploration at
removal of the stone and its fragments was
37, an excision of a uterine myoma at 50, an
achieved.
operation for intestinal obstruction at 54 years,
and a mastectomy for breast cancer at the age
of 57 years. With the previous five abdominal
operations, and severe myocardial ischemia it
Case 3
was decided to perform cholangioscopic sur- The patient was a 73-year-old man. He was hos-
gery. Under ultrasound-guided cholecystogra- pitalized with complaints of pyrexia and pain in
phy a larger stone was seen occupying half the the right hypochondrium. With a PTCD from
gallbladder lumen. Dilating the percutaneous the right hepatic duct stones were recognized in
transhepatic cholecyst drainage tract the cho- the common duct and the right and left hepatic
langioscope was inserted. The stone was a ducts and a stricture identified in the right duct
white, 3 cm diameter, cholesterol stone. Using with small stones in its periphery. The left he-
the Nd:YAG laser the calculus was fragmented patic duct and commOn duct stones were easily
94 Teruo Kouzo and Yoshikazu Yamazaki

FIGURE 14.3. (Left) Cholesterol

stone in the gallbladder. PTCCD,
percutaneous transhepatic cho-
lecyst drainage. (Right) After
lithotripsy using the YAG laser
through the PTCCD fistula and
added endoscopic papillotomy.

removed by use of a laser. The right duct stric- ural approach distinguishing those requmng
ture was dilated using the SLT contact probe major operative surgery compared to cholan-
with 20 W for a I-second repeated irradiation. gioscopic lithotripsy. Also, in using the Nd: Y AG
After dilation insertion of a 5 mm diameter cho- laser in lithotrity, progress has been made from
langioscope was possible, and all the stones in the noncontact irradiation method to the SLT
the distal ducts were removed. contact method.
At present both modes are being used. For
example, in a situation where the length of the
Discussion rigid part of a contact rod interferes with the
Recently, bile tract endoscopy has become an irradiation of the calculi surface, we adopt a
increasingly popular mode of therapy. The noncontact mode by using the quartz fiber of
Nd:YAG laser is the instrument of choice in this the tip from which the metal nozzle has been
treatment. In the near future the endoscope is removed. Although the irradiation is performed
also likely to be commonly used for the curative under water, a spark is visible, but there is no
treatment of early bile duct carcinoma, while danger of duct damage in the area of the calculi. 8
cholangioscopic surgery with the use of laser in During irradiation, the point of greatest concern
relieving stenosis and in bile tract calculi lith- is performing the irradiation within a good and
otomy is already quite popular. confident field of vision while simultaneously
Hepatolithiasis requires that there be no res- confirming the depth of the opening made on
idue and the stenotic bile duct must be unob- the surface of the calculus.
structed. Cholangioscopic lithotomy offers a When calculi are found in the periphery of a
new treatment and an alternative to a formal stenotic duct into which a choledochoscope
hepatectomy. Following removal of intrahepatic cannot be inserted, it may be well to insert a
stones, the dilated ducts return to normal and percutaneous transhepatic drainage tube into the
strictures often disappear. We believe in the fu- periferial ductule. From a pathologic study of
ture, assessment of each case will lead to a nat- these stenoses however, it is considered a simple
14. Nd:YAG Laser Use in Choiangioscopic Surgery 95

FIGURE 14.4. (Left) The

stricture of the right he-
patic duct and stones in
the periphery of the
duct. (Right) After dila-
tation with the use a
contact rod.

procedure to dilate it sufficiently to pass a fi- tients requiring this treatment are increasing. It
berscope through.9 The trick in dilating the ste- is hoped that in the future this method will be
nosis with a laser is not to create carbonization adopted for bile duct carcinoma.
on the irradiated area but rather to stop the pro-
cedure when tissue becomes pale. Some two
days later, insert the choledochoscope and per- References
form the lithotripsy becomes possible when
passing a Fogarty catheter through. At this 1. Mahorner H, Bean WJ: Removal of a residual stone
from the common bile duct without surgery. Ann
point, laser irradiation can be performed on all
Surg 173:857-860, 1971.
calculi. 2. Mazzariello RM: A fourteen-year experience with
In the early stages of this study, it was thought nonoperative instrument extraction of retained bile
that calcium bilirubinate stones were the only duct stones. World J Surg 2:447-455, 1978.
ones suited for laser lithotripsy. However, with 3. Magarey CJ: Non-surgical removal ofretained bil-
the development of contact probes, cholesterol iary calculi. Lancet 1:1044-1046, 1971.
stones, which comprises the majority of gall- 4. Burhenne HJ: Nonoperative instrument extraction
bladder calculi, are easily fragmented and re- of retained bile duct stones. World J Surg 2:439-
moved. Bile duct calculi extraction, with duct 445, 1978.
dilation, is now an established technique. 5. Warshaw AL, Barlett MK: Technique for finding
and removing stones from intrahepatic bile duct.
In the future, photodynamic therapy using
Am J Surg 127:353-354, 1974.
photosensitizers and Nd:YAG laser treatment 6. Yamakawa T, Komaki F, Shikata J: Experience
may be expected to advance to include even bile with routine postoperative choledocoscpy via T-
duct carcinomas using cholangioscopy. tube sinus tract. World J Surg 2:379-385, 1978.
7. Hwang MH, Yang JC, Lee SA: Choledocofiber-
Summary scopy in the postoperative management of intra-
hepatic stones. Am J Surg 139:860-864, 1980.
In this study we have reported our experience 8. Kouzu T, Sato H: Endoscopic laser treatment of
with cholangioscopic surgery using the N d: YAG intrahepatic stones. In Intrahepatic Calculi. Alan
laser. This includes bile duct calculi lithotripsy R. Liss, New York, 1984, pp. 321-332.
and dilation of duct stenosis. The laser irradia- 9. Yamazaki Y: Basic and clinical investigation of
tion method has evolved from the noncontact cholangioscopic lithotomy. Gastroenterol Endosc
mode to the contact mode. The numbers of pa- 27:27-43, 1985.
15
N d: YAG Laser Treatment of
Bladder Tumors
A. G. Hofstetter

Since 1976 we have treated more than 1000 pa- Immediately after irradiation, the tumor is re-
tients with urinary bladder tumors of stages pTA- moved with biopsy forceps. This tissue removed
pT4 with the Nd:YAG laser. 1,3 immediately after the Nd:YAG irradiation can
The advantages of this technique are: (a) con- be subject to histological workup to confirm the
tact-free tumor destruction in excellent visual diagnosis and to classify the tumor.
conditions, since there are no or only unimpor- Before the operation, biopsies are taken from
tant hemorrhages during the operation; (b) the base of the tumor and the tissue immediately
blocking tumor supplying blood and lymphatic surrounding the tumor for a distance of 1 cm at
vessels; (c) general anesthesia is not required in 3, 6, 9, and 12 o'clock. This procedure is sup-
the most cases, only adapted sedation; (d) dis- plemented by "quadrant biopsy." Since no, or
pensing with a postoperative catheter treatment, only very insignificant, hemorrhage occurs un-
so that nosocomial infections can be largely der Nd:YAG laser irradiation, a transurethral
avoided; and (e) replacing of electrolyte-free catheter can as a rule be dispensed with after
flushing solutions by sterile water, leading to the operation. This is important to avoid no-
saving in costs. I socomial infections.
Apart from these advantages, the question as The patient should be kept under observation
to the degree of efficacy of the Nd:YAG laser for 1 day after the operation, in order to detect
as compared to conventional transurethral re- a possible intestinal perforation in good time, in
section techniques has to be checked. Therefore particular when large areas are irradiated at the
we performed a prospective, randomized study. posterior wall of the bladder. With a radiation
dose of up to 45 W, using water as a flushing
fluid, we have yet to observe such a compli-
Techniques cation, although we have treated several thou-
sands tumors. Within 8 years only in three cases
Endoscopic destruction of bladder tumors is did small intestinal perforations occur after
cairied out in three steps if the tumors are bulky. faulty irradiation at too high a power (about 80
In these cases, the exophytic portion is first re- W). Clinically, these perforations manifested as
sected with the electric snare deep into the signs of acute abdomen with 12 h after the ir-
bladder wall after prior coagulation of the mar- radiation.
gins of the tumor. The base and edges of the
tumor are then postcoagulated with the Nd:YAG
laser. Smaller tumors are primarily destroyed Clinical Results
with the Nd: YAG laser. Here, we first irradiate
until blanching of the tissue surrounding the tu- As mentioned above, we have compared the ef-
mor occurs to a breadth of about 0.5 to 1 cm, ficacy of the Nd: Y AG laser with the results ob-
in order to seal off the afferent blood vessels tained with TUR, using the rate of recurrence
and lymphatics. Subsequently, the tumor is as a criterion. Patients with stage pT r pT 2 , No,
necrotized linearly. Mo urothelial carcinomas (n = 66; 39 men, 27
15. Nd:YAG Laser Treatment of Bladder Tumors 97

TABLE 15.1. Primary Tumors (pTA-pT" No, Mo) TABLE 15.3. Classification and Incidence
Number: 40 (M = 23, F = 17) distribution of transitional cell carcinoms (PT) in
Age: Males 45-81 years, xM = 66.5 years 24 (M = 15/F = 9) Patients of Laser Group and
Females 54-84 years, xF = 69.1 years 16 (M = 11iF = 5) of TUR Group
Laser Group TUR Group

pT/G 2 3 N 2 3 N
TABLE 15.2. Relapse Tumors (pTA-pT" No, Mol
A 7 4 12 6 4 0 10
Number: 26 (M = 16, F = 10) 1 4 4 1 9 1 0 2 3
Age: Males 40-79 years, xM = 62.1 years 2 0 I 2 3 0 2 3
Females 53-83 years, XF = 72.1 years

women; average age 68 years) were included in TABLE 15.4. Classification and Incidence
the study. Laser or TUR treatment was carried distribution of transitional cell carcinom (RT) in
out in accordance with a randomization scheme. 20 (M = l2/F = 8) Patients of Laser Group and
In addition, adjuvant chemotherapy with mi- 6 (M = 4/F = 2) Patients of TUR Group
tomycin C (20 mg/14 days) was administered 8 Laser Group TUR Group
days after the operation. The control group re- pT/G 2 3 N 2 3 N
ceived no chemoprophylaxis. The study was A 3 3 0 6 3 0 4
commenced on September 1, 1981. The patients 1 5 6 3 14 1 1 0 2
were divided into a group with primary tumors 2 0 0 0 0 0 0 0 0
(Table 15.1) and a group with relapse tumors
(Table 15.2). The classification of primary tu-
contrast to the results obtained with TUR (I to
mors is shown in Table 15.3 and the classifi-
40%). Otherwise it is interesting to note that
cation of relapse tumors in Table 15.4.
there was never any change from localized to
The therapeutic results obtained in primary multiple tumor growth after laser irradiation,
tumors are shown in Table 15.5 It can be seen
unlike TUR. Our experience has been confirmed
that laser application with and without chemo- in general by Meier et al. 2
therapy is superior to TUR with and without
chemotherapy, as indicated by the relapse rate
(p < 0.0001 four fields test). The superiority of Summary
laser application was also seen in relapse tumors
(Table 15.6). In addition, a particularly important Our 10-year clinical experience with the
observation is, we believe, that after laser ap- Nd: Y AG laser permits us to state that the con-
plication hardly any local relapses occurred in ventional TUR method for treatment of bladder

TABLE 15.5. Therapeutic results after Nd:YAG laser

coagulation V.C. TUR (PT) (N = 40)
TUR +
Laser + MC Laser MC TUR
(N = 15) (N = 9) (N = 13) (N = 3)
Number of
patients with
recurrence 6 3
Recurrence
rate" 0.17 0.27 1.32 7.89
Mean follow-up
(months) 38.00 41.00 25.00 13.00
Deaths 1b 0 1" 0
Total months of
follow-up 581.0 372.0 329.0 38.0

No. recurrences
"Recurrence rate = M h" II x 100.
ont 10 ow up
bNot due to cancer.
98 A.G. Hofstetter

TABLE 15.6. Therapeutic results after Nd: YAG Laser

Coagulation VZ. TUR (RT) (N = 26)
TUR +
Laser + MC Laser MC TUR
(N = IS) (N = 5) (N = 2) (N = 4)

Number of
patients with
recurrence 2 3 2 4
Recurrence
rate" 0.4 2.2 7.14 11.1
Mean follow-up
(months) 27.4 27.2 14.0 9.0
Deaths 0 0 0 0
Total months of
follow-up 411.0 136.2 28.0 36.0

No. recurrences
"Recurrence rate = h " II x 100.
Mont LO ow up

tumors should be reconsidered. Randomized, 2. Meier U, Hofstetter A, Pfluger H: Effects of in-

prospective studies comparing the efficacy of travesical instillation of mitomycin after endoscopic
TUR and laser treatment indicate the superiority treatment with TUR or laser on recurrence rate of
of Nd:Y AG application. bladder tumors. XXth Congress of the International
Society for Urology, Vienna, 1985.
3. Staehler G, Hofstetter A, Schmiedt E, Keiditsch
References E: Endoskopische Laser-Bestrahlung von Bla-
1. Hofstetter A, Frank F: The Nd:Y AG Laser in sentumoren des Menschen. Fortschr Med 95:3,
Urology. Editiones Roche, Basel, 1979. 1977.
16
Contact Laser Treatment for
Bladder Cancer
Hiroto Washida

The word laser, an acronym for Light Ampli- a quartz fiber, 5.0 mm in length and 0.1 mm in
fication by Stimulated Emission of Radiation, diameter at the tip (Figures 16.1 and 16.2).
was coined by Maiman, I who succeeded in the
amplification of electromagnetic waves in the
region of visible light, using a ruby crystal. As Method of Operation
laser equipment must fulfill many requirements
for use in the medical field, the following laser The surgeon and his staff wear protective eye-
systems have become available only today: (1) glasses during the operation. The patient is
the ruby laser, (2) the argon laser, (3) the placed in the lithotomy position as for any
Nd:YAG laser, and (4) the CO 2 laser. Among transurethral intervention. Prior to laser treat-
these lasers, the Nd:YAG laser developed in ment, specimens for histologic examination were
1962 by Johnson and colleagues 2 and described taken from the apex and base of the tumor. The
in 1966 by Snitzer3 has been increasingly ac- laser is set for a continuous period and is con-
cepted because of its possibility to transmit the trolled by the surgeon with an on and off foot
Nd:YAG laser beam by means of a flexible switch similar to using electrocautery. The
quartz fiber, as well as a highly efficient coag- power is around 15 W/second. A modified 27
ulation and penetration capability. 4 However, French size sheath and telescope with Albarran
such distinct disadvantages as damage to the tip element (Olympus Co.) are inserted transure-
of the laser light guide, instability, and uncer- thrally. The SL T endoprobe connected to a
tainty, have been pointed out for endoscopic quartz fiber is passed into the bladder and passed
surgery due to the noncontact method for de- into the cancer under direct vision. It is possible
livering laser energy.5,6 We devised and prepared to drive the endorod freely into any area by
a new probe called an endorod, which can moving the Albarran element and/or the scope
transmit laser light interstitially. 7 This chapter itself. The irradiation effect can be distinguished
discusses the features of contact laser irradiation by a whitish discoloration of the cancer. The
using the endorod for the treatment of bladder bladder is filled and irrigated continuously with
cancer, namely, transurethral laser destruction 10% Urigal solution (Nikken Chemical Co., Ja-
of bladder cancer (TULD). pan) during the surgery. The progress of the
cancer destruction can be observed. The op-
eration is further carefully conducted until the
The Endorod (SLT Contact cancer disappears.
Endoprobe®)
The endoprobe is made out of new ceramic Subjects and Results
which is a fusion product of aluminum oxide
(A1 2 0 3). The probe has been shaped into a fine The subjects were 25 patients with bladder can-
needle forming a conical trapezoid of 2.0 mm in cer hospitalized at the Department of ,Urology
diameter at the part of incidence connected with of Anjo Kosei Hospital from February to Oc-
100 Hiroto Wash ida

2.2mm FIGURE 16.1. Scheme of the endorod.

O.lmm

j
I Diagramatical representation of the SLT
contact endoprobe.

n~ 0'"-"-+-3_ _ 1O.6mm
I ---~ ___1. ~~

I------ I~I
4.2mm O.8mm '
micro laser rod quartz fi ber

tober 1984. The cancers were classified by the lack of experience with the laser apparatus,
Japanese Association of Urology for bladder techniques, and so on.
cancer care. There were 19 cases of single tu- A tumor in the vicinity of the ureteral orifice
mors, six cases of large tumors. Histologically, was seen in five cases, but in none of them was
there were 24 cases of transitional epithelial the ureter affected in the bladder wall or the
cancer, one being a mixed type with squamous ureteral orifice, and no abnormality was noted
epithelial cancer, and 1 case of adenocarcinoma. in the upper urinary tract using the indigocar-
The malignancy was of Grade I in eight cases, mine excretion test and excretory urogram im-
Grade II in eight cases, Grade III in six cases, mediately after operation.
one case being mixed with squamous epithelial
cancer. Further, one case of a single large Grade
III tumor was diagnosed as cancer of the ureter
Case 1: A 56-Year-Old Man
infiltrating into the bladder by subsequent ex- The patient was examined with a chief complaint
aminations. To completely treat a bladder cancer of hematuria. The cystoscopy revealed a pap-
of such a background with TULD alone, 16 illary tumor with a stalk, about 1 cm large, on
treatments were required. With TUR-Bt 6 treat- the left lateral wall (Figure 16.3A). TULD was
ments were required and TULD combined with performed after biopsy of the tumor. The SLT
laparotomy (cases in which the total cystectomy contact endoprobe was placed superficially into
was judged desirable from the histologic type) the neck of tumor and laser irradiation started
was applied in three cases, including one case
of cancer of the ureter, as mentioned before
(Table 16.1). In six cases, where the treatment
could not be completed with TULD alone, TABLE 16.1. Summary of clinical cases of bladder
tumors treated by SLT contact laser surgery
bleeding was marked, and TUR-Bt was re-
quired, but these were all cases in the early pe- TULD + Open surgery
Treatment TULD TUR-Bt after TULD
riod when TULD was started, resulting from
Number
Single 11 5 3
Multiple 5 0
Size
Small 3 0 0
Medium 8 2 0
Large 5 4 3
Grade
I 8 0 0
II 6 5 0
III 2 3
+ SCC 1
AC 0 0
FIGURE 16.2. An endoprobe connected to the quartz TULD = transurethral laser destruction (of bladder cancer).
fiber. (SLT contact endoprobe.) TUR-Bt = transurethral surgery for bladder tumor.
16. Contact Laser Treatment for Bladder Cancer 101

A
o

B
E
FIGURE 16.3. (A) A papillary tumor about 1 cmlarge on
the left lateral wall of the bladder. (B) During the
TULD. Showing an SLT contact endoprobe in the
tumor (arrow). (C) Tumor site immediately after laser
treatment. (D) Treatment site at 4 weeks. (E) Treat-
ment site at 8 months showing a healed mucoser with
no evidence of recurrence on biopsy.

with a 15-W power output. The tumor was de"

c strayed instantaneously and this action was re-
peated to complete the operation using a total
of 2800 J (Figure 16.3B,C). It had taken about
2 months for the wound to heal (Figure
16.3D,E). The histologic changes of the cancer
are shown in Figure 16.4.
102 Hiroto Washida

FIGURE 16.4. Histologic changes of a bladder tumor after transurethal contact laser surgery.

Discussion doscopic operations. 12 Daikuzono and Joffe 7 had

previously developed the laser surgical scalpel,
Since it became possible to use a flexible fiber and we clinically applied it from February 1984
in the conduction of light,8 the laser has come after completing basic studies on the transure-
into use for endoscopic operations. The thrallaser destruction of bladder cancers.
Nd:Y AG laser, in particular, has shown an ex- At about the time when this technique was
cellent capacity for coagulation and hemostasis, started, we were not sufficiently experienced
and has been applied to excise tumors of the using lasers and method for manipulation of the
digestive tract or bladder and others. SLT contact laser system and thus a TUR-Bt
The treatment of bladder tumors with the was initially needed. Since it was found that an
Nd:YAG laser was started by Staehler and col- output of about 15 W at a time was the most
leagues. 9 They reported excellent results and suitable, the purpose of the treatment has been
stated such advantages as absence of bleeding, sufficiently achieved.
short period of hospitalization and less risk of Based on this present experience, the follow-
perforation, as compared with TUR-Bt. In Ja- ing aspects of the laser apparatus need to be
pan, in 1980, Murase and colleagues 10 published considered or improved. Concerning the laser
a pessimistic report on laser treatment using apparatus, a high output (around 100 W) was
Nd: Y AG laser irradiation in the rabbit bladder, necessary for the noncontact laser treatment. If
while others II recognized its significance as a the endorod is used, the output needs to be sta-
new treatment method for bladder tumors from ble at a low setting (less than 20 W). For in-
basic and clinical studies. stance, the MediLas Y AG (MBB, GFR), is fre-
We started the treatment of bladder cancer quently used in Japan and is suitable for a high
with the Nd:YAG laser beam in 1983. Due to output only. When compared to Cooper 8000
laser instability and uncertainty of tissue dam- (Cooper, USA), the output of the MBB laser is
age, we studied the laser conduction path of the unstable at low powers « 20 W). Further, it
SLT contact endoprobes for transurethral en- takes several seconds for the laser energy to be-
16. Contact Laser Treatment for Bladder Cancer 103

come stabilized. (Immediately after switching on Continuous operation of a solid-state optical laser.
the MBB laser, the output at the fiber tip is very Phys Rev 126:1406, 1962.
different from the output displayed, often by a 3. Snitzer E: Glass lasers. Appl Opt 5:1487, 1966.
several-fold difference at low power. This leads 4. Hofstetter A, Frank F: The neodymium-Y AG
to difficulty in safely and effectively carry out laser in urology. Roche F (ed): Hoffmann-La
Roche, Basle, 1980, pp 17-30.
contact laser surgery.
5. Suzuki S, Shiina Y, Miura T, et al: Effects ofNd-
When using the contact laser system, de- YAG laser radiation 0 the gastrointestinal mucosa
struction of the tumor is excessively rapid at a the sixth report: Experimental studies with a new
power output of 30 W, with potentiation of contact type of the YAG laser rod. Gastroenterol
bleeding and TUR-Bt is needed. However the Endosc 26:705, 1984.
SLT laser and the Cooper 8000 have a stable 6. Washida H, Tsugaya M, Hirao N, et al: Interstitial
output of 10-15 W. The transurethral endo- laser irradiation for bladder cancer using laser
scopes for laser operations available at present micro rod. Jpn J Urol 76:1524, 1985.
are unsatisfactory. It will be necessary to de- 7. Daikuzono N, Joffe SN: Med Instrum 19, 173,
velop endoscopes suitable for these operations. 1985.
The treatment of bladder cancer using the 8. Nath G, Gorisch W, Kiefhaber P: First laser en-
doscopy via a fiberoptic transmission system.
SLT contact laser system is in the early stages
Endoscopy 5:208, 1973.
and there are still some problems to overcome. 9. Staehler G, Hofstetter A, Schmiedt E, et al: En-
The technique, however, is simple to apply in doskopisch Laserbestrahlung von Blasentumoren
practice, bleeding is hardly seen, there is less des Menschen. Fortshr Med 95:3, 1977.
damage to surrounding tissue. All these factors 10. Murase T, Matsumoto K, Nishisaka T: Histolog-
suggesting the possibility that interstitial laser ical change of the rabbit bladder by irradiation of
irradiation is superior to TUR-Bt. Work is cur- the Nd-YAG laser. Nishinihon J UroI42:1l47,
rently in progress to evaluate a larger number 1980.
of patients with a longer follow-up period. II. Amagi T: Experimental and clinical studies for
laser application to the treatment of bladder tu-
References mor. Nichidai Ishi 40:985, 1981.
12. Washida H, Tsugaya M, Hirao N, et al: Funda-
1. Maiman TH: Stimulated optical radiation in ruby. mental and clinical study of micro laser rod for
Nature, 187:493, 1960. endoscopic laser surgery. Jpn J Laser Med 5:521-
2. Johnson LF, Boyd GD, Nassau K, Soden RR: 524, 1985.
17
Endoscopic N d: YAG Laser Treatment in
Airway Lesions
Kenkichi Oho and Ryuta Amemiya

A CO 2 laser was first employed in the treatment In this chapter, the present status and points
of respiratory diseases by Strong et al., J who at issue concerning endoscopic Nd:YAG laser
treated a papilloma of the airway. However, the treatment in airway lesions are discussed based
CO 2 laser has been used only with the rigid on the experience of the authors.
bronchoscope because it cannot be transmitted
by a quartz fiber as its wavelength is long (10,600
nm). Hence the CO 2 laser has been used pri- Materials and Methods
marily for lesions located in the larynx to the
main bronchus that can be seen by the rigid Between 1980 and 1985 we have treated a total
bronchoscope. As a result, the CO 2 laser has of 136 cases consisting of 64 lung cancer, 9 pri-
been used mainly in the field of ENT. mary tracheal cancer, 33 benign lesions, and 30
With the advent of the neodymium:yttrium- metastatic airway lesions. In 107 cases (79%)
aluminum-garnet laser (Nd:Y AG laser) which effective results were obtained.
has a short wavelength (1064 nm) that can be All procedures were performed under local
transmitted by quartz fibers, high-energy laser anesthesia except in an ll-year-old boy with a
treatment of airway lesions with the fiberoptic mucoepidermoid carcinoma in the left main
bronchoscope became possible. In 1979 Godard bronchus. The standard method of topical anes-
et al. 2 first reported treatment of a bronchial tu- thesia using a 4% Xylocaine spray is performed,
mor using the Nd:YAG laser. followed by the insertion of the fiberoptic bron-
On the other hand, photodynamic therapy choscope with the patient in a supine position.
(PDT), a method which involves intravenous After the target site has been brought under ob-
injection of the photosensitizer, hematopor- servation the transmission fiber is inserted
phyrin derivative, followed by application of an through the instrumentation channel and is
argon-dye laser as an activator of the photosen- projected about 5 mm from the distal tip of the
sitizer, has been widely performed in lung cancer endoscope. The fiber is maintained at a distance
cases by Hayata et al. 3 since 1979. Its application of about 5-10 mm from the target. Air is flushed
for the diagnosis of lung cancer was reported by continuously and coaxially through the Teflon
Doiron et al. 4 sleeve of the laser fiber in order to prevent frag-
We have performed basic research on the ap- ments of carbonized material from adhering to
plications of the Nd:YAG and argon lasers in the tip. A red helium-neon laser beam is em-
dogs, beginning in 1978. 5 .6 On the basis of those ployed as a pilot beam. In cases of severe ven-
results, in 1980 we began to use this modality tilatory disturbance with Pao 2 below 60 torr, 15-
in clinical cases of airway stenosis as far distal 30 mg pentazocine and 10 mg diazepam are ad-
as the segmental bronchi; tracheal tumors; lung ministered to temporarily reduce the level of
cancer; and tumors metastatic to the airway in consciousness in order to facilitate the perfor-
addition to cases of cicatricial lesions due to tu- mance of the laser procedure.
berculosis and granuloma. 7 . 8 We used an Olympus model MYL-l contin-
 17. Endoscopic Nd: Y AG Laser Treatment in Airway Lesions 105

uous wave laser with a power output of 1 to 100 uate the effectiveness of this procedure. Many
W. The time interval of irradiation is set at 0.2 cases have been treated and represent a wide
to 2.0 seconds. 9 and varying range of advanced malignant dis-
eases and clinical symptoms. Furthermore, since
this procedure is intended to produce only a lo-
cal effect, it would not be tenable to attempt to
Results evaluate its effectiveness in terms of length of
survival. For the meantime therefore, it is un-
Our standard of "therapeutic effectiveness" avoidable that a certain amount of subjectivity
means only that the desired result was obtained be involved in the evaluation of effectiveness.
and is not related to long-term survival. Many This procedure has been performed in a total
of the cases were treated for emergency relief of 136 cases up to February 1986, using an
of stenosis and obstruction, not for cure of the Nd:YAG laser. These cases consisted of 47 cas-
underlying disease. When detected, the majority es of tracheal lesions, 15 cases of tracheal and
of central-type lung cancer cases have already bronchial lesions, and 74 cases of bronchial le-
invaded extensively along the longitudinal axis sions. Out of the 52 emergency cases in which
of the bronchus, or show stenosis due to sub- the procedure was performed to widen the air-
mucosal invasion connected with many meta- way, effective results were obtained in 49. It was
static lymph nodes, or else show invasion con- also effective in 47 of 66 cases in which the pro-
tinuing to the periphery from the tumor in the cedure was performed for palliative (staged)
main bronchus. Considering the developmental widening of the airway. In 11 of 18 cases in
behavior of the lung cancer, it is natural that the which the procedure was performed for curative
effectiveness of endoscopic Nd:Y AG laser vaporization of tumor and 1 of 3 cases in which
treatment be limited. The purposes for the per- the procedure was performed for hemostasis,
formance of endoscopic Nd:Y AG laser treat- successful results were obtained. Effective re-
ment differ significantly according to each in- sults were obtained in 46 of 64 cases (70%) of
dividual case. Cases in which the procedure is lung cancer. Results were effective in all 9 cases
indicated can include malignant and also benign of primary tracheal cancer. Effective results
diseases. The purposes of the procedure are he- were obtained in 27 of 33 cases (82%) of benign
mostasis in some cases and palliative widening airway lesion cases. Effective results were ob-
of the airway in other cases. Consequently, it tained in 25 of 30 cases (71%) of metastatic air-
is difficult to establish uniform criteria to eval- way lesions (Table 17.1).

TABLE 17.1. Cases treated by endoscopic Nd:YAG laser treatment.

Effective
Emergency Palliative Curative
Effective widening of widening of vaporization N oneffecti ve
Lesion Cases cases airway airway of tumor Hemostasis cases
Primary lung cancer 51 34 3/3 (100%) 25/37 (65.5%) 6/10 0/1 (0%) 17
bronchial lesions (66.7%) (60.0%)
Tracheal and 13 12 10111 (90.9%) III (100%) III
bronchial lesions (92.3%) (100%)
Primary tracheal 9 9 8/8 (100%) III 0
cancer (100%) (100%)
Benign airway 33 27 6/6 (100%) 20/26 (76.9%) 1/1 (100%) 6
lesions (81.8%)
Metastatic airway 30 25 22124 (91.7%) 112 (50.0%) 3/3 0/1 (0%) 5
lesions (71.4%) (100%)
Total 136 107 49/52 (94.2%) 47/66 (71.2%) 11115 1/3 (33.3%) 29
(78.7%) (73.3%)

February 1986.
106 Kenkichi Oho and Ryuta Amemiya

Indications tilage. We have experienced 12 cases of this type

of lesion (Figure 17.2). This procedure may be
There is a tendency to consider a wide range a possible alternative method to conventional
of conditions as indications for endoscopic surgery, to curatively treat certain malignant le-
Nd:YAG laser treatment, because this proce- sions limited to within the bronchial cartilage as
dure can vaporize and remove tissue easily. 10 far as the vicinity of the orifices of segmental
However, great caution is necessary in deciding bronchi. However, it would not be indicated in
the indications of this procedure in advanced lesions located in the right upper lobe segmental
cases of lung cancer. We consider that the in- bronchi and left B 1 + 2 and B3 , and both right and
dications are limited to an extremely small left B6 , due to the difficulty of maneuvering the
number of cases. At present we judge the in- quartz fiber.
dications of this procedure as follows: 3. Maintenance of airway, regardless of depth
of lesions, and cases in which improvement can
1. Pathologic changes of the trachea causing be expected by widening the airway. In such
ventilatory disturbances or bleeding, regardless cases this procedure is performed as a noncu-
of the histologic diagnosis and requiring im- rative treatment. In cases in this category it is
mediate treatment (Figure 17.1) . Moreover, necessary that the peripheral airway and the
there is no other therapeutic option for these parenchyma distal to the stenosis or obstruction
cases at present apart from this procedure. be viable in terms of ventilation and circulation .
However, in cases of malignant disease it is fre- 4. Benign tumors originating from the trachea
quently impossible to totally vaporize the entire to segmental bronchi are good indications (Fig-
lesion, even if most of the lesion can be elimi- ure 17.3). This procedure is often the treatment
nated. In advanced cases this method is high- of choice for a benign tumor. Lesions of cica-
energy vaporization of tissue and must be halted tricial stenosis are indications for this therapeu-
before damaging normal tissue. tic modality. However, lesions extending 1 cm
2. Pathologic changes located from the trachea or more longitudinally in length and cases in
to segmental bronchi limited to within the car- which tuberculous granulomatous tissue are ob-

FIGURE 17.1. (Left) A 75-year-old man with squamous bronchus was recognized. The Pa0 2 increased to 78
cell carcinoma was admitted with orthopnea even re- torr breathing room air, and he was subsequently able
ceiving oxygen (Pa0 2 on admission: 58 torr) . Chest to receive radiotherapy and chemotherapy. (Right)
x-ray revealed no tumor, atelectasis , or obstructive Ten months after completion of a 60 GY course of Li-
pneumonia in either lung field. Endoscopic Nd:YAG nac radiotherapy good regeneration ofthe mucosa and
laser treatment was performed as emergency treat- sharpening of the bifurcation was recognized. Lo-
ment in an attempt to render him a candidate for ra- cal and general conditions improved remarkably. The
diotherapy and chemotherapy. (Center) One week laser treatment consisted of 24.345 J over two ses-
after the first session a part of the necrosis-covered sions, at a power level of 60 to 80 W. Treatment was
tumor was observed to move on respiration and when considered successful because most of the lesion was
a small aperture was made at the site with the laser exposed in the airway lesion and endoscopiciaser treat-
a flood of pent-up secretions appeared. Following as- ment was the first step in a multimodality therapeu-
piration of the secretions opening of the left main tic approach, rather than being treatment for relapse.
17. Endoscopic Nd:Y AG Laser Treatment in Airway Lesions 107

tilation and circulation, can laser vaporization

be considered. Therefore, indications are limited
to a relatively small number of cases. Consid-
ering the reasons for the noneffectiveness in 19
of 64 lung cancer cases in this series, these in-
cluded 2 procedures for emergency widening,
12 procedures for palliative widening of the air-
way, 4 for curative vaporization of a tumor, and
I for hemostasis. An underestimation ofthe ex-
FIGURE 17.2. (L eft) A 59-year-old nonsmoker had tent of cancer invasion was recognized as the
undergone left lower lobectomy for a squamous cell single most important factor in these noneffec-
carcinoma in the left basal bronchus. Following the tive cases . In 14 cases, of which 2 cases were
appearance of bloody sputum 17 months later a sec- performed for emergency widening and 12 cases
ond squamous cell was discovered in the truncus in- for palliative widening of airway, the reasons
termedius. Deep bite biopsy specimens revealed that for failure was that cancer invasion continued
the extent of invasion was limited to within the ex- to the periphery. There is no completely reliable
tramuscular layer and the peripheral margin of the diagnostic method to obtain information con-
tumor was endoscopically visible. Since the poor lung
cerning the peripheral airway and the paren-
function of this patient contraindicated operation,
chyma distal to the stenosis or obstruction, al-
endoscopic Nd :YAG vaporization was performed as
a curative procedure. The Nd:YAG laser treatment though Pearl berg et al. 13 reported that chest CT
was spread over 3 sessions during a during a period provides useful information and also Joyner et
of 3 weeks. The power intensity was 20 to 50 W de- al. 14 reported the effectiveness of instillation of
livered in 0.1 to 2.0-second shots, with a total of 823 contrast medium distal to the sites of airway
J. No other method of treatment was employed. stenosis or obstruction.
(Right) The findings 3 weeks after completion of the In 4 cases residual carcinoma or carcinoma
third vaporization procedure show that the tumor has in situ were found in resected specimens fol-
disappeared and that there is good regeneration of lowing an attempt at curative laser vaporization.
the mucosa at the site where it was located, although At present the major indications for curative
the longitudinal folds are interrupted. Follow-up
endoscopic Nd:YAG laser treatment in squa-
bronchoscopy and sputum cytology are being per-
formed at 3-month intervals and he is apparently dis- mous cell carcinoma of the airway are as fol-
ease-free 8 months after the first vaporization session. lows: (J) The deepest portion of cancer invasion
is limited to the extramuscular layer of the
bronchus. (2) The tumor invasion is localized to
the site of possible laser irradiation. (3) The pe-
ripheral margin of the cancer invasion is seen
tained from the lesion should be excluded from via the endoscope. For these lesions laser treat-
the indications for this treatment. ment is performed at a power of 40 to 50 W at
1 second or less for areas of apparent cancer
invasion and 20 to 40 W, for 0.2 to 0.5 seconds
Discussion for surrounding areas. These power conditions
are advisable to prevent perforation of the
Endoscopic Nd:Y AG laser treatment has re- bronchial wall and to minimize the damage of
cently gained popularity. The main airway dis- normal bronchial architecture and to obtain early
ease in which this procedure is employed in and good reepithelialization.
these institutions is advanced lung cancer. 11.12 For the treatment of airway diseases, espe-
Therefore, we should keep in mind that the pri- cially for tracheal, tracheobronchial, and bron-
maratory disturbance due to obstruction or chial malignant tumors, there are two types of
marked stenosis by a tumor growing as a po- endoscopic laser treatments. One is using en-
lypoid in a large airway. Only in such cases in doscopic hematoporphyrin derivative (Hpd) and
which the peripheral airway can be maintained photodynamic therapy (PDT) and the other is
and in which the parenchyma distal to the ste- endoscopic Nd:YAG laser treatment. Cases
nosis or obstruction is viable in terms of ven- presenting with respiratory insufficiency due to
108 Kenkichi Oho and Ryuta Amemiya

FIGURE 17.3. (Left) A 41-year-old female presented the upper division bronchus and the lower right is the
with episodes of frequent cough, sputum, and slight lingular bronchus in which tumor originated after
dyspnea during the past year. Endoscopically, a po- treatment by Nd:YAG laser. No edema or scar can
lypoid tumor can be seen in the left main bronchus. be recognized. Reepithelialization also appears to be
No tumor invasion can be recognized in the sur- completed in this area. Glomus tumor was diagnosed
rounding bronchial wall. The tumor appears to ob- by biopsied specimen. We can say that endoscopic
struct the main bronchus. (Center) Findings before Nd: YAG laser treatment for such benign tumors in
the second session. The tumor originated in B4 and the airway is a most appropriate therapeutic modality,
polypoid proliferation to the left main bronchus was which not only can be performed with the least dam-
recognized in the left upper lobe bronchus. (Right) age to bronchial architecture and the least compli-
Findings of the treated portion 2 months after en- cations but is also a single therapeutic modality to
doscopic Nd:YAG laser treatment. The left upper is replace thoracotomy.

obstruction or stenosis by tumors in the trachea, the bronchial wall, if the lesions extend to the
the carina or main bronchi are good indications sub segmental bronchi the case should not be
for endoscopic Nd:YAG laser treatment. Tu- considered for either type of endoscopic laser
mors occupying the airway lumen are vaporized, treatment because it is difficult to treat such le-
leading to a rapid improvement of the condition. sions safely and effectively. PDT needs great
Such cases are not indications for PDT. How- care to ensure that the PDT beam reaches only
ever, in cases not presenting with ventilatory the lesion in order to prevent possible destruc-
insufficiency even if there is obstruction or ste- tion of the architecture of the surrounding nor-
nosis due to a tumor in main bronchi or lobar mal bronchial wall in segmental or sub segmental
bronchi, both PDT and Nd:YAG laser treatment bronchi. If this is not done, in cases of lesions
can be employed. In order to prevent perforation located in segmental bronchi, bronchial stenosis
of the airway wall in cases of tumor invasion or obstruction and delayed reepithelialization
extending beyond the bronchial wall, YAG laser will occur. In the case of Nd:YAG laser, care
treatment should be stopped, even if the wid- must always be exercised concerning the depth
ening of the airway is incomplete. With PDT, of irradiation in order to prevent perforation of
delayed complications should be kept in mind, the airway wall.
such as bronchial fistula, bronchoesophageal Preoperative laser treatment to widen the
fistula, and massive bleeding. 15 In tumors limited range of indications for surgery and to reduce
to within the bronchial wall originating in bron- the extent of resection has come to be performed
chi larger than lobar bronchi, both types of en- in a few institutions. 16 However we consider that
doscopic laser treatments can be used. How- the indications of preoperative laser treatment
ever, lesions such as those limited to within the are limited to a small number of cases because
bronchial wall extending to segmental bronchi exact evaluation of the actual extent of sub-
differ according to each individual case. As mucosal invasion and lymphatic involvement is
mentioned above, it is imperative that the pe- extremely difficult. Cases of adenocarcinoma
ripheral margin of cancer invasion be recognized should in general be excluded because of the
within the extent of the visual field of the en- tendency toward submucosal extension of this
doscope. Even if the invasion is limited to within histologic type.
17. Endoscopic Nd: YAG Laser Treatment in Airway Lesions 109

The limitations of this procedure are as fol- the treatment of lung cancer. Chest 81:269,1982.
lows: 4. Doiron DR, Profio E, Vincent RG, Dougherty TJ:
Fluorescence bronchoscopy for detection of lung
1. The procedure requires skill in the manipu- cancer. Chest 76:27, 1979.
5. Amemiya R, Oho K, Ohtani T, et al: Laser pho-
lation of the endoscope, skill in laser irradiation,
toradiation via the fiberoptic bronchoscope: Ef-
and strict analysis of endoscopic findings. Si- fects on the bronchial wall. In Bronchology.
multaneously, as the N d: YAG laser beam is a Martinus Nijhoff, The Hague, Boston, and Lon-
high-energy laser, perforation of the bronchial don, 1980, p 540.
wall and massive bleeding will follow mistaken 6. Hayakawa H, Oho K, Amemiya R, et al: Pho-
irradiation. Therefore a detailed anatomic todynamic effect of laser surgery on the trachea
knowledge concerning the branching of bronchi and bronchi of mongrel dogs. In Bronchology.
and pulmonary vessels is required. In addition, Maltinus Nijhoff, The Hague, Boston, and Lon-
the level of endoscopic expertise largely influ- don, 1980, p 543.
ences the therapeutic results. 7. Oho K, Ohtani T, Amemiya R, et al: Laser sur-
1. Pulmonary function limitations of this pro- gery in the trachea and bronchus via the fiberoptic
bronchoscope. 4th Congress of the International
cedure are Pa0 2 below 50 torr, or PaCO z above
Society for Laser Surgery. Laser Tokyo '81 14,
50 torr due to the danger of postprocedural acute 1981.
respiratory insufficiency and cardiac decom- 8. Oho K, Ogawa I, Amemiya R, et al: Indications
pensation. for endoscopic N d-YAG laser surgery in the tra-
3. In cases of lesions in the trachea or main chea and bronchus. Endoscopy 15:302, 1983.
bronchi, destruction by a tumor involving 2 or 9. Oho K, Amemiya R: Practical Fiberoptic Bron-
more cartilaginous rings can result in an airway choscopy, 2nd ed. Igaku-Shoin, Tokyo and New
collapse following treatment, even if a tempo- York, 1984, p 174.
rary opening is achieved by this procedure. 10. Dumon JF, Reboud E, Garbe L, et al: Treatment
Therefore most lesions such as those with com- of tracheobronchial lesions by laser photoresec-
tion, Chest 81:278, 1982.
pressive stenosis are generally not indications
11. Hetzel MR, Millard FJC, Ayesh R, et al: Laser
for this procedure. treatment for carcinoma of the bronchus. Br Med
4. Finally, less extensive lesions along the lon- J 286: 12, 1983.
gitudinal axis of the airway causing stenosis and 12. Dumon JF, Shapshay S, Bourcereau J, et al:
obstruction can be vaporized more safely and Principles for safety in application of Neodymium-
quickly. In general, vaporization of tumors less YAG laser in bronchology. Chest 86: 163, 1984.
than 3 cm in length can be performed safely and 13. Pearlberg JL, Sandler MA, Kvale P, et al: Com-
easily. puted-tomographic and conventional linear-tom-
ographic evaluation of tracheobronchial lesion for
laser photoresection. Radiology 154:759, 1985.
14. Joyner LR, Maren AG, Sarama R, Yakaboshi A:
Neodymium-YAG laser treatment of intrabron-
References chial lesions, a new mapping technique via the
1. Strong MS, Vaughan CW, Polanyi T, Wallace R: flexible fiberoptic bronchoscope. Chest 87:418,
Bronchoscopic carbon dioxide laser surgery. Ann 1985.
Otol 83:769, 1974. 15. Cortese DA, Kinsey JH: Hematoporphyrin de-
2. Godard P, Draussin M, Lopez FM, et al: Utili- rivative phototherapy in the treatment of bron-
zation du rayonnement laser en bronchologie. chogenic carcinoma. Chest 86:8, 1984.
Resection de deux tumeurs trachebronchique. 16. Kato H, Konaka C, Ono J, et al: Preoperative
Pulmon 35:147, 1979. laser photodynamic therapy in combination with
3. Hayata Y, Kato H, Konaka C, et al: Hemato- operation in lung cancer. J Thorac Cardiovasc
porphyrin derivative and laser photoradiation in Surg 90:420, 1985.
18
Developments in Bronchoscopic Nd:YAG
Laser Resection
J-F. Dumon and B. Merie

Medical lasers have not been available for very delivery system, and, although the last mirror
long. The Nd:YAG laser was not marketed for can be positioned at the entrance of the bron-
medical use until the late 1970s. Thus it is not chosope, no other instrumentation, including the
an exaggeration to say that the laser is currently viewing lens, can be used during firing. Ob-
one of the frontiers of medical science. This no- viously under these conditions aiming is prob-
tion of newness in laser medicine is important lematic and accuracy difficult. For this reason,
because it explains that techniques and equip- up to now the CO 2 laser has been extensively
ment are still emerging and evolving. Bron- used by ENT specialists and surgeons, but rarely
chology is one of the first fields in which the by bronchoscopists.
laser was used "internally," and the basic prin- Argon laser beams can be delivered through
ciples are now well-defined. Today laser resec- an optical fiber, but, because the power output
tion is one of the newest and most effective pal- of these lasers is low, they do not penetrate the
liative modalities in medicine's arsenal against tissue and consequently are not very useful in
lung cancer. It has no aftereffects and requires endoscopy. One notable exception to this is an
no particular follow-up. In case of recurrence, endoscopic technique called hematoporphyrin
it can be repeated as needed. It can be associated phototherapy in which small, very local, inop-
with any other form of treatment (e.g., radio- erable lesions are destroyed by activation of he-
therapy or chemotherapy). The purpose of this matoporphyrin retained in malignant tissues by
chapter is to discuss the current status of laser a dye laser-pumped argon laser. On the other
technology in lung medicine with respect to laser hand, argon lasers have been used advanta-
systems, instrumentation, and methodology. We geously in ophthalmology and dermatology.
also wish to take this opportunity to repeat the As far as precision resection is concerned, it
principles of our laser resection technique and is the Nd: YAG laser that is, at the present time,
to update our results. the most valuable laser system for endoscopic
use. With this system 20 to 100 W of power can
be delivered to the tip of an air-cooled optical
Laser Systems fiber measuring only 2.6 mm in diameter.
Standard fibers are 4 m in length. The effects of
Not all laser systems are suitable for endoscopic the Nd:YAG laser on living tissue range from
use. At the present time the three main biomed- vaporization to coagulation and depend on
ical lasers are the CO 2 , the argon, and the power setting, firing range, pulse duration, and
Nd:YAG. The CO 2 laser, which is a very precise tissue color. On dark tissue vaporization is
cutting instrument, is not well adapted to en- quickly achieved at high power and close range.
doscopy. Although it may soon be available, Hemostasis is accomplished at medium power
there is no optical fiber that can transport the and range. In fact, coagulation is not a direct
CO 2 laser beam. Delivery of CO 2 energy is effect of the Nd:YAG laser. Rather, it is an in-
achieved by means of a cumbersome mirror arm direct result of tissue shrinkage, which cuts off
18. Bronchoscopic Nd: YAG Laser Resection III

the flow of blood. A major danger with the complications in the first category, including
Nd:YAG laser is that it is difficult to control the perforation, pneumothorax, and fire, are cata-
depth of penetration of the beam, especially strophic, and, once they have occurred, little
when working on pale tissue. It behooves every can be done to prevent a fatal outcome. Those
physician using the Nd:Y AG laser to be aware in the second category, hypoxia and hemor-
of the dreaded "popcorn effect." As described rhage, may, if left unattended, become life-
by Fisher, this phenomenon occurs as the tem- threatening, but, if the endoscopic team is prop-
perature in underlying tissue rises and steam erly trained and equipped, it should respond
builds up in a pocket below the surface. Given quickly. In the area of instrumentation specifi-
these unseen effects, great care must be taken cally suited to laser resection, some very inter-
in the tracheobronchial tree to avoid inadvert- esting develpments have recently taken place.
ently creating a fistula, especially on the back- Only very small lesions can be safely resected
side of the trachea, which is not reinforced by with a flexible fiberscope. Fiberscopic resection
cartilage, or damaging the cartilaginous rings accounted for only 20% of our procedures. In
themselves. In extreme cases the steam pocket our experience flexible instrumentation using
may ultimately explode, causing extensive optical fibers carried some major liabilities. The
damage. It is ill-advised to use the laser in the fiberscope is a solid tube measuring 5 to 6 mm
continuous mode at any time and any power in diameter; when it is introduced into the air-
setting. Properly controlled, however, the ability way, it results in a considerable reduction of the
of the Nd:YAG laser to penetrate into tissue can tracheal lumen. In cases involving high-grade
be used to stop a hemorrhage, to coagulate tissue tumoral occlusion or intubated patients, 50% or
before mechanical resection, and probably to kill more of the lumen is blocked. The fiberscope is
viral infection (such as in the case of papillo- inflammable and has reportedly ignited during
mas). laser resection. Though fiberscopic lenses now
To conclude this discussion on biomedical provide excellent definition, their location at the
lasers, it should be said that research and tip of the instrument exposes them to constant
development will certainly lead to the design soiling by secretions. The most serious draw-
of other laser systems that can be used for back of the fiberscope for laser resection, how-
biomedical purposes. One exciting innovation ever, is that its working channel is, at the most,
that should be ready in the very near future is only 2.6 mm in diameter. This is too small to
the copper-vapor laser. The particularity of this allow passage and simultaneous use of both the
laser is that its beam is made up of several dif- laser fiber and a suction tube.
ferent wavelengths-green, yellow, and red- In view of these problems, most endoscopists
which it is technically possible to filter and use practicing laser surgery have learned how to use
separately. The green beam has the same char- a rigid bronchoscope for laser resection. Indeed,
acteristics as the argon laser, the yellow is a new the rigid open tube offers many advantages over
wavelength never used in medicine, and the red the fiberscope for laser resection. Depending on
is a tunable dye laser beam that may lead to the the manufacturer and model, the working chan-
development of new photochemical modalities nel is 8 to 9 mm in diameter, which is large
like the hematoporphyrin technique. We will enough to allow simultaneous viewing, lasing,
soon begin an experimental program with such and suctioning. In cases of high-grade occlusion,
a laser in our unit in Marseille and will report the rigid scope can be used to prop open the air-
our findings. way, thereby restoring patency. Vision through
a telescope is much better than through a fiber-
scope, and the lens is better protected against
Instrumentation soiling. In addition to these advantages the tip
of the rigid tube can be used to palp the lesion,
The dangers of laser resection are now well thus providing "tactile" feedback that is crucial
known. They may be classified into two cate- in deciding what and how much to resect.
gories, namely, the irreversible ones that can Many of the bronchoscopes now being sold
and must be prevented by limiting the amount have in fact been designed specifically for ther-
oflaser exposure and the controllable ones. The apeutic purposes and especially laser resection.
112 J-F. Dumon and B. Meric

In collaboration with J. Harrell of the University from any combination of these factors. De-
of California in San Diego, we at Salvator Hos- pending on the patient's cardiovascular status,
pital have developed a third-generation universal hypoxia can very quickly lead to more serious
bronchoscope especially suitable for lasing in the problems, including bradycardia and cardiac ar-
tracheobronchial tree. It comes with a set of in- rest. In order to be able to respond to hypoxia
terchangeable barrels, ranging in size from 3.5 promptly, blood oxygenation should be moni-
to 9 mm in diameter, which can be used for chil- tored. The Ohmeda Biox 3700 Pulse Oximeter
dren as well as adults. A second set of short is very well suited for noninvasive monitoring
barrels with no lateral ventilation ports is also of arterial oxygen saturation. Light generated in
available for the treatment of tracheal stenosis. a finger probe is passed through the tissue and
The fact that barrels are interchangeable is a is converted into an electronic signal by a pho-
great advantage for tracheal stenosis, since pro- todetector. This signal is relayed back to the
gressively larger barrels must be used to dilate oximeter where it is amplified and processed.
and gauge the trachea as tissue is resected. In Patient data and status information, including
addition to the main entrance through which the SaOz, pulse rate plethysmographic waveform,
telescope and/or other instrumentation is intro- trend data, status messages, and alarm mes-
duced, the head of the bronchoscope has a side sages, are presented on two liquid crystal dis-
port that is designed to accommodate the laser plays. At the first sign of a consistently negative
fiber and one suction tube, and to allow removal trend, lasing should be interrupted long enough
of resected fragments. All openings can be to oxygenate the patient and perform tracheo-
sealed with Silastic caps so that closed-circuit bronchial toilet. An oximeter is also a great asset
ventilation is possible. With regard to ventila- in the recovery room, where the risks of hypoxia
tion, it should also be noted that the T -tube are the same as in the endoscopy room.
adaptor is mounted on a swivel so that it is not Another useful accessory that is now available
necessary to interrupt lasing under closed-circuit for N d: Y AG and argon lasers is the artificial
conditions. The Dumon-Harrel bronchoscope is sapphire laser tip designed to be attached to the
thus a truly all-purpose instrument that can be end of the optical fiber for contact photocoag-
used on adults or children under closed- or open- ulation and tissue vaporization. Until now, laser
circuit conditions, with or without jet or high- energy has been delivered by noncontact irra-
frequency ventilation. diation. Contact irradiation has several advan-
Experience has shown that suction tubes are tages, including greater precision in aiming,
a key component of the equipment setup for lower power requirements for equivalent effects,
tracheobronchial laser surgery. The presence of greater control over depth of penetration, and
at least one suction catheter in the airway is an protection of the laser fiber from soiling and de-
absolute requirement for most procedures, and, terioration. These advantages are particularly
should hemorrhage occur, a second catheter is important for the application of laser energy
sometimes needed. These tubes are used not in closed tubes like the esophagus, but the la-
only to keep the operative field and airways ser tip also opens up new possibilities in bron-
clean by constant suctioning of blood and se- chology.
cretions, but also to palp the lesion and to seize
and pull out resected fragments. The design and
quality of the suction tube is very important. It
must be made of rigid and ignition-resistant Methodology
plastic. Catheters meeting these standards are
now available from several manufacturers, and Six years of experience has given us a good idea
they should be used by any team that practices of the applications for laser resection. The best
endoscopic laser resection. indications are inoperable tumors located in the
Hypoxia during a laser procedure can result trachea or main stem bronchi and causing dys-
from the following: the presence of instrumen- pnea, regardless of the degree of malignancy.
tation in the airway, oversedation, tumoral oc- Patients with these lesions are often in acute
clusion, treatment-related complications (e.g., respiratory distress, and palliative laser resec-
hemorrhage and secretion accumulation), or tion literally saves them from death. Another
18. Bronchoscopic Nd:YAG Laser Resection 113

strong advantage of the laser is that it can be general condition, the degree of obstruction,
used repeatedly at each recurrence, thus hemorrhagic potential (e.g., carcinoid tumors),
greatly extending survival time. Inoperable and the age of the lesion, greatly influence the
malignant tumors in peripheral regions of the degree of risk. Probably the most important fac-
tracheobronchial tree can also be treated, but tor of all-even more than pathology-is loca-
because of their inaccessibility, they are not tion. All tracheal and main stem bronchial le-
very good indications. Although extrinsic sions are dangerous because the risk of hypoxia
compression is an absolute contraindication is high. Especially dangerous are lesions located
for laser resection, treatment of the endolu- on the posterior wall of the trachea and left main
minal portion of inoperable extrabronchial tu- stem bronchus because of the added danger of
mors (tip of the iceberg) is possible. Finally, esophagotracheal perforation. Also demanding
for benign tumors without extrabronchial great caution are lesions on the anterior wall of
involvement, laser treatment may be the the lower third of the trachea due to the prox-
treatment of choice. In this regard, it is inter- imity of the aorta and in the left upper lobe due
esting to note that papilloma recurrence after to the difficulty of access. However, the most
laser resection is lower than with other ther- dangerous lesions of all are recurrences after
apies. pneumonectomy.
With regard to nontumoral tracheal pathology, In the previous section it was said that most
there are a few minor applications for laser re- laser procedures were carried out through a rigid
section, such as destroying granulomas on su- open tube, but there are some for which the fi-
ture threads, cutting suture threads, controlling berscope can be used safely. Fiberscopic pro-
local bleeding, and removing impacted foreign cedures can be carried out with no premedica-
bodies, but the most significant nontumoral in- tion other than atropine. The patient should lie
dication for bronchoscopic laser therapy is tra- on the pathologic side. This "safety position,"
cheal stenosis. At our institution the laser has first proposed by our team in 1980, prevents
completely changed our approach to this type flooding of the healthy bronchus in the event of
of pathology, which had previously been treated a hemorrhage. With regard to the choice of rigid
exclusively by sleeve resection-contraindicat- and flexible bronchoscopy, it should be added
ed for older patients or patients in poor condi- that the endoscopist must have sound experi-
tion. Presently, endoscopic laser resection is the ence with both systems. After each laser resec-
initial treatment for most patients with tracheal tion, a fiberscopic inspection of the whole
stenosis. With a concentric web or a solitary tracheobronchial tree is necessary to ensure that
tracheal granuloma, laser resection is usually all secretions and/or debris have been removed.
curative in only one or two sessions. In order Along with careful coagulation of the resected
to maximize the effect of each treatment, re- zone, this inspection is the key to a complica-
section should be complemented by forceful tion-free recovery period.
dilatation with various-sized open tubes. For A variety of general anesthesia techniques for
more extensive lesions involving inflammation rigid bronchoscopy is used by the different
and chondromalacia, recurrence after laser re- teams practicing laser resection. Because many
section is systematic. In these cases we either drugs of proven reliability in Europe are un-
recommend the patient for sleeve resection, or, available in the United States, it is useless to
if his condition or age makes surgery unfeasible, give a detailed description of our protocol. Suf-
we insert a Montgomery T-tube after the first fice it to say that we still recommend use of a
laser session and then wait for the inflammatory "light" anesthesia, leaving the patient breathing
process to subside before deciding on further spontaneously and allowing rapid awakening.
treatment (laser or surgical). With respect to the We are against jet high-frequency ventilation,
T-tube, it should be stated that significant im- which, in our opinion, unnecessarily complicates
provements have been made, and this device is the procedure and increases the risk for the pa-
now very reliable and easy to use. The greatest tient. Gas anesthesia with a noninflammable
improvement is the presence of a lock ring on agent like nitrogen pentoxide can be practiced
the perpendicular segment to prevent migration. but requires closed circuit conditions at all times.
Certain other factors, such as the patient's The Dumon-Harrel bronchoscope with its Si-
114 J-F. Dumon and B. Meric

las tic seals on all ports is compatible with gas anesthesia with a short recovery time is impor-
anesthesia. Prior to general anesthesia, each tant).
patient must have a chest x-ray, an electrocar-
diogram, and laboratory tests, including an ion-
ogram and a coagulation test. Other tests, such Results
as measurement of blood gas levels, may also
be performed. Our series now comprises 1367 resections on 751
Our experience has taught us that, in practice, patients. The vast majority (80%) of these
cooperation between the endoscopist and the procedures were carried out under general
anesthetist is more important than the anesthesic anesthesia with a rigid open tube. Table 18.1
technique itself. The main risks during laser re- summarizes indications and methodology.
section are hypoxia and hemorrhage, which can Tracheobronchial tumors were the most com-
lead to irreversible cardiovascular complica- mon indication for laser resection in our expe-
tions. To keep this from happening, it is nec- rience. Malignant tumors alone (463 cases) ac-
essary to monitor vital signs continuously. At counted for over half our indications (61 %). The
the least sign of hypoxia, the endoscopist must most frequent malignant entity was squamous
interrupt lasing and allow the anesthesist time cell carcinoma (Figure 18.1). Immediate results
to seal off the bronchoscope for mechanical are easily assessed and depended mainly on lo-
ventilation, if the procedure is not already being cation (Figure 18.2). Because they are the most
carried out under closed circuit conditions. A accessible, tumors in the trachea or main stem
tracheobronchial toilet should also be per- bronchi are the best indications.
formed. The exact response to hypoxia or hem- Assessment of long-term results is more dif-
orrhage depends on the location of the lesions. ficult, if not impossible, since these patients
For tracheal lesions, the bronchoscope is distal were referred to us from all over the world and
to the main stem bronchi; thus, in order to have underwent a wide variety of complementary
access to the lungs, it must be passed forcibly treatments. We did, however, record long sur-
through the stenosed area. For lesions in one vival times in several "last chance" cases with
main stem bronchus, the bronchoscope must be extensive tracheobronchial involvement. Laser
withdrawn from the pathologic bronchus and . resection should be considered as an emergency
positioned at the entrance to the healthy one. measure destined to reestablish airway patency.
Once hypoxia has been reversed, or the hem- Resection can be also done to prepare a patient
orrhage is under control, lasing can be resumed. for radiotherapy or chemotherapy under optimal
The postoperative period is crucial to the conditions. We also performed laser surgery on
success of a laser procedure. A recovery room tumors with uncertain prognosis (Figure 18.3).
in close proximity to the endoscopy room is Given the likelihood of extrabronchial involve-
therefore a very important facility in a unit ment, carcinoid tumors are best treated sur-
practicing endoscopic laser surgery. The risk of gically, even if they require a delicate procedure
hypoxia from secondary bleeding or secretion such as resection-reimplantation. For carcinoid
accumulation remains high. In the recovery patients beyond the reach of surgery, the laser
room, the patient should be watched and mon- can be called on as a palliative alternative. The
itored by a specially trained team until he or she endoscopist must, however, keep in mind that
awakes (another reason why "light" general carcinoid tumors are highly hemorrhagic. Mas-
sive bleeding occurred in 2 of the 13 cases of
carcinoid tumor that we treated. Adenoid cystic
TABLE 18.1. Indications for laser
carcinoma is also a surgical entity, but recur-
resection and methodology rences are frequent. Furthermore, as these tu-
No. of No. of mors almost always become refractory to ra-
Indication patients treatments diotherapy, the laser is often the only treatment
Tumors 463 807 available to patients that are inoperable or pres-
Tracheal stenosis 136 333 rent recurrences after surgery. One or two re-
Miscellaneous 152 227
Total 751
sections a year usually provide excellent pallia-
1367
tion in cases of adenoid cystic carcinoma. One
IS. Bronchoscopic Nd: YAG Laser Resection 115

FIGURE IS.I. Histology of

malignant tumors.

•
.•- -
SQUAHOU:~ CELL \

II1II ADENOCf\.
nm INDfFFER.
D St'l ALL CELL
0 HISCELL .
1,8 UNKNO ...·/N 1
__ ,i'

23%

61%

of our patients, who was referred to us with After cancer, nontumoral tracheal stenosis is
subtotal obstruction of the trachea and the left the second most frequent indication for laser re-
main stem bronchus, has been undergoing reg- section (18% of our procedures). Stenosis
ular resections for 5 years. Though they are ex- caused by a solitary tracheal granuloma or a
cellent indications for laser surgery, purely en- granuloma at the rim of a tracheostomy catheter
dobronchial benign tracheobronchial tumors are can be easily resected endoscopically with the
rare (only 44 cases in our series: Table 18.2). Nd:YAG laser. By contrast, genuine tracheal

'.
IE] POOR
I
I

I
I
III FAIR

I EXCSLLENT I

TR RMS L~1S RUL Ti RLL ML LUL LLL

FIGURE IS.2. Immediate results of laser resection of main-stem bronchus; RUL, right upper lung; TI,
tracheobronchial tumors in various locations. TR, ; RLL, right lower lung; ML, middle lung; LUL, left
trachea; RMS, right main stem bronchus; LMS, left upper lung; LLL, left lower lung.
116 J-F. Dumon and B. Meric

stenosis, that is, inflammatory stenosis following

intubation or tracheotomy, are very difficult to
manage due to the risk of recurrence. Treatment
of these lesions must be undertaken in an in-
10%
stitutional environment. Regardless of their type
or location, our approach to these lesions is to
examine the lesions endoscopically and then at-
tempt to reestablish normal tracheal gauge by
laser resection through a rigid bronchoscope
under general anesthesia. A week after this in-
itial session, the patient is reexamined fiber-
scopicaUy, and, based d on the findings and the
patient's condition, a decision about further
treatment is made. There are four options: con-
tinued endoscopic observation, further laser re-
section, placement of a Montgomery T-tube, or
sleeve resection. The therapeutic strategy may
be modified in the light of future developments.
In our series we treated 93 cases of genuine tra-
FIGURE IS.3. Prognosis of tumors treated with laser cheal stenosis. In 70 cases the results were good
surgery. and the patients have been in stable condition
for over a year. In 13 cases, follow-up is too
TABLE IS.2. Forty-four benign tumors short to judge results. Six patients treated in in-
tensive care were lost from view, and the re-
Amyloidosis 5 Angioma 4
Botryoid tumor 2 Bronchoosteoblastoma maining four are dead. One death occurred after
Chondroma 3 Fibroid leiomyoma 2 surgery and one after removal of a T-tube (Fig-
Fibroma Hamartoma 7 ure 18.4). Miscellaneous indications include re-
Hemangioma Lipoma moval of suture threads, granulomas on suture
Lymphoma 3 Myoblastoma 2 threads, management of local bleeding, treat-
Neurofibroma I Papilloma 7
Tuberculosis 4 ment of bronchial stenosis, and dislodgement of
an impacted foreign body. These procedures can

r- I
LAS. I!III LAS.+1'1NTG lE1 LAS.+I'·lNTG
+SURG.
D LAs.+SUF~G. l
J

70

60

50

40

30

20

10
FIGURE IS.4. Therapeu-
tic strategy for trachael
0 stenosis.
TOTAL Cor·jCENTF.: IC BOTTLENECK COt1PLEX
18. Bronchoscopic Nd: YAG Laser Resection 117

usually be carried out with a flexible fiberscope bradycardia two days after laser resection of a
under local anesthesia. tumor in the right main stem bonchus of a patient
Serious complications have been rare and with mediastinal and pericardial tumor, and one
were always due to anoxia. We do not attempt from respiratory arrest in an 82-year-old woman
to distinguish between anesthesia-related and one day after removal of a Montgomery T -tube.
resection-related complications, rather, we We also recorded 2 cases of mediastinal em-
consider all problems to result from the tech- physema and 2 cases of transient pneumothorax.
nique as a whole. The most frequent incident
was hemorrhage, which was always stopped; no
death by exsanguination was recorded. We ex- Conclusion
perienced 13 cases of bleeding in excess of 200
cc and 4 in excess of700 cc. Hypoxemia-related After 6 + years of use, the indications and pro-
cardiovascular complications also occurred in- tocol for endoscopic Nd:YAG laser resection are
traoperatively, including 1 cardiac arrest, 3 se- now well-defined. Considering the very serious
vere bradycardias, and 1 bronchospasm. All condition of most of the patients treated, com-
were reversed. The postoperative period is es- plications are rare and results often spectacular.
pecially dangerous. We recorded 2 deaths during This new modality constitutes an important ad-
this period: one from cardiac arrest after severe vance in the field of pneumology.
19
Neurosurgical Applications of
Laser Technology
William D. Tobler and John M. Tew, Jf.

It has now been a decade since lasers for neu- fects of laser radiation. 3 ,4 The ruby laser, applied
rosurgical applications have been widely avail- in a pulsed mode to experimental animals, pro-
able. Since then, the carbon dioxide and duced cerebral contusions, subdural hemor-
Nd:YAG lasers have gained a firm position in rhage, and often death. Direct radiation of cor-
clinical neurosurgery. The carbon dioxide laser tical surfaces of cats with ruby lasers showed
is more widely employed than the Nd:YAG laser various degrees of tissue destruction and in-
and is used primarily as an ablative instrument depth reports of the histologic detail were pro-
for benign extraaxial tumors, usually at the base vided. 5- s
of the brain, or in the spinal canal. The Nd:YAG Stellar and colleagues 9 demonstrated the pre-
laser functions primarily as a coagulative instru- cise cutting and vaporization effects of the laser
ment, to shrink and coagulate vascular tumors in 1968. In experimental tumors in mice, the
and vascular malformations. At the University carbon dioxide laser was shown to coagulate and
of Cincinnati Medical Center our combined vaporize entire masses of tumor . Histologic eval-
laser experience approaches 700 cases, begin- uation of experimental lesions consistently
ning with the carbon dioxide laser first used in showed three zones of injury: (1) an inner
late 1981. charred layer; (2) a middle zone of desiccation,
The development of the quantum theory and (3) an outer layer of edema (Figure 19.1). In
paved the way for Einstein's landmark paper in 1970, Stellar and collegues 9 reported the first hu-
1917 entitled "Zur Quantum Theorie der Strah- man neurosurgical application of the carbon
lung," which detailed the principles for stimu- dioxide laser to partially vaporize a glioblastoma.
lated emission of photons. 1 Bascow and Pro-
kehnov further contributed to an understanding Development of the Carbon
of stimulated emission. The first molecular os- Dioxide Laser
cillator or maser (microwave amplification by
The present era of laser neurosurgery began in
the stimulated emission of radiation) was pro-
1976. The development of portable laser units
duced by Gordon in 1954. 2 The 1958 paper by
that could easily be transported into the oper-
Schawlow and Townes, "Infrared and Optical
ating room enabled surgeons to develop and
Masers," described the structure and function
apply laser technology to clinical practice.
of a laser, but it was Theodore Maiman who was
Ascher 10- 12 first used the laser in Austria to re-
credited with producing the first laser light in
move a brain tumor in 1976, and since then has
July of 1960 from a ruby crystal.
accumulated an experience of greater than 1000
cases. Simultaneous reports of precise tissue
effects and histologic studies of laser effects be-
Early Neurosurgical gan to appear.
Applications of Lasers Shortly thereafter, neurosurgeons began to
use the carbon dioxide laser in the United States.
Most early efforts of pioneering neurosurgeons With improving technology and the recognition
were directed toward describing the ablative ef- of significant benefits of laser application, the
19. Neurosurgical Applications of Laser Technology 119

B tion has turned toward the application of the

Nd:YAG laser for shrinking and coagulating ar-
teriovenous malformations. Reports by Fasano
and co-workers 29.3o Wharen and Sundt/ 1and re-
cently by Tew and Tobler32,33 indicate its use-
fulness, but there is not total consensus about
its applicability to vascular malformations. Re-
cent approval by the Food and Drug Adminis-
tration now enables any trained neurosurgeon
to use the Nd:YAG laser in the United States
for coagulation of tumors and vascular malfor-
mations.

The Argon Laser

The argon laser has a minor but interesting role
B-char 20-50 microns in neurosurgery. Edwards and his group34.35
C- middle layer dessication ...100u Powers and his associates 36 have reported the
0- outer edema ....100 u only significant neurosurgical experience with
the argon laser to date. It has not gained wide-
FIGURE 19. 1. A: Morphology of layers of tissue injury
after exposure to a pulse of carbon dioxide laser en- spread use because of the relatively low powers,
ergy; B: char, 20-50 /-Lm; C: middle layer desiccation, making it inefficient as an ablative instrument.
100 /-Lm; D: outer edema, 100 /-Lm. The production of dorsal root entry zone
(DREZ) lesions has been reported with argon as
well as with carbon dioxide laser. 36-38 Unless a
use of carbon dioxide lasers has become wide- more powerful argon system is developed ,
spread in the United States. Training programs widespread use of this laser in neurosurgery is
to familiarize the surgeon with the features and not likely.
advantages as well as the safety aspects of laser
surgery have become requisite. \3 Clinical Applications of Lasers
Encouraging reports of the efficacy of carbon
dioxide laser techniques of vaporizing menin- A consensus continues to evolve about the rel-
giomas, acoustic neuromas, and other tumors ative indications of laser for brain and spinal
have appeared . 14-24 The carbon dioxide laser has cord tumors. The following summary indicates
become a standard part of the armamentarium our current opinions. We believe that the laser
of the neurosurgeon of the 1980s. It is used pri- is absolutely indicated in basal tumors, including
marily as an ablative tool and, adapted to the meningiomas, acoustic neuromas, chordomas,
microscope, becomes a precision microsurgical and para- and suprasellar tumors. The carbon
instrument. The area of greatest impact in laser dioxide laser is uniquely suited to remove very
microsurgery is the removal of basal, intra- firm tumors that would require significant ma-
ventricular, and spinal tumors. nipulation for removal by other techniques.
Densely calcified meningiomas most commonly
present this type of challenge. The laser is also
Development of the Nd:YAG Laser useful in the removal of previously radiated, fi-
Development of the Nd:YAG laser for biomed- brotic pituitary tumors. The carbon dioxide las-
ical applications began in the late 1960s. The first er, because of its precision, is indicated in the
clinical neurosurgical application was reported removal of all spinal cord tumors, especially in-
by Beck in 1976. 25 The deeper tissue scatter ef- tramedullary, intradural, and foramen magnum
fect and its preferential pigment absorption pro- region tumors . The Nd: Y AG laser is indicated
vided neurosurgeons with a potent coagulation for the removal of vascular tumors, such as glo-
laser. 26 Initial clinical reports have shown the mus tumors, hemangioblastomas, and angiob-
Nd:YAG laser to be effective for vascularized lastic meningiomas.
tumors such as meningiomas, hemangioblasto- Relative indications for the carbon dioxide and
mas, and chordomas .27 .28 More recently, atten- the Nd:Y AG laser are pituitary tumors. He-
120 William D. Tobler and John M. Tew

mostasis by coagulation of the dura by both las- this tumor was rock-hard and the lesion could
ers can be accomplished, but more easily with not have been removed safely by mechanical
the Nd: Y AG laser. In many cases, the laser fa- force. The powerful carbon dioxide laser gently
cilitates intrasellar tumor removal, but a high vaporized this tumor and its origin along the
level of concern for potential injury to sur- medial' sphenoid wing and cavernous sinus.
rounding arteries and nerves is critical. In any Postoperative computed tomography (CT)
patient where blood loss is a factor because of demonstrates complete removal of the lesion
medical condition or religious beliefs, the laser (Figure 19.2). The patient was neurologically
may be of significant benefit. There is no indi- intact postoperatively, and there is no evidence
cation for the use of the laser in the excision of of recurrence four years later.
superficial, nonvascular tumors. However, the A 32-year-old woman with headaches was
inexperienced surgeon may first develop his found to have a posterior fossa meningioma
laser skills with these less critical cases. arising from and attached to the critical left
The following case summaries represent cat- transverse sinus (Figure 19.3). The dural at-
egories where we find the laser to be indispen- tachment of the tumor at the juncture of the vein
sable. The discussions further emphasize the of Labbe and transverse sinus could not be re-
salient features of laser application. moved, but the carbon dioxide laser enabled
vaporization of the tumor origin at this critical
Clinical Applications of the vascular juncture.
A 69-year-old woman presented with numb-
Carbon Dioxide Laser
ness of the right hand, mistakenly diagnosed as
A 60-year-old surgeon was found to have a large, carpal tunnel syndrome, was found to have an
densely calcified, left sphenoid wing menin- intraspinal mass at C 1 placed anteriorly, causing
gioma (Figure 19.2). The surface of the tumor posterior displacement of the spinal cord (Figure
was easily exposed but very firm. Without any 19.4). This inaccessible lesion was exposed
tugging or pulling, the tumor was vaporized in posteriorly and vaporized with a focused carbon
a noncontact technique. The central portion of dioxide laser beam. The noncontact, no-instru-

FIGURE 19.2. Heavily calcified left sphenoid wing meningioma. Tumor excision was facilitated with the carbon
dioxide laser.
19. Neurosurgical Applications of Laser Technology 121

FIGURE 19.3. Posterior fossa meningioma attached to and obliterating a segment of the transverse sinus
(arrow).

mentation technique of laser technology per-

mitted total removal of this chordoma through
an exposure of less than 5 mm, with neurologic
function spared.
Surgical removal of acoustic neuromas is one
of the major applications of laser technology.
Rapid debulking can be achieved without trac-
tion or transmission of heat to surrounding
nerves, arteries, or the brainstem. Electrical in-
terference with evoked potential monitoring is
eliminated and delicate dissection of the tumor
capsule from critical structures can be achieved
with ease. Many of our acoustic patients have
been operated on because the referring surgeon
was unable to totally remove the residual cap-
sule from the brainstem .
This 29-year-old man with von Recklinghau-
sen's disease has had two subtotal resections of
a right-sided acoustic neuroma with rapid re-
currence (Figure 19.5). He also had a smaller
left acoustic neuroma. Total excision of the tu-
mor, especially the adherent portion attached to
the brainstem, was achieved (Figure 19.5).
FIGURE 19.4. Magnetic resonance imaging (MRI) scan Careful nontraumatic dissection and vaporiza-
shows discrete lesion (chordoma) anterior to and dis- tion can be accomplished with the carbon diox-
placing the spinal cord at Cl. ide laser. Routine monitoring of brains tern
122 William D. Tobler and John M. Tew

FIGURE 19.5. Pre- and postoperative scans of a patient with bilateral acoustic neuromas. The right-sided
lesion was removed (arrow).

evoked potentials and facial nerve function has and vascular malformations. The laser is effec-
remarkably aided our ability to preserve neu- tive for incising the corpus callosum and im-
rologic integrity. proving access deep in the third ventricle be-
In 30 patients, we used a transcallosal ap- cause of the elimination of instrumentation. We
proach to gain access to intraventricular tumors are able to limit the opening of the corpus cal-

FIGURE 19.6. Hamartoma of the posterior thalamus pulvinar region excised by means of a transcallosal ap-
proach and carbon dioxide laser vaporization.
19. Neurosurgical Applications of Laser Technology 123

losum to no more than 2.0 cm to avoid discon- is not as great as for the carbon dioxide laser in
nection symptoms. 39 .40 Both the Nd:YAG and neurologic surgery. General availability of the
the carbon dioxide lasers are useful for removing Nd:YAG laser will permit the accumulation and
these deeply placed lesions . evaluation of a larger experience in brain tumor
A 25-year-old male with headaches and hem- and arteriovenous malformation surgery.
isensory deficit was found to have an enhancing
tumor in the left pulvinar region of the thalamus
Brain Tumors Treated with
(Figure 19.6). At surgery this tumor was effec-
tively and completely vaporized through a pos- Nd:YAG Laser
terior transcallosal approach. The patient ex- Although the Nd:YAG laser is not used as fre-
hibited a temporary, partial visual disconnection quently as the carbon dioxide laser, it is an in-
syndrome, and improvement in his preoperative strument of unique capabilities for a neuro-
symptoms. surgeon. Specifically, its potent coagulative
capabilities permit the removal of highly vas-
Clinical Applications of the cularized tumors, minimizing blood loss.
Hemangioblastomas are highly vascularized
Nd:YAG Laser tumors associated with a very high operative
At our institution we began to use the Nd:Y AG mortality because of their vascularity. The
laser for clinical applications in late 1984. To chances of safe removal of this, fortunately, rare
date, we have treated 25 cases: 8 tumors and 17 tumor can be increased with the Nd:YAG laser.
arteriovenous malformations. Understandably, Such a tumor was found in a 57-year-old woman
the range of applicability for the Nd:YAG laser with headaches and ataxia. A solid hemangio-

FIGURE 19.7. Densely enhancing solid

hemangioblastoma of the posterior fossa
removed with the Nd:YAG laser.
124 William D. Tobler and John M. Tew

FIGURE 19.8. Glomus jugulare tumor growing through the base of the brain into the posterior fossa, coagulated
with the Nd:Y AG laser. Postoperative view on the right.

blastoma was found in the left cerebellar hemi- Arteriovenous Malformations Treated
sphere (Figure 19.7). At surgery, this tumor was with the Nd:YAG Laser
beefy-red and bled profusely when palpated with
a dissector. The tumor was coagulated with the Reports concerning the clinical effectiveness of
Nd:YAG laser, then vaporized with the carbon the Nd:YAG laser for coagulation and induction
dioxide laser in alternating fashion until com- of hemostasis associated with vascular tu-
plete removal was obtained. The hemostasis mors,41A2 aneurysms,43 and arteriovenous mal-
provided by the Nd: Y AG laser was excellent formations (A VMs)43-45 have varied from enthu-
and enabled vaporization to be carried out rap- siastic to disappointing. Blood selectively
idly, in a dry field. This case also demonstrates absorbs the energy emitted by this laser wave-
the limitation of the carbon dioxide laser as a length, and obliteration of vessels can be effec-
coagulative instrument. tively induced without imparting substantive
The addition of the Nd: YAG laser to the neu- damage to adjacent brain tissue. Because the
rosurgeon's armamentarium will likely lead to operative removal of A VMs of the brain, and
dramatic improvements in the morbidity and particularly those arising from the central core,
mortality of this classification of tumor. remains one of neurosurgery's major unresolved
Glomus jugulare tumors are highly vascular technical challenges, we have directed our ef-
and infiltrate the skull base. This tumor is ideally forts toward technical developments of the
suited for the Nd:Y AG laser. Like the heman- Nd:YAG laser as a mode of therapy. We agree
gioblastoma, this is a rarely encountered lesion. with Wharen and colleagues 45 that refinements
A 57-year-old woman underwent a posterior are necessary. However, our experience in a
fossa craniectomy and biopsy of a glomus tumor substantial number of cases of complex A VMs
in 1959, but surgical excision was not attempted. confirms the safety of the device and indicates
In January 1984, she presented with progressive that it can be of inestimable benefit in the sur-
headaches and loss of facial sensation. Com- gical extirpation of some malformations.
puted tomography (CT) disclosed a large cere- The Nd: YAG laser was first used at our in-
bellopontine angle tumor (Figure 19.8). Preop- stitution in February 1984, and we have treated
eratively, the patient underwent particulate a total of 17 A VMs with this laser. The following
embolization of the tumor, which significantly summaries represent our more challenging
decreased blood flow to the tumor. At surgery, cases.
the Nd: Y AG laser coagulated the tumor, and in A 27-year-old woman with headaches and
a nearly dry field it was vaporized with the car- temporal lobe seizures had a large temporal-
bon dioxide laser for total excision. Sylvian arteriovenous malformation. The nidus
19. Neurosurgical Applications of Laser Technology 125

+
FIGUR E 19.9. Dominant temporal lobe arteriovenous malformation vaporized with the Nd:Y AG laser. (Top)
Preoperative views. (Bottom) Postoperative views.
126 William D. Tobler and John M. Tew

FIGURE 19.10. Left thalamic arteriovenous malformation fed by deep thalamoperforate and posterior cerebral
artery branches.
19. Neurosurgical Applications of Laser Technology 127

FIGURE 19.10. (continued) Postoperative angiogram.

of the malformation was treated with the eral ventricle. The left thalamus was entered,
Nd:YAG laser to reduce its bulk. Complete dis- and the hematoma cavity was evacuated. The
section and excision of the A VM was accom- arteriovenous malformation was identified, and
plished with a combination of bipolar and its vessels were coagulated with Nd:YAG laser
Nd:YAG energy (Figure 19.9). The patient made energy. Some large feeders required bipolar co-
an excellent recovery with no detectable speech agulation and application of a surgical clip. A
deficit. This experience demonstrated the ca- second-stage procedure was necessary to totally
pacity of the laser to effectively coagulate dural excise a few residual vessels of the A VM; The
vessels and radically reduce the flow in a large patient had no residual motor dysfunction, but
malformation located adjacent to eloquent did have short-term memory loss, which was
brain. temporary.
A 33-year-old female presented with sudden The last case chosen for illustration is a 48-
onset of a severe headache and a left intracer- year-old man who presented with intracerebral
ebral hematoma. Angiography confirmed a left hemorrhage. His arteriovenous malformation
thalamic A VM whose primary feeding branches was in the right posterior thalamus (Figure
were the thalamoperforate and posterior cho- 19.11). At surgery, the nidus was coagulated
roidal branches of the left posterior cerebral ar- with the Nd:Y AG laser, and total excision was
tery (Figure 19.10). Neurologic examination was achieved (Figure 19.11). The patient's hemipa-
normal except for athetoid movements of the resis gradually resolved.
right upper extremity. The Nd:YAG laser is helpful for dissecting
The patient underwent a left parietal crani- the plane between nidus and normal brain, and
otomy and transcallosal approach to the left lat- also for achieving hemostasis in the bed of re-
 'I ", .:.J
7 .L .: t.,!)

.r+.::..;. ,,

...
..:.;.,..
.;.
:.~

FIGURE 19.11. (Top) Preoperative filling of right thalamic arteriovenous malformation. (Bottom) Postoperative
angiogram shows no residual malformation.

128
19. Neurosurgical Applications of Laser Technology 129

section. More importantly, direct radiation of References

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lumen, and results in failure to achieve shrinkage after laser radiation. An electron microscopic
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of a bleeding vessel with the Nd:YAG laser. 4. Rosomoff HL, Carroll F: Reaction of neoplasm
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~hrinking and totally occluding most AVMs with
5. Fox JL: The use of laser radiation as a surgical
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of high-flow vessels. cranial and vascular studies of the effects of pulsed
The development of a precise micromanipu- and continuous wave laser radiation. J Neurosurg
lator for the surgical microscope has greatly fa- 27:126-137, 1967.
cilitated the precision of application. The spot 7. Fox JL, et al: Lasers and their neurosurgical ap-
size can be accurately controlled and the laser plication. Milit Med 131:493-498, 1966.
beam precisely directed under direct vision 8. Liss L, Roppel R: Histopathology of laser-pro-
without the interposition of vision-obstructing duced lesions in cat brains. Neurology 16:783-
handpieces. The application of microlaser tech- 790, 1966.
niques has improved results in deep-seated mal- 9. Stellar S, Polanyi TG, Bredemeier HC: Experi-
mental studies with the carbon dioxide laser as a
formations of the ventricles, thalamus, and neurosurgical instrument. Med Biol Eng 8:549-
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techniques is unusually difficult. 10. Ascher PW, Heppner F: CO 2 -laser in neurosur-
We are encouraged by our experiences with gery. Neurosurg Rev 7:123-133, 1984.
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ergy in neurosurgical applications continues. the use of a CO 2 laser on CNS tissue. Acta Neu-
Development of new micromanipulators for rochir Suppl (Wien) 28:572-581, 1979.
combined CO 2 and Nd:YAG fibers is needed, 13. Brown JT, Cerullo LJ: Laser workshops in neu-
and endoscopic techniques for Nd:YAG appli- rological surgery. Lasers Surg Med 4:241-246,
1984.
cations hold promise for future development in
14. Bartal AD, Heilbronn VD, Avram J, et al: Carbon
neurosurgery. dioxide laser surgery of basal meningiomas. Surg
Great caution must be exercised in the use of Neurol 17:90-95, 1982.
the Nd:YAG laser, especially at the base of the 15. Gong-bai C: Laser vaporization on intracranial
brain in close proximity to critical vascular and tumors. Lasers Surg Med 1:235-240, 1981.
neurologic structures, particularly the brainstem 16. Hara M, et al: Evaluation oflaser surgery against
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CO 2 laser energy is virtually entirely absorbed surgical laser vaporization of inaccessible tumors
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on the surface.
76:245-250, 1981.
We concur with the reports of others that the
18. James HE, Williams J, Brock W, et al: Radical
unique features of the Nd: YAG laser will ensure removal of lipomas of the conus and cauda equina
its future use in the treatment of brain tumors. with laser microsurgery. Neurosurgery 15(3):340-
These two lasers, the Nd:YAG and carbon 343, 1984.
dioxide, have become important tools for the 19. Mattos Pimenta LH, Mattos Pimenta A, Martins
neurosurgeon. JL: The use of the CO 2 laser for the removal of
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awkwardly situated meningiomas. Neurosurg Rev with the neodymium: YAG laser. Adv Tech Stand
4:53-55, 1981. Neurosurg Vol. 14 (in press) 1988
20. Robertson JH, Clark WC, Robertson JT, et al: 34. Edwards MSB, Boggan JE: Argon laser surgery
Use of the carbon dioxide laser for acoustic tumor of pediatric neural neoplasms. Child Brain 11:171-
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Neurological Surgery, 3rd ed. 1983.
22. Takizawa T: The carbon dioxide laser surgical unit 36. Powers SK, Adams JE, et al: Pain relief from
as an instrument for surgery of brain tumours- dorsal root entry zone lesions made with argon
Its advantages and disadvantages. Neurosurg Rev and carbon dioxide microsurgical lasers. J Neu-
7: 135-144, 1984. rosurg 61:841-847, 1984.
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physics, and neurosurgical applications. Clinical and radiofrequency dorsal root entry zone lesions
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laser-assisted excision of a metastatic midbrain Laser-induced dorsal root entry zone lesions for
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11:754-760, 1982. 43. Fasano VA, Urciuoli R, Ponzio RM: Photoco-
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section of arteriovenous malformations. J Neu- mation of the brain with laser sources. Lasers
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ment of arteriovenous malformations of the brain rosurg 60:540-547, 1984.
20
The Use of Contact Lasers (Nd:YAG and
Argon) in Neurosurgery: Clinical and
Experimental Data
Victor Aldo Fasano

Recent technical improvements have resulted in probe. This accounts for a more uniform dis-
the introduction of laser contact-delivery sys- tribution of energy on the target and less extent
tems. These combine the main features of the of the lesion in depth.
laser source with the tactile feedback. A new In this chapter, the advantages and limits of
contact laser technique has thus taken its place contact delivery systems in neurosurgery are
beside conventional noncontact lasers. The ideal discussed in the light of personal clinical and
material for contact irradiation should prevent experimental results.
tissue adhesion and combine several properties:
physiologic neutrality, hardness, mechanical
strength, and low thermal conductivity. The Subjects and Methods
standard surgical laser light transmitter, that is,
the single quartz crystal fiber, has proved to All experiments were obtained using a synthetic
have several drawbacks, as far as beam irradia- SLT sapphire contact probe (manufactured by
tion and damage to the quartz tip are concerned, Surgical Laser Technologies Inc., Malvern, PA)
when used in contact with tissues or blood. attached to a handpiece and connected by a uni-
Several natural and artificial substances have versal metal adapter to the conventional fiber-
therefore been investigated. optic delivery system of commercially available
Daikuzono and Joffe l have shown that a single lasers (a Teflon-coated quartz fiber light guide
Al 2 0 3 artificial sapphire crystal is a good trans- with 0.6 mm diameter).
mitter of the Nd:YAG laser and combines the
coagulating properties of the source with cutting
Experimental Studies
capabilities previously offered by the CO 2 laser
only. This preliminary work has shown that In a first series of experiments the distribution
noncontact irradiation from a noncontact quartz of brain tissue temperature was studied at time
fiber entails backscattering, accounting for 30- of surgery after Nd:YAG laser impact. Power
40% of the total irradiated power, whereas with settings were 10 to 30 W (noncontact) and 5 to
a contact probe there is no sideward irradiation 20 W (contact). The exposure time was 5 sec-
and all the power is delivered at the distal end. 1 onds. Iron-constantan thermocouples were
Because of this feature the sapphire crystal pro- placed at variable distances and depths from the
vides the substantial reduction in laser energy target (0.1 to 10 mm). The recording system used
required. Even when on low power, the thermal for thermal measurements was a Honeywell E
energy is always enough for sharp incision by 195 LAB/TEST recorder. Successively, the an-
means of rapid vaporization of tissue. In addi- gular distribution of N d: Y AG laser light in a
tion, the beam from a contact probe has greater noncontact system (bare fiber) and a contact
divergence and provides a concentric circular surgical scalpel (0.6 mm Tip) has been measured.
pattern due to interference attributable to laser The dependence of the probe/temperature and
light coherence and the conical shape of the corresponding thermal radiated power on the
132 Victor Aldo Fasano

radiated laser power has been studied in order I. hemostasis, either on the surface or in cavities
to discriminate the responsibility of a direct (SLT Flat Probe®);
thermal diffusion from the probe in the expres- 2. cutting poorly vascularized tissues, mainly
sion of the biologic damage. For the experi- white matter, using a O.l-mm SLT Probe®
mentation we used: designed for microsurgery (a 0.05-mm di-
ameter probe will be available in the near fu-
1. Thermopile Scientech model 360203 with a
ture); and
maximal resolution of 10 fJ., Wand 10 fJ.,J, con-
3. cutting highly vascularized tissues with a the
stant spectral answer in the wavelength range
SL T Frosted Probe®. The beam is emitted
0.25 to 35 fJ.,m.
both at the probes distal end and along the
2. Optics of collection in NaCl.
lateral aspect of the crystal to improve the
3. Calibrated filters for the selection in the in-
hemostasis.
frared range. The effects of heating and ther-
mal radiation from the Tip and the bare fiber
have been evaluated by a germanium filter,
which is able to absorb the Nd:YAG radiation
Results
with high transparency for the thermal radia-
tions at the temperature of interest (less than
Physical Data
2000°C). From the mathematical evaluation of 75 thermal
measurements the thermal increase seems to be
In a second series, the modifications occurring
governed by the following law:
in perilesional areas, after contact laser radiation
with a contact probe, were studied by electron ilT = To e - ar,
microscopy. The experimentation was per- where To and a are two parameters whose values
formed during neurosurgical procedures on can be deduced by best fitting: we found To =
gliomas (10 cases), on meningiomas (7 cases), 269°C and a = 0.21 mm- I . The analysis suggests,
and on normal brain whenever the surgical ap- moreover, that, because of the loss of heat by
proach to the lesion made it necessary to remove vaporization, only 37% of the power used pro-
peritumoral tissue (8 cases). Irradiation was de- duces thermal effects. The law enables us to
livered at a power output of 3-5 W with argon calculate the radius of the hemisphere in which
and 15 to 20 W with Nd:YAG for 5 seconds. the tissue temperature after laser impact is a
Thin sections were observed in a Siemens EI- certain value T.
miskop lA electron microscope. 2 r = In [PtJPo(T - T I )]
,
a

Series of Cases where To and a are known, Po is a reference

power value: 28 W for noncontact irradiation
Since 1985 we have treated 147 cases: 104 intra- and 36 W for contact irradiation, P is the power
axial lesions (60 subcortical cerebral gliomas, used, and TI is the tissue temperature on the
13 cortical metastases, 7 cerebral abscesses, 1 surface or in depth.
lymphoma, 1 radionecrosis, 3 ependymomas of Figure 20.1 indicates the radius of the hemi-
the fourth ventricle, 15 cerebellar spongioblas- sphere in millimeters, in which the temperatures
tomas, 1 cerebellar hemangioblastoma), and 40 of 42°C (threshold of cellular damage), 60°C
intracranial extracerebral tumors (15 dural en- (tissue coagulation), and 100°C (tissue carbon-
dotheliomas, 14 parasagittal meningiomas, 6 ization) are reached on the assumption that only
sphenoid wing meningiomas, 5 meningiomas in 37% of the power used produces thermal effects.
the cerebellar region). A comparison of the contact and noncontact
Depending on tissue consistency, powers delivery systems has demonstrated the following
ranging from 12 to 20 W with Nd:YAG and 2 to characteristics.
5 W with argon were used. Exposure time was In Nd:Y AG laser light transmitted through
5 seconds with 2-seconds interval after each bare quartz fiber, 80% of the laser power is
pulse; to avoid melting of the tip, probes had to emitted in a cone-shaped beam of about 12°
be replaced after three sequential pulses. SLT (Figure 20.2). The power density at the end of
Contact Laser Probes were used for the fiber is about 400 W/cm 2 for a laser power
20. Use of Contact Lasers in Neurosurgery 133

mm of about 13 W. The thermal radiation is not ap-

preciable (less than 1/10,000 of the total laser
10 power).
In Nd:YAG contact delivery systems 80% of
the laser power is emitted in a cone-shaped beam
of about 90°; the angular distribution shows a
7 .5 peak in the axis and two symmetrical latera l
lobes (Figure 20.3). The power density at the
Tip is about 2.5 kW/cm~ for a laser power of
about 6.5 W. At a distance of 2 mm from the
5
probe the power density is reduced to 50 W/cm 2 ,
while for the quartz bare fiber at the same dis-
28 W tance the power density is unchanged. The
thermal radiation power is in the range of 1/1000
2 . 5
of the total laser power. Table 20.1 shows the
temperature of the Probe for various levels of
18 W the laser power. Values of 1800 K are reached
for a laser power of 23.5 Wand a 10-second ir-
radiation time.
42 60 1 00

FIGURE 20.1. Thermal diffusion in cerebral tissue. The

graph shows the values of the radius in millimeters,
Histologic Data
in which temperatures of 42, 60 , and 100°C are The following data apply only to the periphery
reached, at corresponding powers of 18 and 20 W. of the lesion (approximately 1.5 to 3.0 mm away
. , contact Nd :YAG laser; e, noncontact Nd :YAG from the center of the lesion) . Significant tissue
laser. or microvascular lesions were not observed after
contact argon irradiation; slight modifications in
morphology of the blood-brain barrier and ner-
vous tissue constituents (slight swelling of as-
trocyte pedicles, small vesicles in the basement

NORMALIZED INTENSITY

.9

.8

.7

.6

.5

.4

.J

.2

FIGURE 20.2. Angular dis- .,

tribution of Nd:YAG laser
light. Noncontact surgical o-~50~---~40~---~30~---~20~---~,~o--~O~--·1~O~~2~O----~JO~--·40~---E50
system (bare fiber). ANGLE (decJrees)
134 Victor Aldo Fasano

NORWAUZED INTENSITY FIGURE 20.3. Angular dis-

tribution of Nd:YAG laser
light. Contact surgical
.9
system (0.6-mm Tip) .
.8

.7

.6

.5

.4

.3

.2

.1

0
-50 -to -30 -20 -10 0 10 20 50
ANGl£ (dewees)

membrane) with complete preservation of cap- Surgical Results

illary patency and tissue architecture were de-
The procedures used to approach intraaxial le-
tected (Figure 20.4).
sions (incision of cortex and subcortical layers)
Lesions were more severe with the contact
and to separate residual infiltrating tumors from
Nd:YAG laser. At the blood-brain barrier level,
surrounding fibrous, neurovascular, and paren-
erythrocytes were aggregated, the as!rocytes
chymal deep structures were effective and rapid
and the endothelial cells were vacuohzed and
in all cases, even in the presence of blood or
swollen. The structure of the basement mem-
liquids. In the extraaxial tumors the dissection
brane was well retained and capillary patency of the arachnoid was performed with conven-
preserved. Neurons and myelin sheaths retained tional instruments, and then the tumor was dis-
their structure sufficiently well to be fully rec- sociated from the surrounding healthy structures
ognizable (Figure 20.5). with a contact laser with good results in all cases
treated. In tumors adjoining nerves or important
vessels, the neurovascular structures involved
were always preserved. The base of tumor im-
plant on falx, tentorium, and durk is easily re-
TABLE 20.1. Direct thermal radiation in a sected.
Nd : YAG contact surgical system
Maneuvers were difficult in hard, heavily cal-
P-thermal cified tissues (separation of thick abscessed
P-Iaser (W) (mW)* Temperature (K) capsula from marked perilesional gliosis; inci-
23.5 21 1800 sion of calcified meningiomatous capsulae) and
16.5 IS 1650 in procedures on grey matter because of the dif-
11 9 1450
8.5 7 1350
fuse bleeding; this maneuver, however, has been
highly improved by the use of the SLT Frosted
Dependence of the tip temperature and corre- Probe. Cutting the arachnoid is ineffective. He-
sponding thermal radiated power (P-thermal) on
mostasis has been often insufficient in tumors
the radiated laser power (P-Iaser)
Irradiation time: 10 seconds. fed by arteries larger than 1 mm and in the pres-
*P-thermal is normalized to the same angular ap- ence of bleeding vessels. Another disadvantage
erture of the outcoming laser radiation . is the frequent rupture of the contact probe,
20. Use of Contact Lasers in Neurosurgery 135

FIGURE 2004. (Top) Cerebral capillary after contact (Bottom) Cerebral tissue after contact irradiation with
irradiation with argon laser. Slight swelling of astro- argon laser. No important morphologic changes.
cyte pedicles; vesicles into the basement membrane.
136 Victor Aldo Fasano

FIGURE 20.5. (Top) Cerebral capillary after contact swelling of endothelial cells; cytoplasmic vesicles.
irradiation with Nd: Y AG laser. Swelling of astrocyte (Bottom) Cerebral tissue after contact irradiation with
pedicles, shrinkage of basement membrane and Nd: YAG laser. No important morphologic changes.
20. Use of Contact Lasers in Neurosurgery 137

which depends on the fluctuations in energy de- agulation of diffuse superficial bleeding can ex-
livery, because of the instability of the power tend the tissue damage; moreover, the dissection
range in high-power laser systems. of tumors adjoining neurovascular structures is
more traumatic with this technique.
Poorer control of the maneuver means that
Discussion separation of irregular-shaped lesions from sur-
rounding structures is difficult with noncontact
The literature indicates that the most important CO 2 irradiation. The main risk being damage to
difference in morphology between contact and nerves or important vessels by accidental de-
noncontact radiation is related to the depth and viation of the beam. Moreover, hemostasis is
volume of necrotic tissue found at the target site. limited to vessels up to 0.1 to 0.2 mm.
The standard noncontact/technique resulted in With contact irradiation the incision is sharp,
a lesion depth of 1.0 to 4.4 mm, the mean values the cut is thinner than that produced by non-
increasing with the amount of energy delivered. contact irradiation, there is no smoke, and car-
The contact technique resulted in a lesion depth bonization of the edges is avoided; moreover,
of only 0.1 to 0.2 mm, with no significant the control of subadjacent planes is continuous,
changes related to alterations in the power and the hemostasis is complete for veins and
range. 3 Data on the morphology of perilesional arteries up to 1 mm. Less laser energy is re-
tissues after laser impact are limited to our his- quired and thermal diffusion is reduced.
tologic observations on the effects of noncontact Due to the shape and the small diameter of
CO 2 and Nd:YAG irradiation. 4 The damage ap- the probe there is less interference with the field
peared to be related to the duration of radiation, of vision, even under the operating microscope.
rather than to the power of the source. Accord- The feeling and appreciation of the texture of
ingly, only minimal damage of the astrocyte- tissues increases the safety and rapidity of the
capillary junctions were observed after CO 2 and maneuver. To assure maximal precision in deep
Nd:YAG exposure at 20-40 W for 2-3 seconds; lesions, expecially in proximity of neurovascular
tissue changes (more severe after Nd:YAG) structures, direct constant visual control is re-
consisted of swelling of astrocyte pedicles and quired by sufficient exposition of all sectioned
endothelial cell cytoplasm, while the basement planes. Due to its very limited side effects the
membrane was unaffected. 4 Similar findings argon laser scalpel has distinct indications for
have now been observed with argon and procedures near important vessels or nerves.
Nd: Y AG contact irradiation. Conversely, after Contrary to noncontact Nd:YAG exposure, the
noncontact CO 2 and Nd:YAG exposure at 20 to decreased thermal spreading allows the
40 W for 5 to 10 seconds, prominent lesions up Nd:YAG laser scalpel to be used safely even in
to complete destruction of the tissue and occlu- critical areas; uncontrolled deepening of the ir-
sion of capillaries were observed; with Nd:YAG, radiation and postoperative hemorrhages from
perivascular hemorrhages occurred in highly residual infiltrating tumors, in fact, were never
vascularized brain tumors. 4 .5 Such lesions were observed in our series.
never observed in the present study after contact The two laser techniques can occasionally be
irradiation. The similarity between effects pro- associated, such as in preliminary vaporization
duced by short noncontact irradiation and con- of a small lesion and subsequent separation of
tact irradiation can thus be attributed to the re- remnants from surrounding structures. In highly
duced thermal diffusion of the latter technique. vascularized tissues, laser scalpel incision can
The greater extension of damage after noncon- be preceded by non contact irradiation with de-
tact irradiation explains why this technique is focused Nd: Y AG laser or contact coagulation
indicated for vaporization of small deep-seated so as to improve hemostasis.
lesions or tumor remnants in the cavity.6 Ex- In conclusion, contact laser systems are suit-
perimental results also support indication of the able for progressive dissection and cutting in
contact laser technique for dissection and cut- depth, while noncontact lasers seem to be useful
ting. 7- 9 mostly for the vaporization and tissue ablation
The SLT laser scalpel shows many advantages in surface. In the future, surgical procedures will
over traditional and noncontact laser techniques. be deeply conditioned by the proper selection
Cutting with bipolar forceps is irregular and co- between the two techniques.
138 Victor Aldo Fasano

References in Neurosurgery. Springer-Verlag, Wien and New

York, 1986.
1. Daikuzono N, Joffe SN: Sapphire probe for contact 7. Fasano VA, Ponzio RM, Bolognese P: Preliminary
photocoagulation and tissue vaporization with the experiences with contact Nd:YAG and argon laser
Nd:YAG laser. Med Instrum 4:173-178,1985. in neurosurgery. Clinical data. Proceedings of the
2. K~rnowsky MJ: A formaldehyde-glutaraldehyde 4th General and Scientific Meeting of the LANSI
fixative of\high osmolarity for use in electron mi- (L\tser Association of Neurological Surgeons In-
croscopy. J Cell BioI 27: 137A-138A, 1965. ternational), Venice, pp 13-14 1986.
3. Diaz FG, Dujovny M, King PK, et al: Use of the 8. Fasano VA, Peirone SM, Fiscella B, et al: Prelim-
contact Nd:YAG laser scalpel in neurosurgery. inary experiences with contact Nd:YAG and argon
Proceedings of the 4th General and Scientific laser in neurosurgery. Experimental data. Pro-
Meeting of the LANSI (Laser Association of Neu- ceedings of the 4th General and Scientific Meeting
rological Surgeons International), Venice, pp. 30 of the LANSI (Laser Association of Neurological
1986. Surgeons International), Venice, pp. 32-33 1986.
4. Fasano VA, Peirone SM, Ponzio RM, et al: Effects 9. Fasano VA, Ponzio RM, Lanotte M, Gawlik J:
at the periphery of the laser lesion in human brain Preliminary Experiences with Argon and Nd: YAG
and its tumors after CO 2 , Nd:YAG and CO 2 high Scalpel Laser in Neurosurgery. Proceedings of the
peak pulsed radiation. Lasers Surg Med 6:308-317, 7th International Congress of Laser/Optoelectron-
1986. ics in Medicine with 2nd International Nd: YAG
5. Yain KK: Complications of the use of the Nd:YAG Laser Conference. pp 424-427 Springer Verlag,
laser in neurosurgery. Neurosurgery 16:759-762, 1986.
1985.
6. Fasano VA: Advanced Intraoperative Technologies
21
Fiberoptic Laser Endoscopy in
Neurosurgery
P.W. Ascher

Flexible fiberoptic endoscopy and stereotaxic in animals, as a potential treatment of hydro-

procedures are of interest to neurosurgeons. . cephalus.
Stereotactic psychosurgery is now rarely per- Between 1982 and 1983 L.M. Auer developed
formed, due to the availability of specific drugs, a rigid encephaloscope for the evacuation of
and is used only in certain chronic pain syn- acute cerebral hematomas. The biopsy channel
dromes and extrapyramidal movement disor- would be used for suction, irrigation, and in-
ders. Stereotactic procedures are invaluable for sertion of the laser fiber. The original device was
the biopsy of deep and often inaccessible tumors then modified to produce a neuroendoscope with
and abscesses. These procedures also allow the a 6.0-mm diameter shaft. These endoscopes
interstitial laser therapy of benign tumors, such were used to puncture and evacuate cystic tu-
as astrocytomas grades 1 and 2. Following top- mors. For all other procedures a pediatric 5.5-
ographic localization, these tumors are biopsied, mm cystoscope with wide-angle optics is used
examined bylight microscopy, and, finally, im- (Figure 21.2). Still, some technical improve-
planted with radioactive seeds. ments are needed, for example, the shaft of the
Neurosurgical fiberoptic endoscopy was ini- endoscope should be longer.
tially used for diagnosis. Following a spinal
puncture, the cerebellopontine angle and the
spinal cord can be inspected, and, with a ven- Indications
tricular puncture, the ventricles can be viewed.
Today, flexible fiberoptic endoscopy, used with Nd:YAG laser endoscopy is currently used in
the Nd:YAG laser, will permit minimally in- three main areas: (1) intraventricular and peri-
vasive neurosurgical procedures. ventricular tumors, especially meningiomas and
ependymomas, (2) acute intracranial hemato-
mas, and (3) cystic tumors.
Meningiomas and ependymomas in the lateral
Development of Nd: YAG and third ventricles are extremely responsive to
Laser Endoscopy laser irradiation. These tumors shrink following
photocoagulation of the vasculature. Mter this
The combination of the Nd: YAG laser with an procedure, as shown in our study of four pa-
endoscope was first used clinically in urology tients, open surgical removal of the tumor,
and gastroenterology. This led neurosurgeons in whether in toto or piecemeal, is technically eas-
Graz to use the laser initially with a flexible ier and less traumatic to the patient.
bronchoscope (Figure 21.1). In Munich in 1982 Two patients with inoperable tumors of the
O. Beck, using the rigid pediatric cystoscope, thalamus were treated with the Nd:YAG laser
punctured a ventricular cyst, aspirated its con- via a pediatric cystoscope. The tumor disap-
tents, and coagulated the cyst wall. Coagulation peared, as confirmed by computed tomography.
of the ventricular choroid plexus was then tried Neither patient had any neurologic deficit at a
140 P.W. Ascher

FIGURE 21.1. Flexible bron-

choscope used in neurosur-
gery.

2-year follow-up. Since 1983, L.M. Auer has Future Indications

evacuated over ISO intracranial hematomas, us-
ing the neuroendoscope in combination with the The Nd: Y AG laser is currently being evaluated
Nd:YAG laser for photocoagulation. Following in three main areas: in the treatment of inter-
aspiration, the cystic tumors were evacuated. vertebral disk disease; as a method of perform-
Tissue samples were obtained for light micros- ing a thoracic sympathectomy, and in the man-
copy, and the stroma or cavity of the tumor was agement of occlusive carotid artery disease.
lasered on the internal surface, leading to tumor Daniel Choy (New York) suggested introduc-
shrinkage in all cases. One week later, a less ing a laser probe through a needle puncture di-
complicated surgical operation was performed. rectly into the intervertebral disk, which would

FIGURE 21.2. Rigid pediatric cystoscope used in encephaloscopy.

21. Fiberoptic Laser Endoscopy in Neurosurgery 141

FIGURE 21.3. Lumbar punc-

ture needle inserted into L4-
L5 disk space for vaporization
of nucleus pulposus.

cause the disk to collapse, thereby relieving the 15% of patients currently undergoing conven-
symptoms. Theoretically, the CO 2 laser would tional surgery to be treated by laser vaporization
be suitable for vaporizing the nucleus pulposus of the nucleus pulposus.
because of its high water content. As suitable Thoracic sympathectomy used in the treat-
CO 2 fibers are not yet available, the Nd:YAG ment of upper limb hyperhydrosis and various
laser, coupled to either a 400 or 600 J..Lm diameter pain syndromes has been made easier by using
quartz fiber, is being used (Figure 21.3). To the Nd:YAG laser endoscopically. Experience
minimize the Nd:Y AG laser light absorption in and follow-up is too short at present. The sym-
water, the nucleus pulposus is first stained by pathetic cord is vaporized for three segments
injecting methylene blue. In the first 12 patients beneath the stellate ganglion, but laser photo-
we treated with the Nd:Y AG laser, 20 to 35 coagulation may be an adequate form of treat-
pulses at a total energy output of 350 to 500 J ment without total excision (Figure 21.4).
reduced the intervertebral disk sufficiently to Carotid laser angioplasty was initially per-
alleviate the symptoms in all patients with a 4- formed with the argon laser by using the per-
month follow-up to date. A larger number of pa- cutaneous transfemoral approach. Although
tients now need to be treated and carefully eval- feasible, it was technically very complicated.
uated. The current technique used with the The Nd:YAG laser (1.06 J..Lm wavelength) with
future the CO 2 laser fiber, or the Nd: Y AG at a the contact synthetic sapphire point has provid-
1. 32-J..Lm wavelength, may allow between 10 and ed excellent results in a limited number of pa-
tients. Other wavelengths (1.32 J..Lm) and new
lasers (excimer) need to be evaluated. Current
experimental and clinical studies will lead to
greater applicability of this technique. Vascular
endoscopes that permit direct visualization with
the contact probes are also being evaluated.

Conclusions
FIGURE 21.4. Contact synthetic sapphire used with New and exciting applications of the Nd:YAG
the Nd: YAG laser for therapeutic fiberoptic and rigid continue to increase since the advent of YAG
neurosurgical procedures. laser endoscopy in neurosurgery. Endoscopic
142 P.W. Ascher

procedures previously petformed for diagnosis applications of the Nd:YAG laser in neurosur-
are now routinely being used in treatment. gery.
In the near future, based on the present ex- Coagulation of the choroid plexus may treat
perience with benign ventricular astrocytomas, certain types of hydrocephalus. The use of se-
stereotactic laser probes will be used with mag- lective tumor dyes (hematoporphyrin deriva-
netic resonance imaging. Newer optic systems, tives) and corresponding laser wavelength will
including the contact sapphire probe, which treat tumors, and may prevent tumor recurrence
prevents overheating of the quartz fiber, reduce following excision. The era of lasers in neuro-
tissue damage and allow selective and uniform surgery is just beginning.
heating of tumor tissue. This will increase the
22
The Contact Nd:YAG Laser in
Neurosurgery
Hirotsugu Samejima, Satoshi Iwabuchi, and Nobuo Yoshii

It took 10 years to recognize the laser for its 40°C and it transmits more than 90% of the
neurosurgical application since Rosomoffl tried Nd:YAG laser beam. 2 •3 Compared to the quartz
to use a ruby laser for surgery on a brain tumor. scalpel, which was developed as a contact optic
Today three lasers, CO 2 , argon and Nd:YAG, delivery conduit, the laser rod has a higher ther-
are widely used for neurosurgery. Among these mal resistance and a lower thermal conductivity,
lasers, the Nd:YAG has been evaluated to be which concentrates energy more effectively by
inappropriate for neurosurgery, in spite of its a sharp increase of local temperature at the distal
excellent hemostatic capability, because of an end. This may be the most distinctive charac-
unsatisfactory cutting-off effect. At the same teristic of the equipment. The laser beam shows
time, this ability to achieve hemostasis has been a markedly wide degree of divergence-more
highly successful in endoscopic procedures. than 100° at the distal end of the laser rod, in
We have found a way to resolve this problem contrast to 7_8° at the end of the optical quartz
for neurosurgery. We can now obtain a satis- fiber. It shows a remarkable attenuation of
factory cutting-off effect, in addition to good power density at a distance in a straight line to
hemostasis, by using a contact laser scalpel, with high energy concentration at the distal end.
a rod made of artificial sapphire, attached to a Moreover, the laser rod is said to rarely cause
Nd:YAG laser. The experimental and clinical backscattering on the surface of the tissue, while
results of our study are discussed in this chapter. the quartz fiber causes a fair amount. 2

Equipment Confirmation of Safety

The Medilas Type 2 Nd: YAG laser (Messersch-

In Vitro Effects
mitt Bolkow Blohm, Munich, Germany) was We studied the effect of a noncontact laser and
used and its laser beam was conducted by an a contact laser, fixed vertically on the surface
optic conduit of the 600-f-Lm core quartz fiber- of a pig liver, on the depth of the liver tissue
optic delivery system. The handpiece with fo- irradiated for 6,4, and 2 seconds at 50 W. The
cusing lens was used for the noncontact laser noncontact laser vaporized the target tissue to
scalpel and the artificial sapphire rod was used a depth of 2.5 mm for 6 seconds, 1.8 mm for 4
for the contact laser. The contact laser has also seconds, and 1.1 mm for 2 seconds, while the
been used with a quartz fiber inside a Burnett depth of vaporization produced by the contact
handpiece developed for neurosurgery. laser was 1.8 mm for 6 seconds, 1.4 mm for 4
The laser rod is structured as a single artificial seconds, and 1.1 mm for 2 seconds. The depth
sapphire crystal of aluminum oxide (Al 2 0 3 ). Its of edema in the heat-affected pale zone that en-
melting point is 2030-2050°C and the thermal sued from the non contact laser application was
conductivity is 0.OOI~.0034 W/cm 2 Isecond at 2.1 mm for 6 seconds, 2 mm for 4 seconds, and
144 Hirotsugu Samejima, Satoshi Iwabuchi, and Nobuo Yoshii

FIGURE 22.1. Light micrograph of tumor tissue vaporized (left); 4 seconds (right); 2 seconds (inset) . H & E, x
by the laser rod immediately after extirpation at an 20.
output of 70 W. Duration of the current was 6 seconds

0.9 mm for 2 seconds, and from the contact laser

In Vivo Effects
the edema was 0.7 mm for 6 seconds, 0.5 mm In the frontal region craniotomy of a white rabbit
for 4 seconds, and 0.4 mm for 2 seconds. Com- under intravenous anesthesia the frontal lobe
pared to the quartz fiber directly, the effect on was irradiated by the contact laser rod. Thirty
the tissue was decreased by 30% in vaporized minutes after the irradiation, for 5 seconds at
depth and 70% in the pale zone at the distal end 25 W, demention of the vaporized crater did not
of the laser rod point. exceed 2 mm. There was no clear boundary line
To observe a direct effect of the laser rod on between the coagulation zone and the edema
tumor tissue immediately after the extirpation, zone,4 and a microcystic honeycomblike zone
the surface of a meningioma was irradiated for was found in the outer stratum. An engorgement
2, 4, and 6 seconds at 30, 50, and 70 W. Even was caused by intravascular thrombi and an ac-
with the irradiation at 70 W, the maximum out- cumulation of erythrocytes in and partial tran-
put, the extent of thermocoagulation beyond the sudation occurred, but no obvious hemorrhagic
vaporized zone was 410 fLm, and it was only 700 lesion was found. Brain tissue directly under the
fLm including the peripheral edema zone. Effects pale zone, that resulted from the thermal effect,
on tissue deeper than that observed in the pig showed a normal structure. With irradiation for
liver, were not found in meningioma, perhaps 5 seconds at 40 W, which caused a compara-
because of the solidity of this tumor. The extent tively greater depth of edema than at 25 W, the
of irradiation, that is, the depth of the honey- extent of the thermocoagulation zone was nearly
comblike area seen in the pale zone, was gen- the same and no hemorrhagic lesion was ob-
erally invariable in the hematoxylin-eosyn stain served. One week after irradiation for 5 seconds
(Figure 22.1). at 25 W, the boundary between the microcystic
22. The Contact Nd:YAG Laser in Neurosurgery 145

FIGURE 22.2. Light micrograph of rabbit brain section 5 seconds. Microcysts were observed in the edem-
one week after the laser rod irradiation at 25 W for atous zone. H & E, x 20.

tissue and normal tissue became clearer than in Discussion

its acute stage, the edema zone contained many
macrophages, fibroblasts, and glial cells, and the There have been many reports on the medical
number of nerve cells decreased. Vessels were applications of the laser, and its safety has been
shrunken and there were no signs of hemor- rather firmly established. s- 8 However, some cli-
rhagic lesions (Figure 22.2). nicians are still apprehensi ve of the safety of the
146 Hirotsugu Samejima, Satoshi Iwabuchi, and Nobuo Yoshii

Nd:Y AG laser, owing to its optical character- and the preservation of coagulative function,
istics. 9 . 10 Edwards 9 explained it in terms of ab- which is a primary characteristic of the Nd:YAG
sorption coefficiency and extinction length, laser, makes it possible to control hemorrhage
showing that the depth in the tissue laser beam at the same time as cutting-an advantage the
is derived from photobiology. The Nd:YAG conventional scalpel did not possess.
laser, which is a scattering-dominated instru-
ment, as opposed to the absorption-dominated
CO 2 laser, has an extinction value of 60 mm in Clinical Application
length to water, but 2.3 mm to the stomach wall
and 3.5 mm to the human brain. 11 Even if the Procedures
extinction length to water is 80 mm, such depth
Fifty-four operations using the laser rod have
in tissue will not be affected due to the scattering
been performed at our hospital. Though it may
effect. 7 In in vitro transmission, the ratio of the
be difficult to absolutely compare the conven-
Nd:YAG absorption of blood to brain was 100:1,
tional operation and this procedure, the time of
and the in vivo change in tissue by the thermal
operation and the amount of hemorrhage during
effect was only 2 mm at the acute stage and 3 the operation were generally evaluated by the
mm at the chronic lesion by irradiation for 8 same surgeon as "very helpful" (helpful both
seconds at 10 Wand 2.5 mm and 4 mm by 8 in time and hemorrhage), "not helpful" and
seconds at 40 W irradiation. This was because "questionable benefits" (result shown in Table
the Nd:YAG laser was preferentially absorbed 22.1). It was very helpful for the solid extra-
by hemoglobin in blood. 8 In acute and chronic medullary tumor, especially for the case that re-
experiments on the rat brain, Nd:Y AG laser ir-
quired coring in order to reduce the volume of
radiation was found to be safe, and normal brain tumor, because of an inclination to hemorrhage,
tissues had a tolerance for this laser. 12 Besides,
firm accretion, and possible adhesion to the
in the microvasculature experiment, CO 2 laser surrounding tissue in depth.
irradiation caused vascular dilation and hem-
The case of meningioma which was most ef-
orrhage peripheral to coagulation or the edema
fectively operated on is described below. In
zone, while the Nd:Y AG laser irradiation caused
cases of convex meningioma, it is not necessary
avascularity or oligo vascularity at the irradiated
to use the laser because the tumor can be re-
part and constricted the blood vessels with little
moved by conventional microneurosurgical
hemorrhages. 13
techniques without damaging the cortex. How-
Safety in direct irradiation by the quartz fiber
has been confirmed as mentioned above; how-
ever, there have been no reports on the effect
of the laser rod yet. The laser rod has no side- TABLE 22.1. Experience with the contact Nd: Y AG

ward irradiation from the surface of the tapered laser in 54 neurosurgical procedures
conical portion, and all of the irradiation is from No. of
the distal end. 2 As the laser rod has little back- Result Lesion cases
scattering, as opposed to 30 to 40% of back- Very helpful Meningioma 13
scattering by the noncontact type, the output Neurinoma 7
Lymphoma
can be reduced about 20-30% as compared to
Metastasis
the noncontact type. 2 Moreover, the angle of Chordoma
divergency is more than 100° at the distal end Helpful Glioma 10
of the rod in contrast to 10° or less by the non- Glioblastoma 6
contact laser, which reduced remarkably the Pituitary adenoma 2
power density at the distance in a straight line. Metastasis 2
Lymphoma
These facts have been shown experimentally by Epidermoid
our results in vitro and in vivo. 3 A shorter ex- Craniopharyngioma 1
tinction length, both in the vaporized and the Not helpful Glioma 2
edema zones, than that with the noncontact las- Lymphoma
Questionable Arteriovenous
er, enables the contact laser rod to be utilized
benefits malformation 5
the same as the conventional scalpel for surgery
22. The Contact Nd:Y AG Laser in Neurosurgery 147

FIGURE 22.3. (Left) Preoperative CT scan with contrast sected in a wedge-like shape by the laser rod. Total
enhancement showing olfactory groove meningioma. removal of the tumor was then done without trans-
At the beginning, the attachment of tumor was re- fusion. (Right) Macrograph showing the tumor.

ever, in basal meningioma, especially in olfac- operated quickly, incomplete hemostasis may
tory meningioma expanded bifrontally (Figure possibly cause excessive hemorrhage. After the
22.3), or when hemorrhage is anticipated by firm initial treatment of the attachment, coring or
attachment, for example, to the planum sphen- enucleation is recommended for huge meni-
oidale. For this operation the low power rod, gioma, and then detachment may be performed
25 W, is used for slow excision of the lesion, by conventional techniques.
either directly or wedge-shaped. If the rod is In case the tumor is located at depth and a

FIGURE22.4. (Leji) Preoperative CTscan with contrast feeding artery was a tentorial artery. Total removal
enhancement showing tentorial meningioma. The of the tumor was done by the coring method. Hem-
huge tumor sat in the right cerebellar hemisphere and orrhage was easily controllable. (Right) Postoperative
adhered to the transverse sinus and tentorium. The CT scan after 6 days.
148 Hirotsugu Samejima, Satoshi Iwabuchi, and Nobuo Yoshii

feeder cannot be treated at the beginning, the lation of the flexible quartz fiber and safety to
capsule should be incised by the laser at 25 to the operating team staff. Perceiving the coag-
40 W, then coring should be done in advance of ulativeness which is a distinguishing character-
the detachment in order to reduce the volume istic of the Nd: YAG laser's wavelength, it is also
of the tumor (Figure 22.4). In that case, de- applied for the extirpation of arteriovenous
tachment should not be done before the tumor malformations. 16
volume is reduced sufficiently. This may spare As the Nd:YAG laser does not damage tissue
unnecessary cortex damage by retraction. If the and has strong coagulative ability, hemorrahgic
attachment is burned off after sufficient coring, degeneration in deeper parts other than the va-
the tumor may be resected easily. This method porized zone found when the CO 2 laser was
is also applied for detachment from the sinus or used, does not occur.13 Clinical application has
important vasculature. increased by these safety confirmations.
When the tumor cannot be completely extir- It has been said that the laser should have
pated but is left partially, due to infiltration into
been operated a certain distance from the lesion
the bony matrix or dura where the tumor cannot for beneficial usage, but as the laser is used rou-
be reached, the remains are preventatively ir- tinely, invasion of the tissue and dangers beyond
radiated by the laser beam. However, further the operation field are well-known problems.
long-range follow-up and cumulative practices Some investigators require further development
are required for satisfactory judgment as to of the contact instrument, which is even more
whether this method inhibits the tumor from easily operable than the flexible quartz fiber. 5.9 • 16
growing again. For the surgeon, especially the neurosurgeon
Although the laser rod is also effective for the who performs microsurgery, it may be essential
enucleation of a large acoustic tumor, an op- that delicate operations be possible and instru-
eration should be carefully done at the part ments be controlled by himself touching the tis-
where the facial nerve traverses. In soft and sue directly for a safe operation. In this regard,
easily aspirated tumors, such as glioma, he- the laser rod whose safety has been confirmed
mostasis possibly occurs by a low power output, enables an incision of the tissue by the distal
but there is absolutely no better method than end of the rod at the same time as vaporization,
the conventional one. and coagulativeness, a distinguishing charac-
Though the effectiveness of arteriovenous teristic of the Nd:YAG. Moreover, the thin dis-
malformation has been reported,16 it was eval- tal end of the rod with 0.5 to 2.0 mm diameter
uated as of "questionable benefit" from our ex- and a Burnett type of handpiece are expedient
perience: the detachment from normal tissue for microsurgery. 2.3
was easy but the tissue change was unknown. Detaching a deep tumor and controlling hem-
orrhage through a small space is a definite ad-
vantage compared to the conventional bipolar
electric forceps or CO 2 laser. However, if the
Discussion
high power output is applied from the beginning,
It was Rosomoff and Carroll I who reported the smoke may disturb visibility and the distal end
use of the laser in neurosurgical practice in 1966. of the rod may possibly melt. 2 The ultrasonic
But the safety and effectiveness of the laser scalpel (CUSA) is useful for coring to reduce
beam was first confirmed in 1978 by Heppner, 14 the content of the tumor, but its thick handpiece
Ascher,15 and Takizawa. 7 The CO 2 laser was is unsuitable for microsurgery.
used mainly at that time. Clinical application of When operation on Sympson's types II and
the Nd:YAG laser was first reported by Beck5 III meningioma is required, or in case of glioma,
in 1980, which showed superior effectiveness to the effect of photoradiation therapy can be ex-
the CO 2 laser for richly vascular meningioma in pected by radiating the remains. 5.6.9 However,
resection with a distinct decrease of transfusion. the effect of the laser beam on inhibition of the
Takeuchi and co-workers6 reported that it was growth of tumor cells has not been explained
efficacious for hard and hemorrhagic tumors yet, and we expect further developments in this
with a shorter time of operation, easy manipu- field in the future.
22. The Contact Nd:YAG Laser in Neurosurgery 149

5. Beck OJ: The use of the Nd-YAG and the CO 2

Conclusions laser in neurosurgery. Neurosurg Rev 3:261-266,
1980.
The Nd:YAG laser that was delivered by the 6. Takeuchi J, Handa H, Taki W, et al: The Nd: YAG
artificial sapphire laser rod was used as a contact laser in neurological surgery. Surg Neuro118:140-
laser instrument. 142, 1982.
7. Takizawa T, Yamazaki T, Miura N, et al: Laser
1. The laser beam radiating from the distal end
surgery of basal, orbital, and ventricular menin-
of the rod acts to histologically coagulate giomas which are difficult to extirpate by con-
maintaining its characteristics as N d: Y AG ventional methods. Neurol Med Chir 20:729-737,
laser. The depth of the effect in the tissue was 1980.
shallower than that directly by the Nd:YAG 8. Wharen RE, Anderson RE, Scheithauer B, et al:
laser delivery fiber and its safety was con- The Nd:YAG laser in neurosurgery. Part 1. Lab-
firmed. oratory investigations: Dose-related biological
2. In clinical applications, it showed an effec- response of neural tissue. J Neurosurg 60:531-
tiveness for the resection of solid and hem- 539, 1984.
orrhagic tumors, especially useful in micro- 9. Edwards MSB, Boggan JE, Fuller TA: The laser
surgery. in neurological surgery. J Neurosurg 59:555-566,
1983.
The use of the contact laser in microsurgical 10. Saunders ML, Young HG, Becker DP, et al: The
procedures should increase, especially for the use of the laser in neurological surgery. Surg
surgical resection and treatment of tumors. Neurol 14:1-10, 1980.
11. Halldorsson T, Rother W, Langeholc J, et al:
Theoretical and experimental investigations prove
N d: YAG laser treatment to be safe. Laser Surg
Acknowledgment. We are grateful to Dr. Shiro
Med 1:253-262, 1981.
Naoe M.D. Department of Pathology, Toho 12. Yamagami T, Handa H, Takeuchi J, et al: His-
University Ohashi Hospital for his advice in tologic study of normal rat brain tissue after neo-
pathological examination. dymium-yttrium aluminum garnet laser irradia-
tion. Surg Neurol 23:475-482, 1985.
13. Kuroiwa T, Matsutaira T, Takei H, Inaba Y: Ef-
References fects of Nd:YAG and CO 2 laser on cerebral mi-
crovasculature. Study in normal rabbit brain. J
I. Rosomoff HL, Carroll F: Reaction of neoplasm Neurosurg 64:128-133, 1986.
and brain to laser. Arch Neurol14: 143-148, 1966. 14. Heppner F: The laser scalpel on the nervous sys-
2. Daikuzono N, Joffe SN: Artificial sapphire probe tem. In Kaplan I (ed): Laser Surgery II. Academic
for contact photocongulation and tissue vapori- Press, Jerusalem, 1978, pp. 79-80.
zation with the Nd:YAG laser. J Med Instrum 15. Ascher PW: The use of CO 2 in neurosurgery. In
19: 151-192, 1985. Kaplan I (ed): Laser Surgery II. Academic Press,
3. Samejima H, Mizokami T, Ushikubo Y, et al: Jerusalem, 1978, pp. 28-30.
Clinical use of contact type Nd-YAG laser (laser 16. Wharen RE, Anderson RE, Sundt TM: The
rod). Nippon Laser Igaku Kaishi 4:117-118,1984. Nd:YAG laser in neurosurgery. Part 2. Clinical
4. Beck OJ, Wilske J, Schonberger JL, et al: Tissue studies: An adjunctive measure for hemostasis in
changes following application of lasers to the rab- resection of arteriovenous malformations. J
bit brain. Neurosurg Rev 1:31-36, 1979. Neurosurg 60:540-547, 1984.
23
Nd:YAG Laser Surgery: Overview of
Applications
Stanley M. Shapshay

Since its introduction into clinical medicine the mittent exposure settings, are most often used
neodymium:yttrium aluminum garnet (Nd:YAG) for volumetric heating of tissue to achieve co-
laser has found definite multi specialty use. The agulation, ablation, and control of hemorrhage.
carbon dioxide (C0 2) laser is clearly established The 1060-nm wavelength of the Nd:YAG laser
as the premier precision cutting device but is makes it ideal for heating a large volume of tissue
seriously lacking in endoscopic applications be- below 100°C. This effect results from scattering
cause of its inability to be transmitted through of the N d: YAG laser wavelength in tissue rather
available fibers. Certain specialties, such as than absorption on the tissue surface as is char-
otolaryngology, gynecology, and neurosurgery, acteristic of the CO 2 laser. In fact, in heavily
still use the CO 2 laser in preference to other laser pigmented soft tissue, such as that of the skin,
wavelengths, since accessibility to the larynx, liver, and spleen, scattering is about twice as
cervix, and brain is adequate without fiber tech- great as absorption. This "cooking" effect with
nology. Good hemostasis with the CO 2 laser, the Nd:YAG laser is ideal for ablation of ma-
primarily for capillary-size blood vessels (mi- lignant tissue with increased hemorrhagic po-
crovasculature), and the ability to predict its tential. However, a problem associated with the
precise soft tissue interaction have made it ideal scattering effect is the clinician's difficulty in
fqr such applications as excisional biopsy of judging the depth of penetration, particularly in
early carcinoma of the vocal cord and control pale-colored tissue. The surface appearance of
of carcinoma in situ of the cervix. However, the laser irradiated area is not necessarily in-
treatment of malignancy originating in such dicative of the degree of underlying laser pen-
vascular areas as the trachea or bronchus re- etration. Under these conditions the less ex-
quires more reliable hemostasis. For control of perienced clinician may cause serious tissue
blood vessels larger than capillary size the damage by continuing to irradiate the tissue
Nd:YAG laser is the ideal wavelength. without pausing intermittently to evaluate the
The first successful application of the effects and, more important, to allow cooling of
Nd:Y AG laser was in gastroenterology and the tissue. High-power Nd:YAG laser applica-
bronchology through standard endoscopes tions can be used for the following: thermal co-
available in these specialities. I The availability agulation of neoplastic tissue, usually for pal-
of flexible quartz fibers facilitated this appli- liation of tumor obstruction, such as in the
cation. Recently, the Nd:YAG laser has been tracheobronchial tree; ablation of neoplastic
applied as a macroscopic tool with unfocused tissue, such as removal of superficial bladder
quartz fibers in holders, with focused hand- tumors; and control of hemorrhage, in partic-
pieces, or in a contact mode. ular, gastrointestinal bleeding. In general, if a
large amount of Nd:YAG laser energy is ab-
sorbed as heat, the result is immediate vapori-
High- and Low-Power zation. Slightly lower energy levels may cause
Applications necrosis with subsequent sloughing of tissue. A
still lower amount of laser energy may cause
High-power applications of the Nd:YAG laser, necrosis with some stimulation of an inflam-
namely, at 40 W or greater, usually with inter- matory response with subsequent healing with
23. Overview of Nd:Y AG Laser Applications lSI

fibrosis. The primary hemostatic mechanism Applications by Specialties

with laser application is thermal contraction of
the blood vessel wall. Usually, the laser power Pulmonary Medicine, Otolaryngology,
is reduced if longer exposure is used to accom-
plish hemostasis. 2
and Thoracic Surgery
At low power the Nd:YAG laser has recently Application of the Nd:Y AG laser through rigid
been used for photocoagulation of vascular le- and flexible endoscopes has helped to create the
sions, such as angiodysplasia, telangiectasia exciting new area known as therapeutic endos-
(associated with Osler-Weber-Rendu disease), copy. Thanks to the pioneering efforts in France
and cavernous hemangiomas.3,4 In this appli- by Dumon et al. 6 and Toty and co-workers 7 and
cation a power setting of 30 W or less is em- by others in the United States,8 the Nd:YAG
ployed at short-interval exposures of less than laser has been extremely successful for palliation
1 second to photocoagulate vascular lesions of obstructing malignancy poorly treated by
without disrupting overlying epithelium, either other therapeutic modalities. For the most part,
skin or mucous membranes. The success of such symptoms as dyspnea, hemoptysis, and
treatment depends on the color selectivity or obstructive pneumonitis have been palliated
pigment concentration as well as the hemoglobin with minimal morbidity in this high-risk group
content of tissue. The purple color of a cavern- of patients. Although lacking the precision of
ous hemangioma is particularly good for selec- the CO 2 laser, the Nd:YAG laser with its su-
tive absorption of the Nd:Y AG laser wave- perior hemostatic abilities and ease of applica-
length. tion through flexible quartz fibers has proved
A new and promising application of the indispensable to the bronchologist. Other uses
Nd:YAG laser is in its contact mode utilizing for the Nd:Y AG laser in bronchology appear to
artificial sapphire tips. The treatment relies on be palliation of benign tracheal stenosis limited
high-power density at the tissue contact site to weblike scar formation and some miscella-
achieved by high-power output. This Nd:YAG neous applications, such as removal of granu-
laser technique developed by Joffe s has both lation tissue and selected benign neoplasms, that
endoscopic and macroscopic uses. is, hamartomas, chondromas, and papillomas.

Long instrument guide with three ---'

separate channels for telesco~e.
laser fiber and suction catheter

Prismatic light deflector

Standard ventilation
side vents

Short bridge with openings

for telescope and two
suction catheters in
addition to laser fiber
Manual venturi
jet ventilation port

FIGURE 23.1. Shapshay laser bronchoscope. Illustra- allowing passage ofa telescope(OO), suction catheter,
tion shows component parts of the rigid ventilating and laser fiber. (Courtesy of Karl Storz Endoscopy,
laser fiber bronchoscope. Inset shows proximal part 10111 West Jefferson Boulevard, Culver City, CA.)
152 Stanley M. Shapshay

The new contact probes seem promising for Laryngeal applications of the Nd:Y AG laser
precise removal of tracheal webs and scarring have thus far been limited to the treatment of
because less charring of surrounding tissue oc- vascular lesions, such as laryngeal cavernous
curs than with the free, noncontact fiber mode. hemangiomas. Isolated rare occurrences of these
With the integration of newer endoscopic sys- vascular malformations have been treated suc-
tems and primarily rigid bronchoscopes with cessfully with the Nd:Y AG laser through a
special features for laser fiber application, laryngoscope 4 (Figure 23.2). A low-power set-
Nd:YAG laser bronchoscopy has reached a ting of 20 to 30 W at an exposure setting of 0.5
stage of greater precision and safety (Figure second permits photocoagulation of the heman-
23.1). giomas without disruption of the overlying ep-
ithelium. Minimal bleeding and negligible mor-
bidity have been associated with this type of
application. Because of its lack of precision,
however, the Nd:YAG laser has not challenged
the secure role of the CO 2 laser in microlaryn-
goscopy.
In the field of thoracic surgery the N d : YAG
laser as well as the CO 2 laser has been used
mostly experimentally for pulmonary resections
and thoracoscopy. The latter application shows
promise for sealing of lung defects in sponta-
neous pneumothorax or emphysematous blebs
and for thoracoscopic lung biopsy. The Nd: Y AG
laser wavelength either delivered through a bare
quartz fiber or by contact probe makes thora-
coscopic lung biopsy possible, with sealing of
the lung and adequate hemostasis. 9

Gastroenterology
Upper Gastrointestinal Tract
The two major applications of endoscopic
Nd: Y AG laser therapy in the upper gastroin-
testinal tract are for control of hemorrhage and
neoplastic disease. Treatment for the latter is

FIGURE 23.2. Treatment of hemangioma with the

Nd:YAG laser. (Top) Endoscopic view shows cav-
ernous hemangioma involving the superior surface of
the right true vocal cord. The patient also had cav-
ernous hemangiomas involving the oral cavity and
oropharynx. (Middle) Result immediately after
Nd:YAG laser photocoagulation at a power setting
of 30 Wand exposure setting of 0.5 second. Marked
shrinkage of the hemangioma is seen with some
crusting on the surface. (Bottom) Result two months
after photocoagulation with the Nd: Y AG laser. Fi-
brous tissue has replaced the hemangioma. The su-
perior surface of the right true vocal cord can now
be seen. (Courtesy of Marvin Fried, M.D ., 398
Brookline Avenue. Boston. MA . Reprinted with per-
mission of Laryngoscope.)
23. Overview of Nd:YAG Laser Applications 153

generally palliative to reduce symptoms of ob- investigators. Standard flexible gastrointestinal

struction and to improve the quality of life. A endoscopes have been used making this tech-
departure from this approach has occurred in nique available to well-trained endoscopists.
Japan where diagnosis of early gastric cancer is
more commonly made and experience with ap- Lower Gastrointestinal Tract
plication of the Nd:YAG laser for curative
The Nd:YAG appears to be the laser of choice for
treatment is growing. to
. palliation of obstructing carcinomas of the colo-
Most endoscopists at present tend to agree rectal area. Kiefhaber et al. 14 reported a series of
that hemorrhage associated with non variceal le- 13 patients in whom unmodified colonoscopes
sions-particularly those that are discrete, such
were used for laser treatment of obstructing co-
as ulcers and erosions-should be treated by
lorectal tumors. Lumen recanalization may be
Nd:Y AG laser photocoagulation. Although the
achieved obviating the need for a colostomy.
Nd:YAG laser has been used to stop variceal
Successful palliation is often obtained with one or
bleeding, endoscopic injection sclerotherapy
more Nd:YAG laser phototherapy sessions.
seems to be utilized more commonly. The first
Again, acceptable morbidity is associated with
reports of endoscopic laser therapy appeared in
this type of application. Recently, the contact
the middle 1970s with data from Nath et aLI
laser endoprobes have been used effectively at
Dwyer et al. ll and Friihmorgen et al. 12 Nath et
low-power settings (10 to 15 W) to palliate ob-
al. I reported the largest experience-994 acute
structing colorectal neoplasms. Investigations
bleeding incidents in 625 patients-and their
are under way concerning applications of the
overall success rate for achieving initial hemo-
Nd: Y AG laser for benign mucosal lesions, such
stasis was 94%. Considerable experience from
as familial polyposis syndrome, villous adeno-
several investigators both in Europe and the
mas, adenomatous polyps, hemorrhoids, and
United States now suggests that endoscopic
condyloma acuminata. In treating condyloma
laser therapy effectively produces initial he-
acuminata, in the colorectal specialty and gyne-
mostasis for acutely bleeding lesions. However,
cology, both the CO 2 laser and the Nd: YAG laser
few data are available from controlled studies.
have been found useful.
Therefore, controversy exists among gastroen-
terologists whether Nd:Y AG laser therapy for
hemorrhage is more effective than electrocau- General Surgery
tery or other methods for controlling gastroin- In general surgery, great interest has been stim-
testinal hemorrhage. Encouraging reports uti- ulated by the development of the contact "laser
lizing the Nd: YAG laser for angiodysplasia have scalpel." This device, developed for use with
appeared in the literature documenting good the Nd:YAG laser by Joffe,5 promises to provide
control of bleeding with decrease in transfusion a hemostatic effect with partial resection of vas-
requirements and hospitalizations. Both the ar- cular organs, such as the liver, spleen, and pan-
gon and Nd:YAG lasers have been used for this creas. In addition, its endoscopic application in
purpose. the hepatobiliary tract may prove helpful in the
The Nd:YAG laser appears to have made a treatment of obstructing carcinomas of the bile
definite contribution for therapy of obstructing ducts. Another possible application in an en-
neoplasms in the difficult-to-treat upper gas- doscopic mode might be destruction of bile duct
trointestinal area. This endoscopic approach for stones utilizing continuous-wave or pulsed laser
the palliation of obstructing carcinoma obviates technology. The studies in this area are still ex-
the need for surgery and general anesthesia with perimental but appear promising.
their attendant morbidity, diminishes the like-
lihood of systemic side effects, and may be per-
formed under direct vision and applied repeat-
Urology
edly, since laser energy is nonionizing. 13 Both The Nd:YAG is the most versatile and preferred
prograde and retrograde approaches for treating laser for use in urology because it is easily
esophageal carcinoma have been utilized on an adapted to standard cystoscopes, ureteroscopes,
outpatient basis. Appreciable palliation with ac- and nephroscopes and because the equipment
ceptable morbidity has been reported by several can be used in a medium of water or urine. The
154 Stanley M. Shapshay

Nd:YAG laser provides the highest degree of interaction on the uterine cervix and vagina.
tissue penetration and therefore permits trans- Likewise, laparoscopic laser applications have
mural laser irradiation and destruction of lesions been primarily with the CO 2 laser because of its
by thermal coagulation necrosis rather than ex- precision in establishing tubal patency and in
cision, making it a superior hemostatic device removing pelvic adhesions.
for endoscopic application. The most successful
uses of the Nd: Y AG laser have been in patients
with bladder cancer and, to a lesser extent, in Dermatology and Plastic Surgery
patients with transitional tumors of the ureter The control of vascular lesions utilizing pho-
and renal pelvis, urethral strictures, bladder toablation techniques with the Nd: YAG laser is
neck contractures, and carcinomas of the pe- a new development in dermatology and plastic
nis. 15 surgery. 17 In particular, treatment of cavernous
Bladder tumors up to to 3 cm have been treat- hemangiomas of the skin and mucosal surfaces
ed effectively with the Nd: YAG laser. Typical of the head and neck, as reported by Shapshay
dosimetry seems to be 40 W of power at 4- to and David,4 is extremely promising. Extensive
5-second pulses applied broadly so that one area cavernous hamangiomas, bulky port-wine
is not overly treated. A conical area of necro- stains, and lesions associated with Osler-We-
sis 3 to 5 mm in depth is created with this tech- ber-Rendu disease (intranasal and gastric telan-
nique. The largest series is from Hofstetter and giectasia) have been treated with success in a
Frank, 15 who reported 302 bladder tumors treat- small number of patients with limited follow-up
ed between 1976 and 1979. Local recurrence rate study. The laser is used with low-power settings
in a short-term follow-up period was 9% with of 20 to 30 W at intermittent 0.5- to 1.0-second
standard electroresection techniques and 1% exposures to photoablate these lesions without
with the laser technique. Although results with disrupting the overlying epithelial or skin cover.
early bladder carcinoma are encouraging, the Since the depth of penetration of the Nd:YAG
initial reports from several investigators regard- laser is limited to approximately 5 mm, glass
ing urethral strictures are less optimistic. Res- slide compression and laser coagulation are used
tenosis after irradiation with the Nd:YAG laser to permit deeper full-thickness coagulation of
appears to be common, and many groups of in- larger hemangiomas. Good healing with minimal
vestigators have abandoned use of this laser for bleeding has been observed in patients treated
urethral strictures. External applications of the thus far. High-flow lesions, such as arteriove-
Nd:YAG laser in urology utilizing handheld de- nous malformations, are not well treated with
vices were considered effective in a small series the Nd:YAG laser because of the excessive heat
of patients with carcinoma of the penis in stages sink effect. Although most port-wine stains may
Tl and T2.15 Equally encouraging results have be treated effectively with the argon laser,
been reported for condyloma acuminatum on the thicker raised port-wine stain lesions respond
urethral caruncle and for condyloma of the vul- well with the Nd: YAG laser used in a photo-
va. coagulative mode.

Gynecology Summary
The Nd:YAG laser has been used more exten-
sively than the CO2 laser for lesions of the in- The Nd: YAG laser has found multi specialty ap-
trauterine area. In particular, the ablation of en- plication because of its suitability for endoscopic
dometrium in women who wish to avoid transmission through currently available quartz
hysterectomy for refractory menometrorrhagia fibers. When used appropriately as a photocoa-
appears promising. 16 Since the Nd:YAG laser gulative instrument, this laser is effective on
can be used with a fiberoptic bundle in a fluid- neoplastic tissue with a high hemorrhagic po-
ftlled medium, its particular wavelength appears tential and can achieve excellent palliation in
well suited for this application. Otherwise, the such areas as the gastrointestinal tract and
CO2 laser has certainly found more usefulness tracheobronchial tree. In addition, its affinity for
in gynecology because of its precise soft tissue pigmented tissues rich in hemoglobin or melanin
23. Overview of Nd:YAG Laser Applications 155

makes it an extremely attractive tool for selec- 5. Joffe SN: Contact neodymium: YAG laser surgery
tive ablation of vascular neoplasms, such as te- in gastroenterology: A preliminary report. Lasers
langiectasia and cavernous hemangiomas. With Surg Med 6: 155-157, 1986.
the advent of effective contact probes for the 6. Dumon J-F, Reboud E, Garbe L, et al: Treatment
Nd:Y AG laser an entirely new area of appli- of tracheobronchial lesions by laser photoresec-
cation has emerged. High-power density laser tion. Chest 81:278-284, 1982.
7. Toty L, Personne C, Colchen A, Vourc'h G:
scalpel effects on tissue have made possible the
Bronchoscopic management of tracheal lesions
removal of vascular lesions and partial resection using the neodymium yttrium aluminum garnet
of vascular organs, such as liver, kidney, and laser. Thorax 36:175-178, 1981.
spleen. In addition, precise endoscopic removal 8. Shapshay SM, Dumon J-F, Beamis JF Jr: En-
or coagulation of tissue may be achieved with doscopic treatment of tracheobronchial malig-
contact probes. nancy: Experience with Nd-YAG and CO2 lasers
The importance of the N d: Y AG laser in var- in 506 operations. Otolaryngol Head Neck Surg
ious medical specialties has been established but 93:205-210, 1985.
still needs to be defined with the help of carefully 9. Shapshay SM, Beamis JR Jr, Shahian DM: The
controlled studies. The burden of proof rests use of lasers in thoracic surgery (editorial). Chest
with the laser operator when the Nd:YAG laser 87:706-707, 1985.
10. Mizushima K, Marada R, Namik M, et al: En-
is judged against more "conventional" modal-
doscopic therapy of the YAG laser in early gastric
ities, such as electrocautery and the scalpel cancer and gastric polyp. In Atsumi K, Nimsakul
blade. Will this expensive new technology be- N (eds): Laser Tokyo 81. Inter Group Corp, To-
come the treatment of choice in many of the kyo, 1981.
areas reviewed in this chapter? Will other laser 11. Dwyer RM, Yellin AE, Craig J, et al: Gastric he-
wavelengths replace the Nd:YAG laser in some mostasis by laser phototherapy in man: A prelim-
of these applications? Certainly, this new tech- inary report. JAMA 236: 1883-1884, 1976.
nology promises eventual cost-effectiveness in 12. Friihmorgen P, Reidenbach H-D, Bodem F, et al:
that it often obviates the need for external sur- Experimental examinations on laser endoscopy.
gical approaches when used endoscopically. It Endoscopy 6:116-122, 1974.
is hoped that controlled studies and the test of 13. Fleischer D: Laser therapy of the upper GI tract.
In Shapshay SM (ed): Endoscopic Laser Surgery
time will provide the answers to these important
Handbook. Marcel Dekker, New York, 1987.
questions. 14. Kiefhaber P, Kiefhaber K, Huber F, Nalb G: En-
doscopic applications of Nd: Y AG laser radiation
References in the gastrointestinal tract. In Joffe SN, Muck-
erheide MC, Goldman L (eds): Neodyrnium-YAG
1. Nath G, Gorisch W, Kiefhaber P: First laser en- Laser in Medicine and Surgery. Elsevier, New
doscopy via fiberoptic transmission system. En- York, 1983, pp 5-14.
doscopy 5:208-213, 1973. 15. Hofstetter A, Frank F: Laser use in urology. In
2. Bown SG: Tumour therapy with the Nd:YAG Dixon JA (ed): Surgical Application of Lasers.
laser. In Joffe SN, Muckerheide MC, Goldman Year Book Medical Publishers, Chicago, 1983, pp
L (eds): Neodymium-YAG Laser in Medicine and 146-162.
Surgery. Elsevier, New York, 1983, pp 51-58. 16. Goldrath MH, Fuller T A, Segal S: Laser photo-
3. Shapshay SM, Oliver P: Treatment of hereditary vaporization of endometrium for the treatment of
hemorrhagic telangiectasia by Nd-YAG laser menorrhagia. Am J Obstet Gynecol 140: 14-19,
photocoagulation. Laryngoscope 94: 1554-1556, 1981.
1984. 17. Landthaler M, Brunner R, Haina D, et al: First
4. Shapshay SM, David LM, Zeitels S: Neodymium- experiences with the Nd:YAG laser in dermatol-
YAG laser photocoagulation of hemangiomas of ogy. In Joffe SN, Muckerheide MC, Goldman L
the head and neck. Laryngoscope 97:323-329, (eds): Neodymium-YAG Laser in Medicine and
1986. Surgery. Elsevier, New York, 1983, pp 175-183.
24
Applications of the Nd:YAG Laser in
Otorhinolaryngology
Masaru Ohyama, Kouichi Yamashita, Sbigeru Furuta, Takuo Nobori
and N orio Daikuzono

Treatment of Head and Neck Tumors by Contact

Nd:YAG Laser Technique
Masuru Ohyama

Recently, the clinical application of the Nd: YAG Clinical Studies

laser has begun to assume an increasingly im-
portant role, with a multidisciplinary approach In our department during the past three years,
to its uses. However, the conventional noncon- contact Nd:YAG laser surgery was carried out
tact Nd:YAG laser system delivers irradiation on 80 patients with head and neck tumors-23
at some distance, from the target tissue, and this benign and 57 malignant. Of the 23 benign tu-
beam spread at the quartz fiber tip causes back- mors, 9 were in the larynx and oral cavity, 2
scatter and damage to adjacent tissue and va- were in the nasal cavity, and 3 were in other
porization and coagulation of soft tissue is lim- sites. The histopathologic classification of these
ited. tumors showed 7 hemangiomas, 6 granulomas,
The convergent Nd:Y AG laser system has 6 papillomas, and 4 others. Of the 57 malignant
been made possible by using lenses like the car- tumors, 23 originated in the oral cavity, 8 in the
bon dioxide laser technique, but the target spot larynx, 7 in the maxillary sinus, 6 in the nasal
of the tissue irradiated by this high power laser cavity, 6 in the hypopharynx, 6 in the tonsils,
beam, 40 to 60 W, becomes carbonized and and 2 in other sites. Histopathologic findings
generates smoke, which often disturbs the sur- showed 52 specimens of squamous cell carci-
gery. Additionally, the surgeon has to wear spe- noma and 5 specimens of malignant lymphoma
cial eye glasses to avoid injury by the laser beam and other neoplasms.
as it is reflected by the tissue or instruments. Figure 24.2A shows the views during contact
In order to resolve these problems, we have Nd:YAG laser excision of tongue cancer (T2,
attempted to devise a laser probe, constructed Nt, MO) and the resected tissue in a female pa-
of a new ceramic, to be attached to the tip of tient, aged 52. Figure 24.2B indicates the mac-
the laser optical quartz fiber. This contact roscopic findings of a large papilloma in the
Nd: YAG laser technique would be capable of tongue, the wound sutured with several stitches
focusing the laser beam on a target spot, or oth- after removal of the tumor by contact Nd: YAG
erwise diffusing it. Its low power requirement laser excision, and the extirpated tumor in a
of 6 to 8 Wallows a more precise excision of male patient, aged 72. Figure 24.3 shows mi-
soft tissue, with less bleeding and minimal injury crolaryngoscopic views of a laryngeal granuloma
to uninvolved tissue (Figure 24.1). Also, the before and after contact Nd:YAG laser micro-
contact N d: YAG laser scalpel requires no pro- surgery. There was less bleeding during contact
tection of the eyes from injury by the laser beam. Nd:YAG laser surgery, and the surgical wound
This chapter is concerned with clinical studies healed rapidly in most of the patients with head
on the effectiveness of this laser treatment in and neck tumors, especially tumors in the oral
head and neck tumors. 1-4 cavity, tongue, and larynx (Figure 24.4).
24. Nd:YAG Laser in Otorhinolaryngology 157

FIGURE 24.1. The histologic appearances of mice buccal mucosa after contact Nd:Y AG laser surgery. (A)
Azan staining immediately after. (B) The 3rd day after.

Discussion problem. Laser surgery, on the other hand, re-

quires only a limited number of operations and
The role of laser surgery in the management of there is no risk of radiation-induced cancer.
head and neck cancer can be divided into the We have also used the contact Nd:YAG laser
following three categories: (1) removal of the technique as part of a multidisciplinary treat-
tumor by laser surgery alone, (2) the use of laser ment of T2 cancer of the tongue and oral cavity.
surgery as part of a multidisciplinary treatment, In hemiglossectomy, the tip of the tongue is
and (3) the use of laser irradiation as a palliative threaded and pulled in the opposite direction to
treatment. give tension. Contact Nd:YAG laser surgery
In general, Tl cancers originating in the mu- should be performed by maintaining a sufficient
cous membrane of the head and neck region are safety margin from the cancer tissue: As the
most suitable for contact Nd:YAG laser excision contact Nd:YAG laser scalpel touches the target
and may be curable only by this procedure. For tissue, we can incise, relying on the tactile sense,
Tl malignancies such as oropharyngeal or vocal with a conventional surgical knife. Also, the
cord cancer, radiotherapy has been used as the contact Nd:YAG laser consumes one fifth the
treatment of choice with successful results at light required by the conventional system. At
many medical facilities. Nevertheless, radio- the same time it eliminates the danger of beam
therapy requires treatment as long as six weeks reflection for the surgeon because the laser beam
or more, and furthermore, the possibility of ra- is concentrated on the object, and thereby dis-
diation-induced cancer may become a grave perses the energy efficiently.
158 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

FIGURE 24.2. The photographs were taken during is the resected tongue tissue with cancer. (Right) The
contact Nd:YAG laser surgery of tongue tumors. upper view shows the preoperative state of tongue
(Left) The upper view shows the preoperative state papilloma. The middle view shows the sutured wound
of tongue cancer (T2, N2, MO). The middle view in- of tongue after the removal of tumor. The bottom view
dicates a shene of hemiglossectomy. The bottom view is the extirpated tumor specimen.

The contact Nd:YAG laser can be applied for In conclusion, the contact Nd:YAG laser tech-
skin and mucosal incisions in maxillary cancer. nique will probably be very beneficial in head
As the operating field in the nasal cavity is very and neck surgery, and its indications should be
narrow, there is a fear that the excessive bleed- expanded through further study.
ing accompanying a mucosal incision may dis-
turb the process of operation visually. But the
contact Nd:Y AG laser can perform incision and
hemostasis simultaneously without such adver-
Summary
sity, which makes this technique unparalleled
The advantages in clinical practice of the contact
for this type of operation.
Nd:YAG laser system are summarized as fol-
The blood vessels with a diameter of 1.5 cm
lows:
are cut off after coagulation by pulse emission
of the laser beam. Moreover, in cases where 1. This system can be performed at a low power
plastic surgery is necessary, this laser technique of 6 to 8 W in contact laser incision of soft
is very useful for incision of the skin or muscle. tissue.
24. Nd:YAG Laser in Otorhinolaryngology 159

FIGURE 24.3. Laryngoscopic views of glottic granuloma. (A) Before contact Nd :YAG laser laryngo-
microsurgery. (B) After contact Nd: YAG laser laryngomicrosurgery .

2. It permits accurate and precise incision be- or scar formation.

cause miss hots of laser irradiation can be 6. It may prevent metastasis of cancer cells by
eliminated in the target tissue. sealing up the lymphatic vessels.
3. It causes less bleeding with minimal damage
to adjacent tissue. On the basis of the results obtained, the con-
4. It has remarkably high controllability . tact Nd:Y AG laser technique is very useful as
5. It causes only slight pain and edema and one of the treatment modalities in head and neck
avoids the proliferation of granulation tissue surgery.

800 1000 1200 1400 1600 1800

ora l cavity
(r esecti o n only )
+ RNDr,.,.,..,.,..,.,..,..,..,..,===..,..,..,..,.===~=

+flaPi~~iiii~~~:;:;::~~~~~~~
partia l maxil lectomy
total maxillectomy
tongue. ora l floor
(resect ion on ly)
+RND • • • •~
+ RND + flap
mic r o lary ngosurgery
t ota l laryngectomy ]:~~~:;;;~~

24.4. A comparison of the volume of bleeding in the different kinds of operation during contact
FIG URE
Nd:YAG laser surgery.
160 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

References 3. Ohyama M: Near future of laser medicine in oto-

laryngology and, head and neck surgery. J Jpn Soc
1. Joffe A: Neodymium-YAG Laser in Medicine and Laser Med 6:21-25, 1985.
Surgery. Elsevier, New York, 1983, pp. 216--239. 4. Ohyama M, Nobori T, Veno K, et a1: Contact Nd-
2. Ohyama M, Katsuda K, Nobori T, et a1: Treatment YAG laser surgery for head and neck tumor. Pract
of head and neck tumors by contact Nd-YAG laser Otol (Kyoto) 79 (suppl 3): 1-9, 1986.
surgery. Auris Nasus Larynx (Tokyo) 12 (Suppl
I1):S138-S142, 1985.

Tonsillectomy and Other Same-Day Laser Applications

Shigeru Furuta and Takuo Nobori

Tonsillectomy and conchotomy are common Recently, we have also developed a chisel probe
operative procedures in the practice of otorhin- for tonsillectomy.
olaryngology. Sudden bleeding and other com- The present study concerns the new modal-
plications often compromise these operations. ities of contact Nd:YAG laser surgery and clin-
It was thought that cryotonsillectomy would re- ical applications in both tonsillectomy and con-
solve these problems, but this procedure has not chotomy.I-7
been taken up enthusiastically throughout the
world because it is extremely difficult to con-
trol the freezing range in cryosurgery. Another Development of the Contact
clinical modality, the argon-ion laser, has been Nd:YAG Laser Probe
reported by Lenz as very promising for tonsil-
lectomy, but its reception has also been luke- Figure 24.5 is a schematic representation of the
warm. beam pattern of the surgical rod used for general
The use of the conventional laser to coagulate, surgery or for conchotomy, and Figure 24-
vaporize, or resect soft tissue requires the beam lI.lB ,C shows the chisel probe used for tonsil-
to travel a certain distance to reach the target. lectomy. This procedure can be performed with
Although the CO 2 laser is useful for the vapor- no or minimal bleeding in tonsillectomy and
ization or excision of tissues, it often produces conchotomy. Figure 24.6 shows histologic find-
a carbonized layer on the tissue surface. Fur- ings of the tonsil tissue excised with the contact
thermore, it cannot be used for fine dissection Nd:YAG laser. These is no marked beam dam-
such as tonsillectomy and conchotomy. age in the adjacent tissue after dissection by
On the other hand, the Nd:YAG laser beam contact Nd:YAG laser irradiation.
may be scattered in the tissue even if the focus
is concentrated on the target spot, thereby cre-
ating a dispersion of energy. The rise in tem- Contact N d: YAG Laser
perature induced by Nd:YAG laser irradiation
is slow and gradual, but the resultant coagulation
Tonsillectomy
is significantly more efficient than that produced
by the CO 2 laser, with an equal volume of en-
Anesthesia
ergy. General anesthesia is usually administered in
We have improved the Nd:YAG laser system this operation. After local sterilization, the pa-
with our innovation of a microtip or probe con- tient is placed in the supine position on the op-
structed from the new ceramic and attached to erating table. The surgeon stands at the cranial
the tip of the quartz fiber. The probe is used to side of the patient's head, directly confronting
focus the beam on a target spot or to perform him. Using a Davis mouth retractor, the surgeon
contact laser tonsillectomy and conchotomy. opens the mouth wide, and depresses the base
24. Nd: YAG Laser in Otorhinolaryngology 161

FIGURE 24.5. Schematic drawing of A, a surgical

rod, Band C, chisel probes, and their beam pat- surgical rod
terns.

chisel probe for tonsillectomy

B

of the tongue and the endotracheal tube so that from the surrounding soft tissues by medical re-
he has direct visualization of the fossa. Physi- traction. The upper tonsillar pole then is exposed
ologic saline, in a volume of 4-6 ml, is injected by blunt dissection, using the new chisel probe
into several peritonsillar submucosal layers, in of the contact N d: Y AG laser. The tonsillar cap-
order to prevent excessive parenchymal bleed- sule is usually in loose contact with the con-
ing during the operation. strictor muscle posteriorly. Consequently, an
initial dissection may be started from this region;
the tonsil can be easily enucleated from the fossa
Surgical Technique by low-powerlaser irradiation, 10 to 15 W, even
The surface tissue of the tonsil is grasped with if the connective tissue is compact as a result
a vulsellum or tonsil clamp and is retracted me- of a previous peritonsillar abscess. Care is taken
dially so as to place the posterior tonsillar pillar in the dissection to preserve both tonsillar
on a stretch. The saline is injected again into the pillars and constrictor muscles, as well as to
submucosal layer at the posterior region of the avoid penetration through the tonsillar capsule.
tonsil. With the application of contact Nd: Y AG The lingual tonsil near the base of the palatine
laser irradiation, the pillar mucosa is superfi- tonsil can easily be removed by using a laser
cially incised along its attachment to the tonsil. beam without scissors or raspatory. These steps
The laser incision begins at the plica trian- are then repeated for removal of the other
gularis and then continues superiorly to the su- tonsil.
pratonsillar fossa. After confirming the tonsillar The fossa is then carefully inspected, and any
capsule the tonsillar tissue is prepared away bleeding is usually controlled by hemostasis
162 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

FIGURE 24.6. Histologic findings of a removed tonsil using the contact Nd:YAG laser technique. There is
no marked evidence of a coagulated or carbonized tissue layer.

achieved by localized laser vaporization. How- Diet and activity are gradually advanced as
ever, excessive sponging or suction may disrupt tolerated. Normal activities can be resumed with
retracted vessels or remove vital factors nec- in two weeks . Generally speaking, local treat-
essary for normal coagulation. Profuse bleeding ment of the oral region is necessary at one week,
from the vessel should be avoided because the and medical follow-up is commonly one month
internal carotid artery could be injured. After after surgery. Various foods may be prohibited
the bleeding is under control, topical thrombin during the immediate postoperative period, pri-
should be applied; this powder expands within marily those foods with significant roughage that
the tonsillar fossae and controls hemorrhage. In might injure the pharynx or induce bleeding.
most instances, adequate hemostasis is the result Periods of food prohibition vary from one to
of careful surgical dissection and direct control three days postoperatively, after which normal
of bleeding vessels. diets are resumed.

Postoperative Care Clinical Results

In the period immediately following a tonsillec- Contact Nd:YAG laser tonsillectomy was per-
tomy under general anesthesia, the patient is formed in 10 patients-5 males, 5 females, aged
taken to a recovery room and placed on his side. 6 to 51 years-with chronic tonsillitis during the
This allows easy removal of secretions from the past 7 months. One patient had had a previous
mouth or pharynx, although care is taken not to episode of peritonsillar abscess. For this appli-
injure the tonsillar fossae with a suction appa- cation, the Nd: Y AG laser was set at a low power
ratus. of 10 to 15 W, in the continuous wave mode,
24. Nd:YAG Laser in Otorhinolaryngology 163

TABLE 24.1. Clinical evaluation of tonsillectomy using contact Nd:YAG laser with a
new dissector
Case no. Age (years) Sex Dissector Ligation Pain* Diet** Complications
1 14 M Rod 1 1
2 33 M Rod 2 5
3 23 F Rod 7 8
4 29 F Chisel + 3 4
5 24 M Rod 3 3
6 17 M Rod and chisel 0 I Infection
7 49 M Rod 3
8 51 F Chisel 2
9 6 F Chisel 1 2
10 11 F Chisel 2 3

*Duration of pain after the operation (days).

**Beginning of normal diet (days).

with a total delivered energy of 3000 to 6000 J.

Table 24.1 indicates the clinical evaluation of
tonsillectomy wtih the contact Nd:Y AG laser
and accessories. In 5 of our cases a surgical rod
was attached to the laser, in 5 cases a chisel
probe was affixed, and in 1 case we used both
the rod and the chisel probe (Figure 24 .7).
After this laser tonsillectomy the patients were
relieved of chronic tonsillitis. They had sore
throat for one to three days postoperatively.
However, the laser wound did not heal as
quickly as the wound produced by classical ton-
sillectomy procedures, and complete epitheli-
zation took about 14 days. A normal diet was
resumed three days after surgery. One patient
had a mild localized infection, which responded
to oral antibiotics.

Contact N d: YAG Laser

Conchotomy
Anesthesia
Local anesthesia is administered for contact
Nd:YAG laser conchotomy. After general ster-
ilization, the patient is placed in a supine position FIGURE 24.7. (Top) Postoperative tonsillar fossae.
on the operation table. The surgeon stands at (Bottom) The removed tonsils in case 6 (see text and
the lateral side of the patient's shoulder. After Table 24-II.l).
stabilizing the nasal speculum, with the aid of a
head mirror the surgeon inspects the nasal
chambers. An anesthetic solution of 4% lido-
caine with epinephrine (1: 1000) is applied to the
Surgical Technique
mucous membrane of the nasal cavity. Then, 4 The surgeon stabilizes the nasal speculum with
ml of 0.5% lidocaine is injected into the sub- his left index finger. The surgical rod (Figure
mucosal layer of the inferior turbinate. 24-U.IA) attached to the Nd:Y AG laser is used
164 Masaru Ohyama , Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

TABLE 24.2. Clinical evaluation of conchotomy using the contact Nd: YAG
laser technique
Diagnosis No. of Patients Age (mean) No packing Complications
Allergic rhiniti s 8 26. 1 2 0
Hypertrophic rhinitis 7 31.8 0 0

to make an incision on the anterior point of the

inferior turbinate. The turbinate mucosa is dis-
sected through the turbinate periosteum by
the irradiation of the contact Nd:Y AG laser
beam. Before surgery, it is necessary to pre-
pare for postoperative blockage by using gauze
with antibiotic ointment to suppress bleed-
ing from the resection wound . After surgery,
however, nasal packing is not required be-
cause there is no bleeding from the incision
wound.

Clinical Results
During a period of two years, we performed
contact Nd:Y AG laser conchotomy on 15 pa-
tients, aged 12 to 58 years with allergic (8 pa-
tients) or hypertrophic (7 patients) rhinitis. Table
24.2 indicates the clinical evaluation of concho-
tomy with the contact Nd: Y AG laser technique.
Satisfactory results were obtained in all the pa-
tients with nasal obstruction. Postoperatively,
two patients were free from the blockage of the
gauze-applied ointment in the nasal cavity. Fig-
ure 24.8 shows pre- and postoperative views of
the nasal cavity in a patient with allergic rhini-
tis. Seven days after the operation a fibrin mass
and crust had formed on the surface of the
inferior turbinate but in one month regenera-
tion of the epithelium was good in the surgical
fields.

Discussion FIGURE 24.8. Postoperative findings in a conchotomy

of the inferior turbinate, using the contact Nd:YAG
A total removal of the tonsillar tissue with min- laser technique on a patient with allergic rhinitis. (Top)
imum bleeding and minimum trauma to adjacent Before the operation. (Middle) One week after the
tissues is the primary goal in tonsillectomy. A operation. (Bottom) Two months after the operation.
24. Nd:YAG Laser in Otorhinolaryngology 165

guillotine-type tonsillectomy as well as tonsil- Summary

lectomy are useful in children with extremely
swollen tonsils, although dissection techniques The advantages of the contact Nd:YAG laser
using tonsil snares may be more common at the technique for tonsillectomy and conchotomy are
present time. On occasion, cryosurgical tonsil- as follows:
lectomy has been performed successfully in se-
lected patients. In other patients, electrocoa- I. It can be used at a low power of to to 15 W
gulation of the tonsils has been advocated. in the incision of mucous membrane or the
However, regardless of the method used in dissection of soft tissue.
tonsillectomy, the skill and experience of the 2. It has a remarkably high controllability.
surgeon predict the technical success of the 3. It causes less bleeding, with minimal damage
procedure. As previously noted, selected to adjacent tissue.
procedures are usually carried out in very young 4. A normal diet can be resumed relatively soon
patients in whom even minimal blood loss results after surgery because postoperative edema
in significant whole-body fluid volume depletion. and pain are negligible.
Selective procedures are also performed if ex- On the basis of the results obtained, the con-
cessive bleeding is encountered or if unexpected tact Nd:YAG laser technique is clinically ben-
problems arise during surgery that necessitate eficial as one of the operative modalities for both
rapid termination of the procedure. On the other tonsillitis and hyperthrophic or allergic rhinitis.
hand, the carbonization caused by the CO 2 laser
and the electrocoagulator hinder the surgeon
References
from certifying the capsule of the tonsil. For this
reason the tonsillar wound grows larger and 1. Joffe A: Neodymium-YAG Laser in Medicine and
larger, and there is a possibility that the sur- Surgery. Elsevier, New York, 1983, pp 216-239.
geon will leave part of the tonsillar tissue at the 2. Ohyama M, Nobori T, Ueno K: Contact YAG laser
site. surgery for the treatments of head and neck tumors.
Pract Otol (Kyoto) 79(S3): 1-9, 1986.
Nd:YAG surgery has been performed in oto-
3. Ohyama M, Nobori T, Yamamoto M: Clinical
rhinolaryngology since 198 I. The vaporization
evaluation of the contact YAG laser irradiation
approach of noncontact laser surgery has been applied to the nasal and paranasallesion. Pract Otol
successfully carried out on lesions in this cat- (Kyoto) 79: , 1986.
egory. However, recently we developed a ce- 4. Ohyama M, Nobori T, Miyazaki Y, et al: Contact
ramic rod, which, attached to the contact Nd: Nd-YAG laser surgery in the treatment of the head
Y AG laser we have used in the surgery of head and neck tumors. In Laser / Optoelectronics in
and neck tumors. Medicine. Springer-Verlag, Berlin, 1986, pp 432-
Our distress at the excessive bleeding con- 437.
comitant with conventional tonsillectomy and 5. Lenz H: Tonsillectomie mit einem Laserraspato-
conchotomy led us to new procedures. We de- rium. Laryngol Rhinol Otol 63:582-584, 1984.
veloped two new dissectors, a ceramic rod and 6. Ohyama M, Katsuda K, Nobori T, et al: Treatment
of head and neck tumors by contact Nd-YAG laser
chisel probe, and attached them to the contact
surgery. Auris Nasus Larynx (Tokyo) 12:s138-
Nd:Y AG laser. We have used these new ac- s142, 1985.
cessories, both separately and in combination, 7. Almqvist U: Cryosurgical treatment of tonsillar
very effectively in our recent tonsillectomies and hypertrophy in children. J Laryngol Otol (London)
conchotomies. 100:311-314, 1986.
Flexible Fiberoptic Endoscopic Applications of the
Nd:YAG Laser
A. Application in Chronic Sinusitis
Masaru Ohyama

Chronic sinusitis is a common rhinologic dis- due to local infection, trauma, or swelling of the
order. Severe cases of chronic sinusitis have nasal mucosa.
gradually decreased during the past 20 years, In the closed sinus, oxygen is absorbed and
but there are still a large number that require the pressure may fall. A blocked ostium facili-
surgery. Many attempts have been made to as- tates transudation and mucous secretion, and
sure satisfactory surgical treatment, but with consequently, provides a salutary environment
limited success until now. The Denker-Watsuji for bacterial invasion or growth. In such cases,
and Caldwell-Luc radical sinuectomies are gen- mucociliary function is disturbed by an engorged
erally used for treatment of chronic sinusitis. and suppurative mucous layer. A vicious circle
With these techniques it is necessary to remove thus commences, as illustrated in Figure 24.9.
all of the pathologic sinus mucosa. At the end
of the operation, a drainage hole is made in
the inferior meatus, where the medial wall of
the antrum has thick bone. Later, this drainage
route often becomes blocked. In addition, the Surgical Procedure
larger fenestration made in the canine fossa
may be responsible for neuralgic pains and Local anesthesia is usually used for most of this
hypesthesia of the teeth and around the upper operation. With the contact Nd:YAG laser
lip. Finally, the sinus mucosa is often removed technique a mucosal incision with a diameter of
unnecessarily. about 1.5 em along the labiogingival line is made
To overcome this unsatisfactory procedure, laterally from the root of the canine tooth. The
we have designed a new surgical technique that incision is carried down to the bone and the soft
produces minimal trauma and takes into con- tissue of the cheek and the periosteum are el-
sideration the physiologic anatomy of the nose evated.
and paranasal sinuses. Since 1983 we have per- A fenestration in the canine fossa is made just
formed Nd:YAG laser antrostomy, using a flex- large enough to permit the access of instruments
ible fiberscope for chronic sinusitis. 1-3 and general inspection of the antrum. This fen-
estration, with a diameter of 8 mm, is made with
a bone drill using a perforating burr on the ap-
propriate level of the sinus wall, as determined
by x-ray examination. Through the hole, the
Pathophysiology of Chronic sinus can be observed with the flexible fiber-
Sinusitis scope, and the Nd: Y AG laser beam is used to
vaporize the pathologic mucosa. The nonpath-
The causes of mucosal pathology in chronic sin- ologic sinus mucosa is untouched and promotes
usitis are numerous. Great importance is attrib- reepithelization of the vaporized focus.
uted to the ostium, mucociliary function, and Figure 24.10 shows a flexible fiberscope with
characteristics of sinus secretion. the Nd:Y AG laser quartz fiber placed into a
Owing to such inflammatory factors as shown fenestration in the canine fossa. The Nd:YAG
in Figure 24.9, there is often a blocked ostium laser beam vaporizes the trans maxillary closed

166
24. Nd:YAG Laser in Otorhinolaryngology 167

Physical-chemical Allergy
irritation Infection
Anatomical disposition ( Endotoxin)

Cesution of PG. LT.

ventlatlon Increased thickness
& drainage of the mucosa

{ Prot....
Prot. inhlbitOf slgA
\
Inflammation of
the lamina propria
Ig

Alteration of the Mucociliary

physical property function damaged
of the secretion C3. C5 others

~ Changem'" metabolism of
the mucosa

FIGURE 24.9. The relationship between the pathobiochemistry ofthe sinus mucosa and the vicious circle of sin us
inflammation.

natural ostium so that a middle meatus can be 3. Sinus bleeding

widened and antrostomy can be carried out. 4. Localized tumor in the sinus
Mucociliary transport inside the antrum is di- Clinical Results
rected toward the natural ostium, and secretions
are expelled out of the new large opening. Two Table 24.3 shows the efficacy of antrostomy with
silk sutures are used to close the mucosal in- Nd:YAG laser irradiation using the fiberscopic
cision. technique. This operation was carried out in 98
Ethmoidal cells adjacent to the natural ostium patients with chronic sinusitis during the years
are often diseased, and the removal of pathologic 1983 to 1985. Based on the results of both sub-
mucosal or nasal polyps is obligatory for the jective and objective findings, followed up over
success of this operation, as infection in these six months after the operation, 73 patients
cells may be responsible for creating edema and (74.5%) were markedly improved, 23 (23.5%)
stenosis of the ostium. showed moderate improvement , while only 2
(2.0%) showed no improvement.
Indications for the Operation Figure 24.11 shows the comparative x-ray
findings of healing conditions in the sinus for
The indications for Nd:Y AG laser antrostomy
the Nd:Y AG laser antrostomy on the right side
with a flexible fiberscope are as follows:
and the Caldwell-Luc operation on the left side,
I. Chronic maxillary sinusitis at one week to six months after the operation.
2. Antral polyps and cysts It can be seen that there is more remarkable
168 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

VAG -LASER

FIGURE 24.10. Schematic representation of the status of the flexible fiberscope with Nd: Y AG laser optic
quartz fiber introduced into the sinus bony hole.

evidence of aeration in the right antrum, showing The advantages of this technique for maxillary
the original sinus configuration. sinusitis are summarized as follows:
1. The normal anatomic and physiologic rela-
TABLE 24.3. Clinical results based on both tionships are restored.
subjective and objective findings over 6 months 2. Any pathologic changes involving the max-
after Nd: YAG laser antrostomy illary sinus can be observed by direct visu-
Evaluation Male Female Total Rate (%)
alization.
3. Less bleeding and minimum mucosal damage
Good 53 20 73 74.5
Fair 12 1\ 23 23.5 during the operation are seen.
Poor 2 0 2 2.0 4. The severe sequelae of the conventional
Total 67 31 98 100 technique of sinus operation can be reduced
or eliminated.
5. Postoperative care can be simple.
Discussion Nd:Y AG laser antrostomy using a flexible fi-
berscope is therefore a promising new treatment
There have been various surgical treatments of
for chronic maxillary sinusitis.
paranasal sinusitis. The most popular operations
for chronic maxillary sinusitis were developed
by Caldwell and Luc and Watsuji and Dp.nker. Summary
These operations resulted sometimes in unex-
pected trouble for patients owing to hyperplasia In 1983 we developed a new operation technique
of granulation and inflamed remnants of the si- for chronic sinusitis: Nd:YAG laser antrostomy
nus mucosa. using a flexible fiberscope. This procedure was
To overcome these unsatisfactory procedures performed in 98 patients with chronic sinusitis
we have developed a new technique of Nd:YAG during the years 1983 to 1985.
laser antrostomy using a flexible fiberscope for Better results and fewer complications were
chronic maxillary sinusitis. This new approach obtained by this new operation than with the
to the surgical treatment of chronic sinusitis is conventional techniques such as the Caldwell-
based on anatomic, physiologic, and pathobio- Luc or Watsuji-Denker operations.
chemical considerations.
24. Nd:YAG Laser in Otorhinolaryngology 169

3 4
FIGURE 24.11. A comparison of x-ray findings of the of the left maxillary sinusitis. (3) X-ray findings of
postoperative sinus state by the Caldwell-Luc oper- sinus one week after Nd: YAG laser antrostomy of
ation and by N d: YAG laser antrostomy. (1) Preop- the right sinus, at an interval of one week following
erative x-ray findings of sinusitis. (2) X-ray findings the left sinus operation. (4) X-ray findings of the sinus
of sinus one week after the Caldwell-Luc operation 6 months after the last operation.

References 3. Matsune S, Miyazaki Y, Ueno K, et al: Histo-

pathological study of nasal ostium in experimental
1. Ohyama, M: Pathobiochemistry of Chronic Si- sinusitis in rabbits. Oto Rhino Laryngol (Tokyo)
nusitis. Shibundo, Kagoshima, 1984. 255-262, 1986.
2. Ohyama, M: Laser treatment for sinus diseases.
Pract Otol. (Kyoto) 79:694-697, 1986.
B. Applications in Nasopharyngeal Diseases
Kouichi Yamashita

In otorhinolaryngology the CO 2 laser has been scc:)e is 2 mm, the thicker laser guide with its
effectively applied for laryngeal diseases by use air insufflation lumen cannot be applied. There-
of the operating microscope and other accessi- fore, air insufflation is made through the scope
ble means from outside the body. However, channel itself to remove smoke during coagu-
application of the Nd:YAG laser through the lation. The 1.1-mm laser guide can also be used
flexible fiberscope is expected to lead to further as a contact laser coagulator by itself.
efficiency of laser surgery in difficult-to-reach To generate the Nd:YAG laser beam, the
sites. Nd:YAG laser coagulators of Molectron Model
In the nasopharynx, the Nd: YAG laser 8000, Olympus MYL-1, and Pentax SLY -1 have
through the flexible fiberscope inserted peri- been used. The procedure is performed using a
nasally has no dead angles and all sites of television monitor under general anesthesia.
the nasopharyngeal structure are accessible. This way, the safety of the surgeon's eye and
Thus, Nd:YAG laser surgery is indicated as an of the patient himself may be ensured (Figure
efficient method to manage nasopharyngeal pa- 24.12).1-3
thology.

Indications and Cases

Dissimilar Characteristics of
Indications for this procedure were selected as
Laser Beams follows.
The CO 2 and Nd:YAG lasers are distinctly dif- (1) Hypertrophied tubal tonsil on and around
ferent. The CO 2 laser beam is totally absorbed the tubal torus of the eustachian tube at the
on the tissue surface, therefore its effects are nasopharynx, which is considered to be the
superficial and well-defined, resulting in direct cause of tubal dysfunction in cases of persistent
evaporation of the tissue. The N d: YAG laser secretory otitis media or middle ear cholestea-
beam can penetrate the tissue and coagulate it. toma.
The absorption of the Nd:YAG laser beam and Eighteen patients, ranging from 4 to 38 years of
the capacity to backscatter are contingent on the age, were treated for this disorder with the
color of the tissue to which the beam is applied. Nd:Y AG laser and flexible fiberscope.
The different characteristics of these beams
must be taken into consideration when therapy (2) Benign and malignant neoplasms of the na-
is administered. sopharynx. Nasopharyngeal angiofibroma, na-
sopharyngeal carcinoma, and malignant lym-
phoma are relatively common neoplasms in the
nasopharynx, and lymphangioma, hemangio-
Method of Treatment ma, neurilemoma, paraganglioma, and papilloma
are found less frequently. Because of the ana-
To introduce the Nd:YAG laser beam into the
tomic situation, nasopharyngeal neoplasms tend
nasopharynx, a thin Teflon-coated quartz guide,
to be found at a rather advanced stage and larger
1.1 mm diameter, is used. The fiber guide is in-
size.
troduced through the instrumentation channel
of the Olympus ENF-LB fiberscope, and irra- One patient with nasopharyngeal extension of
diation is performed under visual control. The glomus jugulare tumor and one patient with
tip of the laser guide is usually protruded ap- Stage III nasopharyngeal carcinoma were treat-
proximately 5 mm in length on irradiation. Since ed with the Nd:Y AG laser and flexible fiber-
the diameter of the channel of the ENF-LB scope.

170
24. Nd:YAG Laser in Otorhinolaryngology 171

FIGURE 24.12. Nd:Y AG laser

surgery procedure with use of
closed-circuit television.

Results and Discussion beam is limited to below 30 W to prevent too

much penetration, which will result in destruc-
Hypertrophied Tubal Tonsil Causing tion of the tubal cartilage underneath the torus.
In this procedure, 15 to 25 W has proved to be
Tubal Dysfunction sufficient.
The tubal tonsil is found on the tubal torus at It is characteristic that granulation formation
its postrior half side and continues to the Ro- after laser coagulation is minimal. The super-
senmiiller fossa. In cases of markedly hypertro- position of necrotic debris is observed for 1 week
pied tubal tonsil, it is also observed at the Ro- after irradiation. However, the wound heals
senmiiller fossa, filling the fossa and the an- completely after 3 weeks (Figure 24.13).
terior surface of the torus facing the tubal orifice. The results of 18 cases treated are shown in
Since adenoid enlargement is also complicated Table 24.4, classified by age. The best results
in such cases, laser application follows adeno- were obtained in the group from 13 to 23 years
idectomy by the usual methods. Coagulation old; yet 100% of the cases showed good results.
is not performed around the orifice to avoid In the age group below 10years, 90% of the cases
a scarred stricture of the orifice after irradia- showed an improvement of tubal dysfunction.
tion. The energy level of the Nd:YAG laser Less improvement in this age group may result

FIGURE 24.13. Pre- and postoperative (10 months) conditions of hypertrophied tubal tonsil, showing marked
improvement around the tubal orifice after surgery.
172 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

TABLE 24.4. Patients receiving Nd: YAG laser treatment for tubal dysfunction due to tubal
tonsil hypertrophy*
Duration
of ear Imporovement
Tympanogram
Ear diseases Additional of tubal
Case Age (years) diseases (years) surgery function Preop Postop
I KY 4 r. SOM 2 + B C
I. SOM + B B
2* MN 4 r. ate 3 + B B
I. ate ++ B C
3 YY 5 r. SOM 10 mos ++ B C
I. SOM ++ B C
4 FH 5 r. cho 3 +++ B A
I. cho +++ B A
5 OT 6 r. cho 3 +++ B A
I. normal Good condition A A
6 KT 6 r. COM 4 Myringoplasty ++ B
I. normal Good condition A A
·7* OY 6 r. SOM 3 Tubing +++ B A
I. SOM Tubing ++ B C
8 OS 6 r. COM 5 +
I. SOM Myringotomy + B Cs
9 KA 6 r. SOM 2 Tubing B
I. SOM Tubing B
10 MK 8 r. SOM 4 Myringotomy ++ B C
I. SOM ++ B A

II TK \3 r. cho 6 +++ B
I. cho Tympanoplasty +++ As A
12 SA 14 r. ret (I) Tympanoplasty +++ C A
I. SOM +++ B As
13 AH 14 r. SOM 10 ++ B C
I. SOM ++ B C
14 SK 16 r. ret (I) +++ A A
I. cho Tympanoplasty +++ B Cs
15 SS 23 r. pos 7 Tympanoplasty +++ Cs
I. SOM +++ C A

16 NJ 31 r. ate 20 Typanoplasty
I. pos Tympanoplasty
17 1M 36 r. sca 20 A
I. ate B
18 MS 38 r. COM 10 Tympanoplasty C
I. COM Tympanoplasty C
*All the patients are male-except Case 2 and Case 7.
SOM: secretory otitis media. COM: chronic otitis media. cho: cholesteatoma, ret: retracted ear drum. pos:
postoperative. sca: scarred ear drum. ate: atelectatic ear

from immaturation of the tubal function, which Benign and Malignant Neoplasms of
is not controlled by this procedure. Three pa- the Nasopharynx
tients over 30 years old showed no improvement
of tubal function. In these cases, the tubal dys- Since the Nd:YAG laser is regarded as a co-
functions were considered to be of tubotympanal agulator, when it is applied to neoplasms, the
origin secondary to a long-standing pathologic treatment is mainly palliative (Figures 24.14 and
condition of the tubal orifice area. 24.15). Certain limited and circumscribed lesions
It can be concluded that the Nd:YAG laser of benign and also malignant neoplasms can be
surgery is one of the most effective and appro- treated curatively. In a proliferative lesion, ef-
priate treatments against hypertrophied lymph- fective destruction is attained by an application
oid tissue causing tubal dysfunction. of high-energy laser of 50 to 100 W.
24. Nd:YAG Laser in Otorhinolaryngology 173

FIGURE 24.14. Nasopharyngeal extension of glomus jugulare tumor, pre- and postoperative. Surgery was
performed palliatively for airway obstruction.

Bony tissue is relatively to the Nd: Y AG laser culature underneath the mucous membrane at
beam and it plays a protective role in extending the soft palate, which may cause postoperative
its effect to the posterior direction. However, immobility due to cicatricial contracture of the
the surgeon should take special care of the anat- tissue.
omy of the internal carotid artery, the internal
jugular vein, and caudal cranial nerves that are
just lateral to the nasopharynx in the parapha- Conclusion
ryngeal space. Therefore, in cases with naso-
pharyngeal malignant neoplasm, only limited Nd: Y AG laser surgery, with the flexible fiber-
lesions indicate sufficient need for Nd:Y AG scope attached, is appropriately applicable to
laser surgery. To investigate the indication in nasopharyngeal pathology. It has been found
such cases, a high resolution CT of the naso- that this is one of the most effective procedures
pharynx and the parapharyngeal space provides against hypertrophied tubal tonsil causing long-
indispensable assistance. When the Nd:YAG standing tubal dysfunction, to which no appro-
laser beam is applied to the nasopharyngeal priate and effective therapeutic procedure has
cavity, the surgeon should also take care of the been established.
effect of the penetrated laser beam to the mus- Certain limited and circumscribed lesions of

FIGURE 24.15. Nasopharyngeal cancer, pre- and postoperative. The extension of the tumor to the para-
pharyngeal space was not controlled by this procedure.
174 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

benign and malignant neoplasms in the naso- 2. Buiter CT: Endoscopic Nd:YAG laser therapy in
pharynx are also good indications for Nd:YAG the upper airways. In Clement PAR (ed): Recent
laser surgery. Advances in E.N.T. endoscopy. Scientific Society
for Medical Information Gent, Belgium, 1985, pp
197-205.
References 3. Yamashita K, Sakamoto M, Ogawa A, et al: Man-
agement of tubal tonsil hypertrophy by means of
1. Yamashita K, Ogawa A: The use ofNd:YAG laser
Nd:YAG laser. Jpn J Tonsil 24:70-76, 1985.
in the management of nasopharyngeal pathology.
J Jpn Laser Med 4:229-230, 1984.

Clinical Trials of Interstitial Localized Nd:YAG Laser

Hyperthermia on Head and Neck Malignancies
Masaru Ohyama and Norio Daikuzono

In recent years, remarkable progress has been in the heated area. Furthermore, immunohis-
made in thermotherapy. This technique has tochemical study by laminin staining (Figure
proven to be one of the most promising methods 24.16) showed evidence of a steady regeneration
available for treatment of cancer. However, of the basal membrane, and the blood vessels
treatment using microwave or radiofrequencies of the hyperthermic wounds were gradually
has been limited to thoracoabdominal malig- healing and were completely healed one week
nancies. There is little information on localized later. Quantitative analysis performed imme-
laser hyperthermia or on the conventional hy- diately after laser hyperthermia, and again 3
perthermia technique applied to head and neck days later, showed that lipoxygenase metabo-
tumors. lites such as 5-HETE, 12-HETE, and 15-HETE
We have developed a ceramic probe to insert and cyclooxygenase metabolites such as PGE 2 ,
into tumor tissue and irradiate the laser omni- indicators of inflammation, had increased mod-
directionally. This probe can heat a spherical erately; but after the seventh day these arach-
range of 1.5 cm to 43°C. This is applicable as idonic acid metabolites had returned to normal
interstitial localized laser hyperthermia (laser levels (Figure 24.17).
hyperthermia). These results and histologic findings revealed
This chapter concerns experimental and clin- that the effect of laser hyperthermia on normal
ical studies on the effectiveness of laser hyper- tissue is very slight, and, moreover, the con-
thermia using our technique in the head and neck comitant inflammation is of relatively short du-
regions. 1-4 ration.

Experimental Studies Effects of the Combined Treatments

of Laser Hyperthermia and
The Effects of Laser Hyperthermia on Chemotherapy
Normal Rabbit Mucosa It is known that cellular function is influenced
Morphologic and biochemical investigations by the environment, including, primarily, tem-
were carried out on rabbit tongue and lip after perature, pH, osmotic pressure, and microcir-
laser hyperthermia. Figure 24-IV.IA shows the culation.
typical histopathology on the third day after All the reports regarding the effect of tem-
treatment. There is no remarkable tissue damage perature on cellular metabolism agree that the
24. Nd:YAG Laser in Otorhinolaryngology 175
":'-",-- , .. " ' '; , .
FIGURE 24.16. Morphologic findings
f~ "ji< .
of rabbit oral tissues after Nd :YAG ,~1'
.~ .'
laser irradiation. (A) The histologic
...
appearance of rabbit tongue 3 days
after laser hyperthermia. (B) Im-
munohistochemical findings in rabbit ..
'"' - .. ~
~.
:' _ :
r
",

" .' ~ .
.. . ~~

- . ." .....
. . . .-

"

lip 7 days after laser incision. Evi-

dence of basal membrane regenera-
tion can be seen by laminin staining.
. '. '
."

cellular function of malignant tumors is much tion, and the last is the control group, receiving
more easily affected by high temperature. Above no therapy.
43°C, the tumor cell would virtually fall into an The results of this study indicated that the
irreversible failure. This is based on fundamental combination of laser hyperthermia and CDDP
research concerning the cell-lethal effect. On the injection was the most effective treatment for
other hand, it was confirmed that, as a result of these tumors (Figure 24.18). We believe that the
exposure to hyperthermia, an acceleration in the combined modality of laser hyperthermia and
local microcirculation occurs through the ample antitumor chemotherapy may have some effi-
blood vessels peculiar to the vicinity of tumor cacy in the management of papillary adenocar-
cells. On the basis of these works, the combined cinoma of the human thyroid gland, even though
therapy with laser hyperthermia and cis-dich- this malignancy is known to be chemoradiore-
lorodiamine platinium (CDDP) injection was sistant.
studied in nude mice implanted with human
thyroid cancer cells.
The subjects were divided into four groups of Clinical Study
five animals : the first group was treated with
laser hyperthermia alone, the second received On the basis of experimental studies, laser hy-
CDDP injection, the third received the combined perthermia with chemoradiotherapy was applied
therapy of laser hyperthermia and CDDP injec- to the advanced malignant neck mass in patients
176 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

5- HETE (ng/ g) 12-HETE(ng/g) 15- HETE (ng/ g) PG Ez (pg/ It)

~
45

immedia te ly after
~
53

immed iately af ter

ill immediat ely af t er
.rl
542

immediat ely after

h IfL
102
B5

32 26

---...rl
3days a f ter 3 days after 3 days after 3 days

62

.IlL
510
35

~
33 25

--..0...
Bdays after
..I...CL
Bdays after Bdays after B days after

.Iil LASER normal

FIGURE 24.17. Changes of arachidonic acid metabolites in rabbit tongue after localized Nd :YAG laser hy-
perthermia.

....
( )
2000

,pCONTROL
,
,,
,
I
I
1500 LASER HYPERTHERMIA
I
I

,,
I

,d
w
,,
I
:E
::> 1000 ,, , COOP
...J
o ,
> ,,
,,
,,
500
tf
,
,, " CODP+LASER
HYPERTHERMIA
"

o~----~----~--------
lW 2W 3W

TIME
FIGURE 24.18. A comparison of the effects of the transplanted in nude mice. (Subjects: 15 nude mice
combined therapy of localized Nd: Y AG laser hyper- with tumors of 1.5 em diameter.)
thermia and chemotherapy on human thyroid cancer
24. Nd:YAG Laser in Otorhinolaryngology 177

A laser beam of less than 3 W is sufficient for therapy in a total dose of 40 Gy and Tegafur in
this laser hyperthermia. The center of the tumor a total dose of 20 g over 4 weeks.
is irradiated for 30 minutes at 43°C. Then a hemiglossectomy and radical neck
Temperature in the tumor and peripheral tis- dissection were performed, using the contact
sue is recorded by using a thermogram and is Nd: Y AG laser technique. Although this tongue
also monitored by a digital thermometer in order cancer had been classified as T2, N 1, MO, a his-
to maintain 42 to 43°C, the requisite temperature tologic examination of the excised specimen
around the target tissue. The patient tolerated failed to find any evidence of cancer cells (Figure
this therapy well and the neck tumor responded 24.19B). The combined therapy with laser hy-
markedly after two treatments (laser hyper- perthermia and chemoradiotherapy was applied
thermia once a week, combined with radiother- to 10 patients with advanced head and neck ma-
apy in a total dose of 40 Gy). After laser hy- lignancies, and very good clinical results were
perthermia, radical neck dissection was usually obtained in 8 patients during the past two years.
performed in these cases. Since hyperthermia modifies the response of
Figure 24.19 shows a histologic specimen of tumors to ionizing radiation, it is lethal to ra-
a patient with tongue cancer who received laser dioresistant cells such as hypoxic cells or cells
hyperthermia two times combined with radiation in the S-phase, it is synergistic with radiother-

FIGURE 24.19. Localized laser hy-

perthermia in tongue cancer (T2, N2,
MO). (A) Laser probe inserted in the
left side and the tip of the thermo-
couple in the right side of cancer tis-
sue. (B) Histologic findings of the
resected cancer tissue. There is no
evidence of vivid cancer cells.
178 Masaru Ohyama, Kouichi Yamashita, Takuo Nobori, Shigeru Furuta, and Norio Daikuzono

apy, and it enhances the action of selected combined modalities of hyperthermia, chemo-
chemotherapeutic agents. therapy, radiotherapy, and surgery could be
By continuing efforts to substantiate the ap- highly useful for cancer treatment in the head
plication of laser hyperthermia to malignant tu- and neck regions.
mors in the head and neck regions, this treat-
ment may establish itself as one of the new
multidisciplinary cancer therapies.
References
Further study on the relationship between I. Brenne EJ, Yerushalmi A: Combined local hyper-
laser hyperthermia and chemoradiotherapy will thermia and X irradiation in the treatment of met-
be necessary to confirm these interesting results, astatic tumors. Br J Cancer 33:91-96, 1975.
and a multichannel laser hyperthermia system 2. Hahn GM: Hyperthermia and Cancer. Plenum,
should be developed. New York and London, 1982.
3. Ohyama M, Nobori T, Veno K, et al: Contact Nd-
YAG laser surgery for head and neck tumor. Pract
Otol (Kyoto) SuppI3:1-9, 1986.
Summary 4. Ohyama M, Katsuda K, Nobori T, et al: Treatment
of head and neck tumors by contact Nd-YAG laser
Although most malignant tumors cannot be surgery. Auris Nasus Larynx (Tokyo) 12(Suppl
controlled by laser hyperthermia alone, the 2):SI38-142, 1985.
25
Reconstructive Surgery for Head and Neck
Tumors by Contact Nd:YAG Laser
Technique
Goro Mogi, Yuichi Kurono, and Issei Ichimiya

Although the usefulness of laser power in sur- precise control and tactile sensation of steel
gery has been proven, its application using car- scalpel techniques.
bon dioxide (C0 2 ) or the Nd: YAG laser in the
field of head and neck surgery has only recently
begun. Usage of the Nd:YAG laser has a ben- Subjects and Methods
eficial effect on hemostasis and coagulation. Its
weakness, however, lies in the cutting and The contact Nd: YAG laser instrument employed
evaporation of tissue. The contact laser probe, was Model 130 YZ (Nippon Infrared Industries
made of ceramic, is a new form of the Nd: YAG Co., Ltd. Tokyo). Two ceramic probes (Surgical
laser delivery system that by means of contact Laser Technologies Japan Co., Tokyo), one with
irradiation, can be used in coagulation, vapor- a O.4-mm diameter tip (small), and the other with
ization, and cutting. 0.6-mm diameter tip (large) were used. Both ce-
Reconstructive procedures using a pedicle flap ramic scalpels were 9 mm in length and attached
have improved the cure rate of head and neck to a holder (Model SRH 1, Surgical Laser Tech-
cancer because such procedures make it possible nologies Japan Co., Tokyo). The laser power
to resect a large part of the dissected lesion, in- output was 20 W for the large probe and 16 W
cluding an adequate safety margin, and to pro- for the small probe.
vide acceptable, functional, and cosmetic re- Seven patients were treated with con.tact
habilitation. Particularly, it has been proven that Nd:YAG laser surgery. Four patients (3 male
the myocutaneous (MC) island flap is invaluable and 1 female) had a pharyngoesophageal cancer,
reconstructive material for head and neck cancer and three had a cancer lesion in the oral cavity,
patients. 1-4 The one-stage operation, which tongue, or palatopharynx. All patients had uni-
consists of a composite resection of the primary lateral or bilateral neck metastasis and were
tumor, radical neck dissection (RND), and sub- classified as stage 3 or 4. All patients underwent
sequent reconstructive surgery, causes a large a composite resection of the primary tumor and
volume of blood loss due to the highly vascu- RND after receiving Linac X-Ray radiation to-
larized operation field, thus requiring a blood taling 30 grays and 3000 mg of 5-Fu by intra-
transfusion. Postoperative hematoma sometimes venous or intraarterial infusion. Intraarterial in-
causes major flap necrosis. 4 fusion to the feeding artery was used for cancer
In order to compensate for the disadvantages of the tongue, oral cavity, and palatopharynx.
of this procedure, contact Nd:YAG laser sur- Reconstructive surgery using the Me flap was
gery, using a new SLT contact laser probe, was performed immediately after the composite re-
applied. It was chosen because the contact laser section of the tumor lesion. A pectoralis major-
probes provide hemostatic abilities of the MC flap was prepared as reported by Ariyan,5
Nd: Y AG laser and cutting proficiency of the and the lattisimus dorsi-MC flap was made ac-
CO 2 laser and because this surgery combines the cording to the method described by Morris et
180 Goro Mogi, Yuichi Kurono, and Issei Ichimiya

al. 6 The latter flap was used in the female patient No blood is seen on the left half, whereas the
with pharyngoesophageal cancer. Three of seven right half is moistened with blood.
patients underwent bilateral RND, preserving
the internal jugular vein on one side. Dissection of Subcutaneous
As shown in Figure 25.la, a skin incision was Tissue and RND
made with the small contact probe, producing
adequate tension on the skin. Dissection of the Dissection of the subcutaneous tissue and the
subcutaneous tissues and resection of the mu- procedure for RND were completed safely. This
cosal wall of the pharynx, esophagus, and was because such tactile cues provided by steel
tongue were carried out by use of the large con- scalpels can also be obtained by use of contact
tact-scalpel (Figures 25.lb and 25.2). All pro- probes, and because the identification of blood
cedures of RND, except for the isolation, liga- vessels, nerve fibers, and other parts is easier
tion, and cutting off of the internal jugular vein, with the contact N d: Y AG laser surgery than
were also performed using the large contact with conventional operating methods because of
probe. The cut surface of the MC island flap less bleeding (Figures 25.lb and 25.2b). Contact
was slightly resected by scissors to removed the laser techniques can be used to detach the ster-
burned skin layer. nocleidomastoid muscle from its attached parts
and to dissect it from scalenous muscles.

Results Cutting Off the Mucosal

Wall and Tongue
Skin Incision During dissection of the skin and muscular lay-
Incisions of the skin could be made without ers, relatively large vessels in which bleeding
bleeding. Figure 25.1 d shows a skin incision does not stop when incised by the contact laser
made by the contact Nd:YAG laser (right half) probe were easily identified and suture ligated
and by a conventional surgical scalpel (left half). (Figures 25. Ib and 25.2b). Since the contact las-

FIGURE 25.1. Skin incision and preparation of my- pectoralis major-MC flap. (c) Preparation of a lattis-
ocutaneous flap. (a) Skin incision using a ceramic simus dorsi-MC flap. (d) Skin incision made by con-
probe with OA-mm diameter tip. (b) Dissection of the tact Nd:Y AG laser (right half) and by a conventional
subcutaneous tissues during the preparation of the surgical scalpel (left half).
25. Reconstructive Surgery for Head and Neck Tumors by Contact Nd:Y AG Laser Technique 181

FIGURE 25.2. Dissection of the subcutaneous tissues tery. (b) Resection of the posterior wall of the phar-
and resection of the mucosal wall of the pharynx and ynx. (c) Exposure of the hypopharynx by dissecting
tongue. (a) Separation of the radical neck dissected the suprahyoid space. (d) Resection of the tongue.
material from bifurcation of the common carotid ar-

er scalpel differs from the electric knife, large Results of Reconstructive Surgery
muscular bundles were cut off without muscular
In one of the four patients who had pharyngo-
spasm or contraction.
esophageal reconstruction, a fistula occurred at
the lower attachment between the flap and re-
Blood Loss cipient mucosa. All three patients who under-
The mean volume of blood loss during a com- went reconstruction of the tongue and oral cav-
posite operation with RND performed on 7 pa- ity had a dehiscience between the flap and
tients by use of the contact Nd:YAG laser was donor's mucosa. However, this was probably
98 ± 27 ml, whereas that of 110 patients operated due to an insufficient amount of remaining oral
on in our department by conventional proce- mucosa. The dehiscience closed spontaneously
dures was 730 ± 351 m!. The making of the Me within 3 weeks in each case.
flap caused an average loss of 71 ± 46 ml of
blood in 7 cases using contact laser surgery,
whereas conventional procedures resulted in an Conclusions
average loss of 280 ± 134 ml in 28 operations.
The mean volume of blood and exudate from The results of the present study demonstrate that
negative pressure suction drains after contact contact Nd:YAG laser surgery using SLT con-
laser surger was 92 ± 31 ml from the RND in- tact probes is extremely useful in head and neck
cision and 56 ± 51 ml from the donor's site of tumor surgery and reconstruction. Moreover,
the Me flap. Using conventional surgery it was this new method apparently surpasses conven-
206 ± 104 ml from the RND incision and 124 ± tional surgical procedures in many ways. Since
39 ml from the donor's site of the Me flap. Only contact laser surgery offers precise, controlled
one patient received a blood transfusion due to cutting and hemostasis, the surgeon is not trou-
preoperative anemia. bled by bleeding from small vessels during the
182 Goro Mogi, Yuichi Kurono. and Issei Ichimiya

incision of the skin and mucosal wall and while Acknowledgment. The authors greatly thank
dissecting subcutaneous tissue. It is easy to Professor Masaru Ohyama, Kagoshima U ni-
identify blood vessels, nerve fibers, and other versity Medical School, for his kind invitation
anatomical parts which increase the operation's to publish in this book.
safety factor. If bleeding occurs, it can be
stopped by use of the lateral surface of the
probe. Contact ceramic probes are, of course, References
unable to control all bleeding. Experience in-
1. Biller MF, Baek S, Lawson W, et al: Pectoralis
dicates that vessels less than 0.5 mm in diameter
major myocutaneous island flap in head and neck
are probably best controlled by contact laser surgery. Analysis of complications in 42 cases.
scalpels. The cutting speed is slow with contact Arch Otolaryngol 107:23-36. 1981.
laser probes as compared to conventional sur- 2. Schuller. DE: Pectoralis myocutaneous flap in head
gery using steel scalpels. However, the opera- and neck cancer reconstruction. Arch Otolaryngol
tion is not prolonged in contact laser surgery 109:185-189,1983.
because of the hemostatic capability. 3. Mogi G, Fujiyoshi T, Kurono Y, et al: Latissimus
The most notable merit of contact Nd:YAG dorsi myocutaneous-iliac bone flap for massive
laser surgery for one-stage operations of head defects of mandible and oral basis. Laryngoscope
and neck cancer is the remarkable reduction in 96: 171-177. 1986.
blood loss, thus eliminating blood transfusions. 4. Mogi G. Fujiyoshi T. Kurono Y. et al: Recon-
structive surgery of head and neck cancer using
Conventional one-stage operations cannot be
various pendicle flaps. Auris Nasus Larynx
carried out without blood transfusion, with all 12(Suppl 2):S24-S29. 1986.
the inherent risks of hepatitis and AIDS. 5. Ariyan S: The pectoralis myocutaneous flap. Plast
Based on these results, we believe it is not an Reconstr Surg 63:73-81. 1979.
overstatement to say that contact Nd: YAG laser 6. Morris RL. Given KS. McCabe JS: Repair of head
techniques are revolutionary in the field of head and neck defects with the lattisimus dorsi myocu-
and neck surgery. taneous flap. Am Surg 47:167-173. 1981.
26
Laser Conization of the Uterine Cervix
Ryozo Totani, Tesuro Karasawa, and Yozo Suzuoki

The optimum treatment for intraepitheial cerv- between October 1984 and May 1985. Colpos-
ical cancer (carcinoma in situ, CIS) has been copy was performed in all patients before the
the subject of much controversy. For many operation, and cases that did not reveal any
years hysterectomy was the recommended suspicion of malignancy received laser coniza-
therapy because a rather high incidence of re- tion for the purpose of treatment of the disease.
currence of carcinoma was reported after con- Diagnostic laser conization was performed for
servative treatments such as conization or de- the cases in which a deep cervical evaluation
struction of the uterine cervix. I - 3 Recently, could not be obtained through preoperative col-
focused CO 2 laser conization, which excises se- poscopical examinations. The mean age of the
lected cervical tissue, enabled us to evaluate the patients was 39.6 years, ranging from 22 to 54
histologic findings of the resected cone. 4 . S But years. The mean parity and gravity were 2.3 and
we found that this method also has some serious 3.4, respectively. None of the women were
deficiencies. pregnant at the time of conization. All patients
Today, we are more optimistic about the fu- who underwent conization were admitted to the
ture of laser conization. A new ceramic scalpel hospital in expectation of likely complications,
has been designed for attachment to the a precaution typically taken in Japan. The heal-
Nd:Y AG laser, which converts this laser into a ing process of conization was checked daily, and
surgical instrument that can cut as accurately cytologic examinations of the cervical area were
and precisely as the CO 2 laser, without sacrific- performed every 2 weeks for a 6-month period,
ing any of the coagulative properties of the non- and then monthly. All cones were fixed in 10%
contact Nd:YAG laser. formaldehyde and extensively sectioned for
In this report we present the details-subjects, histopathologic analysis. The severity of the
methods, operational procedures, and results- malignancy and the affected areas, as well as
of a conization study we implemented at our the distance from the edge of the cone to the
hospital, using the newest modality ofNd:YAG affected area, were evaluated. When the edge
laser equipped with a synthetic sapphire laser of the cone was more than 5 mm from the af-
scalpel. We also discuss the advantages of this fected area, the patient was considered cured.
technique for both the surgeon and the patient. When the affected area was less than 5 mm from
the edge of the cone, a hysterectomy was per-
formed by either the vaginal or the abdominal
route. Therapeutic conizations were performed
Subjects on nine patients. From the colposcopic findings
and the pathologic analysis of the punch biop-
Our study group consisted of 16 patients with sies, we were convinced that the malignancies
abnormal cervical pap smears indicating CIN III had not advanced beyond carcinoma in situ. Of
(severe dysplasia and carcinoma in situ) or class nine therapeutic conizations, additional hyster-
IlIa (Table 26.3) who underwent laser conization ectomies were performed on two patients. One
184 Ryozo Totani, Tetsuro Karasawa, and Yozo Suzuoki

patient (Case 8) had an incomplete resection of

the cone-its affected area was within 3 mm of
the cone's edge. The second patient (Case 9)
wanted to have a hysterectomy, although the
cervical findings did not indicate it was neces-
sary. Seven patients were followed-up for 10 to
20 months postoperatively.
Diagnostic conizations were performed on
seven patients. Of these, four cases were di-
agnosed as carcinoma in situ by punch biopsy
through colposcopy. But deep findings could not
be obtained by this method. In order to procure
a more precise diagnosis, laser conization was
performed on these patients. This procedure
enabled us to determine which surgical therapy
was most appropriate: panhysterectomy, ex-
tended hysterectomy, or simple total hyster-
ectomy with or without lymphadenectomy of the
pelvic cavity.
The three remaining patients had diagnostic
laser conization, although they were recom-
mended to have hysterectomies because of FIGURE 26.1. The synthetic sapphire-ceramic probes
larger than fist-sized myoma uteri. These pa- with laser hand pieces-the SLT contact laser scal-
tients were among many others having myoma pels.
uteri, and their screening pap smears and punch
biopsies showed Class IlIa and mild dysplasia,
which are inconclusive findings of further ma-
lignancy. Preliminary examinations of clinical trials were
done on the resected uterine cervix or just before
the hysterectomy for myoma uteri or adenom-
Methods yosis. Conization was attempted with several
probe sizes with the laser scalpel and with vary-
The Nd:YAG laser equipment we used was the ing laser wattage. The 0.6-mm scalpel probe with
Molectron Model 8000 (Molectron Industries, 30 W of power was found to be the most effec-
USA). The wavelength of the laser was 1.06 /-Lm tive combination to conize the uterine cervix.7
and the maximum power output was 110 W. The This SLT contact laser scalpel, used with the
benefit of this equipment was that stable and Nd:YAG laser, surpasses the noncontact fo-
accurate wattage was available from low power, cused CO 2 laser by allowing narrower and deep-
1 to 30 W. The ceramic laser scalpel was made er incisions and by considerably reducing back-
of synthetic sapphire (aluminum oxide, AI 2 0 3), scattering. It is also a distinctly safer procedure
which can center the laser beam at the tip of the for the medical staff (Table 26.1).
scalpe1. 6 (Figure 26.1).
This AI 2 0 3 crystal scalpel (Surgical Laser
Technologies, Malvern, PA and Japan, Tokyo),
transmits a laser beam of more than 90% of the Operational Procedures
original power, and so greatly surpasses con-
ventional artificial sapphire or quartz crystal Conization was performed under general anes-
scalpels. This SLT Laser Scalpel® is fixed at thesia after colposcopy, which determined the
the tip of the holder and the Nd: Y AG laser beam size and shape of the cone. The operational pro-
is delivered from the Molectron Model 8000 cedures are as follows (Figure 26.2): (1) After
through several meters of optical quartz fiber. the disinfection of the vaginal cavity and portio
26. Laser Conization of the Uterine Cervix 185

TABLE 26.1. Comparison of Contact and Noncontact

Procedures
Contact Noncontact
Characteristics (Nd:YAG) (CO, focused)
Heat damage of marginal tissue Minimal Great
Incision width Narrow Wide
Laser power Low High
Backscattering of laser beam Minimal Great
Surgical procedure Simple Complex
Danger from laser exposure Minimal Caution required

vaginalis, four sutures are placed at 3, 6, 9, and minimal bleeding of the incision site, additional
12 0' clock on the portio just outside the affected laser therapy can be used to coagulate blood
area, for the purpose of controlling the uterine vessels not sealed off by the earlier incisions.
cervix. The use of cervical forceps is not rec- (5) The weight and length of the resected cone
ommended because they frequently cause dam- are determined after removal of the cone from
age that later hinders the pathologic evaluation the cervix (Figure 26.5). The cone is vertically
of the resected cone. (2) The rami descendens incised at 12 o'clock (Figure 26.6). (6) The
of the uterine artery on both sides of the cervix opened cone is pinned to a small board and the
are sutured with 2-0 chromic catgut close to the affected area is again examined by the colpo-
lateral vaginal fornix. (3) The cervix is pulled scope. More exact measurements of the cone
out with the implanted sutures 2 or 3 cm, so that are taken, and the specimen is then delivered to
the tip of the laser scalpel can easily maneuver the pathologist for evaluation. Figure 26.7 shows
around the portio (Figure 26.3). The laser scalpel the pathologic findings of one case (Case 6).
is carefully aimed to cut approximately 5 mm Note that the malignant area is at a reasonably
around the affected area before it is actually safe distance from the cone's edge, which is lo-
switched on for use with a foot pedal. The scal- cated both on the top of and on the right side
pel is hand-operated clockwise around the portio of the photographed specimen. The black marks
repeatedly with 5 mm incisions until the cone is identify the boundaries of the affected area. A
finally resected (Figure 26.4). (4) Although this schematic representation of the stages of the
method of laser conization usually results in operation are shown in Figure 26.8

FIGURE 26.2. The tip of the

laser scalpel is placed directly
on the sutured portio at the
beginning of the procedure.
186 Ryozo Totani, Tetsuro Karasawa, and Yozo Suzuoki

FIGURE 26.3. Repeated circu-

lar incisions are made at
depths of 5 mm.

FIGURE 26.4. Hemorrhage is

almost nonexistent after re-
sectioning of the cone.

Results two cases were hysterectomized. Seven patients

were followed-up for 10 to 20 months postop-
eratively. No abnormal findings on periodical
Table 26.2 shows the surgical data of Nd:Y AG pap smears were obtained. All seven patients
laser conization of 16 cases. The mean operating who received diagnostic conizations were hys-
time for each case was about 22 minutes, but terectomized after full analysis of the pathologic
the actual laser operational time was only about data was obtained . Among the group treated by
8 minutes; disinfection, suturing of the portio to conization, only one postoperative diagnosis
stretch the cervix, and observation time for (Case 8) was more severe than its preoperative
postoperative hemorrhage took 14 minutes on diagnosis, with a finding of severe dysplasia ex-
the average. Of nine cases treated by conization, tending to carcinoma in situ (Table 26.3).
26. Laser Conization of the Uterine Cervix 187

(Cases 4 and 8) because the edge of the affected

area extended within 5 mm of the apex of the
resected cone. Of the nine hysterectomies per-
formed , however, postoperative examinations
indicated that only two cases actually required
the operation to forestall uterine malignancy.
According to GrundselV malignancy on the
surface of the resected cone is not a reliable in-
dicator of malignancy on the unoperated facing
portion of the uterus. In fact, he reports that
recurrence of cancer in such cases is limited.
Concerning the partial resection of the uterus
as a treatment of early cervical cancer, the ac-
curacy of the treatment is the most important
factor because the uterus is not an indispensable
organ for life. If some women have a recurrence
/'
81!!14Re .' of cancer after the conization of the uterine cer-
vix, the responsibility of the medical staff is ex-
ceedingly serious. This explains why hyster-
ectomy or extended hysterectomy is frequently
FIG URE 26.5. Cone resected by Nd:Y AG laser con- performed in Japan. But owing to progress in
ization.
the accuracy of preoperative diagnosis of this
condition, the number of patients who have
Discussion conization increases slightly every yearS (Figure
26.9). The conization of the uterine cervix be-
For all 16 cases, the affected areas were resected comes a truly valuable operation when its post-
by laser conization, but hysterectomies were operative recurrence ratio closely approaches
performed on 9 patients: 3 because of myoma that of the hysterectomy. Thus, the crucial cri-
uteri, 4 to determine the thermal effect of the terion used in deciding whether to perform the
laser on tissue of the remaining uterus, and 2 hysterectomy is the extent of the malignancy it-

• 15
FIGURE 26.6. Cone resected at 12 o'clock S!541i2e
and opened.
188 Ryozo Totani, Tetsuro Karasawa, and Yozo Suzuoki

FIGURE 26.7. Pathologic specimen with edges of malignant areas marked by black dots.

self, that is, whether or not it extends to within significant bleeding from the operational site has
5 mm of the edge of the resected cone. Figure been a reason for the popularity of conization.
26.10 shows the management scheme adopted The uterine cervix is one of the hardest of the
for patients suffering form early-stage cervical soft tissues in the human body, capable of di-
cancer. lating more than ten times its circumference
Besides the problem of tumor recurrence, in- at the time of delivery of the fetus. Although

suture the lateral edge of

~
emanate ceramic sca lpel laser laser to stop ancillary bleeding

removed cone incised cone

FIGURE 26.8. Schematic representation of the

operative procedure of Nd:YAG laser conization
using the synthetic sapphire scalpel.
 26. Laser Conization of the Uterine Cervix 189

TABLE 26.2. Surgical data of SLT contact To resolve these difficulties of traditional
Nd:YAG laser conization conization, Nd:Y AG laser conization applied
Cases treated with Nd:YAG laser 16 with an synthetic contact sapphire scalpel was
Total operation time (min) 22.4 ± 4.0 clinically evaluated. As for confirmation of the
Total laser joule (J) 11033.7 ± 4856.6 removal of the affected area, conization sur-
Total blood loss (g) 54.4 ± 47.9 passes the destructive procedures such as cry-
Weight of removed cone (g) 9.3 ± 4.9
Length of removed cone (mm) 22.7 ± 7.6
osurgery, cauterization, or vaporization with
CO 2 or Nd:YAG laser. It is also superior when
compared to conization procedures with the
cold-knife or CO 2 focused conization. The
bleeding from the conized cervix is negligible Nd:YAG contact procedure surpasses the others
during or soon after the traditional operation, a in its ease of use in cutting the hard tissue of
few weeks later, when patients have already re- the cervix more precisely; it allows a more ac-
turned to their ordinary lives, they can suddenly, curate cutting of tissue at the top of the cone,
and unexpectedly, have a severe hemorrhage. in contrast to the CO 2 laser procedure.
The third problem of traditional conization is There is much discussion as to the complete-
the difficulty in detecting tumor recurrence at ness of resection and how many millimeters
the operational site. The cervical tissue of the of tissue from the affected area need be re-
resected surface is usually scarred after the tra- moved. 5 . 10-12 Our experience with these cases
ditional conization, such as destructive proce- is too limited to make any definite claims, but
dures, Scott's open-cut edge operation, or 5 mm of tissue beyond the affected area seems
Sturmdorff's well-known operation. When af- to be adequate. Some reports have indicated that
fected tissue remains under the scar of cervical even when isolated cancer cells remain after re-
tissue, or sometimes under the vaginal wall tis- section, these remaining cells rarely result in a
sue, detection of the recurrence of the tumor is recurrence of the tumor. 5
very difficult, and frequently it is discovered Concerning the second problem of conization,
only after it has already developed to some ex- bleeding, the focused CO 2 laser or Nd:YAG
tent. 3 laser, used with adequate wattage, can coagu-

TABLE 26.3. List of the cases treated with SLT contact Nd:YAG laser conization
Purpose Affected Histologic diagnosis
Pregnancy of Pap Colposcopic area at punch biopsy ---> Follow-up
Case Age history conization smear findings the portio (%) cone specimen (months)
45 P(2) G(3) D Class IlIa W 50 ! Mil.dys. ---> N.M. STH"
2 43 P(2) G(2) D Class IlIa W + AGO 50 ! Mil.dys. ---> N.M. STH"
3 48 P(2) G(4) D Class IlIa W 50 ! Mil.dys. ---> N.M. STH"
4 42 P(2) G(5) D Class IV W + AGO + P 50 t CIS ---> la EH
5 42 P(3) G(3) D Class IV W 50 ! CIS ---> CIS STH
6 48 P(2) G(3) D Class IV W + M + aV 50 t CIS ---> la STH
7 43 P(2) G(2) D Class IV W+M+P 50 t CIS ---> CIS STH
8 40 P(2) G(2) T Class IlIb W + AGO 50 t Sev.dys. ---> CIS STH"
9 39 P(4) G(5) T Class IlIb W + P 50 t Sev.dys. ---> N.M. STH'
10 22 PO) G(2) T Class IV W 50 ! CIS ---> CIS 17
II 54 P(2) G(3) T Class V W + P + M 50 t CIS ---> CIS 16
12 34 P(3) G(5) T Class lIla W 50 ! CIS ---> CIS 17
13 34 P(3) G(5) T Class IlIb W 50 ! CIS ---> N.M. 10
14 31 P(2) G(2) T Class IlIb W 50 ! Sev.dys. ---> N.M. 14
15 33 P(2) G(3) T Class IlIb W 50 ! Sev.dys. ---> Mil.dys. 18
16 35 P(3) G(5) T Class IlIa W + AGO 50 t Sev.dys. ---> Mil.dys. 20
p, parity; G, gravity; D, diagnosis; T, treatment; Mil.dys., mild dysplasia; N.M., no malignancy; CIS, carcinoma in situ: Sev.dys.,
severe dysplasia; STH, simple total hysterectomy; EH, extended hysterectomy.
"Incomplete resection.
"Patient hope for operation.
'Hysterectomy for myoma uteri.
190 Ryozo Totani, Tetsuro Karasawa, and Yozo Suzuoki

0
( n)

10000
•
(%)
N umber of total cervical cancer

8000
30

6000
x CIS (%)
( %) 20
8 4000
6
10
4 2000
2
0 0 a
74 75 76 n 78 79 80 81 82 83

FIGURE 26.9. Increasing incidence of CIS (carcinoma in situ) and conization in Japan.

late the bleeding from arteries less than 0.5 mm suturing the ramis descendens of the uterine ar-
in diameter. When the Nd:Y AG lasers is used tery before laser conization. This step can prob-
with the SLT contact scalpel attached, this tech- ably be omitted, but as this procedure is simple
nique for conization surpasses all other proce- and easy, it seems wise to simply reduce any
dures.4.6.13.14 risk of bleeding. However, there are very few
In our operative procedures we recommend reports of postoperative bleeding in laser pro-
cedures when compared to other operational
procedures. 4
Concerning the third point, the difficulty in
detecting recurrence of cancer seems to remain
class In .......v even in Nd:Y AG laser conization, although we
have had not experienced any such recurrence.
colposcope and biopsy In most cases, we observed that the edges of
! the remaining cervical tissue turn inside grad-
severe dysplasia seve re dysplasia ually and fold upon themselves thus the neigh-
CIS CIS
(not indica ted) ( i nd ica ted) boring vaginal tissue gathers at the cervical canal
stage la carcinoma

TABLE 26.4. Indications for laser conization

I. Severe dysplasia or carcinoma in situ, which has been
incomplete resectio n diagnosed by means of punch biopsy during
colposcopy
comp lete resec t ion 2. The entire infected area is visable through colposcopic
severe dysplasia stage Ia invasive ( se Vere dYSPlaS ia ) examination and the area of infection falls clearly
CIS carc inoma carcinoma CIS
within the bounds of cone removal
!
hys te rectomy
!
extended
!
panhyster ec t omy
!
10 lIow up
3. Patients whose postoperative follow-up can be reliably
hys terec tomy
assured
4. Patients who are hoping for future pregnancies, or for
other reasons desiring preservation of the uterine
FIGURE 26.10. Management of early-stage cervical
function
cancer.
26. Laser Conization of the Uterine Cervix 191

as is observed whenever a surgical procedure is References

used to remove the large cone.
We do not recommend conization for peri- or 1. Kirwan H, Smith IR, Naftalin NJ: A study of
postmenopausal patients (Case 11) because fol- cryosurgery and the CO 2 laser in treatment of
low-up reevaluation is extremely difficult owing carcinoma in situ (CIN III) of the uterine cervix.
Gynecol Oncol 22: 195-220, 1985.
to the wrinkling and shortening of the cervix that
2. Nagell JR: Diagnostic and therapeutic efficacy of
takes place at this time. cervical conization. Am J Obstet Gynecol
Conization of the cervix should be limited to 124: 134-139, 1976.
patients who are still hopeful of a pregnancy or 3. Ahlgrem M: Conization and treatment of carci-
who have reasons for wanting to preserve the noma in situ of the uterine cervix. Obstet Gynecol
uterus. Although we had no pregnancies among 46:135-140, 1975.
our contact Nd:YAG laser conization cases, 4. Meandzija MP, Locher G, Jackson JD: CO 2 laser
Shirodkar's operation of the cervical mucosa is conization versus conventional conization: A
strongly recommended to prevent premature clinico-pathological appraisal. Lasers Surg Med
delivery at 12 to 16 weeks of gestation (Table 4: 139-144, 1984.
26.4). Two pregnancies occurred in the non- 5. Grundsell H., AIm P, Larsson G: Cure rates after
laser conization for early cervical neoplasia. Ann
contact vaporization of Nd:YAG laser coniza-
Chir Gynecol 72:218-222, 1983.
tion that are not included in this report. Both 6. Dakiuzono N, Joffe, SN: Artificial sapphire for
resulted in full-term deliveries after Shirodkar's contact photocoagulation and tissue vaporization
operation. with the Nd:YAG laser. Med Instrum 19:173-178,
Clinically, there are many cases in which the 1985.
severity of the affected areas of the cervical 7. Totani R, Korasawa T, Suzuoki, Y: Application
canal are not confirmed by colposcopy and also of newly-developed contact type surgical rod for
in which findings of the colposcope and the pap Nd: YAG laser conization of uterine cervix. Laser
smears are at variance. In such cases, Nd:YAG Optoelectonics in Medicine Springer-Verlag, To-
contact conization is recommended to make a kyo, 1986, pp 495-501.
definite diagnosis. 8. Japan Obstetrics and Gynecology Society. Annual
Reports: Statistical Data of Cervical Cancer,
Although conization has a long history, it is
1974-1983.
not commonly used in the management of early- 9. Scott JW, Welch WB, Blake TF: Bloodless tech-
stage cervical cancer because of the many dif- nique of cold knife conization Am J Obstet Gy-
ficulties with the operation itself, such as hem- necol 79:62 1960.
orrhage, and toughness of the tissue. We 10. Baggish MS, Dersey JH: Carbon dioxide laser for
achieved some progress with our combination combination excisional vaporization conization.
of the Nd:YAG laser and the synthetic SLT Am J Obstet Cynecol 131:23-27 (1985).
sapphire scalpel in cervical conization by sim- 11. Wright VC, Davies E, Riopella MA: Laser cylin-
plifying the procedure and resolving some of the drical excision to replace conization. Am J Obstet
previous difficulties, especially hemorrhage, and Gynecol 150:704-709 1984.
by making reevaluation of the resected cone a 12. Lobraico RV: Lasers in gynecology. Med Instrum
17:411, 1983.
possibility. The laser also allows cones of var-
13. Schellhans HF, Weppelmann B: The neodym-
ious sizes and shapes to be resected, in contrast ium: YAG laser in the treatment of gynecologic
to the earlier CO 2 and electrocautery conization malignancies. Lasers Surg Med 3:225-229, 1983.
procedures. It is hoped that this procedure will 14. Larsson G: Conization for preinvasive and early
be widely used as both a diagnostic tool and as invasive carcinoma of the uterine cervix. Acta
therapy in the near future. obstet Gynecol Scand Suppl 114, 1983.
27
Endometrial Ablation
Theresa Zumwalt

History and financially nonproductive convalesence. In

fact, most patients experience only mild cramps
The use of the high-energy N d: Y AG laser for and resume normal activities in 1 or 2 days.
endometrial ablation was recently approved by The success rate of ablation is dependent on
the Food and Drug Administration for endo- the technical expertise of the physician and
metrial destruction by vaporization and coag- proper patient selection. In the past, patient se-
ulation. Some years ago this technique was lection was based on medical contraindications
designed by Milton Goldrath 1 •2 as a low-risk al- for surgical hysterectomy; that is, cystic fibrosis,
ternative to hysterectomy for the treatment of multiple lower abdominal surgeries, heart valve
menorrhagia. To date he has completed 350 replacement, or coagulopathies. When evalu-
procedures, mainly in patients who are high risk ating a patient for endometrial ablation, the
for surgical hysterectomy.3 The results are im- uterus should be examined, its depth deter-
pressive: 50% of his patients now have hypo- mined, a Pap smear obtained, and a hysteros-
menorrhea, consisting of mild spotting, and the copy with endometrial biopsy performed. Any
rest are amenorrheic. 2 Endometrial ablation has malignancies should be triaged into a standard
proven to be a safe, outpatient surgical proce- treatment protocol. Benign endometrial curet-
dure to correct menometrorrhagia, with an in- tings should be obtained within 6 months of the
direct result of amenorrhea and sterility. ablation. The patient should have failed standard
treatment for menometrorrhagia (dilatation and
curettage, followed by cyclic progesterone
Controversial Factors therapy). Existing endometrial polyps should
also be removed at the time of the initial office
Significant factors involved with this clinical hysteroscopy. The use of a six-injection-point
application of the Nd:Y AG laser are cost con- paracervical block will improve patient comfort
tainment, painless convalesence, procedure during these procedures. Initially, the surgeon
success rates, patient selection and preparation, should select only a normal-sized uterus to
physician and surgical staff training, laser safety ablate. The patient should be placed preopera-
supervision, and future applications. tively on 4 to 8 weeks of Danazol 800 mg daily
Today, the delivery of quality care appropriate to achieve endometrial atrophy. 2,4 Patients on
to the presenting symptoms, with attention to coumadin will need their dose adjusted. Depo-
the economic use of time, materials, and hospital Provera should not be administered preopera-
beds, is influencing health care significantly. tively.4 Routinely, hysterograms are not needed.
From an economic aspect, same day surgery is Laboratory screening should include a serum
less expensive than a 4-day hospitalization. pregnancy test, blood count, type and screen,
From the patient's point of view, she will lose electrolytes, BUN and creatinine, and a coag-
only 3 days of work and will not undergo the ulation screen. An investigational consent is no
standard 4- to 6-week physically uncomfortable longer required by law but may be helpful for
27. Endometrial Ablation 193

patient education. Patients have to be told that

retreatment may be needed (6%).2 The anes-
thesia used can be epidural, spinal, or general.
Overnight cervical dilation with laminaria is
currently done to avoid traumatic manual dila-
tion.

Procedure for Endometrial

Ablation
1. The patient is prepped and draped with a
water salvage system taped under the but-
tocks on a table with leg rest (knee crutch)
stirrups. The cystoscopy table is ideal.
2. A bimanual examination is done to remove
the laminaria, lamicel, or dilapan artificial
dilator. Straight mechanical dilation causes FIGURE 27.1. Uterine template. Initial marking lines
bleeding, which obscures the view. The cer- to be traced on the endometrial sUlface outlining the
vix should be loose around the operating limits of ablation.
hysteroscope (20 French) to allow easy
egress of the irrigant. I Either normal saline
or Ringer's lactate is an excellent irrigation 6. A urologic quartz (0.6-mm) fiber is used at
fluid. 50 to 55 W through an operating hysterscope
with direct surface contact of the fiber on
3. A single-tooth tenaculum is placed vertically
the endometrium. The Nd:YAG laser is set
at 12 o'clock on the cervix. It is most com-
on continuous wave mode with foot control.
fortable to fix the tenaculum to the drape
sheet, freeing the surgeon's hands to operate 7. Goldrath ablates each tubal ostia initially .
the hysteroscope. Check to make sure that He then uses the laser to mark the lower
aNd: YAG eye safety filter is firmly attached limit of ablation and divides the surface of
to the hysterscope. Flush all air from the the uterus into anterior and posterior halves
scope. (Figure 27.\). He begins on the anterior or
posterior work surface, completes it, and
4. A red tape should be placed on the hyster-
then does the remaining half.
oscope 4 cm from the end as a warning to
the laser staff to turn the power off when the 8. Under direct visual control the quartz tip is
tape comes into view. Goldrath does not co- passed over the endometrial surface at a rate
agulate the lower 4 cm of the lower uterine of 0 .25 cm/second . The operator can see the
segment and cervical canal because of the tip "mowing" off the endometrium by direct
proximity of the uterine vessels (Figure contact coagulation. A uniform field of tan
27.1) . vaporized myometrium should remain. The
procedure is as tedious as "mowing the
5. The nursing responsibility is to manually ir-
White House lawn with a hand mower." It
rigate the uterus under pressure to maintain
is, therefore , important for the surgeon to
a clear operative field. A continuous strict
position his/her back for maximum comfort.
intake and output sheet must be maintained
Also, the surgeon must be certain that he
to monitor the intravenous fluid and the
has the patience for this meticulous type of
hysteroscope irrigant balanced against the
surgical discipline .
urine, and vaginal irrigant output. Small, 5-
mg doses of furosemide are given to avoid 9. Start in the anterior or posterior superior
fluid overload. fundus and gradually work down to the
194 Theresa Zumwalt

cervical marked ring. During the procedure, office hysteroscopy are all useful in follow-
occasional point coagulation of specific ing the patient. Early in the surgeon's ex-
bleeders, seen when the water pressure is perience, hysteroscopy would be beneficial
reduced, is helpful for maintaining a clear mainly in improving his own technical skills
visual field and reducing postablationbleed- and completing his educational process.
ing.
10. After completing the ablation, a reinspection
for any pink viable areas of endometrium is Short-Term Complications
needed. These pink areas are re-treated.
II. Finally, a strong sharp curettage to remove Air Embolization
the burnt tissue and to assure scarificaton is Air embolization has occurred twice, once with
performed. a fatal outcome .5 Both cases occurred when a
12. At the close of the case fluid balance is noted sapphire tip had been attached to the gastroin-
and further adjustments in diuretic therapy testinal fiber, with gas probably being used as
the distending medium. The gas was probably
are made if necessary. The patient is ob-
pushed directly into the venous system through
served in the recovery room and may be sent
the dilated uterine venous sinuses (Figure 27.2).
home in a few hours.
The uterine venous sinuses function similarly to
13. Discharge medications can include Tylenol, the prostatic venous plexus. These sinuses
Anaprox, Danazol, Depro-Provera, or an- transfer whatever distending media is used, di-
tibiotics. Narcotics will only rarely be need- rectly into the circulatory system.
ed for the immediate postoperative cramp- The sapphire laser probe has been developed
ing. The patient needs to be seen if she to decrease the power wattage required by fo-
reports severe pain after discharge. Monthly, cusing the laser energy. This probe increases the
and then trimonthly, follow-up as previously precision of the quartz fiber while attempting to
requested by the FDA protocof is indicated. decrease accidental perforation of thin-walled
Uterine sounding, endometrial biopsy, and bronchi or esophageal tissue. 6 Designed for res-

r .....--'--'--Vaginalleakage

FIGURE 27.2. Irrigant absorption routes. 1, Uterine venous sinuses transfer fluid to circulation; 2, fallopian
tubes to peritoneal cavity; 3, cervix to vagina.
27. Endometrial Ablation 195

piratory and gastrointestinal work, it attaches balance and constant bladder decompression.
to the end of the gastrointestinal laser fiber, Patients with aneuric renal failure may need
which has an air or water purge channel along- to be dialyzed immediately after the proce-
side the quartz fiber. The air or water purging dure. The use of a limited volume of irrigant,
channel allows for tip cooling. Overheating the a widely dilated cervix, an experienced laser
tip will render it nonfunctional especially at surgeon, and an atrophic, well-prepared en-
powers greater than 35 W. The sapphire probe dometrium are crucial to proper care of these
as currently designed is not needed for endo- high-risk patients. Pre- and postoperative
metrial ablation because it cannot deliver the 50-- weighing, with the same bed scale for both
55 W of power necessary for adequate depth of weights, may be beneficial. Central venous
myometrial coagulation. 7 The sapphire probe pressure lines have been used for select pa-
may prove helpful in intrauterine plastic surgery tients.
to remove polyps or small septae or to occlude
tubes at its lower power settings.
Gynecologists and urologists should currently Hemorrhage
use the plain O.6-mm quartz "urology fiber" Immediate Hemorrhage
through a hysteroscope or cystoscope-both
instruments have their own fluid channels (Fig- During the procedure, bleeding occurs from
ure 27.1) without an air purge channel. Pul- venous sinuses unroofed by the laser's destruc-
monary and gastrointestinal surgeons use fibers tion ofthe endometrial gland layer. The positive
with coaxial gas or fluid and a completely dif- intrauterine hydrostatic pressure that is neces-
ferent technique. Saline or Ringer's lactate sary for adequate visualization (visual control)
(NOT AIR OR NITROUS OR CARBON DIOX- prevents intraoperative bleeding. Point coagu-
IDE OR WATER) is the safest irrigation medi- lation of individual bleeding sinuses during laser
um. Gaseous insufflation should not be used for vaporization is helpful to maintain clear fluid.
Intractable uterine bleeding, which starts im-
endometrial ablation in view of the risk of air
mediately after the ablation (after removing the
embolization and death.
hysteroscope) and is not changed by the cu-
rettage, may be awesome. Control of this is eas-
Fluid Overload ily accomplished by Goldrath' s intrauterine
Foley technique.~ Place a 28- to 32-gauge Foley
Patients will experience fluid overload (hyper- catheter with a 30-cc balloon into the uterus and
volemia, pulmonary edema, and congestive inflate the balloon with saline just until the
heart failure) until you have developed and per- bloody cascade stops flowing out of the uterus.
fected your hydraulic system. This requires an The catheter can be left in place for 6 to 24
ongoing, accurate, intraoperatively balanced hours. Use of prophylactic antibiotics may be
charting of expended and recovered irrigating helpful if the catheter must stay in longer than
solution. Accurate fluid balancing is dependent a few hours. The catheter is ready to be removed
on an informed, trained operating room staff. when deflating the balloon does not restart the
Currently, the ablation procedure is dependent hemorrhage.
on manual pumping of the irrigating solution.
Several types of infusion pumps, ranging from Delayed Hemorrhage Requiring
cardiac bypass machines to Holters, have been
Hysterectomy
tried without success. Goldrath 3 is currently
testing a new hysteroscope which may eliminate In Goldrath' s original series, he attributed de-
this fluid overload problem. layed hemorrhage to delayed coagulation ne-
crosis into the cervical artery. Goldrath's hys-
1. Small incremental doses of furosemide 5 to teroscope is marked with red tape at 4 cm, which
10 mg intravenously are frequently needed to correlates to this measured entry point of the
maintain fluid balance during surgery. cervical branch of the uterine artery into the
2. An intraurethral Foley catheter to gravity myometrium. He avoids ablation of the last 4
drainage allows accurate recording of fluid cm of the endocervical canal to avoid this po-
196 Theresa Zumwalt

tential problem. No other cases have been re- plete, especially at the early learning phases of
ported to date (Figure 27.1). his skill.
This procedure can be extremely backbreak-
ing for the surgeon . His work can be greatly fa-
Perforation cilitated and enhanced if he administers Danazol
A good background experience in outpatient preoperatively, to try to reduce the depth of the
hysteroscopy will decrease the frequency of endometrial layer to less than I mm . This pre-
uterine perforation. An experienced hysteros- treatment course with Danazol takes 6 to 8
copist should be able to identify visually when weeks or longer-to the endpoint of amenor-
perforation has occurred. He can then avoid rhea. On the other hand, to attempt to ablate a
further damage by stopping the procedure and hypertrophic cavity stimulated by Depo-Provera
completing it a week later. Continuing the abla- is self-defeating.2-4 The only failure in one of the
tion under laparoscopic guidance may rarely be investigator series was in a case pretreated with
indicated. The protective effect by the thickness Depo-Provera for 2 to 3 months by a referring
of the myometrium against bowel burns has been physician4 (Figure 27.3) . The hysterectomy
tested experimentally and seen clinically.l Thus specimen (removed for continual bleeding)
routine laparoscopic monitoring is not needed showed persistent lush endometrium. Depo-
as it is when using a urologic resectoscope for Provera initially produces a pseudodecidual
endometrial ablation. Although the resectoscope state with edema and engorgement of the en-
may be faster, the control of resection depth is dometrial stroma and glandular hypertrophy
difficult, as well as the challenge to remove chips (Figure 27.4). Any chemical or mechanical ma-
of resected endometrium, which orbit in the nipulation that decreases endometrial depth
fluid-filled cavity. An attempted endometrial preoperatively will enhance the ablation success
ablation with a resectoscope ended in total ab-
dominal hysterectomy to control a broad liga-
ment hematoma caused by multiple uterine per-
forations, which occurred when an experienced
hysterocopist did not use laparoscopic guidance.

Long-Term Complications
Continued Menorrhagia
Patients must be informed by written consent,
as well as verbally, of the 6% or greater need
for repeat procedure. This is especially true
when the uterus has a large cavity or fibroids.
Strict attention must be paid to the cornual and
superior fundal areas to avoid creating potential
pockets of residual endometrium. The selection
of small uteri « 8 weeks) that do not contain
fibroids or excessive adenomyosis, combined
with practiced surgical skill, will greatly de-
crease the number of reoperations needed.
The surgeon should not attempt endometrial
ablation on the large more symptomatic uterus
(> 8 weeks) with its spacious cavity, until he is
unconditionally accomplished in this procedure.
He should be able to completely ablate a 4- to FIGUR E 27.3. Hysterectomy specimen. After Nd:
6-week size uterine cavity in less than 1 hour. YAG laser ablation with Depo-Provera pretreatment.
Larger cavities can take up to 4 hours to com- (Courtesy of G. Shirk, Cedar Rapids, IA.)
27. Endometrial Ablation 197

FIGURE 27.4. Microscopic specimen. Lush endometrium residual after Depo-Provera pretreatment. Nd:Y AG
laser ablation failure. (Courtesy of G. Shirk, Cedar Rapids, IA.)

rate by reducing the total volume of endome- stop the procedure, or he can perform both
trium required to be removed. In the future, it ablation and polypectomy. One wonders if the
may be possible to perform the procedure on menometrorrhagia would have resolved initially,
patients whose endometrial mass has been di- if a hysteroscopy had been performed to diag-
minished by the use of low-estrogen, combi- nose and properly remove the polyps at the time
nation birth control pills for a sufficient time. In of the diagnostic dilatation and curettage. Was
these cases, the surgery could be timed for just it really necessary to resort to more expensive
after a withdrawal menses. At present, the pro- laser surgery?
cedure is only approved by the FDA for men-
ometrorrhagia. Hemorrhage
The preoperative evaluation, consisting of
hysteroscopy and endometrial sampling, is done See "Delayed Hemorrhage" in the preceding
to diagnose possible malignancy and to learn the section on Short-Term Complications.
topography of the cavity. Knowing that fibroids,
polyps, and septae are present is helpful in
Hysterectomy
planning laser surgery after conservative med-
ical therapy and polypectomy have failed. Thus In Goldrath's experience, hysterectomy after an
prepared, the surgeon enters the operative cav- ablation was required in 8 of 216 patients. Most
ity, knowing what he will find there. In larger of these hysterectomies occurred during his
referral services this initial preoperative workup early experience and were indicated for contin-
may be done by the referring physician, who ued bleeding associated with adenomyosis and
may not have performed a hysteroscopy. The submucous myoma, cervical bleeding, and an
surgeon's first examination of the cavity would ovarian cyst. 2 To date, none of his patients, all
be at the time of the surgery. The discovery of screened preoperatively with biopsy and, when
a large endometrial polyp, missed in the initial possible, hysteroscopy, has shown any evidence
workup and the probable cause of the menor- of malignancy. Goldrath has abandoned the
rhagia, allows the surgeon to choose one of sev- routine laparoscopic tubal yoon ring occlusions
eral options: he can easily excise the polyp and and postoperative hysterograms that he did early
198 Theresa Zumwalt

in his study. He found that he was able to rou- cologic surgeon. A working expertise in out-
tinely obliterate the endometrial cavity and oc- patient hysteroscopy is needed. In vitro prac-
clude the tubal ostia. The postoperative endo- tice in the laboratory on excised specimens is
metrial biopsy specimens contained only a min- necessary before attempting the procedure in
ute amount of endometrial fragments. At one vivo. Most important is hands-on experience-
year he has shown bilateral tubal occulsion and operating with a senior gynecologist to learn the
endometrial cavity obliteration. This reflects visual changes that occur in the endometrium,
Goldrath's compulsive attention to detail in practicing the manual dexterity required, and
ablating the endometrium. understanding the fluid insufflation system. The
procedure is highly technical for both the sur-
Hematometria geon and the operating crew, who must be com-
pletely familiar with both the N d: Y AG laser and
Retention of blood in the ablated cavity can the fluid insufflation-reclamation system.
easily be diagnosed and treated by a routine 4- Training the operating room crew with a mock
week postoperative Karman canula aspiration. case, making sure the fluid system works and
At the same time, the depth of the cavity can that the nurses have practiced the pump system,
be recorded. The frequency of hematometria in will reward with fewer complications the morn-
Goldrath's series was 71216. ing of your first endometrial ablation. Macular
blindness will result if the eyes are not protected
Urinary Tract Infections by I060-nm filters. Goggles should be worn by
the patient and the room crew. A hysteroscope
During surgery an indwelling catheter is nec- lens filter is commercially available to protect
essary to monitor fluid balance. It is also im- the surgeon's eyes. Prescription glasses made
portant to decompress the bladder to allow for from the 1060-nm filter glass can also be ordered.
adequate uterine mobilization needed to manip-
ulate the hysteroscope for viewing the anterior
uterine surface. Prophylactic oral antibiotics Laser Safety
used for the laminaria insertion should be suf- As laser surgery equipment is rapidly evolving
ficient coverage for the short-4- to 6-hour- with improved units and new devices are ap-
duration of Foley catheter use. The appropriate pearing daily, laser safety must be our first
antibiotic is prescribed at the discretion of the priority.9 The Food and Drug Administration,
surgeon. Office of Device Evaluation, requires manufac-
turers to provide instructions that outline the
operational mechanics of the device as well as
Laser Training and Safety the indications and contraindications for its
use. to The Nd:YAG laser companies share the
Training FDA's concern regarding informed, competent,
The I060-nm Nd:Y AG laser is one of the compliant use of their equipment. The laser
strongest lasers used in clinical medicine. It has companies are prepared to provide extensive
the following characteristics: (I) backscatter, (2) educational support for clinical and research
absorption by the retinal maculae, and (3) deep purposes.' It is your responsibility to read the
(5-10 mm) transmission through fluids as well instructions carefully and to consult with sur-
as solid tissue. These characteristics are com- geons who are more familiar with this technol-
pletely different from those of the CO 2 laser well ogy before you use the new devices. Each hos-
known to the gynecologist. The gynecologic CO 2 pital and surgicenter should employ a laser
laser surgeon must have additional, specialized safety officer who is responsible for knowing
training in the use of the Nd: Y AG laser and its everything about the devices, for teaching laser
physics, he must attend a gynecologic YAG laser safety, for keeping the equipment running, and
course composed of didactic and laboratory ex- for monitoring its safe use in the operating thea-
perience, and, finally, he must acquire a pre- ter. This person must assure safety to the pa-
ceptorship from a senior Nd: Y AG laser gyne- tients as well as the staff.
27. Endometrial Ablation 199

Conclusion 4. Shirk G: Unpublished data. Licensed Nd:YAG

laser clinical investigator, Cedar Rapids, lA, 1986.
5. Rose C: Personal communication. Director, Reg-
Nd:Y AG laser endometrial ablation may be- ulatory Affairs, Cooper LaserSonics, Santa Clara,
come the uterine surgery of the future. At this CA,1986.
time the technique requires a surgeon attentive 6. Daikuzono N, Joffe S: An artificial sapphire probe
to fine details, precise and pedantic in his sur- for contact photocoagulation and tissue vapori-
gical training and technique, and compulsive in zation. Med Instrum 19:173-178, 1985.
his preoperative workup and postoperative fol- 7. Zumwalt T, Wesseler T, Joffe S: A comparison
low-through in this evolving procedure. of artificial sapphire tip with the quartz tip in "in
vitro" endometrial ablation. Colposc Gynecol
Laser Surg 2:47, 1986.
References 8. Goldrath MH: Uterine tamponade for the control
of acute uterine bleeding. Am J Obstet Gynecol
1. Goldrath MH, Fuller T A, Segal S: Laser photo-
147:869-872, 1983.
vaporization of endometrium for the treatment of
9. Fisher J: Principles of safety in laser surgery and
J,11enorrhagia. Am J Obstet Gynecol 104: 14, 1981.
therapy. In Baggish M (ed): Basic and Advanced
2. Goldrath MH: Hysteroscopic laser surgery. In
Laser Surgery in Gynecology. Appleton-Century-
Baggish M (ed): Basic and Advanced Laser Sur-
Croft, Norwalk, CT, 1985, pp 85-129.
gery in Gynecology. Appleton-Century-Croft,
10. Yin L: Personal communication. Director, Divi-
Norwalk, CT, 1985, pp 357-372.
. sion of OB/GYN, ENT, and Dental Devices,
3. Goldrath M: Personal communication. Chairman,
Office of Device Evaluation, Food and Drug
Department OB/GYN Sinai Hospital, Detroit, MI,
Administration, Silver Spring, MD, 1986.
1986.
28
Nd:YAG Laser Applications in Gynecology
Jack M. Lomano

Improved endoscopic techniques, coupled with Photocoagulation of the

advances in laser technology, have spurred an
interest in using laser energy to treat gynecologic Endometrium to Treat Chronic
pathology. Laser therapy offers several advan- Menorrhagia
tages over other modalities, including the ability
to produce precise tissue destruction, better he- Background and Rationale
mostasis, and more rapid tissue healing. In ad-
dition, when combined with endoscopy, the la- Approximately 570,000 to 735,000 hysterecto-
ser increases accessibility to pelvic anatomy. mies are performed in the United States each
Moreover, it achieves all of this at less expense year, making it the most common major oper-
and discomfort to the patient. ation in this country and costing an estimated
At the present time, the carbon dioxide, ar- 1.7 billion dollars annually. Thirty to forty per-
gon, potassium titanyl phosphate (KTP) twin cent of these procedures are performed for
crystal, and Nd:YAG lasers all have application chronic recurrent menorrhagia that is refractory
to gynecology to treat intraabdominal, lower to medical and surgical therapy. Although gen-
genital tract, and intrauterine disease. Specifi- erally responsive to antibiotic therapy, morbidity
cally, these lasers have been used to treat pelvic occurs in 25 to 30% of hysterectomy procedures.
endometriosis, cervical dysplasia, condyloma Indeed, 600 deaths occur each year as a result
acuminata, pelvic adhesive disease, and pre- of complications from the surgery. For all of
malignant diseases of the vulva and vagina. these reasons, a more conservative procedure
The Nd:YAG laser can be used through the for the treatment of chronic menorrhagia has
hysteroscope to treat chronic menorrhagia. In- been sought.
traabdominally, it can be used through the la- Asherman's syndrome, I the development of
paroscope to perform ablation of pelvic endom- uterine synechia secondary to uterine trauma,
etriosis. Lesions of the lower genital tract are was first described in 1948. Although a signifi-
amenable to treatment with the Nd:YAG laser, cant problem for those women desiring preg-
either with direct application of the laser energy nancy, it would be desirable for those seeking
using a fiberoptic handpiece or with a focusing relief from heavy and prolonged menstrual flow.
sapphire tip to perform excisional procedures. Accordingly, several investigators have applied
When passed through the hysteroscope, this various physical and chemical agents to the en-
same fiber can be used to excise intrauterine le- dometrium to intentionally create an Asher-
sions. man's syndrome. 2 .3 Most of these methods failed
28. Nd:YAG Laser Applications in Gynecology 201

because of (1) inadequate destruction of the en- can be used in those patients where general
dometrial lining, allowing subsequent regener- anesthesia is contraindicated.
ation of the endometrium, or (2) complications The photocoagulation process begins at one
resulting from the physical or chemical sub- of the tubal ostia and then extends across the
stance introduced into the uterine cavity. fundus of the uterus and finally down the side
In 1981, Goldrath and his colleagues 4 de- walls of the uterus to the level of the internal
scribed the first cases of successful ablation of os, generally 4 cm above the external os. Two
the endometrium with the Nd:Y AG laser to cre- techniques of delivery have been described. In
ate an Asherman's syndrome. Lomano s corrob- Goldrath's "dragging technique," the fiber is
orated these findings in 1986 when he reported placed in direct contact with the endometrium
on 10 patients who had been treated with the and then is slowly dragged over the surface of
Nd:YAG laser after being given the alternative the endometrial cavity. Approximately 40 to 60
of hysterectomy for the treatment of chronic W are required to achieve ablation by this
menorrhagia. These patients had already under- method. Although the "dragging technique" al-
gone unsuccessful treatment, both with hor- lows the physician to observe a dramatic visual
monal agents and diagnostic curettage. A mul- effect as the endometrium is destroyed, the
ticenter study involving four centers was then buildup of carbonized particles on the fiber tip
carried out and 61 patients 6 were treated (in- results in extremely high temperatures that can
cluding my first 10 patients). To date, over 200 cause the tip to fracture. Consequently, it is
patients have undergone the procedure, although often necessary to remove the fiber and repolish
not under this same protocol. it one to three times during the procedure.
The so-called "blanching technique" is ac-
complished by bringing the fiber tip close to the
Patient Selection endometrial lining without actually touching it.
Patients eligible for this treatment have a history This requires approximately 10 W of additional
of heavy menstrual flow, which has been re- power to penetrate the endometrium sufficiently
fractory to surgical and medical management. (50 to 70 W). The operator observes the color
All have had one or more dilatation and curet- of the endometrial surface, looking for a gradual
tage and have been treated with hormones, in- change from pink to white. The "blanching
cluding estrogen, progesterone, androgens, an- technique" requires a much slower movement
tiprostaglandins, or ergotrate derivatives. All of the laser fiber than that required by the
patients are sterilized or willing to be sterilized, "dragging technique" to achieve temperatures
since the outcome of a pregnancy following this high enough to cause protein coagulation and
procedure has not been established. subsequent tissue death 4 to 5 mm below the
surface. The disadvantage of this technique is
poor visualization in the lower uterine segment.
Procedure Because of the funnel-shaped contour of the
The goal of ablation of the endometrium with uterine cavity, it is very difficult to place direct
the N d: Y AG laser for the treatment of chronic right-angle applications of the laser without ac-
menorrhagia is to obviate the need for hyster- tually touching the endometrial surface. To date,
ectomy and/or to provide complete amenorrhea. no controlled studies have been conducted to
The treatment was removed from FDA proto- compare the clinical effectiveness of these two
cols in March 1986. Two to four weeks prior to techniques.
the procedure, patients are given danazol (800 Patients are discharged on the day of surgery.
mg/day) to decrease the thickness of the en- They may resume normal activity 2 to 3 days
dometriallining and to create the hypoestrogen following the procedure.
state characteristic of Asherman's syndrome.
The procedure can be performed on an out-
patient basis and takes from 20 to 45 minutes.
Results of Treatment
A general anesthetic is used on most patients, Sixty-one patients were treated for chronic
although regional and paracervical anesthesia menorrhagia with the Nd: Y AG laser under the
202 Jack M. Lomano

TABLE 28.1. Results of Nd: YAG laser ablation for the

treatment of chronic menorrhagia (61 patients)
Menstrual flow Pretreatment Posttreatment
Duration (days)
>7 38 (62%) 0
4-6 18 (30%) 21 (34%)
1-3 5 (8% ) 26 (43 % )
0 0 14 (23%)
Amount (pads/menstrual period)
> 40 19 (31 % ) 0
20-40 35 (57%) 0
< 20 7 (12%) 61 (100%)

multicenter protocol. Their ages ranged from 27 Difficulty with visualization in the uterine
to 55 years. Table 28.1 compares menstrual flow cavity continues to be a problem, especially in
of these patients before and after treatment ac- those patients who have not been sufficiently
cording to duration and amount of flow. Prior pretreated with danazol. As the intense burst of
to treatment, 38 patients (62%) reported men- laser energy impacts onto the endometrium, it
strual flow of greater than seven days, 18 pa-
tients (30%) reported flow of 4 to 6 days, and 5
patients (8%) reported flow of 1 to 3 days. After
treatment, no patients had flow lasting longer
than seven days, 21 patients (34%) had flow
lasting 4 to 6 days, 26 patients (43%) reported
flow lasting 1 to 3 days, and 14 (23%) were to-
tally amenorrheic.
When amount of flow was evaluated before
treatment, 19 patients (31%) reported using more
than 40 pads per menstrual period; 35 patients
(57%) reported using 20 to 40 pads, and 7 pa-
tients (12%) used fewer than 20 pads. Following
the procedure, all 61 patients (100%) were using
fewer than 20 pads per menstrual period.

Complications
One of the 61 patients developed pulmonary
edema, and three patients experienced edema
during or following the procedure. All four were
treated successfully with intravenous diuretics
and no permanent complications developed.
15 reported an average fluid absorption of 1930
ml in patients who had previous tubal ligations
and an average of 2160 ml in patients using
other kinds of contraception. Since this differ-
ence is not significant, it is theorized that the
source of this fluid excess is direct intravenous FIGURE 28.1. Nd:YAG laser ablation of the endo-
fluid absorption through the veins of the endo- metrium to treat chronic menorrhagia. To increase
metrium. Loeffer7 reported that his patients the pressure of irrigation during the procedure , 50-cc
experienced less fluid absorption with the syringes are mounted in the main line from the irri-
"blanching technique" than with the "drag- gation solution to the hysteroscope to provide inter-
ging technique." mittent manual "flushing" of the endometrial cavity.
28. Nd:YAG Laser Applications in Gynecology 203

results in some clouding of the visual field. A Ablation of Early Pelvic

rapid irrigation system, therefore, is essential to
reduce these visualization problems. Several Endometriosis
techniques have been described to increase the
pressure of irrigation during the procedure. In Background and Rationale
the first technique, the urologic irrigation bag is Rokitansky described the first case of pelvic
raised on an intravenous infusion pole until the endometriosis in 1860. 8 In 1921, Cattell and
pressure of the irrigation approaches 100 mm Swinton" summarized the entire world's litera-
Hg. A second technique is to mount 50-cc ir- ture on the subject, consisting of 20 cases. Since
rigating syringes in the main line from the irri- then, the incidence of the disease has increased
gation solution to the hysteroscope to provide dramatically. This is particularly distressing,
intermittent manual "flushing" of the endom- since it is occurring at a time when many women
etrial cavity (Figure 28.1). A third option is to in the United States are choosing to postpone
pressurize the urologic irrigation bag with either their age of childbirth.
rapid blood infusion bags or gas cylinder pres- The association between endometriosis and
sure into the irrigation system. We are also an inability to conceive has been recognized for
evaluating a "balloon system," which would al- years.1O Premenstrual and menstrual pain caused
low transmission of the Nd:YAG laser energy, by congestion of sclerosed ovaries and nodules
but would seal off the endometrium to eliminate in the uterosacral ligaments present a significant
the possibility of clouding and intravenous ab- disability annually to thousands of women. Be-
sorption (Figure 28.2). cause of the increasingly young age at initial di-
agnosis, hysterectomy and bilateral salpin-
goopherectomy is an unacceptable treatment.
Conservative treatment with oral contraceptive
or danazol is expensive, and the side effects
often prevent t h elr. Iong-term use. 11- 14 C onserv-
ative surgery has been demonstrated to be ef-
fective in controlling the disease. However,
sharp dissection of pelvic endometriosis is not
only difficult but often results in bleeding, which
can lead to adhesion formation, thus further
compromising fertility. Another option, elec-
trocautery, while providing excellent hemosta-
sis, can produce thermal necrosis and perfora-
tion of underlying bowel, bladder, or ureter.
These problems led several investigators to
treat endometriosis with laparoscopic laser sur-
gery. Feste,15 Martin,16 Daniell and Pittaway, 17
and Kelly and Roberts 18 have reported on the
use of the carbon dioxide laser. Keye and
coworkers I" has reported on treatment with the
argon laser, and DanieWo has treated the disease
with the KTP twin crystal laser.
I was first to report on photocoagulation of
early pelvic endometriosis with the Nd:Y AG
laser." I It is an excellent treatment modality be-
cause of its inherent ability to penetrate tissue
FIGURE 28.2. Experimental "balloon system" for use
without vaporization of the serosa and its ca-
in ablation of endometrium to treat chronic menor- pability of being delivered through an optical fi-
rhagia. The system would allow transmission of the ber (easily manipulated through a laparoscope).
laser energy but seal off the endometrium to eliminate Since the Nd:YAG laser is a coagulating rather
the possibility of clouding and intravenous absorption. (han a vaporizing tool, a smoke evacuation sys-
204 Jack M. Lomano

tern is not needed. The Nd:YAG laser also offers instruments can be placed to facilitate the pro-
the advantage of color selectivity because its cedure . The fiber is placed approximately 1 cm
wavelength is selectively absorbed by the dark from the observed lesion. A laparoscopic fiber
colors of pelvic endometriosis. deflector is used to direct the beam into difficult
areas of the pelvis. Photocoagulation is per-
formed at a 20-W setting until a blanching effect
Patient Selection is achieved 1 to 2 mm beyond the border of the
lesion. Intermittent 1- to 3-second exposures
Patients eligible for this treatment have shown
with a spot size of 2 mm are recommended
signs and symptoms of early pelvic endome-
to avoid the buildup of heat and subsequent
triosis, including pelvic pain, menstrual dys-
vaporization of the serosa. 21 The procedure
function, infertility, or suspicious pelvic ex-
can be completed in approximately 10 to 40 min-
amination. Since the procedure is still on FDA
utes.
protocol, patients must sign an informed consent
Patients are discharged on the day of surgery
approved both by Grant Hospital's Human Ex-
and resume normal activity within 1 to 2 days
perimentation Committee and the FDA. Patients
after surgery. They are followed postoperatively
who are discovered to have severe endome-
at 3-month intervals. Adjunctive therapy with
triosis, as defined by the American Fertility So-
oral contraception and/or danazol can be used
ciety, are considered for open laparotomy, es-
following treatment.
pecially when the pelvic viscera are poorly
visualized through the laparoscope.
Results of Treatment
Of 135 patients who underwent diagnostic la-
Procedure paroscopy at the Grant Laser Center during a
The Nd:YAG laser is placed in the operating three-year period, 61 were considered eligible
room on a standby basis with the optical fiber for Nd:YAG laser photocoagulation of early
sterilized. Patients undergo diagnostic laparos- pelvic endometriosis. Patients have been fol-
copy under general anesthesia; if early pelvic lowed for an average of 22 months (range 1 to
endometriosis is found, the laser fiber is intro- 34 months). There were no operative or post-
duced through the operating channel of the la- operative complications. Symptoms improved
paroscope (Figure 28.3). A double-puncture following surgery in 45 patients (74%), worsened
technique is sometimes used so that additional in 2 patients (3%), and did not change in 12 pa-

FIGURE 28.3. Nd:YAG laser abla-

tion of early pelvic endometriosis.
The sterilized optical fiber is intro-
duced through the operating chan-
nel of the laparoscope.
28. Nd:YAG Laser Applications in Gynecology 205

TABLE 28.2. Results of Nd:YAG laser provide a tissue diagnosis in 80% of suspected
photocoagulation of early pelvic neoplastic lesions of the cervix, vulva, and va-
endometriosis (61 patients*; average gina. In 20% of cases, however, diagnosis cannot
follow-up 22 months) be confirmed with colposcopic-selected biopsy.
Report of symptoms No. of patients % A need exists, therefore, for excisional biopsy
Improved 45 74 in selected cases. The knife and carbon dioxide
Worsened 2 3 laser have been used for this purpose. Although
No change 12 20 both are effective, the knife can result in sig-
*Two patients were lost to follow-up. nificant blood loss as well as potential scarring
of the cervix, vagina, or vulva. The use of the
colposcope with the carbon dioxide laser, on the
other hand, allows procedures to be performed
tients (20%). Two patients have been lost to fol- in a bloodless field. The recent development of
low-up (Table 28.2). sapphire tips for the N d: Y AG laser has allowed
Currently, a multicenter study is underway to laser energy to be used as a cutting tool, mak-
confirm the effectiveness of Nd:YAG laser ing it a potentially effective excisional instru-
photocoagulation in the treatment of early pelvic ment.
endometriosis.

Lesions of the Lower Procedure

Genital Tract Direct Applications of Laser Energy
Nd: YAG laser destruction of lesions of the cer-
Background and Rationale vix, vagina, and vulva can be accomplished by
Changing sexual attitudes have led to a younger placing the laser fiber over the lesion and then
age of first coital exposure and an increase in discharging the laser energy at a power setting
the number of sexual partners. This combination of 20 to 30 W until a white blanching is visible
has resulted in a tremendous increase in sexually 1 to 2 mm beyond the lesion. If intermittent 3-
transmitted diseases. Papilloma virus types 16, second exposures are applied, the depth of pen-
18, and 31 have been implicated in the etiology etration will vary between 3 and 5 mm.
of malignant change in the lower genital tract,
whereas types 6 and 11 have been associated Excisional Procedures with the
with benign lesions. This virus has now been Sapphire Tip
linked directly to cervical, vaginal, and vulvar
intraepithelial neoplasia, as well as condyloma Surgical Laser Technologies (SLT) (1 Great
acuminata in the lower genital tract. If not erad- Valley Parkway, Malvern, PA 19355) has re-
icated prior to invasion of the basement mem- cently developed a sapphire tip for use with the
branes, these premalignant lesions have the po- Nd:Y AG laser, which concentrates the laser
tential of progressing to malignant disease. Thus, energy into a small spot size and allows the laser
a conservative treatment modality is needed to to be used as a cutting modality rather than a
eradicate these premalignant genital tract neo- coagulating one. Excisional procedures involv-
plasms. ing condyloma acuminata and vaginal, cervical,
Local excision, cryosurgery, cautery, and or vulvar neoplasia can be performed with the
carbon dioxide laser vaporization have all been sapphire tip attached to the laser fiber in a man-
used successfully in treating cervical, vaginal, ner similar to cold-knife excisions and excisions
and vulvar intraepithelial neoplasia. The with the carbon dioxide laser. Since the sap-
N d: YAG laser has been used in the treatment phire-tipped Nd:YAG laser is more hemostatic
of this disease process as well, but, as yet, re- than the carbon dioxide laser, it might have po-
sults have not been as promising as those ob- tential benefits in excisional procedures of the
tained with the carbon dioxide laser. cervix (Figure 28.4). Comparison studies be-
Colposcopic evaluation of the lower genital tween the carbon dioxide and Nd:YAG lasers
tract with selected biopsy of abnormal areas will for this purpose are currently in progress.
206 Jack M. Lomano

FIGURE 28.4. Nd:YAG

laser cervical excision with
sapphire tip.

Complications with Procedures Using Intrauterine Excisional

Direct Application of Laser Energy Procedures
Because excisional procedures with the sapphire
tip are just now under investigation , complica- Background and Rationale
tions are as yet undetermined. Complications Removal of uterine septa, submucous fibroids ,
that have been reported involve procedures us- and endometrial polyps and lysis of intrauterine
ing direct application of laser energy. Specifi- adhesions can all be accomplished with laser
cally, as in cryosurgery, surgical excision, and hysteroscopy. The carbon dioxide laser must be
cautery, the N d: Y AG laser does not allow for used in a gas-distending media because it rapidly
good control of the depth of penetration. In ad- absorbs liquid materials. When used with inci-
dition, the energy from the Nd:YAG often scat- sional techniques, however, gas media has the
ters well below the epidermis, causing damage potential to create a gas embolus . Fiberoptic
that requires a longer period of tissue healing. lasers (Nd:YAG, argon , KTP twin crystals) , on
The carbon dioxide laser, on the other hand, the other hand, are used in a fluid-distending
because of its vaporizing characteristic, allows media, thus eliminating the possibility of this
precise removal of these lesions to a depth risk.
measurable with microsurgical calibers. Until
newer techniques are developed, therefore, the
carbon dioxide will likely remain the procedure
Procedure
of choice in these cases. Destruction of con- Excisional procedures with laser hysteroscopy
dyloma acuminata in the lower genital tract can offer very few advantages over those techniques
be accomplished with the Nd :YAG laser, but that have been described using sharp dissection.
once again, it is not possible to achieve a precise The bare fiber or the sapphire tip of the Nd: Y AG
depth of destruction . Since the papilloma virus laser is placed directly against the lesion. If the
is located only in the epidermis, it is prudent for bare fiber is used, very high temperatures can
the operator to destroy only the epidermis and result in the destruction of the fiber tip. To pre-
to leave the dermal layers of the skin undam- vent this, the fiber must be repolished several
aged. Thus, the carbon dioxide laser still remains times during the procedure. When the sapphire
the ideal laser for this procedure. tip is used, however, Nd: Y AG laser excisional
28. Nd:YAG Laser Applications in Gynecology 207

techniques offer the distinct advantage of precise 9. Cattell RB, Swinton NW: Endometriosis with
tissue removal with a minimum of damage to reference to conservative treatment. N Engl J
surrounding normal uterine structures. In ad- Med 214:341, 1936.
dition, these procedures can be accomplished 10. Naples JD, Batt RE, Sadigh H: Spontaneous
with less bleeding and less risk of perforating abortion n rate in patients with endometriosis.
the uterus than techniques using scissors or Obstet Gynecol 57:409, 1981.
1l. Seibel MM, Berger MJ, Weinstein F, et al: The
electrocautery. The fluid-distending media al-
effectiveness of danazol on subsequent fertility in
lows the laser tip to cool and permits irrigation minimal endometriosis. Fertil Steril (Supp!)
of debris to facilitate visualization during the 37:310, 1982.
hysteroscopic excisional procedure. 12. Dmowski WP, Cohen MR: Treatment of endom-
Fiberoptic lasers used in combination with the etriosis with an antigonadotropin, danazol: A la-
focusing sapphire crystal must be limited to less paroscopic and histologic evaluation. Obstet Gy-
than 20 W to avoid fracture of the crystalloid necoI46:147, 1975.
material. After the tissue is excised, the resultant 13. Dmowski WP, Cohen MR: Antigonadotropin
debris is removed with a grasping forceps (danazol) in the treatment of endometriosis.
through the operating channel of the hystero- Evaluation of post-treatment fertility and three-
year follow-up data. Am J Obstet Gynecol 130:41,
scope.
1978.
14. Biberoglu KO, Behrman SJ: Dosage aspects of
References danazol therapy in endometriosis: Short-term and
long-term effectiveness. Am J Obstet Gynecol
1. Asherman JG: Amenorrhoea traumatica (atretica). 139:645, 1981.
J Obstet Gynaecol Br Emp 55:23, 1948. 15. Festy JR: CO 2 laser neurectomy for dysmenor-
2. Droegemuller W, Greer B, David JR: Cryo- rhea. Laser Surg Med 3:27, 1984.
coagUlation of the endometrium at the uterine 16. Martin DC: CO 2 laser laparoscopy for the treat-
cornua. Am J Obstet Gynecol 131: 1, 1978. ment of endometriosis associated with infertility.
3. Droegemuller W, Greer B, Makowski E: Cry- J Reprod Med 30:409-412, 1985.
osurgery in patients with dysfunctional uterine 17. Daniell JF, Pittaway DE: Use of the CO 2 laser in
bleeding. Obstet Gynecol 38: 156, 1971. laparoscopic laser surgery: Initial experience with
4. Goldrath MH, Fuller TA, Segal S: Laser photo- the second puncture technique. Infertility 5: 15,
vaporization of endometrium for the treatment of 1982.
menorrhagia. Am J Obstet Gynecol140: 14, 1981. 18. Kelly RW, Roberts DK: CO 2 laser laparoscopy:
5. Lomano JM: Photocoagulation of the endome- A potential alternative to danazol in the treatment
trium with the Nd:Y AG laser for the treatment of stage I and II endometriosis. J Reprod Med
of menorrhagia: A report of ten cases. J Reprod 28:638-640, 1983.
Med 31:148-150, 1986. 19. Keye WR, Matson GA, Dixon J: The use of the
6. Lomano JM: Ablation of the endometrium with argon laser in the treatment of experimental en-
the N d: YAG laser: A multicenter study. Colposc dometriosis. Fertil Steril 39:26-29, 1983.
Gynecol Laser Surg Vol. 2, Number 4, 1986 pp. 20. Daniell JF: Initial evaluation of the use of the KTP
203-207. twin crystal laser in gynecologic laparoscopy.
7. Loeffer F: Personal communication, May 30, Fertil Steril Vol 46, Issue (3):373-7, September,
1986, Phoenix, AZ. 1986.
8. Kistner RW: Endometriosis. In Sciarra 11, McElin 2l. Lomano JM: Photocoagulation of early pelvic
TW (eds): Gynecology and Obstetrics, Vol. I. endometriosis with the Nd: YAG laser through the
Harper & Row, Hagerstown, MD, 1977. laparoscope. J Reprod Med 30:77-81, 1985.
29
Clinical Application of the Nd:YAG Laser
in Dermatology and Plastic Surgery
K. Arai and T. Sato

Ever since Maiman developed the ruby laser Instrument and Accessories
in 1960, a series of newer laser devices have
been developed and put to practical use, The Nd:YAG laser device we used was the Mo-
having shown great advances in a variety of lectron Model 8000. For incision, vaporization,
fields. and coagulation, we used various SLT contact
At present, four lasers-ruby, argon, CO 2 and laser scalpels and SLT contact laser probes
Nd:YAG-are used for therapeutic purposes in (Surgical Laser Technologies Co., Tokyo and
our field. As each of these lasers has distinctive Malvern PA). There are many different types of
features, frequently they are used for different SLT contact laser probes, but we used mainly
and limited purposes. The Nd:YAG laser de- the SLT contact coagulation probe and SLT
scribed in this chapter has more potential coa- contact vaporization probe for dermatology and
gulability than the CO 2 laser and exerts a better plastic surgery.
hemostatic effect, while its ability for incision
and vaporization is inferior to that of the CO 2
laser. Further, the Nd:YAG laser shows selec- Functions of the Nd:YAG Laser
tivity to some extent depending on the color of Required in the Fields of
the object to which it is applied. Thus, the con-
trol of all functions by this device is somewhat Dermatology and Plastic Surgery
difficult. Because of this setback, its usage had
been greatly limited in the fields of plastic sur-
N oncontact Procedure
gery and dermatology where precision and ac- The coagulability properties of the Nd: Y AG
curacy are important considerations. l However, laser are used in noncontact procedures for the
during recent years a surgical probe made of a removal of pigmented nevus, verruca, neurofi-
new ceramic has been developed for use with broma, cavernous angioma, pachydermatocele
the N d: Y AG laser, which permits more ac- in Recklinghausen's disease, and malignant skin
curate incisions and tissue vaporization, in addi- tumors. For the spherical bulging pigmented
tion to its hemostatic ability through coagula- nevus and verruca of 7 to 8 mm in diameter, the
tion. 2-4 tip of the fiber is held 1 to 1.5 cm away from
The principal surgical procedures required in the lesion and irradiated for 1 second at 40 W.
the fields of plastic surgery and dermatology are The carbonized coagulated layer induced on the
incision, vaporization, hemostasis, and suture. skin surface is then removed with a sharp needle
With the exception of suture, favorable results or a surgical scalpel. This process is repeated
can now be obtained with the Nd:YAG laser in until the protrusion is removed. For neurofi-
all these procedures. bromas, continuous irradiation at about 60 W is
The following describes our clinical experi- used to achieve coagulative necrosis without
ence in the use of the Nd:YAG laser. charring. The lesion is then removed with a
29. Nd:YAG Laser in Dermatology and Plastic Surgery 209

scalpel and the site sutured. For cavernous an- mm operating at 7 to 8 Wand moved at the same
giomas, we use the Nd:YAG laser for protu- speed as the conventional scalpel, produced the
berant lesions limited to the lip, tongue, fundus best incision. Therefore, in the fields of der-
of oral cavity, buccal mucosa, and skin surface. matology and plastic surgery, where aesthetic
For these lesions, we begin by first holding the features are important considerations, irradia-
tip of the fiber a distance away from the lesion tion is conducted under the above conditions.
and begin irradiation at about 60 W continuously This procedure was used in clinical cases of
and then bring the tip of the fiber closer to the pigmented nevus, atheroma, neurofibroma, and
surface of the lesion while carefully watching onychocryptosis (ingrown nail). Incisions must
the surface condition. As soon as a slight change be made very carefully in order to terminate ir-
in the surface is observed, the tip is brought radiation immediately on discontinuation of the
slightly closer to the lesion and held there for incision. Otherwise, coagulative degeneration
using continued irradiation to obtain a satisfac- progresses, resulting in ugly scars.
tory coagulative necrosis. For cavernous an- As for bleeding during the incision, there is
gioma, charring or cracking of the lesion can practically no bleeding in an incision of this
frequently result in profuse bleeding. Therefore, depth. The small hemorrhage that may occa-
caution is necessary in the use of the Nd:YAG sionally occur can be readily stopped by light
laser for the removal of cavernous angioma and touches with the laser scalpel.
avoid charring. Following adequate coagulation In the case of removal of tissues such as tu-
a surgical scalpel or CO 2 laser is used to remove mors, an incision is made around the lesion. The
the coagulated tissue either entirely or as much tissue is lifted and the base is divided with the
as possible in those lesions on the skin surface laser scalpel. If the removed tissue is of a rel-
or on the lip where the external appearance is atively large size that does not allow suturing,
important, and the site is then closed with su- the skin around the lesion is released to allow
tures. Extensive lesions within the oral cavity the skin to be brought together.
are removed and sutured, but smaller lesions are
left open. For the larger pachydermatocele of Vaporization
Recklinghausen's disease, a higher power out- In the fields of dermatology and plastic surgery,
put, around 70 to 80 W, is used. The same small tumors are the major indication for treat-
method as described above induces coagulative ment with contact vaporization. The most im-
necrosis without charring, which is then vapor- portant point is to remove tumor tissue with a
ized entirely or the major portion removed with minimum damage to normal tissue. Based on the
the CO 2 laser. However, if sinusoid large-di- results obtained in animal experiments, the SLT
ameter blood vessels are present in the pachy- Laser scalpel with a 0.2 mm tip diameter op-
dermatocele, it would be extremely difficult to erating at about 5 W is best for vaporization.
control bleeding in this manner. For malignant It is important to maintain careful observation
skin tumors, if not too large, coagulative necro- over the site of irradiation so that the laser beam
sis is induced at the site, including the peripheral does not extend outside the operating area.
area, by irradiation at about 60 W, followed by Furthermore, when the laser scalpel is held away
vaporization with the CO 2 laser. This step is re- from the target tissue, and not being used for
peated until the lesion is removed to the desired surgery the laser should be turned off immedi-
depth. In addition tissues around and beneath ately. This is necessary to perform accurate va-
the tumor are also removed to ensure that no porization and prevent damage to the scalpel.
tumor cells remain. In experiments we found that a laser scalpel of
0.2 mm tip diameter can be damaged within 5
Contact Procedure seconds if irradiated in the air at a power output
of8 W.
Incision
Hemostasis
SLT Contact laser scalpels of various diameters
were tested in animal experiments. It was found The Nd:YAG laser provides excellent hemosta-
that the scalpel with distal probe diameter of 0.2 sis by its powerful protein coagulation effect.
210 K. Arai and T. Sato

Because aesthetic considerations are important, onds. For coagUlation of exposed arteries or
the Nd: Y AG laser has not been used frequently veins, the animal experiment showed that ef-
despite such excellent hemostatic effects, be- fective coagulation with the laser could be
cause of its widespread tissue damage when used achieved in arteries of up to 1.5 mm in diameter
in a noncontact manner. Furthermore it may be and veins of up to 2 mm in diameter. The con-
difficult to induce hemostasis once hemorrhage ditions for laser irradiation were the same as
occurs. Considering these drawbacks, we prefer those used for the hemostasis of actively bleed-
the SLT contact laser scalpel. With this scalpel, ing vessels. The important consideration here is
and a 0.2 to 0.4 mm tip diameter operating at to induce coagulatory degeneration of the target
about 5 W, a gentle touch with the probe can vessel with the probe operating at a suitable
produce adequate hemostasis. However, when output and duration. If charring or cracking re-
bleeding is serious, hemostasis with this pro- sults from excessive output, hemorrhage may
cedure is impossible. Thus we investigated var- be aggravated.
ious hemostatic procedures for such bleeding.
It seemed best to use quartz or sapphire to
sandwich or compress the bleeding site (reported Clinical Cases
at the 123rd Tokyo Regional Assembly of the
Japanese Academy of Plastic Surgery). We fre- The following clinical cases illustrate some of
quently use the coagulation probe (Surgical these points.
Laser Technologies) with favorable results. This
probe is available on the market for endoscopic
use.
Case No.1
To produce hemostasis, the oozing blood is Figure 29.1 shows an 18-year-old female with
cleared with a piece of gauze to determine the an extensive cavernous angioma on the tongue.
site of bleeding. The site is compressed with the Following the noncontact procedure previously
coagulation probe and irradiated with the laser described and using a power output of 60 W,
beam. There are currently two sizes of probes: coagulative necrosis was induced (arrow). The
2.2 and 1.8 mm in diameter. Irradiation should site was necrosed without charring. In cases
be at 8 to 10 W for a duration of 0.3 to 0.5 sec- such as this one, care must be taken to avoid

FIGURE 29.1. Case No.1. (Left) Eighteen-year-old female with cavernous angioma on the tongue. (RiRht) Laser
irradiation was performed at apower output of 60 W to induce coagulatory degeneration (arrow).
29. Nd:YAG Laser in Dermatology and Plastic Surgery 211

charring, as it will result in cracking and can

produce profuse bleeding.

Case No.2
Figure 29.2 shows an 18-year-old female with
cavernous angioma on the right side of the lower
lip. By using noncontact continuous irradiation
at 60 W, coagulative necrosis was induced,
which was then removed with a conventional
scalpel. Because of sufficient coagulation of the
angioma, bleeding was minor, and the entire
procedure took only about 30 minutes.

Case No.3
Figure 29.3, top shows the ingrown nail of the
right first digit of a 32-year-old male, with gran-
ulation tissue with infection. One fourth of the
ingrown nail was removed first, followed by re-

FIGURE 29.3. Case No.3. (Top) Thirty-two-year-old

male patient with ingrown nail on the right first digit.
(Bottom) Condition I month postoperatively.

moval of the nail bed and root with the contact

laser scalpel of 0.2 mm in tip diameter operating
at 8 W . Particularly for the root of the nail, the
laser scalpel with the power output reduced to
5 W was used for thorough vaporization to en-
sure complete removal of the root. If the con-
ventional scalpel is used for this procedure, a
considerable amount of bleeding would have
occurred postoperatively and soaked the band-
age; however, such is not be seen when the laser
scalpel was used. The postoperative course was
uneventful. Figure 29.3, bottom shows the op-
erative site I month postoperatively.

Case No.4
FIGURE 29.2. Case No.2. (Top) Eighteen-year-old fe-
Figure 29.4, top shows a 35-year-old male pa-
male patient with cavernous angioma on the lower tient with two protruding pigmented naevi,
lip. (Bottom) Coagulatory degeneration was induced which were vaporized with the contact laser
with the laser operating at 60 W, followed by remov- scalpel and a probe 0.2 mm in diameter operating
al of the lesion with a conventional scalpel and closing at 8 W; Figure 29.4, bottom was taken 4 months
with suture. This was taken I year postoperatively. postoperatively.
212 K. Arai and T. Sato

angioma, or as a method to stop hemorrhage.

The reason for such limited applications of the
Nd: YAG laser was the lack of its ability to make
incisions. With the recent development of a va-
riety of SLT contact laser probes and SLT laser
scalpels, the Nd: YAG laser now performs many
functions necessary and important to the fields
of dermatology and plastic surgery. These in-
clude ability to make incisions, vaporization,
coagulation, and hemostasis, thus greatly wid-
ening the scope for application of the Nd: YAG
laser. Unlike the supplementary role it played
previously, it is now beginning to playa major
role in surgery.
At present, only a single probe can be fitted
to the Nd: Y AG laser at one time. This may re-
quire frequent changing of the holder and probe
according to the purpose for which it is used.
This is cumbersome, involving a waste of time
and effort. In view of the above, we are devel-
oping a Nd:YAG laser device that allows si-
multaneous use of multiple fibers that can meet
different requirements during an operative pro-
cedure. With a multichannel fiber system, it is
hoped that incision, vaporization, coagulation,
FIGURE 29.4. Case No.4. (Top) Thirty-five-year-old and hemostasis can be performed quickly, as the
male patient with 2 bUlging pigmented nevi on the need arises, permitting laser surgery with the
upper lip; 20 months before surgery. (Bottom) Va- Nd:YAG laser as a principal instrument.
porization was performed with a contact laser scalpel
of 0.2 mm tip diameter; 5 months after surgery.
References
I. Arai K, Waseda T, Ota H, et al: A preliminary
study on clinical application of Nd:YAG laser to
Past, Present, and Prospects of the face and head. Lasers Surg Med 3:231-239,
1983.
the Nd:YAG Laser in the Fields 2. Washida H, Tsugaya M, Hirao N, Hachisuka Y:
of Dermatology and Plastic Experience using the laser rod in urological sur-
gery. Acta Urol Jpn, 30(7):891-896, 1984.
Surgery 3. Daikuzono N , Joffe SN: Artificial sapphire probe
for contact photocoagulation and tissue vapori-
When the Nd:YAG laser characterized by ex- zation with the N d: Y AG laser. Med Instrum
cellent coagulating capability was first used 19(4): 173-178, 1985.
clinically, its application in this field was ex- 4. Arai K, Sato T, Ito Y: On clinical application of
tremely limited and it was utilized only for the surgical rod adapted YAG laser for benign tumor.
removal of malignant skin tumors and cavernous J Jpn Soc Laser Med 6:505-508, 1986.
30
Study of the Benefits of the N d: YAG
Laser in Plastic Surgery
David B. Apfelberg and Teruko Smith

Lasers of various wavelengths have found in- spectrum. This laser light is relatively unaffected
creasing acceptance by plastic surgeons in the by water, as is the CO 2 laser, or hemoglobin, as
treatment of a wide variety of cutaneous and is the argon laser, and can produce tissue re-
subcutaneous lesions. The CO 2 laser has been actions to depths of 5-7 mm into the dermis.
used the longest because of its versatility in When Nd: YAG laser light encounters tissue, the
providing hemostatic incision, photovaporiza- result is a combination of backscatter (reflec-
tion, photocoagulation, and photoablation. \-4 tion), forward scatter, and absorption. The
This laser is widely accepted for excision of scattering effect around the incident laser beam
vascular tumors, vaporization of viral diseases within the tissue heats up a large volume and
such as warts, removal of tattoos, and the like. causes tissue coagulation and necrosis over a
The argon laser provides photocoagulation of large volume of tissue without its removal. Tis-
superficial vascular lesions due to the selective sue vaporization can be achieved by further heat
affinity of hemoglobin to the blue-green light. generation of the coagulated and desiccated tis-
Multiple lesions such as port-wine hemangio- sue with high-energy density over time. The
mas, capillary/cavernous hemangiomas, telan- Nd:YAG laser used in this study can produce
giectasia, and the like are amenable to argon outputs of 0.5-95 W, which may be transmitted
laser exposure. 5- 9 through a fiberoptic handpiece to a specially de-
There exists the need to photoablate certain signed dermal probe. The handpiece is held per-
cutaneous lesions deeper than either the CO 2 or pendicular to the treatment area with a focal
argon laser can achieve. In addition to pho- length of 3-4 em and a 1-mm spot size. Contin-
toablation, precise, hemostatic incision with uous or pulsed beams could be utilized.
sapphire focusing lens and scalpels has largely
supplanted other lasers for surgical incision. Al-
though scattered reports have appeared on the Sapphire Contact Tips and Scalpels
use of the N d: YAG laser in plastic surgery, no Recently, the usefulness of the Nd: Y AG laser
detailed longitudinal report exists to describe the has been dramatically extended by the use of
photocoagulation and photoablation capabilities ingenious peripheral devices based on synthetic
of this laser. This chapter describes the results sapphire technology. Due to the geometry and
of the treatment of multiple categories of cu- optic design of the synthetic sapphire probe, the
taneous lesions in 70 patients by the Molectron laser scalpel combines excellent cutting prop-
8000 Nd:YAG laser. erties with the coagulative ability of the
Nd:YAG laser. Smaller diameter tips provide a
sharp energy concentration for cutting and va-
Materials and Methods porization. Larger round or flat diameter tips
give more diffuse energy distribution for greater
Nd:YAG Laser Physiology hemostatic effect. These products are used with
The Molectron 8000 Nd:YAG laser (Cooper direct tissue contact as opposed to noncontact
LaserSonics) produces continuous wave power with other lasers. They greatly extend the he-
output of 1064 mm in the near-infrared light mostatic incision and vaporization capability of
214 David B. Apfelberg and Teruko Smith

TABLE 30.1. Summary of patients treated for lesions with Nd:YAG laser
Classification No. of patients
Patients 64
Lesions 87
Categories
Capillary/cavernous hemangiomas 13
Epistaxis (Osler-Weber-Rendu) 3
Port-wine hemangioma 8
Keloid/hypertrophic scar 12
Angiokeratoma I
Granuloma faciale 2
Skin cancerlkeratosis 2
Large cavernous hemangioma/lymphangioma 7
Superficial varicosity 16
Male/female 27/37
Average age 36.5 years (range 4 mo.-76 years)

the N d: YAG laser very favorably in relation to age of 36.5 years, ranging from 4 months to 76
standard argon and CO 2 laser usage. (Manufac- years. Of the 37 female patients, 16 were treated
tured by Surgical Laser Technologies, Malvern, by the Nd:YAG laser directly through a sapphire
PA, USA). contact tip (Surgical Laser Technologies) for
superficial varicose veins of the lower extremity.
Of the remaining 48 patients, 12 were treated
Patient Data for keloid/hypertrophic scars, 13 for capillary/
cavernous hemangiomas, 3 for epistaxis sec-
Summary of Patient Group ondary to Osler-Weber-Rendu hereditary hem-
orrhagic telangiectasia, 2 for granuloma faciale,
The treatment group consisted of 64 patients
2 for basal cell cancer/squamous cell cancer/
with 87 different lesions (see Table 30.1). There
keratosis, 1 for angiokeratoma, and 7 for port-
were 27 males and 37 females with an average
wine hemangiomas. Of the 64 patients,; 53 were
treated as outpatients under local anesthesia in
the office, while 11 patients required hospitali-
TABLE 30.2. Keloid/hypertrophic scars zation and general anesthesia. Five heman-
Category Quantity giomas and 2 lymphangiomas in 7 patients were
Patients 12 excised utilizing contact sapphire laser tips/
Lesions 22 scalpels.
Male/female 4/8
Average age 37 years (range 16-76 years)
Location
Chestlbreast 3 Results
Arm 5 .
Ear 2 The results of various treatment groups are
Back/shoulder 2 summarized in Tables 30.2-30.8.
Power density (irradiance) 6400 W/cm 2
Total average joules 2946 W . s
Energy fluence 6.8 J/cm 2 Keloid/Hypertrophic Scars
Immediate shrinkage
Length 5-8% Twelve patients with 22 keloid or hypertrophic
Width 7% scars were treated (Table 30.2). All patients
Height 34%
Time to heal 43 days served as their own controls in that they had
Complications o long-standing keloids (over 2 years) that were
Result resistant to other methods of treatment, such as
Good flat 5/22 (steroid) surgery or steroid instillation. There were 4
Recurrence 14/22 (nonsteroid)
males and 8 females with an average age of 37
Partial recurrence 3/22
years (range 16-76 years). The deltoid upper arm
 30. Nd:YAG Laser in Plastic Surgery 215

'II
FIGURE 30.1. (A) Keloid left deltoid pretreatment. (B)
Escher and necrosis three weeks posttreatment. (C)
Total recurrence after 4 months (no steroid adjunct).
[From Apfelberg DB et al. Preliminary report on use
of the neodymium:Y AG laser in plastic surgery. Las-
ers Surg Med 7:189-198, 1987. Reprinted with per-
mission of Alan R. Liss.J

1A

was the most common area of treatment (5 pa-

tients), followed by the chestlbreast in 3 patients
and the back/shoulder or ear in 2 patients each.
Mter treatment, immediate shrinkage was noted
of 5-8% in length, 7% in width, and 34% in
height, and the wounds averaged 43 days to
healing. Early in the series, patients were treated
with the Nd:YAG laser alone. Although the
treatment resulted in marked shrinkage of the
keloid, all keloids promptly recurred within the
subsequent 3-4 months (Figure 30.1). Later in
the series, the treatment areas were injected with
intralesional steroid (Celestone Soluspan 1-3 cc)
just before or immediately after epithelialization
(average 4-6 weeks) and also treated with topical
18
steroids (Diprolene 0.25%). This resulted in
somewhat improved results (Figure 30.2). Of
these 22 lesions , 5 showed good results with
persistent flattening, 3 suffered minor recur-
rence, and 14 recurred to their original diameter
or larger. There were no complications. Treat-
ment of earlobe keloids in 2 black female pa-
tients was moderately successful at first but
partial recurrence was seen with longer follow-
up.

Capillary/Cavernous Hemangiomas
Thirteen patients with 15 capillary/cavernous
hemangiomas were treated by photocoagulation
1C (Table 30.3). There were 2 males and 11 females,
 216 David B. Apfelberg and Teruko Smith

2A 28

2C
2D

FIGURE 30.2. (A) Keloid left scapula/shoulder mea- much flatter, 2Y2 cm wide, 3 cm long, only 5mm high,
suring 3 cm wide, 4 cm long, and 2 cm high. (B) Im- no recurrence. [From Apfelberg DB et al. Preliminary
mediately posttreatment and beginning eschar (50 W, report on use of the neodymium: YAG laser in plastic
0.5-second pulse, 3394 W·s) . (C) Intermediate stage surgery. Lasers Surg Med 7:189-198,1987. Reprinted
at 5 weeks with flat granulating area (time of steroid with permission of Alan R. Liss.]
injection). (D) Final result at 7 months-keloid is
30. Nd:YAG Laser in Plastic Surgery 217

average age of 16.6 years (range 2-45 years). TABLE 30.3. Capillary/cavernous hemangioma
Immediate shrinkage was noted to be 5-10% in Category Quantity
length, 5% in width, and 32% in height, and
Patients 13
healing averaged 19 days. Two patients' healing Lesions 15
was complicated by minor wound infections Male/female 2/11
rapidly responding to topical and systemic an- Average age 16.6 years (range 2-45 years)
tibiotics. Treatment in 9 of 13 lesions resulted Location
Oral 8
in complete disappearance and flattening, while Forehead 1
2 lesions (both capillary/cavernous hemangiom- Chin 1
as of infancy) showed no significant response Scalp 2
(Figures 30.3 and 30.4). Recently, the adjunct Leg
of intralesional steroid injection simultaneous Power density (irradiance) 3584 W/cm 2
Total average joules 2100 W . s
with Nd:Y AG laser photocoagulation has Energy fluence 3.9 J/cm"
achieved a significant improvement in results Immediate shrinkage
(Figure 30.5). A further technical assistive Length 5-10%
maneuver is the compression of the heman- Width 5%
gioma to a depth of 1 cm by pressure from a Height 32%
Time to heal 19 days
glass slide with application of the laser light Complications:·lnfection 2
through the glass. These adjuncts have marked- Result
ly improved the results in capillary hemangio- Complete disappearance 9113
mas of infancy. No significant change 2113
Progressive shrinkage 2113

Sapphire Contact Scalpel Excision

Five hemangiomas and 2 lymphangiomas in 7
patients were excised under anesthesia as in- Epistaxis
patients (Table 30.4). These hemangiomas were
Three patients (1 male, 2 females, average age
judged to be massive in size, frequently neces-
52 years) with severe recurrent epistaxis sec-
sitating blood replacement. These vascular le-
ondary to Osler-Weber-Rendu hereditary hem-
sions required a hemostatic incision provided by
orrhagic telangiectasia were treated five times
the sapphire contact tips/scalpels and were
with the Nd:YAG laser (Table 30.5). Mucosa
either recurrent from traditional methods of
healed in 15 days, and all patients reported a
surgery or had been rejected for surgery because
marked diminution in nasal bleeding (infrequent
of fear of exsanguinating hemorrhage. There
bleeds lasting only a short time and easy to stop)
were 3 males and 4 females with average age of
for the first 4 to 5 months. At six months, the
7 years (range 4 months to 24 years). Complete
process returned to the original bleeding history,
resection was achieved in all but 1 patient, with
and repeat laser treatment became necessary.
blood loss averaging 200 to 400 cc (Figure 30.6).
One patient who was treated with great difficulty
One patient required transfusion. Resection of
because of intraoperative bleeding suffered the
these lesions was significantly enhanced over
complication of septal perforation following her
traditional surgical modalities and in some cases
second treatment.
made possible when traditional surgery had been
either previously unsuccessful or judged to be
incapable of resection without excess hemor- Miscellaneous Lesions
rhage. One patient was unresectable by sap-
Granuloma Faciale
phire contact scalpel techniques due to a heman-
gioma that extended from the skin of the cheek Two patients with granuloma faciale of the nose
all the way through into the oral mucosa. The and cheeks (3 lesions, 1 male, 1 female, average
resection of this lesion would have involved age 64 years, healing time 44 days) were treated
the removal of all structures in the entire right with good results in 2 lesions and hypertrophic
hemiface. scarring in 1 lesion (Table 30.6).
 218 David B. Apfelberg and Teruko Smith

38

FIGURE 30.3. (A) Pretreatment cavernous hemangioma right buccal

mucosa. (B) Final healing with total disappearance of hemangioma
3A and excellent healing of oral mucosa.

FIGURE 30.4. (A) Capillary/cavernous hemangioma of forehead

in 18-month-old infant. (B) Result 6 months after laser treatment ,
demonstrating minimal involultion and shrinkage (19-30 W, 0.5-
4A second pulse, 3643 W·s). [From Apfelberg DB et al. Preliminary
report on use of the neodymium:YAG laser in plastic surgery.
Lasers Surg Med 7:189-198,1987. Reprinted with permission of
Alan R. Liss.]
 30. Nd:YAG Laser in Plastic Surgery 219

5A 58

FIGURE 30.5. (A) Large capillary/cavernous heman- photocoagulation plus steroid injection (Celestone
gioma of scalp prior to treatment. (B) Marked dimi- Soluspan 3 cc).
nution in size of hemangioma following Y AG laser

TABLE 30.4. Sapphire scalpel excision

Category Quantity
Patients 7
Lesions
Large cavernous hemangioma 5
Lymphangioma 2
Male/female 3/4
Average age 7 years (range 7 months-24 years)
Location
Face 5
Extremity 2
Time to heal 7-14 days
Complications: Dehiscence I
Result
Good 6
Unable to resect
220 David B. Apfelberg and Teruko Smith

6A 68
FIGURE 30.6. (A) Large capillary/cavernous hemangioma of eyelid and eyebrow obstructing vision. (B) Results
after excision with Nd:Y AG laser and sapphire scalpel accomplished with 50 cc blood loss.

Skin Cancer arms, or back completely disappeared without

persistence or recurrence by clinical observation
Two male patients with 7 basal cell or squamous and random biopsy (Figure 30.7), and 1 scalp
cell carcinomas or atypical keratosis (average lesion resulted in a full-thickness skin loss ex-
age 62 years, healing time 41 days) were treated posing skull bone which necessitated flap clo-
(Table 30.7). Six malignant lesions of the trunk, sure (Figure 30.8).

TABLE 30.5. Epistaxis (Osler-Weber-Rendu)

Category Quantity
Patients 3
Lesions 5
Male/female 112
Average age 52 years (range 43-66 years)
Location: bilateral septum 3
Power density (irradiance) 2688 W/cm'
Total average joules 4320 W . s
Energy fluence Unable to calculate
Immediate shrinkage N.A.
Time to heal 15 days
Complications: Septal perforation I
Result
Minor bleeding 4-5 months
Recurrence at 6 months
30. Nd: YAG Laser in Plastic Surgery 221

TABLE 30.6. Granuloma faciale

Category Quantity
Patients 2
Lesions 3
Male/female III
Average age 64 years (range 62-67 years)
Location
Nose
Cheek 2
Power density (irradiance) 2304 W/cm'
Total average joules 1300 W· s
Energy fluence 6.1 llcm'
Immediate shrinkage none
Time to heal 44 days
Complications: Hypertrophic scar I
Result
Good 2
Scar I

S upe rficial Hemangiomas rated by 1 to 2 mm. Untreated interspaces are

treated by similar dots when fading of the orig-
One patient (female, age 14 years) with angio- inal set is obvious (usually averages 12 weeks).
keratoma of the ankle and 7 patients (3 male, 4 Although fading is slower and slightly variegated
female, average age 50 years) with port-wine in appearance, scarring has been minimal (Fig-
hemangiomas previously managed with the ar- ure 30.9).
gon laser were treated (Table 30.8). The areas
healed in an average of 27 days. The angio-
Superficial Varicosities of the Lower
keratoma involuted well. Port-wine hemangiomas
Extremity
undergo full-thickness injury and subsequent
healing by secondary intention and scarring un- Sixteen patients with superficial telangiectasia
less the treatment is broken up by "polka dot" of the lower extremity above the knee were
or segmented treatment. In this method, 1- to treated as outpatients with only ice as anes-
2-mm dots of laser photocoagulation are sepa- thesia. Power of 0.5-0.8 W transmitted through

TABLE 30.7. Skin cancer keratosis

Category Quantity
Patients 2
Lesions 7
Male 2
Average age 62 years (range 49-84 years)
Location
Scalp I
Trunk and arms 6
Power density (irradiance) 3712 W/cm 2
Total average joules 870 W . s
Energy fluence 9.87 J/cm 2
Immediate shrinkage 90%
Time to heal 41 days
Complications: Full-thickness loss I
Result
Complete disappearance 6
Full-thickness loss
 222 David B. Apfelberg and Teruko Smith

7A 7B

FIGURE .30.7. (A) Basal cell carci-

noma of back/scapula. (B) Coagu-
lation necrosis evident 2 weeks af-
ter treatment (30 W, 0.2-second
pulse, 670 W·s). (C) Final healing
at 6 months demonstrating satis-
factory cosmetic result and no re-
currence by biopsy. [From Apfel-
berg DB et al. Preliminary ·report
on use of the neodymium:Y AG
laser in plastic surgery. Lasers Surg
Med 7:189-198, 1987. Reprinted
c with permission of Alan R. Liss.]

a flat 15-mm vaporizing probe diffusing contact Discussion

sapphire tip (Surgical Laser Technologies, Mal-
vern, PA) was applied to produce blanching. All
16 patients were females between the ages of 27
Previous Reports
and 58 (average age 43 years). Patients were The Nd:YAG laser has been reported previously
evaluated every month until 12 months had for treatment of cutaneous lesions . Landthaler
elapsed. Only two patients demonstrated an ex- et al. 10 reported its use in the treatment of skin
cellent result (complete disappearance of vessels tumors such as nodular basal cell carcinomas,
without scar or pigmentary changes). Eight pa- superficial basal cell carcinomas, Bowen's dis-
tients achieved a good result (blanching of the ease, keratoses, and melanoma. Port wine he-
majority of the vessels) and the remaining 6 pa- mangiomas were treated, but significant scarring
tients achieved only fair or poor results. No was noted, and healing was prolonged to ap-
complications were observed in this group of proximately 12 weeks. They concluded that only
patients. the most hypertrophic port wine hemangiomas
30. Nd:YAG Laser in Plastic Surgery 223

8A

88
FIGURE 30.8. (A) Pretreatment dysplastic lesion of DB et al. Preliminary report on use of the neodymium:
scalp. (B) Eschar produced 3 weeks after treatment YAG laser in plastic surgery. Lasers Surg Med 7: 189-
(30 W, 0.5-second pulse , 2923 W·s). [From Apfelberg 198, 1987. Reprinted with permission of Alan R. Liss.]

were applicable for treatment. A later report by mm into the dermis. The same authors l2 dem-
the same authors (Landthaler et al. II) has dem- onstrated coagulation up to 5 mm in the dermis
onstrated the Nd:YAG laser's effectiveness only and that regions of the body with thin skin must
in the most thick nodular port-wine heman- be treated only with caution while safer appli-
giomas, deep capillary hemangiomas, and ma- cation of the Nd:YAG laser occurs in thicker
crocheilia of the lip secondary to hemangioma. skin. This correlates with our study and the
These authors also conducted in-vivo and in- complications encountered. The keratosis of the
vitro exposure experiments in human skin and scalp which was treated resulted in full thickness
concluded that coagulation necrosis in a hemi- loss and exposure of the skull bone, and the port
spheric pattern can be produced as deep as 3.2 wine hemangioma previously treated by argon
224 David B. Apfelberg and Teruko Smith

Be
FIGURE 30.8 (C) Full-thickness loss exposing skull bone which necessitated flap coverage (note CO" laser
drill holes which failed to produce granulation).

laser which thinned the overlying epidermis also 1. The Nd:YAG laser is ideally suited for treat-
resulted in full thickness loss and scar. Nasal ment of thick, deep capillary/cavernous he-
septal mucosa which is very thin may be per- mangiomas, especially around the oral cavity
forated by prolonged bilateral exposure. of adults and produces excellent results with-
out complications.
2. In infants with capillary/cavernous heman-
Nd:YAG Laser Physiology giomas of infancy, no appreciable benefit
Wound healing experiments in relation to the could be obtained by laser alone, but signif-
role of fibroblasts in hypertrophic and keloid icant shrinkage occurred with the simulta-
scars have been conducted by Castro and neous injection of steroids.
coworkers 13 and Abergel and coworkers. 14 3. Nd:YAG laser exposure alone cannot control
These authors have demonstrated beneficial ef- keloids or hypertrophic scars but may pro-
fects of N d: Y AG laser exposure of keloids and duce modest benefit when combined with
hypertrophic scars in clinical patients and in fi- posttreatment topical and intralesional steroid
broblasts in tissue culture. Rosenfeldl 5 has re- applications. Recurrence of keloid is seen
ported treatment of a wide variety of vascular, frequently with longer follow-up.
keloid, and miscellaneous superficial lesions 4. Treatment of thin areas of skin such as scalp
with the Nd:Y AG laser. A recent study with or skin previously treated by argon laser for
wide clinical implications is the observation of port-wine hemangioma produces full thick-
Zimmerman et al. 16 on the ability of the Nd: YAG ness skin loss and deep necrosis resulting in
laser to interrupt lymphatic drainage in the uri- scar. Port-wine hemangioma treatment may
nary bladder, thus inhibiting the spread of tumor be safely accomplished by the "dot" method.
cells. 5. Treatment is effective for approximately 4 to
5 months for the nasal septal mucosa to con-
trol epistaxis in patients with Osler-Weber-
Conclusion Rendu hereditary hemorrhagic telangiectasia,
but septal perforation may occur with over-
A wide spectrum of clinical lesions have treated exposure.
under experimental protocol with the Nd:YAG 6. Excisional surgery of major vascular or lym-
laser. The following conclusions are offered. phangiomatous abnormalities has been greatly
30. Nd:YAG Laser in Plastic Surgery 225

9A

98

9C

FIGURE 30.9. (A) Port-wine hemangioma of face pre- segmental treatment. (C) Improvement of contour
viously treated with argon laser demonstrating sub- with blanching of port-wine hemangioma and no
total blanching. (B) Blanching of "polka dots" of scarring.
226 David B. Apfelberg and Teruko Smith

TABLE 30.8. Angiokeratomalport-wine hemangioma TABLE 30.9. Superficial varicosity lower

Category Quantity extremity
Patients 8 Category Quantity
Lesions 8 Patients 16
Male/female 3/5 Average age 43 years (range 27-58 years)
Average age 32 years (range 14-50 years) Location thigh 16
Location Time to heal 7-10 days
Face 7 Complications None
Ankle 1 Result
Power density (irradiance) 2304 W/cm2 Excellent 2
Total average joules 684W·s Good 8
Energy fluence 5.17 J/cm2 Fair/poor 6
Immediate shrinkage Minimal
Time to heal 27 days
Complications: scar 1
Result
Scar 1
Involution and good fading 5
Fair fading 2

enhanced and in some cases rendered pos- 7. Apfelberg DB, Greene RA, Maser MR, et al: Re-
sible by contact sapphire scalpel tips. The sults of argon laser exposure of capillary heman-
hemostatic incision and contact touch ex- giomas of infancy: Preliminary report. Plast Re-
ceeds the CO 2 laser incision. constr Surg 67:188-193, 1981.
7. Treatment of superficial varicosities of the 8. Apfelberg DB, Maser MR, Lash H, Rivers J: The
argon laser for cutaneous lesions. JAMA,
lower extremities with contact tips or diffus-
245:2073-2075, 1981.
ing lenses has been moderately successful. 9. Apfelberg DB, Maser MR, Lash H, Flores J: Ex-
panded role of the argon laser in plastic surgery.
The Nd: YAG laser definitely deserves a place J Dermatol Surg OncoI9:145-151, 1983.
in the clinical armamentarium of the laser sur- 10. Landthaler M, Brunner R, Haina D, et al: First
geon treating cutaneous and subcutaneous le- experiences with the Nd:YAG laser in dermatol-
sions. ogy. In Joffe SN (ed): Neodymium-YAG Lasers
in Medicine and Surgery. Elsevier, New York,
1983, p 176--183.
References 11. Lanthaler M, Haina D, Brunner R, et al: Neo-
dymium-YAG laser therapy for vascular lesions.
1. Apfelberg DB, Maser MR, Lash H: Review of J Am Acad Dermatol 14:107-117, 1986.
usage of argon and carbon dioxide lasers for pe- 12. Brunner R, Landthaler M, Haina D, et al: Treat-
diatric hemangiomas. Ann Plast Surg 12:353-361, ment of benign, semimalignant, and malignant
1984. skin tumors with the Nd:YAG laser. Lasers Surg
2. Apfelberg DB, Maser MR, Lash H, White DN: Med 5:105-111, 1985.
Efficacy of the carbon dioxide laser in hand sur- 13. Castro DJ, Abergel RP, Meeker CA, et al: Effects
gery. Ann Plast Surg 13:320-327, 1984. of the Nd:YAG laser on DNA synthesis and col-
3. Apfelberg DB, Rothermel E, Widtfeldt A, et al: lagen production in human skin fibroblast cul-
Preliminary report on the use of carbon dioxide tures. Ann Plast Surg 11:214-222, 1983.
laser in podiatry. JAm Podiat Assoc 74:509-513, 14. Abergel RP, Dwyer R, Meeker C, et al: Laser
1984. treatment of keloids: A clinical trial and an in vitro
4. Apfelberg DB, Lash H, Maser MR, White DN: study with Nd:YAG laser. Lasers Surg Med
Benefits of the CO2 laser for oral hemangioma ex- 4(3):291-295, 1984.
cision. Plast Reconstr Surg 75:46--50, 1985. 15. Rosenfeld H, Sherman R: Treatment of cutaneous
5. Apfelberg DB, Maser MR, Lash H: Treatment of and deep vascular lesions with the N d: YAG laser
nevi aranei by means of an argon laser. J Dermatol surgery. Lasers Surg Med 6:20-24, 1986.
Surg OncoI4:172-174, 1978. 16. Zimmerman I, Stem J, Frank F, et al: Interception
6. Apfelberg DB, et al: Pathophysiology and treat- of lymphatic drainage by N d: YAG laser irradia-
ment of decorative tattoos with reference to argon tion in rat urinary bladder. Lasers Surg Med
laser treatment. Clin Plast Surg 7(3):Chap 9, 1980. 4(2):167-172, 1984.
31
Prevention of Dental Caries and
Treatment of Early Caries Using the
Nd:YAG Laser
Hajime Yamamoto and Teruo Kayano

It is well known that since the first laser made irradiation of an acoustooptically Q-switched
with a ruby crystal was built by Dr. Maiman in Nd:YAG laser with low energy.4. 5. 8
'1960, I the laser has been considered to be a po- The studies considered in this chapter are re-
tential tool in dentistry. The energy of high- lated to the application of the N d: YAG laser on
power lasers can be concentrated in a short the tooth not only for the prevention of primary
pulse. Many of the early studies on laser appli- dental caries and secondary caries associated
cations in dentistry first investigated the pos- with marginal closure of dental restorative ma-
·sibility of replacing conventional dental drills terials, but also for the treatment of incipient
with lasers for restorative techniques in cavity enamel caries by means of Nd:Y AG laser ir-
preparation. 2. 3 However these attempts were radiation.
unsuccessful because of too much damage to the
.tooth, especially to the dental pulp. Current in-
vestigations have turned to caries prevention
and treatment by means of laser irradiation. The Prevention of Dental Caries by
clinical application of lasers to the prevention Nd:YAG Laser Irradiation
and treatment of dental caries requires two im-
portant considerations4: First, minimum energy Dental caries is a disease of the enamel, dentin,
density is necessary to avoid damaging the oral and cementum of the tooth, producing progres-
soft tissue, especially the dental pulp, and, sec- sive demineralization of the calcified component
ond, the laser beam must be easily guided with and eventual destruction of the organic com-
a flexible optical fiber to the restricted area of ponent, with the formation of a cavity in the
the tooth surface of the oral cavity. The ruby tooth. 9 The incipient phase of dental caries be-
laser,2. 3 the carbon dioxide laser, 6 and the gins with subsurface demineralization of the
Pockels cell Q-switched Nd:YAG laser,7 all im- enamel 10 by acids produced by oral microor-
part a degree of alteration that reduces subsur- ganisms, especially some specific strains of
face demineralization to the enamel surface of streptococci. 9 A remarkable acid resistance is
the extracted human tooth. They cannot how- imparted to the enamel by some means, which
ever be guided by a flexible optical fiber because seems to be effective in reducing its suscepti-
of their wavelength in the infrared zone and their bility to acids, and thereby preventing caries. It
high peak power. But an acoustooptically Q- has already been pointed out that when the en-
switched Nd:YAG laser beam can be easily amel surfaces of the extracted teeth were irra-
guided by a single flexible optical fiber without diated by laser beams, a degree of alteration was
transmission lo~s of laser energy. 4. 5 Remarkable imparted to the enamel surface, resulting in re-
acid resistance and reduced acid solubility are duced subsurface demineralization. 2. 6. 7 The
imparted not only to the enamel without caries Nd:YAG laser has been proved to be more ef-
but also to the enamel with incipient caries by fective for clinical application than other kinds
228 Hajime Yamamoto and Teruo Kayano

of lasers 4 In this chapter, the different opera- compared with the unlased enamel. But the en-
tional modes of Nd:YAG laser irradiation will amel treated with the combination of the lo-
be compared to determine their effectiveness in cal application of Ag(NH3)2F on the enamel sur-
the prevention of dental caries. 4 face l5 . 16 and this conditioned Nd: Y AG laser
Dental caries will develop secondarily along irradiation showed a degree of acid resistance.
the margin of the dental restorative materials But the lased enamel after treatment with
where a narrow crevice is present. 9 The width Ag(NH3)2F is discolored in silver and brownish
of this crevice must be responsible for suscep- black, and a brown area remains even after
tibility to the secondary dental caries. One of cleaning the discolored enamel surface with
the most important objectives is to close these pumice powder. Because of this cosmetic dis-
crevices between the margin of the dental res- advantage and the complicated operational
torative materials and the enamel in order to techniques, this method is inapplicable to clinical
prevent the secondary caries from developing. practice. However, some modifications have
In this study, we also investigated the possibility been proposed.1 7 • 18
of secondary caries prevention by means of ACOUSTOOPTICALL Y Q-SWITCHED ND:Y AG
Nd:YAG laser irradiation along the margin of LASER IRRADIATION4. 5: The enamel surfaces of
the dental restorative materials. II the freshly extracted noncarious human per-
manent teeth are cleaned and dried in air, and
Prevention of Primary Enamel Caries the enamel surfaces are coated with Chinese
black ink. Then the enamel surface is exposed
In Vitro Experiments to an acoutooptically Q-switched N d: Y AG las-
Different Modes of Nd:YAG Laser er. The irradiation conditions are as follows; a
Irradiation4 peak power of 100 KW with a pulse width of
100 nanoseconds, repetition rate of 1 KHz, av-
POCKELS CELL Q-SWITCHED ND:YAG LASER erage output of 10 W, spot size of 3.5 mm in
IRRADIATION 7 : The enamel surface coated with diameter, and irradiation time of 0.4, 0.8, and
a laser absorption black material (Chinese black 1.2 s, guided by a step index cylindrical quartz
ink) of the freshly extracted human permanent fiber of 300 J-Lm in diameter. After irradiation,
teeth without caries is irradiated by a Pockels the laser absorption material coated on the en-
cell Q-switched Nd:YAG laser. The irradiation amel surfaces must be removed. The enamel
conditions are as follows: peak power of 3 mil- surfaces exposed to this conditioned N d: Y AG
liwatts, pulse width of 30 nanoseconds, repeti- laser show no gross changes after 4 days in the
tion rate of 10 Hz, and total energy densities of demineralizing solution. 14 but the boundary line
20 J/cm 2 • In contrast to that of the control un- between the lased and the unlased area becomes
lased enamel, the lased enamel shows no ob- visible macroscopically on the dried enamel
vious structural change after being exposed for surfaces and the unlased enamel surfaces clearly
7 days to a demineralizing culture system. 12 Be- appear white due to deminefalization. Micro-
cause of its high peak power, this laser beam radiograms demonstrate the difference in acid
cannot be guided by a conventional optical fiber. resistance of the enamel due to different laser
NORMAL-PULSED ND:YAG LASER IRRADIATION irradiation times (Figure 31.1), and also reveal
WITH OR ~ITHOUT AG(NH3)2F!3: The enamel the best irradiation time for acid resistance of
surface coated with Chinese black ink is exposed the enamel to be about 0.8 second.
to a normal-pulsed Nd:YAG laser beam. The CONTINUOUS WAVE BEAM OF ND:YAG LASER
irradiation conditions are as follows: a repetition IRRADIATION 19: Noncarious enamel surfaces of
rate of 20 Hz, spot size of 2.5 mm, energy den- the freshly extracted teeth are exposed to a
sity of 3.4 J/cm 2 per pulse, and irradiation time continuous wave beam of Nd:YAG laser at the
of 3 minutes. The laser beam can be guided by same irradiation condition as the acoustoopti-
a conventional optical fiber. The enamel reveals cally Q-switched Nd: Y AG laser. A laser ab-
only a mild reduced subsurface demineralization sorption black material must be coated on the
and shows no obvious resistance to acid in a enamel surface before irradiation. Acid resis-
demineralizing solution of 6% hydroxyethyl tance imparted by the continuous wave beam of
cellulose and 0.1 M lactate buffered at pH 4.5 14 Nd: Y AG laser irradiation is less than that im-
31. Caries Prevention and Treatment Using Nd:YAG Laser 229

FIG URE 31.1. Microradiogram of

the enamel exposed to an acous-
tooptically Q-switched Nd: YAG
laser after 5 days of in vitro de-
mineralization. No radiolucency
at the left lased area and the clear
subsurface radiolucency at the
right unlased area.

parted by the acoustooptically Q-switched preexisting micropores disappear (Figure 31.2).

Nd:YAG laser irradiation. These findings will be closely related to the re-
duced acid solubility of the lased enamel due to
Mechanisms of Caries Prevention by the a decrease in permeability of acid into the en-
Acoustooptically Q-switched Nd:YAG Laser amel through the micropores and acid diffusion
Irradiation4. 5. 7 in the enamel. This is supported by the asym-
metric electron spin resonance signal observed
The incipient phase of enamel caries develops
in the lased enamel. 4.5.20 According to the x-ray
as subsurface demineralization. 9 • 10 The acid
diffraction analysis, inorganic products other
solubility of the enamel is thought to be due to
than hydroxyapatite are not formed in the lased
a degree of permeability of the enamel. Scanning
enamel. 4. 5 Furthermore, the absence of signif-
electron microscopy reveals that the lased en-
icant changes in the lattice parameters of the
amel shows a very smooth surface and the
lased enamel crystals suggests that the water
may be loosely bound. 21 These findings suggest
that the major contributing factors for acid re-
sistance imparted to the lased enamel must be
due to a physical alteration in acid permeability
and acid diffusion in the enamel. 4. 5

In Vivo Experiments
According to this series of in vitro experiments,
an acoustooptically Q-switched Nd:YAG laser
under the above-mentioned irradiation condi-
tions is concluded to be the most effective in
imparting the remarkable acid resistance to the
enamel at a low-energy density without dam-
aging the living dental pulp.4. 5 Also, this oper-
ational mode of the Nd:YAG laser can be guided
easily by a single flexible optical fiber without
any transmission loss of laser energy. It is now
necessary to clarify the effects of the acous-
tooptically Q-switched Nd:YAG laser irradia-
tion on the tooth enamel in vivo.

FIG URE 31.2. Scanning electron microscopy of the Experiments in Rats 22

enamel surface before (left) and after (right) the
acoustooptically Q-switched Nd:YAG laser irradia- Because rat teeth are smaller than human teeth,
tion. Micropores vanished and smooth surface was the irradiation time and spot size were calculated
imparted by laser irradiation. so that the energy density was approximately
230 Hajime Yamamoto and Teruo Kayano

equal to that of the previous in vitro experiments coated with Chinese black ink. The irradiation
using the extracted human teeth. Calculated ir- time was 0.8 second for the permanent teeth and
radiation time and spot size were 0.1 second and 0.4 second for the deciduous teeth, respectively.
2.0 mm, respectively. After coated with Chinese During the operation, some pain and discomfort
black ink, the first molars of the Wistar rats, was felt by the subjects. There developed no
weighing 140 to 160 g, were exposed to this con- gross carious change in the lased area of the en-
ditioned acoustooptically Q-switched Nd:Y AG amel even after a few years. Of course, this op-
laser guided by a flexible optical fiber. After ir- erational conditioned irradiation by the acousto-
radiation , the rats were fed a cariogenic, low- optically Q-switched Nd:YAG laser does not
casein diets. 23 Caries prevention of laser irra- cause any injury to the human skin without the
diation is clearly demonstrated after 70 days of coating of Chinese black ink.
experiment. At that time, no visible carious le-
sions were detected in the lased and the unlased Clinical Application of Nd:YAG Laser for
teeth; however, the microradiogram of the un- Caries Prevention
lased molar enamel revealed clear subsurface
After numerous careful and prudent fundamental
demineralization in the fissures. On the contra-
experiments, the first test of the laser application
ry , no demineralization was found in the enamel
for caries prevention was performed success-
of the lased molars. After 200 days of experi-
fully and safely. 4.5 These investigations have
ment, severe carious decay developed macros-
revealed some mechanisms of the acid resistance
copically in the unlased molars, but no carious
imparted by the acoustooptically Q-switched
lesions were detected in the fissures of the lased
Nd:YAG laser irradiation. We have already de-
molars. This operational conditioned acous-
tooptically Q-switched Nd:YAG laser showed
only the slightest injury to the soft tissues such
as the tongue and the skin of the rat where the
Chinese black ink is coated. These injuries were
healed within 2 weeks.
Experiments in Humans
TEST OF THE EXTRAORALLY IRRADIATED HU-
MAN ENAMEL PLACED IN THE HUMAN MOUTH 24 :
In order to investigate the degree of acid resis-
tance of the lased enamel in the human oral en-
vironmental influences, small pieces of the en-
amel of extracted sound deciduous human teeth
irradiated by the acoustooptically Q-switched
Nd:YAG laser for 0.8 second were embedded
into several parts of human dentures or were set
into fixed prostheses and were placed in the hu-
man oral environments for 3 and 6 months. Ma-
croscopically, the unlased area of the enamel
showed chalky white lesions by subsurface de-
mineralization. On the contrary, no noticeable
change was observed in the lased area and no
subsurface demineralization was found on the
microradiogram. No damage to the dental pulp
occurred.
THE T E ST OF LASER APPLICATION FOR CARIES
PREVENTION OF HUMAN TEETH IN VIVo. 4 . 5 The FIGURE 31.3. New model ofNd:YAG laser apparatus
occlusal surfaces of noncarious intact teeth of with newly developed laser manipulator for dentistry .
several volunteers were exposed to the acousto- Operational modes; continous wave beam ofNd:YAG
optically Q-switched Nd:YAG laser after being laser/normal-pulsed Nd : YAG laser.
 31. Caries Prevention and Treatment Using Nd:YAG Laser 231

TABLE 31.1. Technical procedure for the as follows; a peak power of 120 KW with a pulse
prevention of dental caries using Nd: YAG laser width of 120 nanoseconds, repetition rate of 1
irradiation KHz, average output of 10 W, and spot size of
1. Clean the tooth sUiface. 3.0 mm. The irradiation times were 0.1 to 0.3
2. Dry the tooth surface. second for resins and 0.8 to 1.5 seconds for in-
3. Coat black material (Chinese ink) on the lays. The effects of a continuous wave beam of
tooth surface and dry it.
N d: YAG laser were also examined. A scanning
I'. Switch on the laser apparatus.
2'. Set the irradiation conditions and measure electron microscopy revealed that complete
the average output. closure of the dental restorative materials and
3'. Select the irradiation time. the tooth enamel was obtained by the acous-
4. Irradiation. * tooptically Q-switched Nd: YAG laser irradia-
5. Remove the coated black material and clean
tion at irradiation times of 0.2 second on margin
the tooth surface.
of resin fillings (Clearfill®) (Figure 31.4) and 0.8
The patient must be informed about this procedure before second on margin of gold alloy inlays. In the
irradiation. case of resin fillings, the same findings were ob-
*Both the operator and the patient must wear protective
eyeglasses during the irradiation process.
tained by the continuous wave beam of Nd: Y AG
laser irradiation. According to the microradi-
ographic findings of the lased tooth samples after
being placed in the demineralizing fluid 14 for 4
veloped the easily operable laser manipulator for days, the sensitivity to acid in the irradiated
the oral cavity, attached to the end of the flexible areas decreased markedly. Although the effects
optical fiber, and also the clinical apparatus of of marginal closure by laser irradiation may de-
the Nd:YAG laser for caries prevention (Figure pend on the irradiation conditions and physical
31.3). Persons who desire caries prevention by characteristics of dental restorative materials,
laser can have their teeth irradiated by the these preliminary results suggest a possibility of
acoustooptically Q-switched Nd:Y AG laser at secondary caries prevention by laser irradiation.
the Pedodontics Clinic of Tohoku University
Dental Hospital. The operational procedure is
shown in Table 31.1.
Treatment of Incipient Enamel
Caries by Nd:YAG Laser
Prevention of Secondary Enamel
Caries and Marginal Closure of Dental Irradiation: A Possible Clinical
Restorative Materials by Nd:YAG Application
Laser Irradiation In order to clarify the possibility of treatment
Several in vitro experiments were carried out in of early enamel caries by N d: YAG laser irra-
order to examine the possibility of marginal clo- diation, we conducted in vitro experiments. 8
sure and fusion between the dental restorative Artificial incipient enamel caries like lesions, that
materials and the tooth enamel by means of is subsurface demineralized lesions, were pro-
Nd:YAG laser irradiation, to obtain resistance duced by exposure to the demineralizing fluid. 14
of teeth to acid and to prevent secondary car- These lesions were exposed to an acoustoopti-
ies. 1I Class V cavities were prepared on the cally Q-switched Nd:YAG laser. The irradiation
buccal surface of the freshly extracted nonca- conditions were as follows; a peak power of 100
rious human teeth, and these teeth were restored KW with a pulse width of 100 nsec, repetition
by dental restorative materials, such as plastic rate of 1 KHz, average output of 10 W, spot size
filling materials and casted metallic inlays. Sev- of 3.5 mm, and irradiation times of 0.4 to 1.2
eral kinds of resins and gold alloy inlays were second. A scanning electron microscopy of the
investigated. The interface between the tooth acid-etched surfaces of the lased lesions showed
enamel and the restorative materials was coated reduced acid solubility of both the surface and
with laser absorption black material (Chinese subsurface enamel. After the lased lesions were
black ink) and exposed to an acoustooptically exposed to the demineralizing fluid,14 the acid
Nd: YAG laser. The irradiation conditions were resistance of the lased lesions was examined.
232 Hajime Yamamoto and Teruo Kayano

FIGURE31A.Scanningelectronmicroscopyofthelased row) between the tooth enamel (E) and the resin (R)
area at the margin of the dental restorative material after the acoustooptically Q-switched Nd:YAG laser
(composite resin, Clearfill®). Complete closure (ar- irradiation.

Fourteen days after demineralization, micro- eralization was produced before the laser ir-
radiographs of the lased lesions showed the ap- radiation. These findings indicate that the
pearance of radiodensity in the subsurface layer acoustooptically Q-switched Nd:Y AG laser ir-
and a small amount of subsurface deminerali- radiation to the artificial incipient enamel caries
zation (Figure 31.5). Microradiographs of the like lesions may not only prevent the deminer-
lased lesions exposed to a remineralizing fluid 25 alization from advancing but also accelerate re-
for 7 days revealed marked radiodensity in the mineralization. This mode of Nd:YAG laser may
subsurface layer where the subsurface demin- be effective for the prevention of the develop-

FIGURE 31.5. Microradiograms of 0.8

second irradiated incipient caries-like
lesions (4 days demineralization) expos-
control unlased lased ed to demineralizing fluid for 14 days.
Subsurface demineralized lesion dis-
O.asec. appeared at the lased area.
31. Caries Prevention and Treatment Using Nd:YAG Laser 233

ment of dental caries. The acoustooptically Q- 3. Gordon JE: Single-surface cutting of normal tooth
switched Nd:Y AG laser may have a advantage with ruby laser. J Am Dent Assoc 74:398-402,
in treating small pit caries. When the focused 1967.
laser beam is irradiated to these lesions, the pit 4. Yamamoto S, Sato K: Prevention of dental caries
by Nd: YAG laser irradiation. J Dent Res 59
lesions can be vaporized in a moment with the (DII):2171-2177, 1980.
formation of a shallow crater. This crater can 5. Yamamoto H, Sato K: Inhibition of dental caries
be easily restored by dental restorative materials by laser irradiation. In Atsumi K (ed): New Fron-
such as an adhesive resin. These procedures tiers in Laser Medicine and Surgery. Excerpta
may not need any more extensive cavity for- Medica/Elsevier, Amsterdam, Oxford, and Prin-
mation to prevent caries. 26 ceton. pp 242-248, 1983.
6. Stern RH, Vahl, J, Sognnaes, RE: Ultrastructural
observations of pulsed carbon dioxide laser ef-
Conclusion fects. J Dent Res 51 :455-460, 1972.
7. Yamamoto H, Ooya K: Potential of yttrium-alu-
It is clearly indicated that the acoustooptically minum-garnet laser in caries prevention. J Oral
Q-switched Nd:YAG laser might prove to be Pathol 3:7-15, 1974.
effective for clinical application for prevention 8. Sato H: Effect of acousto-optically Q-switched
of not only primary caries but also secondary Nd: YAG laser irradiation on the artificial caries
caries. The latter is associated with marginal like lesion. Jpn J Oral Bioi 24:9l3-925, 1982.
closure of the dental restorative materials. This 9. Shafer WG, Hine MK, Levy BM, Tomich CE: A
laser may also be an effective tool for the treat- Textbook of Oral Pathology. Saunders, Philadel-
ment of incipient enamel caries. The irradiation phia, 1983.
conditions of these laser applications are a pulse 10. Thewlis J: The calcification of enamel and dentin.
Br Dent J 62:303, 1937.
width of 100 nanoseconds, repetition rate of 1
11. Shoji S, Iiyama M, Ishikawa K, et al: Changes of
KHz, average output of 10 W, spot size of 3.5 boundary between dental enamel and restorative
mm, and irradiation time of about 0.8 second. materials caused by Nd: YAG laser irradiation. J
It is very important that these operational Jpn Soc Laser Med 4:265-266, 1984.
conditioned acoustooptically Q-switched 12. Gibbons RJ, Nygaard M: Syntheses of insoluble
Nd:YAG laser beams can be guided by a single dextran and its significance in the formation of
flexible optical fiber. This property will make it gelatinous deposits by plaque-forming strepto-
possible for it to be developed into an effective cocci. Arch Oral Bioi l3: 1249-1262, 1968.
tool easily operable in the small oral cavity for l3. Yamamoto H: The actual state and prospect of
the prevention of dental caries and treatment of the laser application in the dental field. Dent J
early caries. Iwate Med Univ 4:3-1, 1979.
14. Gray JA: Kinetics of enamel dissolution during
Lasers may bring about a revolutionary strat-
formation of incipient caries-like lesions. Bri Dent
egy for the prevention and treatment of dental J 120:461-471, 1966.
caries in the near future. 15. Yamaga R: Diamine fluoride and its clinical ap-
plication. J Osaka Univ Dent Sch 12: 1-20, 1972.
16. Suzuki T: Effects of diamine silver fluoride on
Acknowledgments. Collaborating with us in this tooth enamel. J Osaka Univ Dent Sch 14:61-72,
series of studies were Prof. F. lnaba, Prof. K. 1974.
Kamiyama, and Drs. K. Ooya, K. Sato, T. 17. Sato H, Sato K, Toya Y, Yamamoto H: Effect
Ohkubo, Y. Tooya, S. Shoji, and K. Yamada. of an acousto-optically Q-switched Nd:YAG laser
These studies were supported in part by a irradiation on the fissure of the tooth in the pres-
Grant-in-Aid for Scientific Research from the ence of Ag(NH3)2F. Jpn J Oral Bioi 23:401-406,
Ministry of Education, Science and Culture. 1981.
18. Tagomori S, Suzuki K, Morioka T: Combined ef-
References fect oflaser and fluoride on acid resistance. J Jpn
Soc Laser Med 4(1):261-262, 1984.
1. Maiman TH: Stimulated optical radiation in ruby 19. Yamamoto H, Sato K, Ohkubo T, et al: Progress
lasers. Nature 187:493, 1960. in caries prevention by laser irradiation. Dental
2. Sognnaes RE, Stern RH: Laser effect on dental Outlook 57:633-641, 1981.
hard tissue. J South Calif State Dent Assoc 20. Tochon-Danguy HJ, Very JM, Geofferoy M, Baud
33:328-329, 1985. CA: Pramagnetic and crystallographic effects of
234 Hajime Yamamoto and Teruo Kayano

low temperature ashing on human bone and tooth of Pd-marked rats. J Dent Hlth 16:85-90, 1966.
enamel. Calc if Tiss Res 25:99-104, 1978. 24. Tooya Y: Acousto-optically Q-switched Nd:YAG
21. Legeros RZ, Gilbert B, Legros R: Types of laser resistence of human deciduous enamel to
"H 20" in human enamel and in precipitated apa- demineralization in vitro and in vivo. Jpn J Oral
tites. CalcifTiss Res 26:111-118,1978. BioI 24:442-452, 1982.
22. Ohkubo T, Yamamoto H: Experimental study of 25. Cate JM Ten, Arends J: Remineralization of ar-
laser inhibition of dental caries in rats. In Atsumi tificial enamel lesions in vitro. Determination of
K, Nimsakul N (eds): Laser Tokyo '81. pp 12-5- activation energy and reaction order. Caries Res
12-8, 1981. 12:213-222, 1978.
23. Onishi M, Ozaki F, Hamada M: Prevention of 26. Yamamoto H, Kayano T: Laser and dentistry.
experimental rat caries III. Influences of casein Rev Laser Eng 13:549-558, 1985.
contents in a cariogenic diet upon carious lesion
32
Nd:YAG Laser Therapy in Dental and
Oral Surgery
Akinori N agasawa

The laser has brought us numerous technical in- Fundamental Studies

novations in every scientific field since its in-
vention in 1960. 1 Since then, lasers have ele-
vated the level of traditional medicine and given Laser Effect on Tissue
us the benefit of modern advanced technology.
The effect of light on tissues depends on the Spectral Analysis of Tissues
wavelength of the ray and since the coherent
laser beam has a constant wavelength, an ap- The physical effect of light on tissue varies cor-
propriate laser can be selected to achieve the responding to the wavelength of the ray, and
best therapeutic result. The laser affords us the the effect of the coherent laser ray with a con-
following therapeutic possibilities: stant wavelength on tissue depends on the op-
tical characteristics of the tissue at the wave-
1. Selective treatment of the affected area is
length of the laser. The analysis of the optical
possible, based on the differences in optical
characteristics of tissues is most important to
characteristics.
the development of laser technology. The effect
2. Noncontact surgery is possible owing to the
of lasers on tissues can be estimated from the
energy transference by laser radiation.
spectral analysis of the tissues. 6 Spectral anal-
3. Noninvasive surgery is possible for deeply
ysis of dental tissues with the Nd:YAG laser
placed lesions by using optical fibers.
shows the laser ray to be comparatively pene-
4. Various kinds of effects are possible to select.
trable to the structures and, by scattering, it is
Research on application of lasers to dentistry minimally absorbed by them.? The reflectance
was started in 1964 by Goldman and coworkers 2 on a tooth surface decreases with the wave-
and other investigators, and numerous papers length, and therefore the surface of the tooth
have been published with reports of these in- reflects the Nd:YAG laser much greater than
novations that can change the method of tra- CO 2 laser. Carious dentin has much greater ab-
ditional dentristy, still, various problems limit sorptivity of N d: YAG laser than intact dental
widespread applications of laser technology in structures and the difference in the optical char-
dental practice, as previously reported. My co- acteristics can be applied to selective treatment
workers and I have developed several thera- of dental caries. Since these tissues generally
peutic applications of lasers that are useful for consist of multi structures of different optical
medical treatment.3-5 In particular, the Nd:YAG charecteristics, it is not easy to determine the
laser is clinically the most useful because of its laser effect on tissues exactly by spectrum anal-
high tissue penetration and high power output. ysis of a single structure.
236 Akinori Nagasawa

Analysis of the Thermal Effect of Lasers aging, (2) signal transfer, (3) register, (4) read-
ing out, and so is applicable an an excellent
The accurate temperature measurement of lased
imaging sensor for TV cameras. Since the CCD
tissues is very important in identifying the effects
image sensor is sensitive to the near-infrared
of the laser on these tissues. With such a tissue-
ray of wavelength less than 1.2 f-lm, the laser
penetrable ray as the Nd:Y AG laser, however,
distribution on and in tissues can easily be ob-
there are some crucial problems in the temper-
served as a visible image using the TV camera
ature measurement of lased tissues. The direct
provided with a CCD image sensor. Figure
effect of the laser on thermal sensors located in
32.1 shows the CCD TV image of the sectional
the tissue disturbs the accurate indication of the
plane of liver tissue exposed to aNd: Y AG las-
actual temperature of the lased tissue.
er on the surface of the liver. In these results,
We devised an original system to measure the
it is clearly observed that the Nd: Y AG laser
actual temperature of lased tissues. 8 The ther-
scatters spherically in the tissue. The exposure
mocouple probes for the temperature measure-
times of the laser are 1.00.2 second. Since the
ment of lased tissues have been coated on the
scattering areas are similar in these two cases
surface with a very highly reflective material.
the CCD image sensor was proved to have high
An infrared thermometer provided the sensing
sensitivity to the Nd:YAG laser. The CCD TV
wave band of 7 to 11 f-lm used for the measure-
image is too sensitive to the Nd:YAG laser
ment of the surface temperature of the lased tis-
of high power and can easily to go beyond
sues. Since the wavelength of the Nd: Y AG laser
the full range of detection. Therefore, some
is not detected by this thermometer, the actual
light reduction such as an iris or an optical
temperature of the lased tissue can be measured
filter proper to the laser intensity is required
accurately.
when measuring laser distribution of high
resolution.
Observation of Laser Distribution in
Tissues by Charge-Coupled Device
Image Sensor Measurement of Distribution of Laser
Intensity in Tissue
Nonvisible near-infrared laser distribution on
and in tissues can easily be observed as visible It is also important to recognize the distribution
images using a TV camera with a charge-coupled of laser intensity in and on tissues for the study
device (CCD) image sensor. 9 The CCD image on therapeutic application of lasers. We have
sensor was developed in 1970 by W. S. Boyle. lo applied a pinhole scanning technique to this
The CCD has the following capabilities: (1) im- measuremene l Figure 32.2a,b shows the vari-

FIGURE 32.1. CCD TV image of the

sectional view of liver being exposed
to Nd: YAG laser (3 W) (a) 1.0 sec-
ond, (b) 0.2 second (exposure time).
32. Laser Therapy in Dental and Oral Surgery 237

1.0 Tissue
~ LASER a 1.0 Den t .:le
LASER
.J..P.
b
(LiVer)} Po
~ ,I ~-*' t
~ ~ P~ ~
Po P c=J Po
Power
meter
Pow er
me te r
0.5 0.5
Nd - YAG L.
GaAIAs L.
( Po: l 0 mW )
(Po =3 . 9W)

o~.-.-~,-.-~~~~~ 0
o 5 1{)
t (mm,
0 5 10
t (mm)
FIGURE 32.2 . Power density rate of Nd:YAG laser in tissues. (a) Soft tissue (liver), (b) Dental tissue.

ation of the rate of a near-infrared laser intensity the laser beam must be guided only to the root
to the depth along the beam axis in a lased tissue canal for local treatment. Recently, ceramic
in the case of liver tissue and in a dental struc- surgical laser probes for contact laser therapy
ture. have been developed by Surgical Laser Tech-
nologics Inc (SLT) in the USA & Japan and are
being used frequently. Fine needle-ceramic type
Development of Clinically probes have been used in laser root canal treat-
Available Laser Instruments
Laser Handpiece with Variable Beam
Direction
A new laser handpiece provides a unique
method of varying the exposing beam direc-
tion, as shown in Figure 32.3 12 This handpiece
has a rotary reflective mirror at the top of
the shaft. The reflector has a multicoating sur-
face with extremely high reflectance to the
Nd:Y AG laser. Therefore this handpiece is
practical and applicable to use with a 30-W
Nd:Y AG laser in the continuous wave mode
for over 30 minutes without any problems.
This handpiece is useful for laser surgery in a
narrow field such as oral cavity.

Quartz Fiber Probe for Laser

Endodontic Therapy
It is clinically impossible to apply sufficient laser
energy to pulp tissue in treating a root canal by
transmitting laser irradiation on the tooth surface
because of decreased laser energy in the dental
structure. In order to achieve a sufficient treat- FIGURE 32.3. Laser handpiece of variable exposing
ment effect on the root canal and a pulp tissue beam direction. (Morita, Japan).
238 Akinori Nagasawa

Q.F.P.

- - -.....,-- -
I
--- --------- --- - -
_ _ _ .JI _ _ _ _ _ _ _

condensing lens fiber from laser equipment

FIGURE 32.4. Quartz fiber probe system for endodontic therapy.

ment, but they can break particularly when they reamer, since it has a thin diameter of 0.6 mm
come into contact with the dental structures. and a slight flexibility.
An endodontic quartz laser probe as devel-
oped, improving the commercially available
Other Laser Instruments
quartz fiber, for laser waveguide with a core di-
ameter of 0.6 mm. 13 This quartz fiber probe sys- In addition to the above, we have developed
tem is connected to the wave-guide fiber of the laser protectors 14 to safeguard the healthy parts
laser using a connecter (Figure 32.4). This probe of the body except for the treatment site; a laser
is not easily broken. Even when the tip of the irradiating system which can follow a moving
probe breaks off during use, it can be easily re- target, and other equipments useful for dental
paired. This probe is also easy to insert into the laser surgery.
root canal previously enlarged with a root canal
Therapeutic Effects of the
Nd:YAG Laser in Dental and
Oral Surgery
Analgesic Effect on Teeth in Dental
Treatment
The Effect and the Technique
There is an analgesic effect produced on teeth
exposed to the Nd: Y AG laser. 15 The outline of
this technique is as follows: A pain threshold
can be elicited in a patient when a Nd:YAG laser
is applied to the crown surface ofa tooth. When
a patient's tooth crown is exposed to pulsed.
FIGURE 32.5. Clinical application of Nd:YAG laser Nd:YAG laser under the pain threshold, for ex-
analgesia on tooth (ill) . ample, 10 to 20 W in fiber power output, 0.1-
32. Laser Therapy in Dental and Oral Surgery 239

second pulse width, 10 mm exposure distance

(100 to 200 mW/cm2 ), the patient has some tol-
erable sense. When the tooth is exposed re-
peatedly to the Nd:YAG laser under the pain
threshold it becomes insensitive to the laser
shot. At this stage the tooth is sufficiently an-
esthetized for cutting. It is now possible to in-
crease the threshold dose of the laser beam on
the tooth to induce pain in a staged technique
and the analgesic effect on the tooth can be fur-
ther increased. After such pretreatment the
tooth can be cut without feeling pain.
FIGURE 32.6. Microphotogram of a tooth exposed to
the Nd:YAG laser.
Clinical Application
Figure 32.5 shows an example of a clinical ap-
plication of laser dental analgesia. After the an- one of the most useful laser applications in den-
algesic treatment of the Nd: YAG laser under the tistry.
technique discussed earlier, the vital teeth ill
underwent the preparation for a jacket crown
by cutting with a high-speed turbine instrument Reactive Secondary Dentin Formation
without any sense of pain, up to injuring just a in Pulp
corner of pulp of the tooth 2l(indicated with an The Phenomenon
arrow). As a result of the clinical application of
this laser analgesia, more than 95% of cases were We observed, in the pulp tissue of lased rat
effective without any damage to the pulp and teeth, the interesting phenomenon that the sec-
the surrounding tissue. ondary dentin formation grows reactively to-
ward filling the whole pulp cavity and the root
canal of the tooth within a few months after ex-
Discussion posure to the argon laser or the Nd:YAG laser,
Figure 32.6 shows a microphotogram of the as shown in Figure 32.7. 16
dental structure of a tooth exposed the Nd: Y AG
laser. The dentin canal of the surface layer is Results of Exposure of Human Teeth In
observed to have disappeared. This layer is pre- the Nd:YAG Laser
sumed to block the conduction of sensory stim-
Figure 32.8 shows a microphotogram of a milk
ulation to the pulp and provides the mechanism
tooth Cl extracted 4 months after exposure to
for laser dental analgesia. The argon laser has
400 J in total energy of Nd:YAG laser. In the
been found to have a greater analgesic effect on
case of human teeth exposed to the Nd:YAG
teeth than the Nd:YAG laser. The degenerative
laser, similar histologic changes to these exper-
layer in the dentin canal of the tooth exposed
imental results in rat teeth have also been ob-
to the argon laser is thicker than that exposed
served. The permanent adult teeth are weaker
to the Nd:YAG laser. 16
than the milk teeth in the secondary formation
The roentgenographic survey and the long-
by exposure to the Nd:YAG laser.
term follow-up with electric pulp examination
of the teeth exposed to laser analgesia have re-
sulted in no problems. The safety of the pulp
Discussion
and the surrounding tissues in this technique has Thermal effect is well known as a stimulator to
been confirmed by our thermal examinations. induce secondary dentin formation in dental
Freedom from severe pain in dentistry has pulp, and the thermal effect of the CO 2 laser is
long been an earnest desire of patients. There- even greater on dental tissues, in that secondary
fore this laser analgesia that offers painless den- dentin has been observed in the pulp of lased
tal treatment with simple and safe technique is teeth. The secondary dentin formation in the
240 Akinori Nagasawa

FIGURE 32.7. Microphotogramofa rat

molar 3 months after exposed to 10 J
of the argon laser.

pulp induced by the CO 2 laser, or mainly by an epock-making lase~\ dental application of bi-
thermal effect is, however, limited to the area ological endodontic th~rapy or biological root
that receives the thermal effect. This is different canal filling in the near future.
from the chainlike reaction of secondary dentin
formation induced by the argon or the Nd:YAG
laser. In addition to this, we have succeeded in Bone Repair Activation Effect
producing similar reactive changes using the ar-
The Effect
gon-dye laser in the pulp of the rat teeth exposed
to such a low thermal effects as to be negligible In the clinical application of the Nd:YAG laser
after pretreating the rats with the photosensitizer to dental treatment we have identified interesting
hematoporphyrin derivative, as shown in Figure therapeutic effects on bone focuses as well as
32.9. 17 These results suggest that the laser-in- improving the mobility of loosened teeth and
duced reactive secondary dentin formation is the inflammation of soft tissue. Roentgeno-
contingent not only on thermal effects but also graphic survey for these cases proved that the
on photodynamic effect of lasers. These result laser activated the repairing process of the
will hopefully suggest to lead to development of damaged bones. 18 The results of experimen-

FIGURE 32.9. Microphotogram of a rat molar 3 months

FIGURE 32.8.
Microphotogram of extracted milk tooth after exposure to 10 J of argon-dye laser after he-
04 months after exposure to 400 J ofNd:YAG laser. matoporphyrin derivative premedication.
32. Laser Therapy in Dental and Oral Surgery 241

ment prove that the laser activates the bone re-

pair process for destroyed bone.

Clinical Application
Therapeutic Techniques
ENDODONTIC THERAPY . Root canals are
firstly widened completely by the conventional
technique. Then the quartz fiber probe used in
root canal therapy, 0.6 mm diameter, is inserted
as deep as possible. The Nd:Y AG laser is ir-
radiated from the tip of the quartz fiber probe
in the root canal toward the root apex. Exposure
conditions are 2 to 5 W power output at the tip
of the probe in the tip the quartz fiber probe,
0.5 to 1 second in duration. Repeating the las-
ering, the quartz fiber probe is pulled up step
by step toward the pulp chamber (Figure 32.11).
Complete sterilization of the root canal after this
laser treatment has been confirmed by bacterial
culture, and more than 98% of the cases have
been successfully cured.
PERIAPICAL OPERATION. The appropriate
sizes the needle-shaped SLT ceramic surgical
probe (CSR) is inserted on the gingiva to a per-
iapical bone focus or a periodontal bone focus,
FIGURE 32.10. Microphotogram of rat femur 10 days
after artificial bone destruction. (a) The wound ex- and the Nd:YAG laser fired at 3 to 10 W in CSR
posed to 100 mJ/cm 2 of Nd:YAG laser. (b) Without tip, 0.5 to 1.0 second in duration, and is repeated
laser exposure. to destroy the area. The destroyed structure
flows out around the CSR, and the rest is
cleaned up by curettage and washing. The per-
tal studies confirmed the fact that low-energy iodontal bone focus is thus healed without cut-
laser exposure was also effective in activating ting the gingiva or the alveolar bone.
the repairing process of the artificial bone de-
structions. Figure 32.10 shows the micropho-
tograms of rat femur 10 days after the bones
were partially destroyed artificially by drilling.
In Figure 32.10a, the artificial wound was ex-
posed to a Nd:Y AG laser of 100 J/cm 2 just after
bone injury. Figure 32.10b shows the control fe-
mur, without any laser exposure. Comparative
observation of the results shown in Figure 32. lOa
and b are summarized as follows: (1) New spon-
gy bone formation with mUltiple bone trabecula
in the bone marrow around the wound in case
a is far superior to that of case b. (2) As for the
adhesion of the newly produced bone tissue to
cover the bone defect and the original bone wall
in the wound, case A is much closer than case
b. (3) Partial secondary calcification in the newly
produced bone is observed in case A, but very FIGURE 32.11. Nd: Y AG laser endodontic therapy us-
little in case B. These results from this experi- ing quartz fiber probe.
242 Akinori Nagasawa

PERIODONTAL OPERATION. First of all, a CSR

of 0.4 mm apex diameter is inserted into the gin-
gival pocket and Nd:YAG laser is irradiated in
it. The gingival attachment is cut moving the
SLT contact probe with irradiating a few watts
of continuous wave Nd: Y AG laser. Minimal
bleeding occurs. After curettage on the inner
surface of the gingival flap and the root surface
of the teeth, the gingival flap is sutured to reat-
tach to the root surface. Even severe cases of
alveolar pyorrhea of hard gingivitis have been
completely cured without recurrence for long
periods.

Results of Clinical Application

CASE I. CHRONIC ALVEOLAR OSTEITIS (61),
22Y, F. As shown in the roentgenogram before
treatment (Figure 32.12a), the remarkably pro-
gressed granulomatous bone destruction is ob-
served widely spreaded over the two roots. This
tooth suffered a serious gingivitis and percussive
pain. It was remarkably loosened with high mo- FIGURE 32.12. Roentgenograms in Nd:YAG laser en-
bility and could not be used to chew any food. dodontic therapy (chronic alveolar ostitis 61). (a) Be-
In this endodontic therapy complete enlarging fore treatment. (b) 2 months after laser root canal
of the root canals was impossible because of treatment. (c) 5 months after laser root canal treat-
their stricture with curved apex. Then Nd: Y AG ment. (d) 10 months after laser root canal treatment.
laser therapy was applied to this case by the
technique discussed earlier. The laser exposure
in this treatment was as follows: 10 W, 0.5 sec-
ond 37 times, and 10 W, 1 second 23 times, total
energy: 415 J. In spite of the incomplete result
of this root canal filling, the severe gingivitis was
improved soon after the laser treatment, and the
tooth mobility was also improved gradually to
recover normal mastication ability. No problems
have occurred in this patient for 18 months after
laser treatment. Figure 32.12b,c,d show roent-
genograms after laser treatment (b: 2 months af-
ter, c: 5 months after, and d: 10 months after).
These roentgenograms prove that bone repair in
this large bone focus progresses to the stage of
complete recovery.
CASE 2: ALVEOLAR PYORRHOA l±- 59Y. F.
This is a case of extremely severe alveolar
pyorrhea of the upper teeth (~) with a hard
inflammation in the palate, as shown in Figure
32.13a. In particular, the left upper first molar
(l±-) had a remarkable mobility and percussive
pain and was difficult to use for chewing. The
alveolar bone around the whole root was widely FIGURE 32.13. Alveolar pyorrhea of upper teeth
absorbed and destroyed as shown in the roent- (h.1). (a) Hard inflammation in the palate. (b) After
genogram before treatment (Figure 32.14a). This laser operation.
32. Laser Therapy in Dental and Oral Surgery 243

case was difficult to cure by conventional treat- 2. The affected bone tissue structurally improve.
ments (Figure 32.14b). Thus the periodontal op- 3. The bone repairing effect occurs in the apical
eration using the contact Nd:YAG laser was or periodontal bone damaged areas.
tried. As shown in Figure 32.13b the hard in-
flammation of the palate improved soon after Clinical Findings
laser operation. The remarkable tooth move- I. Mobility of loosened teeth improves.
ment and other problems in this tooth have also 2. Severe gingivitis and tooth pain, usually dif-
improved gradually and the mastication has re- ficult to treat can be improved.
covered normally. The roentgenograms 3 3. The mastication ability of the affected teeth
months after operation (Figure 32.14c) and 12 recover.
months after operation (Figure 32.14d) shows
that the bone destruction has progressively being The therapeutic effects in such laser dental
repaired. This case has been problems free 2 surgery are summarized based on the above
years after surgery. therapeutic findings.
The noteworthy findings in dental laser treat- I. Activation of bone repair
ments are summarized as follows: 2. Antiinflammatory and sterilization effect.
3. Mastication recovery.
Roentogenographic Findings
I. The destroyed alveolar bone is activated to Discussion
repair. The Physical Viewpoint
The Nd:Y AG laser ray decreases its intensity
at increased depth in the tissue, becoming quite
weak or negligible in the deeper areas. Since the
needle-shaped contact probe has a compara-
tively large exposure beam angle at the apex,
the decrease in the laser intensity in deep tissues
is much more remarkable than that of fiber ex-
posing instruments. Therefore the bone repair
is stimulated by low-energy lasers, which acti-
vate tissue metabolism. This theory has been
confirmed by the results of the following ex-
periment.
Figure 32.15 indicates the results of experi-
ments on rat bone damages using the Ga-AI-As-
diode laser or the He-Ne laser at milliwatt power
output which are similar to experiments using
the Nd:YAG laser, as shown in Figure 32.10.
In each case the bone injury is exposed to the
same laser energy density of 100 J/cm 2 , but in-
tensity of the lasers was different. In the ex-
periment using the Nd:Y AG laser, 4 W of ex-
posure power was delivered, the Ga-AI-As laser
delivered 40 mW, and the He-Ne laser delivered
6 mW. In the case of these low power lasers
similar result of bone healing to Nd: YAG laser
were obtained as shown in Figure 32.10. This
bone repair appears also to be activated by using
FIGURE 32.14. Roentgenograms in Nd: Y AG laser op- even extremely low power laser of milliwatt
eration (alveolar pyorrhea l.1">. (a) Before operation. level as shown in these cases. These results
(b) 3 months after conventional operation. (c) 9 confirm that the bone repair effect of lasers is
months after laser operation. (d) 12 months after laser contingent on photostimulation1 9 for tissue ac-
operation. tivation.
244 Akinori Nagasawa

FIGURE 32.15. Microphotogram of rat femur 10 days

FIGURE 32.17. Thermographic survey for the thera-
after artificial bone destruction. (a) The wound expos- peutic effect of the Nd: Y AG laser on cancer of cheek.
ed to 100 J/cm 2 of 40 mW Ga-Al-As laser. (b) The (a) Before treatment. (b) 1 day after exposure to
wound exposed to 100 J/cm' of 6 mW He-Ne laser. Nd: YAG laser (indicated by arrow).

Observation of the Light Scattering into a

Tissue in the Laser Treatment
The area of light scattering into a tissue in these
laser treatments can be easily observed as a vis-
ible image on TV by using a charge-coupled de-
vice (CCD) TV camera. Figure 32.16A is the
CCD TV image of a mouth during irradiation of
the N d: Y AG laser into the pulp of a tooth in the
root canal treatment. The laser light can be ob-
served widely spreading over the periodontal
tissue and the effects can be seen. Figure 32.16B
shows another case of the CCD image of a
mouth during irradiation of the Nd:YAG laser
FIGURE 32.16. Charge-coupled device TV image ofa
into the periodontal pocket using a CSR of 0.4
mouth during irradiation of the Nd: YAG laser. (a) mm apex diameter in the surgical operation for
Root canal treatment, 5 W, 0.2 second. (b) Surgical a case of alveolar pyorrhea. The laser light, in
operation for a case of alveolar pyorrhea, 5 W, 1 sec- this case, scatters widely, spreading over the
ond. periodontal bone and, the gingiva also.
32. Laser Therapy in Dental and Oral Surgery 245

Other Therapeutic Effects of rat skin successfully applied with aNd: YAG
laser to weld the skin incision. Figure 32.18B
Therapeutic Effects of the Nd: YAG Laser
shows a clinical example of successful welding
on Malignant Tumor of incised oral mucosa in oral surgery. This
We have developed a laser system for malignant technique holds great promise for the future.
tumors, combining the N d: YAG and CO 2 lasers . 20
The destructive effect of the Nd:YAG laser on Others
malignant tumors can be evaluated using ther- The Nd:Y AG laser is theoretically the most
mography, as shown in Figure 32.17. Malignant useful laser for tissue coagulation and it is very
tumors have a high temperature as shown in useful for controlling bleeding in oral surgery.
Figure 32.17 A, but the cancerous area exposed Further application of the Nd:YAG laser to
to Nd:Y AG laser changes to low temperature dental and oral surgery has been pursued.
immediately after the laser therapy as shown in
Figure 32.17B.
Laser Welding for Mucousa Flap Conclusion
Vascular anastomosis 21 using weak lasers is now Technical innovation is necessary in dentistry,
available for practical use. 22 The mechanism of particularly in the areas of intractable dental
this laser anastomosis is believed to be the en- pain, endodontic therapy, avoidance of tooth
tangling of the collagen fiber activated by laser extraction and in progressive alveolar diseases.
stimulation. We attempted to weld the incised Several interesting therapeutic effects of the
mucosa flap edges using Nd:Y AG laser expo- Nd:YAG laser have been presented. Almost all
sure. Figure 32.18A shows the histologic image of them have been successfully used and the re-
sults indicate that these new therapeutic appli-
cations of the Nd: Y AG laser could fulfil the de-
sire of patients for improvement in traditional
dentistry.

References
1. Maiman TH: Stimulated optical radiation in ruby.
Nature 187:493, 1960.
2. Goldman L, et al: Impact of laser on dental car-
ries. Nature 203:417, 1964.
3. Nagasawa A, et al: Survey of applicability of CO 2
laser to dental and oral surgery. Jpn J Med Bioi
Eng, 17(Supp\):672, 1979.
4. Nagasawa A: Laser in dental and oral surgery.
In Atsumi K (ed): Clinical Laser. Medical Plan-
ning, Sappolo, 1981, pp. 233-273.
5. Nagasawa A: Nd: YAG laser therapies in dental
and oral surgery. Proceedings of the 2nd Inter-
national Nd:YAG Laser Conference 1985, pp 483-
489.
6. Nagasawa A, et al: Optical characteristics of
dental structures and the difference of the effect
of lasers on them. Jpn J Med Bioi Eng 18
(Supp\): 178, 1980.
7. Spitzer S, et al: The absorption and scattering of
light in bovine and human dental enamel. CaIcif
Tiss Res 17: 129, 1975.
8. Nagasawa A, et al: Actual temperature measure-
FIGURE 32.18. Nd: YAG laser welding on the incised ment of tissues by using improved thermocouples
flap. (a) Rat skin. (b) Human oral mucosa. J Jpn Soc Laser Med 3(1): 195-200, 1982.
246 Akinori Nagasawa

9. Nagasawa A, et al: Pilot study on application of 16. Nagasawa A: Histological changes in dental pulp
CCD image sensor to survey near infrared laser exposed to argon laser. Jpn J Med Bioi Eng
distribution in tissues. BMTH (Jap), 6(1):12-15, 19(5uppl):319, 1981.
1986. 17. Nagasawa A, et al: (1985) Reactive changes in
10. Boyle WS, et al: Charge coupled semiconductor the pulp tissue of lased teeth. Proceedings of the
devices Bell Syst Tech J 49:587, 1970. 14th International Congress on Medical and Bi-
11. Nagasawa A, et al: Optical characteristics and ological Engineering, 1985, pp. 1l07-1108.
difference of effects on teeth in various kinds of 18. Nagasawa A, et al: Alveolar bone repair effect of
lasers. Jpn J Med Bioi Eng, 18(Suppl):178-179, Nd:YAG laser in dental surgery. Jpn J Med Bioi
1980. Eng 24(Suppl):179, 1986.
12. Nagasawa A, et al: Fundamental study on ex- 19. Mester E, et al: (1981) The biostimulative effect
posing beam direction variable laser handpiece of laser beam, Proceedings of the 4th Congress
and exposing beam angle variable laser handpiece, of the International Society for Laser Surgery
Med Instrum 53(Suppl):145-147, 1983. (Tokyo), 1981,22-4-22-7.
13. Nagasawa A, et al: Effective Nd-YAG laser tech- 20. Nagasawa A, et al: Combined YAG laser and
niques for endodontic therapy. Jpn J Sci Laser CO 2 laser therapy to malignant tumor. Proceed-
Med 6(3):251-254, 1986. ings of the 4th Congress of the International So-
14. Nishikawa K, et al: CO, laser protectors applied ciety for Laser Surgery (Tokyo), 1981, 11-38--
to laser surgery. The 4th Congress of the Inter- 11-41.
national Society for Laser Surgery (Tokyo), Feb. 21. Beck OJ: The use of Nd:YAG and CO 2 laser in
21-24, 1981. neurosurgery. Neurosurg Rev 3:261, 1980.
15. Nagasawa A, et al: The anesthetic effect of Nd- 22. Jain KK: Nd:YAG laser in Microneurosurgery:
YAG laser in dental treatment. Jpn J Med Bioi Chapter 15, Elsevier Science Publishing Co. Inc.,
Eng 22(Suppl):830-831, 1984. 132-140, 1983.
33
Laser Hemorrhoidectomy
M.Y. Sankar

Hemorrhoids have afflicted mankind since an- 1. Vascular hemorrhoids that consist mainly of
cient times: there is a record of the disease on distended vessels and are seen in the younger
Egyptian papyrus I and surgical treatment was age group
reported in ancient Rome and Greece. 2 The dis- 2. Mucosal hemorrhoids that are composed of
ease may be asymptomatic at times, often de- thickened mucosa and encountered in older
tected on routine rectal and proctoscopic ex- patients
aminations. The incidence of hemorrhoids
increases with age and affects at least 50% of
people over 50 years old. Hemorrhoids occur in In the very early stages, the internal hemor-
males and females of all ages, although men are rhoids protrude slightly into the anal canal as
more commonly affected. congested veins. These are called first-degree
The word hemorrhoid is derived from the hemorrhoids. With the passage of time, they
Greek adjective haimorrhoides, meaning bleed- become larger and descend toward the anal ori-
ing (haima-blood, rhoos-flowing) , which places fice. The piles then may be found externally,
the emphasis on the prominent symptom of especially on straining at defecation, and spon-
bleeding. The term "piles" is derived from the taneously regress into the anus at the end of the
Latin word pita, meaning "a ball," which refers effort. These are second-degree hemorrhoids.
to a swelling around the anus during some stage Later, the internal hemorrhoids protrude not
of the disease. The terms hemorrhoids and piles only during defecation but may stay prolapsed
are often used synonymously. until they are digitally reduced and are called
third-degree. Finally, long-standing piles, es-
pecially in the elderly, become very large, cov-
Classification of Hemorrhoids ered by skin and remain prolapsed permanently
outside the anal canal. These irreducible masses
Hemorrhoids are divided into internal and ex- are known as fourth-degree or complicated third-
ternal types. The internal type arises in the up- degree hemorrhoids and are seen as interoex-
per two thirds of the anal canal, which is lined ternal hemorrhoids.
by columnar epithelium. External hemorrhoids Shafik4 suggests that there is no true anal ca-
arise in the lower third of the anal canal, which nal but rather a continuity of the rectum to
is covered by squamous epithelium of the skin. the perianal skin. The failure of remodeling
This type of classification may fit the description and the persistence of an anorectal band re-
in the early stages, but later, when the hemor- sults in a narrowing of the lower rectal neck,
rhoids have enlarged sufficiently, the internal which initiates the hemorrhoid disease. An
hemorrhoids may present externally at the anus. increase in rectal neck pressure and straining
According to Graham-Stewart,3 internal hem- during defecation eventually lead to a pro-
orrhoids can be further divided into two cate- lapse of the rectal mucosa and venous conges-
gories: tion.
248 M.Y. Sankar

Clinical Features of Internal Beneficial results are obtained with first- and
Hemorrhoids second-degree bleeding hemorrhoids. Third- and
fourth-degree hemorrhoids cannot be cured by
The prominent symptoms of internal hemor- injection treatment. The procedure is done in
rhoids are bleeding and prolapse. Apart from the office and can be repeated as necessary. The
these two main symptoms, the patient may suf- fibrous reaction that occurs after repeated in-
fer from a discharge leading to soiling of un- jections makes further injections more difficult.
derclothing, anal irritation, and symptoms of During the injection therapy of scleroscent
secondary anemia. Severe pain is present only agents (e.g., phenol in almond oil, sodium te-
in complicated cases of irreducible prolapse or tradecyl), the patient may experience some dis-
with an associated perianal fissure. A history of comfort. Late necrosis of the injection site may
slight pain was elicited by Bennett et al. 5 in 86% lead to ulcer formation and other rare compli-
of 138 patients suffering from hemorrhoids and cations, including submucous abscess forma-
was the presenting complaint in 18% of these tion, hematuria, prostatic abscess, and portal
cases. vein embolism.
On clinical examination, proctoscopy is the
essential step in confirming the presence of in- Operative Treatment
ternal hemorrhoids. Barium enema followed by
sigmoidoscopy and/or colonoscopy are man- The multiple operations available for the treat-
datory in patients over 40 years of age with rectal ment of hemorrhoids include the following (see
bleeding. Table 33.1):
1. Ligation and excision6--8
2. Submucosal hemorrhoidectomy9
Treatment of Internal 3. Excision of individual hemorrhoid with pri-
Hemorrhoids mary suture lO • 1I
4. Excision of the entire pile-bearing area with
The treatment of internal hemorrhoids include suture 12
the following major categories. 5. Clamp and cautery technique 13
6. Rubber-band ligation l4 . 15
7. Maximum dilatation of the anus 16
Conservative Treatment 8. Cryosurgery17·18
A conservative treatment is useful for first-de- 9. Infrared coagulation 19
gree hemorrhoids, especially when discovered 10. Laser hemorrhoidectomy
during a routine examination. The treatment
The increasing number of techniques mentioned
consists of regulation of bowel habits, admin-
above for dealing with hemorrhoids attests to
istration of mild laxatives, and advice regarding
the lack of universal satisfaction with those cur-
inclusion of a high-fiber diet. Suppositories and
rently available. Under these circumstances, the
ointments used locally for symptomatic relief
management is not only selected with a view to
probably have negligible value.
tailor the requirement to the individual patient's
specific problem, but also with regard for other
Injection Treatment factors, such as associated morbidity (e.g., pain,
bleeding), long-term complications (e.g., incon-
In selected cases, injection therapy is of great
tinence, recurrence, stricture), hospital stay, and
value. The two important effects are as follows:
cost-effectiveness.
1. Fibrous tissue is formed, which surrounds,
constricts, and obliterates blood vessels in the
submucosa. Lasers in Surgery
2. The fibrosis increases the fixation of the
hemorrhoid and the mucosa to the underlying The first reports on the use of lasers in medicine
tissues, thus preventing prolapse. appeared in the early 1960s 20 at that time the
 ...,
:--'
TABLE 33.1. Hemorrhoidectomy: Summary of review of various procedures, results, and postoperative complications l'
III
Postoperative '"....0>
Urinary Wound Anal incon- Anal Recur- Return to work ::c
0>
Mode of therapy Anesthesia Pain Bleeding Discharge retention healing tinence stricture rences (average) 3
0
Injection therapy + +/+ +" + Good +b */** Immediate. ....
(= 2 days) (7 days) (repetition of 3-
0
procedure in s:
0>
(")
most cases)
Rubber banding +/++ ++/+++c + Good */** Immediate.
0-
3
(= 2 days) (repetition of '<
procedure in
some cases)
Maximum dilation of General/local ++/+++d ± ± Good + +/+ + + ** 7 days
the anus with IV sedation
Cryosurgery Local with IV + +/+ + + +/+ +c + +/ Good */** 7-10 days
sedation (= 7 days) +++ (14 days)
Infrared coagulation + +/+ +" ++ Good */** 3-7 days
(= 2 days)
Formal conventional General/spinal/ + +/+ + + ++/+++c +/++ +/++ Good ±/++ +++ */** 5 days as
hemorrhoidectomy regional (= 7 days) (after 1st (21-28 days) inpatient; 15-
local with IV week) 21 days home
sedation recuperation
Laser hemorrhoidectomy
CO, laser Local with +/++ ± ± Good * Within 5 days
sedation (= 5-6 (14-21 days)
days)
Nd:YAG laser
Noncontact General (short)/ +/++ ± ± ± Good ± * Within 7 days
regional or local (= 5-6 (21 days)
with IV sedation days)
Contact General (short)/ + ± Good Being 2-3 days
regional or local (= 2-3 (7-14 days) assessed
with IV sedation days)

+ = mild/minimal; + + = moderate; + + + = severe; - = nil or none.

* = occasional; ** = sometimes; *** = frequent.
" Injection ulcer.
" Temporary.
" Secondary/reactionary hemorrhage.
d With subsequent daily passage of large anal dilator.
N
~
\Ci
250 M.Y. Sankar

CO2 laser scalpel was used in general surgery. levels found with CO2 laser beam. The contact
In 1973, the first flexible laser waveguide was cutting probes thus combine the coagulating
developed, which made the use oflasers possible properties of Nd:YAG laser with incising ca-
during fiberoptic endoscopy. 21 Lasers produce pabilities previously only seen with CO2 laser.
an intense beam of light of uniform wavelength
and color that can be precisely focused to deliver
high levels of energy to small areas. The most Laser Hemorrhoidectomy
important interaction between laser radiation
and tissue is the absorption of light and con-
In the United States, at present, over 150,000
version of the light energy into heat. In per-
conventional type of hemorrhoidectomies are
forming a laser hemorrhoidectomy, both the CO2
performed each year, with an average inpatient
laser and the Nd:YAG laser have been tried with
hospitalization stay of 5.9 days. The laser offers
varying degrees of enthusiasm. The CO2 laser,
an alternative method of treating hemorrhoids
operating at a wavelength of 10,600 nm and with
as an outpatient procedure under local, regional,
an energy output of 100 W, is effective in cutting,
or short general anesthesia.
but not very adept in performing coagulation.
On the other hand, the Nd:YAG laser, operating
at a wavelength of 1064 nm and with energy
output up to 150 W, can vaporize tissues at
CO 2 Laser
higher powers and coagulate bleeding points at Eddy and colleagues 23 have performed 150 pro-
relatively low powers, including blood vessels cedures using the CO2laser, and they claim that
up to 2 to 3 mm in diameter. Current N d: YAG the incidence of postoperative pain was consid-
laser light transmission systems use a flexible erably reduced, and therefore narcotics were
quartz fiber, which delivers laser energy at a seldom needed. Complications such as urinary
distance of 0.5 to 1.5 cm from the tissue. This retention and constipation were not seen even
noncontact system has distinct disadvantages in the elderly and poor-ri_sk patients. Mokhniuk
regarding beam irradiation, backscatter, and and colleagues,24 in the Proctological Division
damage to the quartz tip should it come into of the Kiev Medical Institute in Russia, treated
contact with tissue or blood. Furthermore, the 352 patients suffering from hemorrhoids between
Nd:YAG laser, due to its depth of penetration 1976 and 1980. Of these, 281 were women. In
into tissue in its noncontact mode, is used pri- 80%, a modified Milligan-Morgan procedure was
marily for coagulation but has poor cutting ca- performed. In the other 9% of patients, they va-
pabilities and may cause excessive tissue dam- porized the hemorrhoids with the CO2 laser,
age resulting in perforation. employing a power of 60 W in a continuous wave
Recently, a synthetic sapphire crystal has mode with a focused beam diameter of 0.2 mm.
been developed, which is easily attached to the Epidural anesthesia was administered and a
end of the quartz fiber, with a universal metal clamp or hemostat was applied to the base of
connector allowing contact irradiation. The each hemorrhoid before removing it. After re-
geometric shape of this contact synthetic sap- moval of the hemostat, no bleeding was ob-
phire provides the desired effect of coagulation served. In the immediate postoperative period,
of bleeding points and/or vaporization, as well edema was minimal and appeared much less
as precise incision of tissues. 22 Furthermore, the than that observed following the conventional
contact probes prevent backscattering of ligation and excision operation for hemorrhoids.
Nd:YAG laser light, reduce the depth of tissue Pain was almost absent, and no discharge was
damage, and allow for much lower powers of noted from the operated site. The laser may have
laser energy to be used. A longer probe attached sterilized the wound surface, preventing infec-
to a handpiece, the laser scalpel, allows for open tion during the postoperative period. In cases
surgery to be performed with ease. The power of hemorrhoids with thrombosis, Mokhniuk and
density at the tip of the contact probe is related colleagues24 recommend cryosurgery, but with-
to the distal probe diameter and the results ob- out supporting evidence. Rausis 25 has also
tained are comparable to the average power used the CO2 laser and found less pain in the
density values of different spot sizes and power postoperative period. Of their 21 proctologic
 33. Laser Hemorrhoidectomy 251

procedures using the CO 2 laser, 12 were for Nd:YAG Laser

third-degree hemorrhoids. The laser hemor-
The Nd:YAG laser has been used for hemor-
rhoidectomy followed the same principles as the
rhoidectomy with success though the techniques
Milligan-Morgan procedure, and there was a
described are different.
decrease in postoperative complaints, normal
bowel movements, and negligible postoperative Noncontact Nd:YAG Laser Technique
bleeding. Healing was complete after 2 or 3
weeks. No incontinence of flatus or feces was Eddy 29 applies the laser energy directly over the
observed nor anal stenosis. The follow-up of 1 target tissue by the noncontact method. The pa-
to 5 months is too short for evaluating recur- tient is placed in the lithotomy position, as this
rences. seems to be better than the jackknife position.
Denis and Lemarchand26 have carried out 150 General anesthesia was administered in 95% of
hemorrhoidectomies using the CO 2 laser, 150 cases, in response to the particular request of
cases by conventional operative methods, and these patients, although he feels the procedure
47 cases by electrocautery within a period of can be done as effectively under local anesthetic
one year. Results showed very little difference infiltration with intravenous sedation. Eddy
at the statistical 5% level between the CO 2 laser prefers a low power of 25 W for a short duration
and the conventional type of hemorrhoidectomy of 0.8 seconds, as opposed to a high power for
when factors like postoperative pain and wound longer duration. An important step is to leave a
healing are taken into consideration. On the normal area of tissue between the lasered sites,
other hand, electrocautery caused severe post- as this seems to give better results. The total
operative pain, requiring high analgesic con- operation time may take about 1 hour. During
sumption. Furthermore, with electrocautery, the postoperative period, mild swelling, a little
wound healing was delayed, and the consequent discharge and bleeding, and a feeling of slight
severe scarring inevitably led to anal stricture pressure could be experienced by the patient.
and stenosis. The initial postoperative bowel The complications that might occur are urinary
movements were similar in producing discomfort retention, especially in the older age group, and
in all three groups. Denis and Lemarchand con- bleeding, but not more than a cupful including
cluded that conventional surgery of hemorrhoids clots. In Eddy's series of 350 cases, the healing
by high ligation and excision was just as effective of the wound has taken about three weeks. The
as the laser. other possible complications are fistula forma-
In support of CO 2 laser hemorrhoidectomy, tion, excessive scarring, and sphincter damage.
the advantages include faster healing, less scar- According to Eddy, the Nd:YAG nontouch laser
ring and fibrosis, decreased recurrence, fewer technique is a "hot knife," which is similar to
postoperative complications, and excellent pa- the "cold knife," but definitely more advanta-
tient acceptance. 27 Zadeh 28 performed CO2 laser geous. Less pain is involved with this technique,
hemorrhoidectomy on 350 outpatients (70% and the patient returns to work sooner. Also,
male) injust over a year. In this group, 27% had as is true of all laser hemorrhoidectomy, it can
second-degree hemorrhoids, 39% third-degree, be performed as an outpatient procedure, which
and 34% fourth-degree. The majority received has two important benefits: Patients are not ex-
a local infiltration of anesthetic drug with intra- posed to nosocomial infections, and the pro-
venous sedation. The hemorrhoidectomy was cedure is cost-effective.
performed in about 20 minutes at a power den- Dwyer, 30 at the University Center of Los An-
sity between 38,200 and 47,000 W/cm 2 in the geles, uses the Nd:YAG laser noncontact tech-
continuous wave mode. Pain was classified as nique through a flexible fiberoptic colonoscope,
none (6%), minimal (29.8%), moderate (41.3%), which is retroflexed in the rectum to visualize
and severe (22.9%), and the average duration of the internal hemorrhoids. The flexible laser
postoperative pain was 5-6 days. Zadeh con- guide is introduced through the operating chan-
cludes that both routine and difficult cases can nel, and the hemorrhoidal veins are lasered from
easily be treated on an outpatient basis, using the proximal to the distal areas.
the CO 2 laser, thereby enhancing the cost-ef- Shude and Fengzao,31 at the Laser Research
fectiveness and convenience of patient care. Unit in Beijing, China, have treated 156 cases
252 M.Y. Sankar

of hemorrhoids using the Nd:YAG laser non- sigmoidoscopy/colonoscopy is performed to

contact technique under local anesthesia. In this confirm or exclude associated chronic lesions.
group also the same advantages were apparent: The nature and position of the internal hemor-
It is a safe and simple procedure that can be rhoids are noted on anoscopy.
used on an outpatient basis. The patients are First- and second-degree internal hemorrhoids
able to return to work much earlier therefore it are coapted by using the SLT flat contact probe
is cost -effective. Finally, there are fewer post- or SLT coagulation probe (Surgical Laser
operative complications. Technologies, Inc., Malvern, PA), which is ap-
plied around the hemorrhoid to begin with and
Contact Nd:YAG Laser finally onto it directly (Figure 33.1). The power
used is between 5 and lOW for a duration of 2
Since 1985 , at the University of Cincinnati
to 3 seconds with coaxial water. Successful
Medical Center, laser hemorrhoidectomy has
coapting is indicated by blanching the tissue, and
been performed using Nd:Y AG laser with the
the blood loss is nil. Care is taken not to use
contact technique. To date, 23 cases have been
higher power levels, causing vaporization of the
treated (17 males), aged 31 to 76 years. A de-
mucosa, which leads on to prolonged discharge
tailed study, including postoperative compli-
per rectum. Local infiltration of a long-acting
cations , cost-effectiveness, incidences of recur-
local anesthetic is carried out at the end of the
rence, and long-term results, is currently in
procedure.
preparation.
Third- and fourth-degree internal hemorrhoids
are treated by submucosal hemorrhoidectomy
Technique of Contact Laser
using Nd:YAG laser contact technique (Figures
Hemorrhoidectomy
33.2-33.4). A Fansler proctoscope is inserted
For two days before surgery the patients are on and the hemorrhoid to be operated on is brought
a low-residue diet, and take golytely preparation under direct view. No dilatation of the anus or
in adequate quantities on the previous afternoon infiltration of norepinephrine is carried out. The
before surgery. On the morning of the third day hemorrhoid is grasped and pulled toward the
they report to the surgicenter on an empty operator with gentle traction. A linear incision,
stomach. One of the following anesthetics is using the SLT Laser Scalpel (Surgical Laser
used, as indicated: epidural, caudal, short gen- Technologies, Inc., Malvern, PA) with a tip di-
eral, or local with intravenous sedation. The pa- ameter of 0.2/0.4 mm, is made from the base of
tient is placed in the lithotomy position, and the the pedicle outward. The power used is in the
anorectal region is examined. Flexible fiberoptic range of 10 to 15 W in the continuous wave mode

·COAPTATlON· USING
CONTACT LASER
SURGERY

FIGUR E 33.1. Internal hemorrhoids

(second-degree): coaptation, using
contact laser surgery technique.
33. Laser Hemorrhoidectomy 253

-SUBMUCOSAL
HEMORRHOIDECTOMY
USING CONTACT
LASER SURGERY
(STEP: 1)

FIGURE 33.4. Internal hemorrhoids: submucosal hem-

orrhoidectomy, using contact laser surgery technique
(step 3).
FIGURE 33.2. Internal hemorrhoids (left lateral, third-
degree): submucosal hemorrhoidectomy, using con-
tact laser surgery technique (step 1). or coapted if they are first- or second-degree.
At the end of the procedure, 0.5% Marcaine
(bupivacaine) (10 m!) is injected around the
controlled by the foot pedal. The hemorrhoid is sphincter region and the area is gently massaged,
separated up to the pedicle and a high ligation and an anal tampon is inserted. A dressing is
is carried out using 0 chromic catgutldexon su- applied and the patient is taken back to the day
ture. The pedicle is then "lased" distal to the care center. The total blood loss during the sub-
ligature, leaving a comfortable sleeve, thus pre- mucosal hemorrhoidectomy by the Y AG laser
venting any possible slipping of the ligature. contact technique is less than 10 m!. The average
Following this, any bleeding points are lased and duration of the procedure is less than 30 minutes.
a dry field almost invariably results. The mu- Patients are advised to take analgesics (acet-
cosal incision is approximated together without aminophen) if and when they feel any discom-
tension using 2/0 chromic catgut. The procedure fort . They are further advised to go on a high-
is repeated on the other hemorrhoids by laser fiber diet from postoperative day 1. Each patient
excision of third- and fourth-degree hemorrhoids is seen in 1 week as an outpatient.

FIGURE 33.3. Internal hemorrhoids:

submucosal hemorrhoidectomy, us-
ing contact laser surgery technique
(step 2).
254 M.Y. Sankar

Evaluation of Contact Laser laser scalpel. No new skin or mucosal tags have
Hemorrhoidectomy been observed after the laser procedure.

Pain Recurrence of Piles

The surgical treatment of hemorrhoids carries The first contact laser hemorrhoidectomy was
with it a notorious reputation for severe post- performed in our center in November 1985. To
operative pain. Following contact laser hemor- date, there have been no recurrences of internal
rhoidectomy, in accordance with the scoring hemorrhoids, but the follow-up period is too
system ofWatts/2 all patients were in the B cat- short. One patient returned with pain at 6
egory-less than average pain. The first night months due to the formation of a posterior fis-
after the operation, all were able to sleep upon sure-in-ano associated with severe constipation
taking 1 to 2 tablets of acetaminophen. All pa- and external hemorrhoids. Neither were present
tients felt some discomfort during the first bowel at the first visit.
movement, which ranged from a burning sen-
sation to pain. This was of short duration and
they were able to go about their daily chores Conclusion
without any further problem.
The main advantage of the submucosal hemor-
rhoidectomy as outlined by Parks9 and modified
Retention of Urine
by Goligher33 appears to be the decrease in
Urine retention, requiring catheterization, has postoperative pain. The reason for this is that
not occurred in our small number of cases. This the ligature does not include any anal mucosa,
may be partially related to the avoidance of local which is particularly sensitive. Furthermore, fi-
infiltration of norepinephrine before the pro- brosis or stricturing does not occur, as neither
cedure. the mucosa nor the skin is excised. The disad-
vantage of this operation is that it is difficult to
Hemorrhage dissect the mucosa off the hemorrhoid because
of bleeding, which may be troublesome and
Postoperative bleeding, either reactionary or
time-consuming. The use of the Nd:YAG laser
secondary, has not occurred.
contact technique in performing this operation
eliminates this disadvantage. Thus, this method
Wound Healing
of contact laser hemorrhoidectomy may become
The lesions produced in the anal canal cannot the preferred treatment, replacing the other
be visualized in the first week after surgery be- standard procedures. Further information and
cause of the pain, discomfort, and apprehension follow-up studies are required.
associated with the introduction of an anoscope.
This method does not produce an actual wound
over the skin area. Inspection at 15 days to 3 References
months will show a healed wound without fi- 1. Banov L: The Chester Beatty medical papyrus:
brosis. The earliest known treatise completely devoted
to anorectal diseases. Surgery 58: 1037-1043, 1965.
Anal Incontinence 2. Parks AG: De Haemorrhoids. Guy's Hosp Rep
104: 135, 1955.
No incontinence of flatus or feces with soiling 3. Graham-Stewart CW: What causes hemorrhoids?
of the underclothing has been observed. The risk A new theory of etiology. Dis Colon Rectum
of anal incontinence is decreased because max- 6:333, 1963.
imal dilatation of the anus is avoided during 4. Shafik A: A new concept of the anatomy of the
contact laser surgery for hemorrhoids. anal sphincter mechanism and the physiology of
defecation, treatment of hemorrhoids: Report of
Formation of Skin and Mucosal Tags a technique. Am J Surg 148:393-398, 1984.
5. Bennett RC, Friedman MHW, Goligher JC: The
Any skin tag that is found during the laser op- late results of hemorrhoidectomy by ligature and
erative procedure is excised with the contact excision. Br Med J 2:216, 1963.
33. Laser Hemorrhoidectomy 255

6. Lockhart-Mummery JP: Diseases of Rectum and doscopy with a fiberoptic transmission system.
Colon, 2nd ed. Bailliere, London, 1934. Endoscopy 5:203-218, 1973.
7. Milligan ETC, Morgan C, Naunton Jones LE, 22. Daikuzono N, Joffe SN: Artificial sapphire probe
Officer R: Surgical anatomy of anal canal and op- for contact photocoagulation and tissue vapori-
erative treatment of hemorrhoids. Lancet 2: 1119, zation with Nd:YAG laser. Med Instrum 19: 173-
1937. 178, 1985.
8. Miles WE: Rectal Surgery. Cassell, London, 1939. 23. Eddy HJ, Yu JC, Eddy EC: Dual laser hemor-
9. Parks AG: Surgical treatment of haemorrhoids. rhoidectomy. (Abstract). Lasers Surg Med 6:201,
Br J Surg 43:337, 1956. 1986.
10. Mitchell AB: A simple method of operating on 24. Mokhniuk YN, Baltaitis YV, Maltsev VN, et al:
piles. Br Med J 1:482, 1903. Comparative evaluation of methods of treatment
11. Ferguson JA, Heaton JR: Closed hemorrhoidec- of patients with hemorrhoids. Clin Surg 2(494):1-
tomy. Dis Colon Rectum 2:176, 1959. 4, 1983.
12. Whitehead W: Surgical treatment of hemorrhoids. 25. Rausis C: Surgery of hemorrhoids by means of
Br Med J 1:149, 1882. CO 2 laser (Chirurgie des hemorroides avec Ie laser
13. Anderson HG: The after results of the opera- CO 2 ). Schweiz Rundschauc Med (Praxis) 71: 177-
tive treatment of hemorrhoids. Br J Med 2: 1276, 180, 1982.
1909. 26. Denis J, Lemarchand N: The present day treat-
14. Blaisdell PC: Prevention of massive hemorrhage ment of hemorrhoids (Etat actuel due traitement
secondary to hemorrhoidectomy. Surg Gynecol des hemorrhoides). Rev Infirm 3:49-51, 1985.
Obstet 106:485, 1958. 27. Riedlinger J: The surgical treatment of hemor-
15. Barron J: Office ligation of internal hemorrhoids. rhoids by means of CO 2 laser. Laser Tokyo '81
Am J Surg 105:563, 1963. 23:30-31, 1981.
16. Lord PH: A new regime for treatment of hem- 28. Zadeh AT: Three hundred and fifty hemorrhoi-
orrhoids. Proc R Soc Med 61:935, 1968. dectomies using the CO 2 laser. Lasers Surg Med
17. Lewis MI: Diverse methods of managing hem- 5: 145, 1985.
orrhoids: Cryohemorrhoidectomy. Dis Colon 29. Eddy HJ: Personal communication, 1986.
Rectum 10:175, 1973. 30. Dwyer R: The technique of gastrointestinal laser
18. Lloyd-Williams K, Haq IV, Glem B: Cryo- endoscopy. The Biomedical Laser. Springer-
destruction of hemorrhoids. Br Med J 1:666, Verlag, New York, 1981, pp 255-269.
1973. 31. Shude Z, Fengzao MA: Hemorrhoidectomy and
19. Leicester RJ, Nicholls RJ, Mann CV: Infrared fistulectomy with neodymium:YAG laser. Per-
coagulation in the treatment of hemorrhoids. Gut sonal communication, 1986.
22:436, 1981. 32. Watts JM, Bennett RC, Duthie HL, Goligher JC:
20. Goldman L, Hornby P, Long E: Effect of the laser Healing and pain after different forms of hemor-
beam on the skin. Transmission of laser beams rhoidectomy. Br J Surg 51:88, 1966.
through fiberoptics. J Invest DermatoI42:231-234, 33. Goligher J: Haemorrhoids or piles. In Surgery of
1964. the Anus, Rectum and Colon, 5th ed. Bailliere
21. Nath G, Gorish W, Kiefhaber P: First laser en- Tindall, London, 1984, pp 123-125.
34
Splenic Resection with the SLT Contact
Nd:YAG Laser System®: A Comparison of
Contact Nd:YAG with the CO2 Laser
John Foster, Tom Schroder, Kim A. Brackett, and Stephen N. Joffe

The spleen has important physiologic and im- cially available Nd:YAG laser systems lends it-
munologic functions and should be surgically self to this application. Experiments comparing
conserved whenever possible. Morris and the noncontact with the contact Nd:YAG laser
Bullock 1 in 1919 showed that splenectomized in liver and pancreas surgery have achieved su-
rats had an increased susceptibility to infection perior results with the contact probes, with
and in 1952, King and Shumacker2 reported a lower requirements of laser power, power den-
significant increase in fatal aepsis in children sity, reduced bleeding, less smoke production,
following splenectomy. Subsequent studies have and decreased tissue damage. 23 •24 This study
confirmed an Increased morbidity and mortality showed the advantages in splenic surgery of the
of 50 to 200 times normal in patients of all ages, new contact Nd:YAG laser over the noncontact
at various times following splenic removal, and CO2 laser, the conventional laser modality. 13.15.16
have therefore advocated surgical alternatives
to total splenectomy. 3-9 Splenic repair with ad-
equate hemostasis is difficult due to the highly Instrumentation
vascular and extremely fragile splenic tissue.
Lasers are ideally suited for use in surgery, For the noncontact method a directed energy
especially in highly vascular organs such as the 25-W CO 2 laser was used with 25-millisecond
kidney, liver, and spleen, where cutting and si- pulses and a spot size of 0.5 mm. For the contact
multaneous coagulation of small vessels are method a Cooper Lasersonica 8000 Nd:YAG
possible. 10-12 Both the CO 2 and Nd:YAG lasers continuous wave laser 0.06 fJ-m wavelength) was
have been used to undertake splenic resections used, operated at 10 W. The beam was directed
using a noncontact method of directing the beam through a 600-fJ-m quartz fiber to the hand-held
at the target tissue. However, the CO 2 laser contact saphire probe. A Surgical Laser Tech-
achieved poor hemostasis while the non contact nologies (SLT) 1.2-mm Frosted Laser Scalpel
Nd:YAG laser provided inadequate cutting. 13-17 probe was used for cutting the tissue and
Other disadvantages included the inability to achieving hemostasis (Figure 34.1).
coagulate larger vessels and the need for high-
power levels leading to unnecessary tissue ne-
crosis and excessive smoke production. 18-20 Surgical Procedure
The concept of laser contact probes has been
previously proposed. 21 The idea is now practical, Ten fasted dogs were divided into two groups.
with the development of an effective and in- Under general anesthesia, the abdomen was
expensive synthetic sapphire probe, which al- opened with a midline incision and the would
lows the laser energy and simultaneous coaptive edges retracted. The spleen was identified and
pressure to be applied to a desired point with transected through its vascular bed into ap-
little effect on adjacent tissue. 22 The conven- proximately two equal portions, each connected
tional fiber optic delivery system of commer- to its vascular pedicle, which was not clamped
34. Splenic Resection With the SLT Contact Nd:YAG Laser System 257

FIGURE 34.1. SLT Contact laser scalpel probe.® The in use in the operative field. Note the fiberoptic de-
hand-held scalpel assembly is seen here during splenic livery system entering the rear of the assembly.
division. The SLT frosted scalpel contact probe ® is

during the procedure (Figure 34.2). One group Analysis of Results

of animals underwent splenic division with the
noncontact CO 2 laser and the other with the Operative data included operating time (in min-
contact N d: Y AG. Any residual bleeding was utes), blood loss (in milliliters), the number of
controlled with 3-0 chromic ties. The abdominal ligatures used and amount of smoke production
cavity was closed and the animals returned to (graded semiquantitatively from 0 to 4 + ). Pre-
their cages with free access to food and water. operative blood samples were taken on days 1,

FIGURE 34.2. Isolated canine spleen and path of di- proximate site of division, separating the spleen into
vision. The spleen has been isolated and elevated from two approximately equal sections and dividing the
the abdominal cavity. The dashed line shows the ap- vascular bed between two adjacent vascular arcades.
258 John Foster, Tom Schroder, Kim A. Brackett, and Stephen N. Joffe

4, and 14 and were analyzed for leukocyte count, probe was also used to achieve adequate he-
hemoglobin, hematocrit, and platelet count. All mostasis, as it provided better coagulating
animals were sacrificed on day 14. Histologic properties than the scalpel probe alone.
samples of the cut splenic edge were taken With the noncontact CO 2 laser, blood loss av-
postoperatively and on day 14 and were used to eraged 103.8 ± 30.2 cc and an average of 6.4 ±
measure the lateral penetration and depth of tis- 2.3 ties were needed, with a minimum of four
sue necrosis from the laser energy. Values are ties per animal (Table 34.1). Blood loss occurred
given as means ± standard deviation. the sta- throughout the operation from oozing at the cut
tistical evaluation of the data used the analysis parenchymal surface, requiring multiple treat-
of variance method. A value of p < 0.05 was ment with the laser beam to achieve hemostasis.
considered significant. Larger vessel bleeding was frequent and was
rapidly controlled with suture ligatures. With the
contact N d: YAG laser scalpel, blood loss av-
Experimental Results eraged 50.2 ± 31.9 cc (p < 0.05), which was
52% less than the CO 2 group, with only one an-
There were no intraoperative deaths. Operative imal requiring one tie, giving a mean of 0.2 ties
results are shown in Table 34.1. Operating time per animal (p < 0.01). Bleeding occurred as the
from the initial incision of the splenic capsule tissue was divided but was rapidly controlled by
until hemostasis was achieved averaged only the laser energy without residual bleeding.
13.2 ± 2.9 minutes with the SLT contact Larger vessel bleeding was rare (2 to 3 sites per
Nd:YAG laser scalpel, as compared to 23.6 ± operation) and hemostasis was usually achieved
8.2 minutes with the noncontact CO 2 laser (p < with repeat application of the frosted laser scal-
0.05). pel or use of the chisel-shaped probe.
The CO 2 laser energy was absorbed by any Noncontact CO 2 laser resection at 25 W was
blood on the splenic surface, preventing pene- associated with moderate to large amounts of
tration of the laser beam to the underlying tissue malodorous smoke (3 + to 4 + ), requiring a large
and necessitating constant suctioning and suction device for its removal. Contact Nd:Yag
sponging with frequent operating delays. This laser resection produced only minimal amounts
prevented achieving hemostasis with even of smoke (l + ), and suctioning was not required.
moderate-sized vessels as the issuing blood All animals survived till 14 days and neither
would prevent penetration of the laser energy group showed any evidence of intraabdominal
to the vessel walls. Suture ties were needed fre- abscess or bleeding. Both groups showed min-
quently as a result. imal peritoneal adhesions that were easily sep-
The SLT Nd:YAG laser scalpel had none of arated from the cut splenic surface.
these problems. Tissue cutting was easily Hematologic studies showed no significant
achieved even in the presence of blood, and he- differences between the two laser modalities,
mostasis was usually adequate, leaving a sealed and there were no major differences between
splenic surface (Figure 34.3). Even the largest preoperative and day 14 values. Several of the
vessels were usually sealed with repeat appli- day 1 samples from the Nd:Yag animals were
cation of energy from the froated sides of the hemolyzed and the data were lost. With accurate
laser scalpel. In three animals a chisel-shaped values from only two animals, day 1 values are
included for reference only but were excluded
from any statistical analysis. In both groups
TABLE 34.1. Operative data for splenic resection there was a slight postoperative increase in the
with the Nd:YAG laser. hemoglobin content (Figure 34.4A) and hema-
Noncontact Contact tocrit (Figure 34.4B) that persisted for the full
Category CO 2 Nd:YAG observation period. However, only in the he-
Operating time 23.6 ± 8.2 min 13.2 ± 2.9 min matocrit values from the Nd:YAG animals did
Blood loss 103.8 ± 30.2 ml 50.2 ± 31.9 ml this achieve statistical significance (p < 0.05).
Suture ties 6.4 ± 2.3 0.2" Both groups showed a similar increase in the
Smoke production 3+ 1+ postoperative white blood cell count that re-
"Only one animal required one tie. solved by day 14 (Figure 34.4C).
34. Splenic Resection With the SLT Contact Nd:YAG Laser System 259

FIGURE 34.3. Division of the spleen with the SLT laser of cut splenic surfaces after division. Both sections
contact probe.® (A) The splenic parenchyma is being are well supplied with their existing vascular pedicles
divided using laser energy focused through the sap- but the division is complete. Note the absence of
phire contact probe . The frosted edges scatter some bleeding only moments after the division and the car-
energy to the sides, aiding in achieving hemostasis. bonized "sealed" cut surfaces. The actual tissue
Note the minimal bleeding from the cut surfaces. No damage extends less than 0.8 mm into the splenic
ties have been used in this division. (B) Appearance prenchyma.

In both groups the platelet count slowly in- 0.4 mm and was equal to the Nd: Y AG laser-
creased postoperatively, but returned to baseline induced damage , which remained at 0.8 ± 0.3
by day 14 (Figure 34.4D). mm. In all cases the tissue damage was limited
Histologic sections showed minimal necrosis to 0.8 mm from the cut parenchymal edge .
and tissue damage that was equivalent between
the two laser modalities by day 14 (Figure 34.5).
Table 34.2 summarizes the histologic results. Discussion
The Nd:Y AG animals showed a larger initial
tissue damage of 0.8 ± 0.3 mm compared to the For over 20 years the importance of preserving
CO 2 damage of 0.35 ± 0.05 mm. However, by splenic function has been recognized. In children
day 14 the CO 2 damage had increased to 0.8 ± especially, but in adults as well, the incidence
 Non-Cont. Contact
C02 YAG
~ _oC._

Hb (gm/dl)
14r-----------------------------------------------~
~
.; ~-----.-- ------- ----~~~

13 "

12

11

o 1 2 3 4 5 6 7 8 9 10 11 12 13 14
A Poat-Operatlve Day

Non-Cont. Contact
C02 YAG
A _oC._

Hot (%)
4Or---------------------------------------------~
/
~---------~-------~
38 /
/
/
38
/
/
/
/
34
I
Y
I
rJ
32

o 1 2 3 4 5 6 7 8 8 W ~ n ~ ~

B Poat-Operatlve Day
FIGURE 34.4. Comparison of hematologic parameters line = noncontact CO 2 laser; dashed line = contact
as measured preoperatively, and on days 1, 5, and Nd:YAG laser. (A) Hemoglobin levels. (B) Hema-
14. Day 1 values were not included in the statistical tocrit levels.
analysis and are included for reference only. Solid

260
 Non-Cont. Contact
C02 YAG
A
-~-

wee (thoueande'
4Or---~------------------------------------------,

30

20
"'eI __ _
--- "'- ...... --..-- ---
---------El
10

o 1 2 3 4 5 e 7 8 9 W ~ ~ ~ u
c Poet-Operative Day

Non-Cont. Contact
C02 YAG
A -,g.-

Pit (thoueande'
500r-~----------------------------------------------,

7
400 /
/
/
/
/
/
/
300 -~

200~ __~__~~__~~__~~__~~~~__~~__~__~
o 1 2· 3 e 7 8 9 10 11 12 13 14
D Poet-Operative Day
FIGURE 34.4 (continued). (C) White cell counts . (D) preoperative and day 14 values for any of the he-
Platelet counts. With both laser modalities there were matologic parameters studied.
no statistically significant differences between the

261
262 John Foster, Tom Schroder, Kim A. Brackett , and Stephen N. Joffe

FIGURE 34.5. Resected spleen, 14 days postopera- debris. This appearance was the same for all samples
tively. The resected surface of the sample is covered regardless of whether resection was by CO 2 or contact
by a layer of dense connective tissue, approximately Nd:YAG laser.
0.8 mm thick, containing small islands of carbonized

TABLE 34.2. Tissue damage (/-Lm) in splenic offatal sepsis and other fatal infections is mark-
resection. edly increased after splenectomy. Often sple-
Day Noncontact CO, Contact Nd:YAG
nectomy is performed when viable splenic tissue
should have been preserved due to the difficulty
o 350 ± 46 781 ± 326
in achieving hemostasis by conventional meth-
14 756 ± 379 763 ± 253
ods.
34. Splenic Resection With the SLT Contact Nd:YAG Laser System 263

Noncontact lasers have been used in splenic operating time (44%) over the noncontact CO 2
surgery for some time with demonstrated im- laser as well as greater ease of handling and use.
provement in achieving hemostasis, decreased During the SLT contact Nd:YAG resection the
intraoperative blood loss, and decreased oper- field remained virtually dry, except when large
ating time. The noncontact CO 2 laser has had vessels were encountered. These were almost
the greatest application due to its excellent cut- always controlled with repeat application of the
ting properties. The CO 2 laser is limited by its scalpel probe, first circumferentially, then with
inability to penetrate water or blood, making pressure on the vessel itself. No suture ties were
work in a bloody field quite difficult with sig- needed in four of the five animals and the fifth
nificant blood loss. In the spleen this is often required only one tie to achieve hemostasis.
compensated for by cross-clamping the splenic With the noncontact CO 2 laser constant
artery while the parenchymal vessels are sealed bleeding occurred, which required continuous
in a bloodless field. However, this can allow is- sucti2-ning, sponging, and repeat applications of
chemic or thrombotic events to occur and can the laser energy. Multiple ties were always
damage the splenic artery. needed due to the inability of the CO 2 laser to
The noncontact Nd:YAG laser is able to pen- stop large-vessel bleeding. These factors led to
etrate water and blood to reach the parenchyma, twice the blood loss, almost twice the operating
and can seal bleeding vessels with great effi- time, and the need for increased tissue manip-
ciency, but is unable to match the cutting prop- ulation when compared to the Nd:YAG group.
erties ofthe noncontact CO 2 laser. The 1.06-f.1m With both laser modalities tissue penetration
N d: Y AG wavelength is absorbed diffusely by and damage, as measured by depth of necrosis,
tissue with a deeper penetration and wider dis- was minimal. The contact Nd:YAG was not sig-
tribution than the CO 2 wavelength, which is nificantly different from the noncontact CO 2
largely absorbed at the surface. This leads to a with its surface-level absorption properties.
greater depth of tissue necrosis and decreased Tissue necrosis was equivalent at day 14 and
cutting ability. was <0.8 mm with both modalities.
The SLT contact Nd:YAG laser has the he- Hematologic parameters varied equivalently
mostatic characteristics of Nd:YAG energy with with both laser modalities, and there were no
precise energy focusing and tissue penetration. significant differences between the preoperative
This allows excellent hemostatic and cutting baseline and day 14 values. None ofthe animals
properties, even in a bloody field, with minimal had postoperative complications, and in all an-
tissue damage and necrosis. The synthetic sap- imals adhesions were minimal and equivalent
phire scalpel probes sharply focus the energy between the two groups.
directly in front of the crystal with a high angle One significant qualitative parameter was the
of diffusion. This provides maximal energy den- ease of operation with the SLT contact
sity over a very limited area with rapid diffusion Nd:YAG. In addition to the decreased blood
and minimal unwanted penetration. With the loss, decreased number of ties, and decreased
"frosted" tips a portion of the energy is scat- surgical manipulation, the entire operative pro-
tered diffusely from the roughened lateral sides cedure was subjectively much simpler and more
of the probe, allowing for better coagulating effective. The hand-held laser scalpel was simple
properties. Adequate coagulation is actually to use while providing tactile sensation and pre-
possible when only the energy from the frosted cise control to the user. The resection procedure
sides of the tip is used. involved simply cutting through the parenchy-
In our study, the SLT contact Nd: Y AG laser mal tissue with the scalpel using variable direct
showed a significant advantage over the non- pressure to assist in cutting and hemostasis. The
contact CO 2 laser for splenic resection in the CO 2 laser, however, was large and cumbersome
dog. We decided to compare the contact and required balancing the laser unit manually
Nd:YAG with the noncontact CO 2 , as the non- while aiming the beam at the target tissue. There
contact CO 2 laser is currently the most widely was only visual feedback from the aiming beam
used laser modality for splenic resection. and tissue observation to assess beam penetra-
The SLT contact Nd:YAG showed a signifi- tion, depth of cut, and cutting characteristics of
cantly decreased blood loss (52%) and decreased the tissue. No direct pressure could be applied
264 John Foster, Tom Schroder, Kim A. Brackett, and Stephen N. Joffe

to the tissue to aid in hemostasis. During the 6. De Boer J, Sumner-Smith G, Downie HG: Partial
operation a great deal of effort was applied to splenectomy. Technique and some hematologic
suctioning and sponging the tissue surface to al- consequences in the dog. J Pediatr Surg 7:378-
low cutting to proceed. With the CO 2 laser, the 381, 1972.
entire operative field and all instrument surfaces 7. Buntain WL, Lynn HB: Splenorrhaphy: Changing
had to be covered with wet gauze to prevent concepts for the traumatized spleen. Surgery
damage from stray beam penetration. This was 86:748-760, 1979.
not necessary with the SLT contact probe, as 8. Boerma EJ, Klopper PJ, Van Der Heyde MN:
Save the spleen-An experimental study on the
the energy is focused immediately in front of
effects of three tissue adhesives on deep wounds
the scalpel tip. of liver and spleen. Neth J Surg 33: 10-13, 1981.
9. Barrett J, Sheaff C, Abuabara S, Jonasson 0:
Splenic preservation in adults after blunt and
penetrating trauma. Am J Surg 145:313-317, 1983.
10. Meyer HJ, Haverkampf K: Experimental study
Conclusion of partial liver resection with a combined CO 2 and
Nd:YAG laser. Lasers Surg Med 2: 149-154, 1982.
Splenic resection in the dog proved to have de- 11. Benderev TV, Schaeffer AJ: Efficacy and safety
creased blood loss, decreased operating time, of the Nd:YAG laser in canine partial nephrec-
and decreased surgical manipUlation when the tomy. J Urol 133:1108-1111, 1985.
SLT contact Nd:YAG laser with the SLT con- 12. Rosemberg SK: Clinical experience with carbon
tact synthetic sapphire probe was used, in con- dioxide laser in renal surgery. Urology 25: 115-
trast to the noncontact CO 2 laser. Tissue damage 118, 1985.
and hematologic changes were minimal and 13. Giler S, Ben-Bassat M, Gassner S, Kaplan I: The
equivalent between both laser sources. The CO 2 laser in surgery of the spleen-An experi-
mental study. In Kaplan I (ed): Laser Surgery II,
overall ease of use and operating technique were
Vol 2. OT-PAZ POB 6048, Tel Aviv, 1979.
subjectively better with the SLT contact 14. Dixon JA, Miller F, McCloskey D, Siddoway J:
Nd:YAG laser, and the danger of stray beam Anatomy and techniques in segmental splenec-
damage is eliminated. The SLT contact tomy. Surg Gynecol Obstet 150:516-520, 1980.
Nd:Y AG laser with the synthetic sapphire 15. Snider WR, Li S: Partial splenectomy with CO 2
probes offers a significant advantage over the laser: An experimental study. Lasers Surg Med
noncontact CO 2 laser in the resection of splenic 1:357-360, 1981.
tissue. 16. Orda R, Wiznitzer T, Bubis n, Alon R: Hemi-
splenectomy using a hand-held CO 2 laser. An ex-
perimental study. J Pediatr Surg 17:163-165,1982.
17. Van der Werken C, Goris RJA, Van der Sluis RF,
References et al: Comparison of sapphire infrared coagulation
and Y AG-Iaser in the surgery of parenchymatous
1. Morris DH, Bullock FD: The importance of the organs: An experimental study. Neth J Surg
spleen in resistance to infection. Ann Surg 70:513- 36:130-133, 1984.
521,1919. 18. Hall RR, Beach AD, Baker E, Morrison PCA:
2. King H, Shumacker HB: Splenic studies. I. Sus- Incision of tissue by carbon dioxide laser. Nature
ceptibility to infection after splenectomy per- 232:131-132,1971.
formed in infancy. Ann Surg 136:239-242, 1952. 19. Ben-Bassat M, Ben-Bassat M, Kaplan I: A study
3. Dretzka L: Rupture of the spleen. A report of of the ultrastructural features of the cut margin
twenty-seven cases. Surg Gynecol Obstet 51:258- of skin and mucous membrane specimens excised
261, 1930. by carbon dioxide laser. J Surg Res 21:77-84,
4. Morgenstern L: Experimental partial splenecto- 1976.
my: Application of cyanoacrylate monomer tissue 20. Brackett KA, Sankar MY, Joffe SN: Effects of
adhesive for hemostasis. Am Surg 31:709-712, Nd: Y AG laser photoradiation on intra-abdominal
1965. tissues: A histological study of tissue damage
5. Bisno AL, Freeman JC: The syndrome of as- versus power density applied. 6: 123, 1986.
plenia, pheumococcal sepsis, and disseminated 21. Durtschi MB, Stothert JC, Ashleman B, et al:
intravascular coagulation. Ann Intern Med Laser scalpel for solid organ surgery. Am J Surg
72:389-393, 1970. 139:665-668, 1980.
34. Splenic Resection With the SLT Contact Nd:YAG Laser System 265

22. Daikuzono N, Joffe SN: Artificial sapphire probe scalpel, with the conventional non-contact meth-
for contact photocoagulation and tissue vapori- od. Surg Gynecol Obstet , 1986.
zation with the Nd:Y AG laser. Med Instrum 24. Schroder T, Brackett K, Joffe SN: Proximal Pan-
19: 173-178, 1985. createctomy: A comparison of electrocutery with
23. Joffe SN, Brackett KA, Sankar MY, Diakuzono the contact and non-contact Nd: YAG laser tech-
N: Liver resection with the Nd:YAG laser: A niques in the dog. Am J Surg In Press, 1987.
comparison of a new contact probe, the laser
35
Liver And Pancreatic Laser Surgery
T. Schroder and Stephen N. Joffe

Pancreatic operations are often associated with were no differences in severe complications be-
technical difficulties due to the anatomy of the tween the groups.
pancreas and its blood supply. 1 Clinical opera- With the development of contact laser surgery
tions are time-consuming and blood loss can be and the contact probes (Surgical Laser Tech-
considerable. 2 Blood vessels are commonly li- nologies, Malvern, PA) the Nd:YAG laser is
gated and pancreatic tissue incised either with now introduced into general surgery. The SLT
a scalpel or electrocautery. 3 There are only a contact probes provide a precise incision and
few reports on the tissue effects of the various dissection and the good coagulation properties
lasers on the pancreas. 2.3 of the Nd:YAG laser. 8 In a recent study the new
The trend in recent years for the treatment of SLT contact Nd:YAG laser technique was
pancreatic carcinoma, and occasionally for compared with the old non contact method and
pancreatit;s, has been toward total pancreatec- with the conventional electrocautery technique. 9
tomy. Furthermore, the pancreas is now being In this study a proximal pancreatectomy was
harvested for transplantation. Sutherland et al. 4 done in 15 mongrel dogs. The head of the pan-
report recent clinical experience with living re- creas was removed and only a small portion of
lated pancreatic transplantation and Rossi et al. 5 the pancreatic tail was left in situ. The electro-
call for refining the technique of total pancrea- cautery ("bovie") technique was used, which
tectomy with duodenal preservation and the use is a modification of the conventional ligature
of total pancreatectomy in cases of chronic pan- technique. The small vessels were coagulated,
creatitis. Preservation of the duodenum during and vessels too big to coagulate were ligated.
pancreatectomy is important in experiments de- Both the bovie and the contact Nd:YAG laser
signed to study the interaction of gut hormones were technically superior to the noncontact
in the apancreatic animal with intact biliary and Nd:YAG. The latter was slower and caused
gastrointestinal tract. Any operative technique more bleeding and smoke than the other two
that can reduce operating time, blood loss, and methods.
associated morbidity and mortality would be The thermal injury to the pancreas by the
advantageous. 6 contact Nd:YAG was less than in the noncontact
In a recent study, pancreatic resections were group. When the pancreas was dissected with
done with the use of a noncontact Nd:YAG laser the contact laser, hemostasis was achieved im-
in dogs. 7 In that study the operative technique mediately. After cutting with the two other de-
and the operative results were compared, using vices, extensive coagulative energy had to be
the noncontact Nd:Y AG and a conventional applied to the resected surface to stop bleeding.
multiple ligature technique. The study demon- This resulted in a thick necrotic surface on the
strated that the laser and the conventional tech- pancreatic stump, which was probably the rea-
nique both caused minimal blood loss, but the son for hemorrhagic pancreatitis resulting in
operative time was significantly shorter in the death in two of the animals. Histologic samples
laser group. All animals survived, and there were taken from the cut surface at the day of
35. Liver and Pancreatic Laser Surgery 267

operation and three weeks later at sacrifice.

From the acute samples the damage to the pan-
creas was determined by the depth of thermal
injury seen at microscopy. The deepest damage
was caused by the noncontact Nd:YAG and the
most superficial by the bovie. The acute changes
are shown in Figures 35.1 to 35.3. Two dogs died
of acute necrotizing pancreatitis in the noncon-
tact laser and bovie groups. All the other dogs
showed degradation of acinar tissue and fibrosis
of the pancreatic tail at autopsy as seen in Figure
35.4.
A recent report on performing a distal pan-
createctomy in dogs using either the bovie, CO 2
laser, or steel scalpel showed that the laser
caused much less damage to the pancreas than
the bovie. 3 The authors found hemostasis to be
difficult on the resected surface when using the
bovie. However, the bovie was faster than the
laser, which in turn was more rapid than the
scalpel and suture method. There are no studies
available to compare to the contact Nd:Y AG
FIGURE 35.2. Acute effect on the pancreas following
contact Nd:YAG laser resection. Coagulated surface
followed by a more developed zone of cavitation of
the tissue. Arrowed region represents transition from
acidophilic zone to normal tissue. x64, Masson's
Trichrome.

laser to the CO 2 laser in surgery of the pancreas.

However, the good cutting properties and the
excellent coagulation properties of the contact
Nd:YAG will probably make the Nd:YAG laser
the superior laser in surgery of the pancreas.
Two patients with pancreatic disease treated
with the Nd:Y AG system have been reported. 10
One was a young male patient who was diag-
nosed as having insulinoma at the junction of
the body and neck of the pancreas, and the other
one was a young female having protracted pan-
creaticobiliary problems due to chronic pan-
creatitis. Both the patients underwent a pan-
creatic resection (50% and 80%, respectively)
with preservation of the head of the pancreas
and the duodenal loop. After lifting the pancreas
FIGURE 35.1. Acute effect on the pancreas following
from its inferior border, the dissection of the su-
bovie resection. Surface is coated by a carbonized perior border was found to be relatively easy
and coagulated layer of protein. Arrowed region rep- and safe using the Nd:YAG laser with the non-
resents plane of transition from acidophilic, necrotic contact technique. The power density used was
cells to normal tissue. x 64, Masson's Trichrome. between 60 and 70 W for 1-2 seconds duration.
268 T. Schroder and Stephen N. Joffe

with good preservation of normal surrounding

tissue. This is especially important in the surgery
of the pancreas since the procedure involves
delicate dissection from the vitally important
surrounding vessels.

Laser Surgery of the Liver

Despite well-standardized techniques for liver
resection, operative mortality rates ranging from
4 to 20% have been reported in recent studies.
Postoperative complications include liver fail-
ure, bleeding, infection, and sepsis. These com-
plications are related to interoperative bleeding,
amount of necrotic liver tissue, and bile leakage.
The techniques used in liver resections are an
important factor for preventing inter- and post-
operative complications. The laser was first in-
troduced for liver surgery by Dr. Fidler in 1975. 11
He used the CO 2 laser for exsanguinating liver
injuries. In 1982 Meyer et al. 12 reported and ex-
perimental study of partial liver resection with
FIGURE 35.3. Acute effect on the pancreas following a combined CO 2 and Nd:Y AG laser system.
noncontact Nd:Y AG laser resection. A comparatively They found this system effective in cutting as
broad area of coagulation and cavitation is seen on well as coagulating liver parenchyma. In 1985
the surface of the specimen. Acidophilic zone of another combination technique using the CO 2
thermal damage extends below the bottom of this and Nd:YAG laser simultaneously was reported
field. x 64, azure A-eosin B. by Sultan et al. 13 This report presents 15 patients
who have undergone liver resection by laser, 10
by the use of a CO 2 laser alone, 1 with the
The postoperative period was uneventful in both Nd:Y AG laser alone, and 4 with combined use.
patients. The acute histologic appearances of the The CO 2 laser provided good cutting effects, but
resected human pancreas were similar in all re- hemostasis was always difficult. This led the
spects to that of pancreas in experimental ani- authors to using the Nd:YAG laser which pro-
mals, with the exception of the depth of pene- vided better coagulation. With the Nd:YAG
tration of the acidophilic cells in zone 3, which alone the necrotic zone of the liver surface was
reached a depth of 3.5 mm. 5-6 mm, but when the Nd:YAG was combined
The Nd:Y AG laser using the contact probe with the CO 2 the damage was decreased to 1.6-
may relatively easy resect the head of the pan- 1.8 mm. The authors used a prototype combined
creas with preservation of the duodenum. No handpiece with the CO 2 and the Nd:Y AG laser
clinical data on this procedure have yet been in the same instrument. The Nd:Y AG was most
reported . effective when used at 100 Wand the CO 2 at
Other innovative procedures include drainage 80-90 W, which blended the hemostatic prop-
of pancreatic pseudocyst by performing an en- erties of the Nd:Y AG laser with the cutting
doscopic laser cystogastrostomy and endoscopic qualities of the CO 2 laser.
papillotomies, but more studies have to be done A recent study compared an ultrasonic dis-
before the evaluation of these methods can be sector (CUSA) and a noncontact Nd: Y AG laser
done. with a conventional blunt dissection technique. 14
The use of the contact Nd:Y AG system in The CUSA was superior to the "finger fracture"
pancreatic surgery provides the surgeon with a technique by causing less postoperative tissue
new tool for precise dissection and coagulation damage and reduced bleeding. The noncontact
35. Liver and Pancreatic Laser Surgery 269

FIGURE 35.4. (A) Chronic bovie resected pancreas. ( x62, collagen infiltration of the parenchyma of the organ
Masson's Trichrome). (B) Chronic contract Nd:YAG have occurred. x 64, Masson's Trichrome.
laser resected pancreas. Extensive acinar necrosis and

Nd :YAG laser had poor cutting properties, and, of blood loss and the resection could be com-
although it produced hemostasis the depth of pleted in a few minutes. Thereafter all large
tissue, damage was considerable. vessels could be visualized and ligated during a
Recently, the SL T contact N d: Y AG laser gradual release of the" strapper." Histologic
scalpel, with a synthetic sapphire, has been de- studies showed that this method did not cause
veloped. 8 This device has proven to be effective more hepatic damage to the resected surface
and safe in general surgery. An experimental than the earlier reported contact laser method.
study comparing the contact Nd: Y AG laser with Liver resections are usually technically dif-
the CUSA and a so-called "suction-knife" ficult and associated with problems in control
showed the inexpensive "suction knife" to be of bleeding. The laser techniques are not yet
as effective as any of the new sophisticated optimal. All new techniques need to be critically
methods. The problem with the contact evaluated and the use of a "strapper" looks
Nd:YAG laser in major liver surgery was the promising. Clinical studies need to evaluate its
difficulty in identifying the major central hepatic application in liver surgery in a larger number
veins before a partial venotomy. The contact of patients.
laser was able to coagulate 80-85% of the ves-
sels. This finding was followed by the devel-
opment of a totally new technique for laser liver References
resection. 15 In this technique a disposable plastic
I. Traverso LW, Tomkins RK, Urrea PT, Longmire
"strapper" was used to give control to the large WP, Jr: Surgical treatment of chronic pancreatitis.
hepatic vessels. The proximal resection surface Ann Surg 190:312-319, 1979.
was compressed by the "strapper," and then 2. White TT, Siavotinek AH: Results of surgical
the liver parenchyma was resected with the SLT treatment of chronic pancreatitis. Ann Surg
contact laser system. This gave complete control 189:217-224, 1979.
270 T. Schroder and Stephen N. Joffe

3. Orda R, Bara J, Orda S, Wiznitzer T: Partial distal 10. Joffe SN, Sankar MY: Lasers in hepato-biliary
pancreatectomy with a hand-held CO2 laser. Arch and pancreatic surgery. In Shapsay SM (ed): En-
Surg 115:869-873, 1980. doscopic Laser Surgery Handbook. Marcel Dek-
4. Sutherland DER, Goetz FC, Rynasiewicz JJ, et ker, New York, 1986.
al: Segmental pancreas transplantation from living 11. Fidler JP, Hoeter RW, Polyani TG, et al: Laser
related and cadaver donors: A clinical experience. surgery in exsanguinating liver injury. Ann Surg
Surgery 90:159-168, 1981. 181:74-80, 1975.
5. Rossi RL, Breasch JW, O'Bryan EM, Watkins E 12. Meyer H-J, Haverkampf K: Experimental study
Jr: Segmental pancreatic autotransplantation for of partial liver resection with a combined CO 2 and
chronic pancreatitis. Gastroenterology 84:621- Nd:YAG laser. Lasers Surg Med 2:149-154,1982.
626, 1983. 13. Sultan RA, Fallouh H, Lefebvre-Vilardebo M,
6. Munda R, Berlatzky Y, Jonung M, et al: Studies Ladouch-Badre A: Separate and combined use of
on segmental pancreatic autotransplants in dogs. N d-YAG and carbon dioxide lasers in liver re-
Arch Surg 118:1310--1315, 1983. sections: A preliminary report. Lasers Med Sci
7. Berlatzky y, Muggia-Sullam M, Munda R, Joffe 1:101-105, 1986.
SN: Use of Nd: YAG laser in pancreatic resections 14. Tranberg K-G, Rigotti P, Brackett KA, et al: Liver
with duodenal preservation in the dog. Lasers in resection. A comparison using the Nd:YAG laser,
Surgery and Medicine 5:107-517,1985. ultrasonic aspirator, or blunt dissection. Am J
8. Daikuzono N, Joffe SN: An artificial sapphire Surg 151:368-372, 1985.
probe for contact photocoagulation and tissue 15. Schroder T, Sankar MY, Bracket KM, et al: Ma-
vaporization. Med Instrum 19:173-178, 1985. jor liver resection in the pig using contact
9. SchroderT, Brackett K, Joffe SN: Proximal pan- Nd:YAG laser-A new technique. International
createctomy: A comparison of electrocautery with Nd:YAG Laser Symposium, Tokyo, November
the contact and noncontact Nd:YAG laser tech- 1-3, 1986.
niques in the dog. Am J Surg, 1987.
36
Contact Laser Applications in
Ophthalmology
Jay L. Federman and Fumitaka Ando

It is not by chance that light energy has been systems; that is, the laser beam must pass
utilized therapeutically in ophthalmology for through a medium, for example, air, aqueous,
over four decades. The human eye has evolved or vitreous, before reaching its target tissue. The
into a compl~,x sense organ that can convert development of contact laser probe made of
minimal amounts of light into a chemical reac- sapphire ceramic crystal, first introduced by
tion to begin the visual process. Its anatomic Joffe and Daikuzono,5 offers new applications
structure is designed to focus light energy onto for lasers in the field of ophthalmology.
the photoreceptor cells of the retina and adjacent The use of contact laser delivery as a tech-
retinal pigment epithelium (RPE). The intensity nique is in its infancy in ophthalmology. The
of light reaching these structures is critically laser energy is transmitted through a quartz fiber
controlled by the lids and pupil. Too much light into the sapphire crystal probe. The laser probe
focused on the retina and the retinal pigment is then applied either to the surface of the eye
epithelium (RPE) can cause damage resulting in to affect inner adjacent tissue layers, or directly
a chorioretinal scar. Clinically, light-induced to target tissue during surgery. Experimental
chorioretinal lesions can be seen in patients after studies in pigmented rabbits show that the ther-
an eclipse of the sun, I arc welding/ and during mal effects of both Nd:YAG and argon wave-
exposure to microscope light source during cat- lengths can be effectively delivered to target tis-
aract surgery. 3 sue sites with contact laser probes, and that the
Light energy was harnessed early in oph- probes work well for both coagulation and cut-
thalmology to produce highly controlled ting of ocular tissues.
chorioretinal burns in the treatment of various With 2.2-mm flat or rounded probes applied
ocular disorders. In the mid-1940s, Dr. Gerd to the surface of the conjunctiva, transcleral
Meyer-Schwickerath4 developed a device to fo- photocoagulation to both the retina and ciliary
cus sunlight into a fine beam, which he con- body has been accomplished experimentally. 6
trolled and directed into the patient's eye for Using argon laser energy, (1 W, 1 second du-
photocoagulation of the retina. Xenon arc pho- ration) this technique caused photocoagulation
tocoagulation was then developed as a more re- burns at the level of the RPE and outer retinal
liable light source. layer in pigmented rabbits. The argon wave-
Over the past two decades, as laser use in length can penetrate the thin sclera of the rabbit
ophthalmology progressed, only a few wave- eye with enough energy reaching the sensitive
lengths have survived. Argon and krypton are RPE to produce a chorioretinallesion with min-
used for their coagulation effects on the retina imal effect to the sclera. The clinical appearance
and RPE, while the mechanical disruptive ef- of the lesion is identical to that seen with non-
fects of Q-switched Nd:YAG are used on the contact slit lamp delivery (Figure 36.1). Within
posterior lens capsule. one week this lesion begins to become pig-
All of our clinical experience with laser energy mented, and there is a firm adhesion between
has been with noncontact slit lamp laser delivery the retina, RPE and choroid. Similar results have
272 Jay L. Federman and Fumitaka Ando

36.2), this does not appear to alter its integrity

and strength. The contact laser could be em-
ployed for the peripheral retinal areas not easily
reached with non contact slit lamp laser delivery.
We believe this technique can be used clinically
for transcleral laser coagulation of the peripheral
retina-for example, in coagulation of peripheral
retinal tears; or for peripheral retinal ablation-
instead of the traditional transcleral cryoretin-
opexy.
U sing the same technique, experimental le-
sions produced in the ciliary body6 result in in-
creased pigmentation within the ciliary body and
areas of destruction of the ciliary epithelium
(Figure 36.3). The integrity of the sclera was
maintained in pigmented rabbit studies, in spite
of destructive lesions to the adjacent inner lay-
ers. Using this transcleral approach, contact
laser probes may be important in glaucoma as
FIGURE 36.1. Fundus photograph of retinal burns im- a highly controlled method of causing focal de-
mediately after transcleral laser coagulation in pig- struction of the ciliary body epithelium. Theo-
mented rabbit. retically, this technique should be more accu-
rate, with less anterior segment reaction than is
seen with cyclocryopexy or the currently used
been attained using continuous wave Nd:YAG. method of noncontact free-running Nd:YAG
However, since this wavelength is absorbed by cyclodiathermy.7
all tissue layers, theoretically one would expect Over the past few decades there has been a
more scleral reaction. Although we have seen revolution in microsurgical techniques, provid-
increased cellularity within the sclera (Figure ing direct access to all intraocular tissues. Ex-

FIGURE 36.2. Histologic section through transclerallaser coagulation lesion showing firm adhesion of retina,
RPE, and choroid with increased cellularity of sclera (3-month lesion). H&E.
36. Contact Laser Applications in Opthamology 273

FIGURE 36.3. Histologic section through ciliary body showing increased cellularity, in a triangular shape, of
sclera and increased pigmentation of ciliary body after transclerallaser coagUlation (1 week lesion). H&E.

perimental work is ongoing with laser probes, I periments with attached retina, cuts in the inner
mm in outside diameter and 2.5 cm in length, scleral fibers were seen. At present, tip config-
developed for cutting and coagulation of target urations are being designed to avoid this, but,
tissues by direct contact during various intra- since retinal cutting will be done predominantly
ocular surgical procedures (Figure 36.4). The on detached retina, this should not present a
sapphire crystal probe is brought into the vit- significant problem. With continuous wave
reous cavity through a sclerotomy, as in multiple Nd:YAG laser delivered through contact probes,
incision vitrectomy procedures. Utilizing a 0.2- retinal cutting can be performed without bleed-
mm conical tip, retinotomies have been suc- ing. With argon laser energy, using the same
cessfully performed with good hemostasis in in- probes, initial studies do not show a cutting ef-
cising the retina in the rabbit eye. 8 At low energy fect. However, when working with a O.4-mm tip,
levels, using continuous wave Nd:YAG with the focal, well-defined endophotocoagulation burns
tip at the retinal surface, incisions have been can be made to the attached retina and RPE with
made through all retinal layers. In the early ex- both continuous wave Nd:YAG and argon

FIGURE 36.4. Sapphire ceramic cystals 2.5 cm in been used as laser scalpels for retinotomies in pig-
length and 2 mm in diameter for intraocular surgery. mented rabbit studies.
These tips have O.l-mm and O.2-mm points and have
274 Jay L. Federman and Fumitaka Ando

wavelengths. These burns appear to cause an essary data on the tissue effects of contact laser
immediate fusion of the retina with the RPE and surgery as this technology makes its entrance
choroid. This is important for detachment work into clinical ophthalmology.
as the laser coagulation may cause immediate
fixation of the retina, RPE, and choroid.
A sapphire crystal has been used experimen-
tally as a laser scalpel during ocular wall resec- References
tions. 9 Full-thickness cuts can be made through 1. VerhoffFH, Bell L, Walker CB: The pathological
sclera, choroid, and retina from an external ap- effects ofradant energy on the eye. Proc Am Acad
proach. With appropriate technique, good he- Arts Sci 51:630-818, 1916.
mostasis can be maintained during cutting. The 2. Naidoff MA, Sliney DH: Retinal injury from a
laser scalpel should be helpful in preventing the welding arc. Am J Ophthalmol 77:663, 1974.
complications of hemorrhage and retinal de- 3. Boldrey EE, Ho BT, Griffith, RD: Retinal burns
tachment seen with the present technique of occurring at cataract extraction. Ophthalmology
91:1297-1302, 1984.
ocular wall resection for choroidal tumors and
4. Meyer-Schwickerath G: Versl Dtsch Ophthal Ges
biopsies. Heidelberg Ber 55:256, 1949.
Another area where contact laser probes may 5. Daikuzono N, Joffe SN: Artificial sapphire tip for
be beneficial involves anterior segment surgery contact photocoagulation and tissue vaporization
for glaucoma. A tip can be passed across the with the Nd:YAG laser. Med Instrum 19:173-178,
anterior chamber to make a hole through the 1985.
angle structures into the subconjunctival space 6. Federman JL, Ando F, Schubert HD, and Eagle,
for filtration of aqueous. This should be an im- RC: Contact laser for transcleral photocoagulation.
provement over present methods to produce an Ophthalmic Surgery 18: 183-184, 1987;
atraumatic permanent filtering fistula. Contact 7. Schwartz LW, Moster MX: Neodymium:YAG
laser probes should also be most helpful for laser transcleral cyclodiathermy. Ophthal Laser
Ther 1:135-141, 1986.
oculoplastic procedures.
8. Ando F, Federman JL, Daikuzono N, Osborn J:
We remain very enthusiastic about the many Contact laser scalpel for intraocular surgery. Am
possible applications for contact laser probes, J Ophthalmol 102:663-664, 1986.
and feel this technology marks the beginning of 9. Federman JL, Ando F, Peyman, GA, Schubert,
a new era for lasers in ophthalmology. Contin- HD: Contact laser scalpel for ocular wall resection.
ued experimental studies will supply the nec- Ophthalmic Surgery 18:(4)305-306, 1987.
37
The Short-Pulsed Nd:YAG Laser in
Ophthalmology: A Review of Current
Clinical Techniques
Carmen A. Puliafito and Roger F. Steinert

The Q-switched and mode-locked Nd:YAG las- that usually is recognized in the early postop-
ers rapidly entered the ophthalmic surgical ar- erative period. Fibrosis present in the first days
mamentarium as the tool of choice for discission to weeks postoperatively probably most often
of the posterior capsule. 1- 3 The large shift in the represents cortical lamellae left at the time of
past decade from intracapsular to extracapsular surgery. Fibrosis that develops months to years
surgery generated a widespread need for safe postoperatively is caused by multiple layers of
and effective techniques to manage both intact anterior lens epithelium that have migrated and
posterior capsules that opacify postoperatively undergone fibrous metaplasia. 6
and visually significant capsular fragments that Migration of epithelial cells with formation of
remain after primary surgical capsular discis- small Elschnig's pearls and bladder cells, the
sion. The Nd:YAG laser also has proven to be second major form of opacity, occurs months
a major tool in the management of postoperative to years after surgery. Pathologic examination
complications, such as pupillary block and ma- indicates that the proliferating anterior epithelial
lignant glaucoma, vitreous incarceration in the cells originate at the site of apposition of the
wound, synechiae formation, and residual an- anterior capsular flaps to the posterior capsule. 6
terior capsular fragments. This finding explains the inability of polishing
of the capsule at surgery to delay the onset or
reduce the frequency of late capsular opaci-
Posterior Capsulotomy fication 4.7 because polishing of the posterior
capsule cannot remove the epithelial cells from
Postoperative opacification of initially clear the anterior capsular flaps.
posterior capsules occurs frequently in patients Capsular wrinkling can have two manifesta-
after extracapsular extraction of senile cataracts. tions. Broad undulations of clear capsule are
In adults, the time from surgery to visually sig- particularly common in the early postoperative
nificant opacification varies from months to period before the capsule becomes tense. Pos-
years.4 In younger age groups, almost 100% terior chamber lens haptics may induce these
opacification occurs within 2 years after surgery; broad wrinkles along the axis of the haptic ori-
in adults, the rate declines with increasing age.' entation. Conversely, a posterior chamber lens
Clinically, optical degradation of initially clear may tend to flatten broad wrinkles if the optic
posterior capsules takes several forms. Fibrosis body or a Y AG spacer bar or tab presses on the
connotes a gray white band or plaquelike opacity capsule. Broad undulating wrinkles of clear
capsule rarely are visually disturbing to the pa-
tient; an unusual patient may perceive linear
All figures and portions of the text are reproduced distortions or shadows that correspond to the
with permission from Steinert, RF, and Puliafito, CA: wrinkles and are relieved by capsulotomy.
The Nd:YAG Laser in Ophthalmology: Principles and
Clinical Applications of Photodisruption. Saunders, Fine wrinkles or folds in the capsule, in con-
Philadelphia, 1985. trast, can result in marked optical disturbance.
276 Carmen A. Puliafito and Roger F. Steinert

These fine wrinkles are caused by myofibro- explain the quality of vision, cystoid macular
?last.ic differenti~tion of the migrating lens ep- edema (CME) should be anticipated and docu-
lthehal cells, WhICh acquire contractile proper- mented, so that unnecessary and possibly del-
ties, resulting in the wrinkles. 6 eterious capsulotomy can be avoided.

Technique for Nd:YAG Laser Preparation of the Patient for

Posterior Capsulotomy Laser Capsulotomy
Dilation of the pupil facilitates visualization of
Preoperative Assessment of the capsule over a broad expanse. Except in the
Capsular Opacity case of an iris-clip lens, dilation is very helpful
for a surgeon inexperienced with laser capsul-
Judging the contribution of a capsular opacity otomy. In the absence of a miotic pupil, how-
to the patient's overall visual deficit may be dif- ever, dilation may be omitted. If the pupil is to
ficult. Table 37.1 lists useful techniques. Some
be dilated, the landmarks of the pupillary zone
capsular opacities are impressive in oblique slit-
of the capsule should be sketched beforehand.
lamp illumination but are insignificant when
Inattention to the pupillary zone results in an
viewed against the red reflex. In general, these
eccentric capsulotomy and may necessitate a
opacities cause little visual difficulty. The single
second session at the laser or induce the surgeon
most reliable technique for assessing capsular
to perform an overly large capsulotomy to pre-
opacity is direct ophthalmoscopy. Retinoscopy
vent this possibility. If the laser is available, the
and the red reflex seen at the slit lamp or with
patient can be brought to the laser before dila-
a direct or indirect ophthalmoscope also reveal
!ion, and a single "marker" shot can be placed
significant optical disturbances.
III the capsule near the middle of the pupillary
The laser interferometer and the Potential
. axis. For routine dilation, weak agents are rec-
Acuity Meter should penetrate mild to moderate
capsular opacity and indicate macular function. ommended to avoid inadvertent iris capture of
Both instruments may give false-positive a posterior capsule intraocular lens (PC IOL),
("good") acuity prediction in the presence of which may be difficult to reposition properly.
cystoid macular edema,8 which is the most likely Particularly after a surgeon becomes com-
fortable with the technique of laser capsulotomy,
cause of postcataract visual impairment besides
capsular opacity itself, and may give false-neg- optimally sized capsulotomies can be achieved
without dilation. As the patient looks up, down,
ative predictions where the capsular opacity
does not have clear "window" zones for pen- left, and right, the laser can be applied to cap-
sular edges behind the sphincter, so the cap-
etration of the testing beam.
Unless the capsule is extremely dense, ade- sulotomy can be both adequately sized and per-
quate visualization may be present for fluores- fectly centered. The slit-lamp illumination
cein angiography or angioscopy. For patients in should be with a narrow beam, angled obliquely,
whom the capsular opacity seems inadequate to to minimize miosis and indicate average pupil-
lary size with ambient lighting.
The surgeon should remind the patient that
the procedure is painless. The patient may hear
TABLE 37.1. Assessment of optical significance of small clicks or pops, but he must simply main-
capsular opacity tain steady fixation.
Direct ophthalmoscopic visualization of fundus structures No anesthesia is generally required for cap-
Retinoscopy sulotomy unless a contact lens is employed. In
Red reflex evaluation by that case, a drop of topical anesthetic is applied
Slit lamp examination
Direct ophthalmoscopic examination
to the cornea immediately before the beginning
Indirect ophthalmoscopic examination of the procedure. In rare circumstances, such
Hruby lens view of fundus as nystagmus, a retrobulbar injection for aki-
Laser interferometer evaluation nesia may be helpful. If topical anesthetic is ap-
Potential Acuity Meter evaluation plied in advance of the procedure for examin-
Fluorescein angiography or angioscopy
ation or instillation of painful mydriatics and
37. Short-Pulsed Nd:YAG Laser in Opthalmology 277

TABLE 37.2. Preparation of the patient an intact posterior capsule and in view of rare
Before the treatment session cases of clinical CME that apparently occur after
Complete ophthalmic history and examination. Nd: YAG laser capsulotomy.1O
Discussion of proposed procedure, including risks, Unlike the situation with surgical discission,
benefits, and alternatives; signing of informed
the only data available to date do not show a
consent form
Pupillary dilation (optional) difference in the rate of complications depending
Determination of visual axis and normal pupillary size: on the interval between cataract surgery and
sketch and preliminary laser marker shot laser capsulotomy.1O However, given the overall
Weak mydriatics and cycloplegics: 2.5% phenylephrine low incidence of long-term complications, rec-
or 0.5% or 1% tropicamide
ognition of such a trend may require an even
At the laser
Review of the procedure, the expected pop or click, larger study.
and the importance of fixation No data exist on laser capsulotomy in eyes at
Application of topical anesthetic if contact lens is to be high risk for retinal detachment. As a minimal
used precaution, the least amount of energy and the
Adjustment of stool, table, chin rest, and foot rest for
lowest number of shots should be used that can
optimal patient comfort
Application of head strap to maintain forehead position accomplish the capsulotomy, and only a small
Darkening of the room (optional) opening should be made.
Provision of fixation target for fellow eye (illumination
of target if room is darkened)
Capsulotomy Technique
The minimal amount of energy necessary to ob-
cycloplegics, the patient should be instructed to tain breakdown and rupture the capsule is de-
keep the eyes closed during the interval while sired. With most lasers, a typical capsule can
waiting for the laser treatment, in order to be opened by using 1 to 2 mJ per pulse.
maintain the surface integrity and optical quality The capsule is examined for wrinkles that in-
of the corneal epithelium. dicate tension lines. Shots placed across tension
Table 37.2 summarizes the steps in patient lines result in the largest opening per pulse, since
preparation. the tension causes the initial opening to widen.
Figure 37.1 shows an actual caps ulotomy pho-
Contraindications for Laser tographed sequentially and drawn from the
photographs, showing the opening as it develops
Capsulotomy and the location of the next laser shot. Table
Attempted Nd:YAG laser capsulotomy is con- 37.3 outlines the basic technique. The usual
traindicated if corneal scars, irregularity, or strategy is to create a cruciate opening, begin-
edema preclude adequate visualization of the ning superiorly near the 12 o'clock position and
target or degrade the las~r beam optics to pre- progressing downward toward the 6 o'clock po-
vent reliable and predictable optical breakdown. sition. Unless a wide opening has already de-
The procedure is also contraindicated if the pa- veloped, shots are then placed at the edge of the
tient proves unable or unwilling to fixate ade- capsule opening, progressing laterally toward
quately, with the threat of inadvertent damage the 3 and 9 o'clock positions. If any capsular
to adjacent intraocular structures. flaps remain in the pupillary space, the laser is
The presence of a glass intraocular lens is a fired specifically at the flaps to cut them and
relative contraindication. The merits of surgical cause them to retract and fall back to the pe-
discission in this instance should be carefully riphery. _
weighed. Laser capsulotomy should be ap- The goal is to achieve flaps based in the pe-
proached with extreme caution and only by an riphery and inferiorly. Free-floating fragments
experienced Nd:YAG laser operator under ideal should be avoided because these may remain
conditions, because of the possibility of causing and cause interference. Cutting in a circle, "can-
a complete fracture in the glass optic. 9 opener style," should be avoided because this
Known or suspected cystoid macular edema tends to create large fragments that may not
is a relative contraindication, given current evi- settle or that may settle against the endothelium
dence regarding a possible beneficial effect from or angle structures.
278 Carmen A. Puliafito and Roger F. Steinert

A B E F

c o G H

FIGURE 37.1 Artist's drawing based on sequential shot at the 3 o'clock capsulotomy margin. (F) The
capsulotomy photographs. The capsulotomy is de- opening now needs to be directed to the left, with a
veloped in a cruciate pattern. (A) The first shot is shot at the 9 o'clock position. (G) The cruciate open-
made superiorly in the location of some fine tension ing has been accomplished, but a triangular flap ex-
lines. (B) The second shot is aimed inside the inferior tends into the pupillary space from the 7:30 o'clock
edge of the initial opening. (C) The next shot again region in the left inferior pupil. A shot is applied to
is made at the 6 o'clock position of the capsulotomy the flap, to both cut it and push it toward the pe-
border. (D) The fourth shot is made across inferior riphery. (H) The capsulotomy is complete, and the
tension lines to allow the capsulotomy to widen. (E) pupil will be clear of capsule when the dilation wears
The opening is nearly 3mm wide. It is widened by a off.

An IOL may be marked in the course of the of the tendency for IOL markings in a noncritical
capsulotomy. This is particularly true for pos- area. If there is a tendency for unavoidable re-
terior chamber lenses for which little or no sep- peated marks, the usual cruciate pattern should
aration of the capsule from the IOL exists. be modified. Instead of progressing from the 12
Visually significant pits and cracks can be o'clock to the 6 o'clock positions across the vis-
minimized and avoided through careful tech-
niques, as outlined in Table 37.4. A contact lens
such as the Peyman or central Abraham lens TABLE 37.4. Minimizing intraocular lens (IOL)
stablizes the eye, improves the laser beam op- laser marks
tics, and facilitates accurate focusing. Following Use minimum energy.
the usual strategy of beginning the capsulotomy Use a contact lens to
in the 12 o'clock periphery gives an indication stabilize the eye.
improve laser beam optics.
facilitate accurate focusing.
Identify any areas of IOL-capsule separation, and begin
TABLE 37.3. Posterior capsulotomy technique
treatment there.
Use minimum energy: If lens marking is occurring, make an opening in the
I m] if possible. shape of a Christmas tree from the 12 o'clock to the
Identify and cut across tension lines. 7:30 o'clock positions without placing any shots in
Perform a cruciate opening: the central optical zone.
Begin in 12 o'clock periphery. Use deep-focus techniques:
Progress toward 6 o'clock position. Optical breakdown occurs in the anterior vitreous.
Cut across at 3 and 9 o'clock positions. The shock wave radiates forward and ruptures the
Clean up any residual tags. capsule.
Avoid freely floating fragments. Higher energy (2 m] or more) must be used.
37. Short-Pulsed Nd:YAG Laser in Opthalmology 279

ual axis, the cut should be made nasally and 0.5% or betaxolol 0.5% at the conclusion of
temporally, staying in the periphery of the op- treatment usually suffices to blunt the pressure
tical zone. The capsule then can be opened in rise, since this medication has a maximal effect
a "Christmas-tree" fashion, based inferiorly, 2 to 4 hours after administration. Alternative
without any shots in the central visual axis. One medications are pilocarpine or a carbonic an-
other technique is very helpful in avoiding IOL hydrase inhibitor. The possibility of a delayed
marks. The laser can be !ntentionally focused pressure elevation after use of these medications
posteriorly to the capsule, to cause optical must be recognized. An examination on the day
breakdown in the anterior vitreous. The shock following laser treatment is indicated.
wave then radiates forward and ruptures the For patients already receiving medication for
capsule. preexisting glaucoma, the level of medication
should be increased, using additional or stronger
Capsulotomy Size medication. If the patient is already on maxi-
mally tolerated medical therapy, a full dose
In the absence of a specific reason for a small (calculated by weight) of an oral osmotic agent
opening, such as concern over a patient at high (glycerin or isosorbide dinitrate) should be ad-
risk for retinal detachment, the capsulotomy ministered at the conclusion of the treatment and
should be as large as the pupil in ambient light. the patient instructed to take another full dose
A small opening in a dense membrane results in 4 hours after treatment.
excellent optics, analagous to those of a small Glaucoma patients on intensive therapy, par-
pupil. When the capsule is only hazy and trans- ticularly with advanced visual field loss, should
mits images to the retina, however, a small be observed closely for at least 4 to 6 hours after
opening is an improvement but is still subopti- treatment. Further options for management of
mal. The hazy membrane continues to transmit sight-threatening pressure elevation include,
a poor-quality image that mixes with the image progressively, intravenous administration of
transmitted through the clear opening. A capsule mannitol, anterior segment paracentesis, ante-
with residual haze not only impairs vision under rior chamber washout, and emergency filtration.
standard conditions but also produces glare. A case of postcapsulotomy intraocular pressure
rise above 80 mm Hg with loss of light percep-
tion was successfully treated with anterior
Postoperative Care for Capsulotomy chamber paracentesis, and visual recovery to 20/
After laser capsulotomy, protocols for routine 25 was achieved. II Treatment of these high-risk
administration of topical steroids and cyclo- patients may be less hazardous if the treatment
plegics vary widely according to the individual is divided across multiple sessions, with a few
surgeon's clinical experience. Many surgeons shots given at low energy per session. However,
recommend routine use of topical steroids. The studies of capsulotomy in the general population
patient is discharged with instructions to apply have not found a consistent correlation of pres-
a strong topical steroid (prednisolone 1% or sure increase with pulse energy, total shots, or
dexamethasone 0.1%, for example) beginning total energy. 10.12-14
immediately and continuing four times daily. Two other causes of acute glaucoma after las-
This application is tapered and discontinued at er capsulotomy have been reported. Vitreous
postoperative visits when the clinical examin- herniation may cause pupillary block and acute
ation discloses an eye without cellular reaction. glaucoma. 15 In the absence of a patent peripheral
An acute increase in pressure in the hours af- iridectomy, the potential for pupillary block after
ter treatment is common. The patient should be posterior capsulotomy should be considered
rechecked 1 hour and 4 hours after capsulotomy, unless a posterior chamber lens is present that
and treatment is begun if the pressure has risen holds the vitreous in place. An aphakic iridec-
5 or more mm Hg above baseline. If the patient tomy can be readily and safely performed with
has a baseline pressure greater than 20 mm Hg, the Nd:YAG laser. A case of vitreous herniation
or has glaucoma, prophylactic treatment is giv- plugging a filtering bleb with acute pressure in-
en. If there is no contraindication such as asthma crease 10 days after capsulotomy has also been
or congestive heart disease, a drop of timolol reported. 16
280 Carmen A. Puliafito and Roger F. Steinert

Results and Complications from posterior chamber lenses, 4.3% with iris lenses,
Nd:YAG Laser Posterior and 6.5% with anterior chamber lenses. A dis-
senting report has been made by Knolle. In a
Capsulotomy retrospective comparison of knife capsulotomies
The initial European response to experience performed at the slit lamp to his early experience
with Q-switched and mode-locked Nd:YAG with the Nd:Y AG laser, Knolle 20 found better
laser secondary capsulotomy in large numbers restoration of vision with the surgical technique.
of patients has been enthusiastic. 1-3 Early short- The patient populations may not have been
term American experience has also demonstrat- comparable, however. Nevertheless, Knolle re-
ed the relative ease of laser caps ulotomy with ported that visual recovery was faster and more
a high rate of visual improvement, but not with- complete with knife discission.
out complications, including acute transient Posttreatment pressure elevation is now rec-
pressure rise, IOL marking, rupture of the an- ognized as a common, although usually tran-
terior hyaloid face, retinal detachment, and sient, complication after Nd:YAG laser capsul-
bleeding from diabetic rubeosis iridis. 17- 19 otomy. In a report of 49 capsulotomies, Terry
Keates, Steinert, Puliafito, and Maxwell lO re- et al. 17 detected a pressure increase in 37 eyes,
ported the results of a study of 526 patients who with a maximal pressure greater than 30 mm Hg
underwent Q-switched Nd:YAG laser posterior in 16 eyes and greater than 50 mm Hg in four
capsulotomy and were followed a minimum of eyes. In most eyes the pressure returned to pre-
6 months by their physicians. These results were treatment levels within 1 week, but in two eyes
compared with observations of a historical con- it did not normalize until 6 weeks after treat-
trol group of 209 pseudophakes who had under- ment. When patients were observed carefully
gone surgical secondary caps ulotomy before the after laser caps ulotomy , the majority were found
laser became available. The surgical control to have a pressure peak within 3 hours after the
population had significantly better prediscission operation. Channell and Beckman l3 found a
visual acuity and lesser preoperative pathology. pressure elevation exceeding 5 mm Hg in 64%
Nevertheless, 85.7% of the laser-treated pseu- of patients and 10 mm Hg in 35% of patients
dophakes achieved 20/40 or better vision com- within 4 hours of laser capsulotomy. Persistent
pared with 80.2% of the surgically treated group. pressure elevation after 1 month occurred in 5%.
Excluding patients with preoperative pathology, Richter and co-workers l2 examined the acute
90.1 % of the laser-treated pseudophakes ob- elevation of pressure after laser capsulotomy
tained better vision after treatment, compared with serial pressure measurements and tono-
with 69.7% of the surgically treated pseudo- graphy in 17 patients. The median time to
phakes (difference significant at p < 0.001). achieve maximal pressure was 3 hours. The
Of the laser-treated pseudophakes, 3.3% had higher the pretreatment intraocular pressure and
diminished vision after capsulotomy, compared the lower the pretreatment facility of outflow,
with 14.8% of the surgical control group (p < the greater was the tendency for a large pressure
0.001). Half of the patients in the laser-treated increase. As a consequence, patients with
group with diminished posttreatment acuity at preexisting open angle glaucoma had a higher
six months were within one line of their pre- risk of developing greater pressure elevation. A
treatment visual acuity. Cystoid macular edema decline in the facility of outflow paralleled any
was diagnosed at anyone of the posttreatment acute rise in pressure after laser capsulotomy,
visits in 2.3% of the patients, but at 6 months and the outflow facility returned to baseline level
persistent CME was reported in only one patient as the pressure normalized.
(0.2%). This was significantly less than the per- Mechanistically, the acute pressure rise is thus
sistent CME rate for the surgical control group caused by impaired outflow, and the rapid onset
of 1.9% (p < 0.05). Retinal detachment occurred suggests that the reduced outflow may be related
in two of the laser-treated (0.4%) and in none to capsular debris, acute inflammatory cells,
of the surgically treated patients. Persistent heavy-molecular-weight protein, or a combi-
pressure elevation, iritis, vitritis, anterior seg- nation of these mechanisms. 21 An immunologic
ment hemorrhage, and IOL dislocation were all reaction to liberated lens proteins is unlikely to
reported in fewer than 1% of the patients. IOL have such a rapid onset and resolution. Re-
marks were reported for 33% of patients with cently, a low-molecular-weight factor from the
37. Short-Pulsed Nd:YAG Laser in Opthalmology 281

vitreous has been implicated in the etiology of surgery were to be performed, require major
postcapsulotomy pressure elevation. 22 procedures in the operating room with irriga-
Patients with IOL tend to have a smaller el- tion-suction-cutting instruments.
evation in pressure, particularly with posterior Several aspects of the treatment of dense
chamber lenses. This effect may be related to membranes must be considered.
posterior trapping of capsular debris by the IOL.
Alternatively, patients with IOLs may have
capsule characteristics different from aphakes,
either because of the IOL itself or because of
Evaluation of Membrane
different visual expectations for IOL patients The density and type of membrane should be
which lead to capsulotomy at an earlier stage, evaluated to determine whether laser treatment
with less fibrotic material or pearl formation. 12.14 is appropriate. Dense membranes may require
Other investigators have not found a significant multiple sessions to achieve an adequate open-
difference in the extent of pressure elevation in ing, and the patient should be informed of this
the presence of IOLs. 13 possibility. Lengthy sessions with many pulses
and liberation of a large amount of debris seem
prone to postlaser inflammation and elevated
irprophylaxis of Acute Pressure pressure. Large Elschnig's pearls from old cat-
Elevation aracts may liberate protein when opened and
result in phacoanaphylactic or phacolytic glau-
Two studies have prospectively studied the ef- coma. Such patients may be best served, in the
fect of prophylactic administration of antiglau- end, by a definitive surgical operation instead
coma medication after Nd: YAG laser capsulo- of attempted laser membranectomy.
tomy. Brown23 administered pilocarpine 4%
hourly from capsulotomy until bedtime on the
day of treatment and markedly reduced the in-
cidence of acute pressure elevation. Richter24 et Membranectomy Technique
al. compared timolol 0.5%, pilocarpine 2%, and Unlike posterior capsules, in which each laser
a placebo drop in a double-masked study where shot results in a large opening because the cap-
one drop was given 5 and 30 minutes after cap- sule is thin and under tension, membranes may
sulotomy. In that study, mean pressure elevation have little or no elastic properties. Treatment
was 8 mm for the placebo control, 5 mm for with the laser may require high pulse energy,
pilocarpine, and 1 mm for timolol 0.5%. This from 4 to 12 mJ. The opening is created by
suggests that acute administration of a beta- "chipping" away at the edge, in a manner sim-
blocking agent topically (or perhaps substituting ilar to that of a stonemason chipping at marble.
a carbonic anhydrase inhibitor if medically in- Retained cortical material may be treated with
dicated) is the better means of prophylaxis. It the laser before it condenses into a permanent
should be noted, however, that, even with ti- membrane or to speed its eventual resorption.
molol prophylaxis, one patient experienced a Early intervention with the laser may be partic-
pressure elevation to 40 mm; the protective ef- ularly important in pseudophakic patients. The
fect is not absolute, and patients should still be higher energy necessary to open membranes
carefully monitored after the laser procedure. compared to capsules can result in severe IOL
marking.

Pupillary Membranectomy
Postoperative Care for
Application ofthe Q-switched Nd:YAG laser to
aphakic pupillary membranes was first described
Membranectomy
by Fankhauser et al. 3 While less common than Pressure elevation and inflammation may be
posterior caps ulotomy , the procedure offers the more pronounced than with simple capsulotomy.
potential to clear the pupil optically in eyes that This result should be anticipated, and steroids
frequently have had serious pathology and are and glaucoma medications should be adminis-
either poor candidates for further surgery or, if tered as indicated.
282 Carmen A . Puliafito and Roger F . Steinert

Aphakic and Pseudophakic and this is the treatment of choice .25 The success
Iridectomy and Anterior Hyaloid of the Nd:Y AG laser "anterior hyaloidectomy"
in curing ciliovitreal block glaucoma, in which
Vitreolysis surgical and argon iridectomies have failed,
demonstrates the pathophysiologic role of the
In acute angle closure glaucoma in aphakia and anterior hyaloid face and represents a major ad-
pseudophakia, corneal edema and haze, anterior vance in treatment.
chamber reaction, and iris congestion may make The role of the hyaloid face in aphakic ma-
argon laser iridectomy impossible. Even when lignant glaucoma due to posterior diversion of
a patent opening is created, an argon laser iri- aqueous, rather than pupillary block, is further
dectomy may not relieve the glaucoma because illustrated by the case shown in Figure 37.2.
of the role of the vitreous. In our opinion the Three months after complicated cataract ex-
Nd:YAG laser can better treat these conditions, traction and subsequent IOL removal in a pa-

FIGURE 37.2. (Top) Aphakic malignant glaucoma with mediately after Nd:YAG laser pulses have opened
apposition of inferior iris to edematous cornea. (Bot- the anterior hyaloid face.
tom) Depth is restored to the anterior chamber im-
37. Short-Pulsed Nd:YAG Laser in Opthalmology 283

tient who had had a large superior sector iri- laser is more successful than the argon laser in
dectomy, the chamber became shallow and the synechialysis because pigmentation of the target
pressure rose to 34 mm Hg over several days is not required and forceful rupture of adhesions
with the onset of deep pain. A thin intact hyaloid can be made.
face was present. The patient was treated with Synechiae can form around anterior chamber
the Nd:YAG laser, which was focused and fired intraocular lens footplates. This condition may
at 3 mJ on the hyaloid face through mild corneal lead to pupillary distortion in the absence of
edema and with less than 1 mm of anterior tuck. In Figure 37.3 the pupil is seen to be ec-
chamber depth. The chamber deepened imme- centric. The patient complained bitterly of edge
diately. glare. Gonioscopy revealed synechia in asso-
ciation with the IOL footplates and haptic struts.
Synechialysis through a gonioscopy lens was
Procedure for Iridectomy and carried out, requiring four sessions before the
Hyaloid Vitreolysis pupil moved behind the edge of the IOL and the
From 4 to 8 mJ is usually adequate to perforate symptoms were relieved.
the iris in one shot. Corneal edema or anterior
chamber reaction may necessitate higher energy
to obtain the same cutting power. At least three Preparation of the Patient for
iridectomies should be made, if possible, to en- Synechialysis
sure full relief of aqueous entrapment, which The patient is told beforehand that multiple ses-
may be localized into sectors, and to increase sions are often necessary for complete syne-
the chance of maintaining at least one long-term chialysis. Pre laser miosis or mydriasis may help
patent iridectomy. Iridectomies tend to shrink by stretching a synechia, which improves both
as bombe is relieved and the iris falls back. In- visualization of the abnormality and the pressure
flammation also may close iridectomies subse- wave cutting action of the laser.
quently.
If the chamber is markedly shallow or flat,
the haptic of an anterior chamber pseudophakos, Procedure for Synechialysis
when present, usually provides a small area of
clearing from the cornea. Generally the laser is set between 4 and 10 mJ,
After the iridectomy has been completed or depending on the stength of the synechia to be
when a patent basal iridectomy is already pres- lysed. When the abnormality can be directly
ent, the Nd: YAG laser should be fired into the visualized, the laser is aimed accordingl~. Often,
anterior vitreous through the iridectomy or the however, a gonioscopy lens is necessary to treat
pupil. This procedure ruptures the hyaloid face synechiae near the limbus and, of course, in the
and relieves any malignant glaucoma caused by angle. Energy losses and optical aberrations
the intact hyaloid face. often require higher laser energy settings with
a gonioscopy lens in order to achieve the irra-
diance necessary to cut a synechia.
Postoperative Care for Iridectomy
Topical steroids are administered as needed.
Cycloplegia, sometimes alternating with miosis, Postoperative Care for Synechialysis
is indicated to prevent formation of synechiae. Strong topical steroids (prednisolone 1%, dex-
The patient must be periodically observed to amethasone 0.1%) are used initially at least four
verify patency of the iridectomies. times daily and more often if severe inflam-
mation occurs. If there is any tendency for for-
mation of new synechiae the pupil should be
Synechialysis moved with intermittent administration of short-
acting cycloplegics and mydriatics. Intraocular
Localized synechiae with associated pigment pressure should be measured and appropriate
may be broken by photocoagulation with the ar- treatment (using timolol or carbonic anhydrase
gon laser. Generally, however, the N d: Y AG inhibitors) should be begun when indicated.
284 Carmen A. Puliafito and Roger F. Steinert

FIGURE 37.3 (Top) Eccentric pupil appearing 1 week postoperatively. (Bottom) The pupil is now fully be-
after intracapsular cataract extraction with anterior hind the area of the intraocular lens optic after lysis
chamber intraocular lens. Vitreous loss with iris ad- of vitreous adhesions to the posterior iris.
herent to the wound occurred at a site of wound leak

Anterior Vitreolysis and Cystoid to cataract wounds. In their series, vision im-
Macular Edema proved by variable degrees in all 14 patients re-
ported. The presence of CME was judged clin-
ically, however, and results of pre- and postlaser
Vitreous strands and bands to the' wound may fluorescein angiography were not reported for
cause eccentric pupils and can be associated 13 of the eyes.
with cystoid macular edema (lrvine-Gass Because of the unpredictable natural history
CME).26.27 Hifes first reported visual improve- of aphakic CME, with erratic response to an-
ment after surgical section of such vitreous tiinflammatory agents and frequent spontaneous
bands to the wound. improvement/o. 31 small uncontrolled series
Katzen and co-workers 29 first reported the use cannot unequivocally prove the efficacy of a
of the Nd: YAG laser to lyse strands of vitreous given technique. However, our initial experience
37. Short-Pulsed Nd:YAG Laser in Opthalmology 285

TABLE 37.5. Fourteen cases of vitreolysis for cases, careful gonioscopy may be necessary to
cystoid macular edema (CME) visualize the strand, particularly if the vitreous
Assessment Patient Data enters the anterior chamber through the area of
Interval from cataract surgery to CME 0-3 months a peripheral iridectomy.
Interval from cataract surgery to laser I-57 months Permanent changes in the iris stroma are fre-
vitreolysis quent in long-term cases with decreased but
Interval from laser vitreolysis to stable persistent ovalling of the pupil after lysis of a
visual improvement*
vitreous strand.
Range 2-26 weeks
Average 9 weeks
Mode 8 weeks
Fluorescein angiographic change (7 Preparation of the Patient for
patients evaluated) Vitreolysis
Resolved CME 3 patients
ReducedCME 3 patients When the vitreous strand or band passes through
Unchanged I patient the pupil, treatment is often facilitated by
Two treatment sessions required 5 patients administration of pilocarpine 2% every 15 min-
*Patient lost to follow-up between 4th and 26th week after utes beginning 2 hours preoperatively. Inducing
vitreolysis. stretch of the vitreous through miosis facilitates
identification of the strand and the cutting action
of the laser and shows the release of the tension
and that of our colleagues at the Massachusetts more definitively.
Eye and Ear Infirmary has confirmed a high rate
of visual improvement after anterior segment
Procedure for Vitreolysis
vitreolysis. The conditions of 12 of 14 patients
improved both objectively and according to the The laser can be directed at a vitreous strand in
patient's own perception. Each patient had four general areas. The most reliable landmark
aphakic or pseudophakic CME documented by during vitreolysis is the cataract wound, since
fluorescein angiography before treatment. The the vitreous band or strand has to terminate at
interval between cataract extraction and vitreo- that line. The cataract wound is visualized with
lysis ranged from 1 to 57 months. The onset of a gonioscopy lens and the laser is fired at the
visual loss occurred within 3 months after cat- wound area with a reasonable chance of suc-
aract surgery in all cases. The interval from laser cessful vitreolysis. Because of the contact lens
vitreolysis to visual improvement averaged 9 and mirror optics, the energy settings of a Q-
weeks. In our first series, postlaser fluorescein switched Nd: YAG laser are usually 4 to 12 mJ
angiograms were obtained for 7 of the 14 pa- in order to obtain adequate cutting power.
tients. Generally, macular edema resolved in If the cornea is clear near the limbus and the
those patients who experienced nearly full re- vitreous strand can be visualized with some
covery of vision (20/30 or better). In patients clearance from the iris stroma, direct cutting
with partial recovery of vision, CME generally without a contact lens or with a peripheral but-
persisted, but to a lesser degree. Table 37.5 ton Abraham lens may be successful. Usually,
summarizes these results. 4 mJ is adequate. Misfocused shots can cause
local damage to the underlying iris or overlying
Preoperative Assessment cornea.
Occasionally directing the laser at the vitreous
Because of the high success rate of Nd:YAG passing over the iris collarette can be helpful.
laser anterior vitreolysis in the treatment of This is particularly true when the vitreous has
aphakic and pseudophakic CME, it is particu- formed adhesions to the collarette, pulling it
larly important to examine carefully for the forward in a tentlike formation. The close prox-
presence of a vitreous strand to the wound in imity of vitreous and iris make damage to the
any patient with CME. The strand is usually best underlying iris stroma likely, but this may be
seen on slit lamp examination with a narrow slit clinically tolerable.
beam in a darkened room, and pigment deposits Directing the laser at the vitreous as it passes
on the vitreous strand may be visible. In some around the pupil is tempting, but rarely suc-
286 Carmen A. Puliafito and Roger F. Steinert

cessful. The vitreous traction components are A gonioscopy lens is occasionally useful to
poorly defined as they come around the pupil. properly direct the laser beam to the target.
The shock wave is ineffective at rupturing vit-
reous strands except directly at the laser focal Postoperative Care
point. Firing the laser immediately adjacent to
Inflammatory reaction and pressure rise are
the pupillary border inevitably causes low-grade
usually minimal and should be treated as they
capillary hemorrhage as well as release of pig-
occur.
ment, obscuring further visualization of the area.
Successful treatment releases the tension and
converts a discrete strand or band to an amor- References
phous gelatinous appearance. Observation of the
1. Aron-Rosa D, Aron JJ, Greiseman M, Thyzel R:
change in any iris deformation is the best indi-
Use of the neodymium-YAG laser to open the
cator of successful release of tension. Hundreds posterior capsule afte'r lens implant surgery. A
of shots may be necessary to cut a large band. preliminary report. J Am Intraocul Implant Soc
6:352-354, 1980.
Postoperative Care for Vitreolysis 2. Aron-Rosa D, Griesemann JC, Aron JJ: Use of a
pulsed neodymium-YAG laser (picosecond) to
Strong topical steroids (prednisolone 1%, dex- open the posterior lens capsule in traumatic cat-
amethsaone 0.1%) are given four times daily aract: A preliminary report. Ophthalmic Surg
until visual improvement occurs, typically in 2 12:496-499, 1981.
to 3 months. 3. Fankhauser F, Lortscher H, Van der Zypen E:
Pressure rise following vitreolysis has not Clinical studies on high and low power laser ra-
been well documented. In our experience no diation upon some structures of the anterior and
patient has been observed to have a pressure posterior segments of the eye. Int Ophthalmol
increase in excess of 10 mm Hg. A drop of ti- 5: 15-32, 1982.
4. Wilhemus KR, Emery JM: Posterior capsule
molol 0.5% at the time of treatment probably
opacification following phacoemulsification. In
provides adequate prophylaxis, if desired. Emery JM, Jacobson AC (eds): Current Concepts
We consider systemic administration of di- in Cataract Surgery: Selected Proceedings of the
flunisal 500 mg twice daily with meals if no visual Sixth Biennial Cataract Surgical Congress. Mos-
improvement has occurred in 1 month and no by, St. Louis, 1980, pp. 304-308.
residual traction is present. If the patient cannot 5. Emery JM, Wilhemus KR, Rodenberg S: Com-
tolerate indomethacin, other nonsteroidal an- plications of phacoemulsification. Ophthalmology
tiinflammatory medications can be substituted. 85: 141-150, 1978.
A 4-week trial of systemic medication should be 6. McDonnell PJ, Zarbin MA, Green WR: Posterior
adequate to assess the potential for improve- capsule opacification in pseudophakic eyes.
Ophthalmology 90:1548-1553, 1983.
ment.
7. Sinskey RM, Cain W: The posterior capsule and
phacoemulsification. J Am Intraocul Implant Soc
Postoperative Anterior Capsular 4:206-207, 1978.
8. Faulkner W: Laser interferometric prediction of
Fragmentation postoperative visual acuity in patients with cat-
aracts. Am J Ophthalmol 95:626-636, 1983.
Retained anterior capsule after extracapsular 9. Riggins J, Pedrotti LS, Keates RH: Evaluation of
cataract extraction can become visually signif- the neodymium-YAG laser for treatment of ocular
icant in several ways. Capsular tags usually re- opacities. Ophthalmic Surg 14:675-682, 1983.
tract if they are small. Larger tags may continue 10. Keates RH, Steinert RF, Puliafito CA, Maxwell
to remain in the visual axis and be visually trou- SK: Long-term followup of Nd-YAG laser pos-
terior capsulotomy. J Am Intraocul Implant Soc
blesome to the patient. These fragments can be
10:164-168, 1984.
readily severed by the N d: Y AG laser. II. Vine AK. Ocular hypertension following Nd-YAG
laser capsulotomy: A potentially blinding com-
Technique for Disruption of Anterior plication. Ophthalmic Surg 15:283-284, 1984.
Capsule Fragments 12. Richter CU, Arzeno G, Pappas H, et al: Intra-
ocular pressure elev~tion following Nd-YAG laser
The anterior capsule fragments generally are posterior capsulotomy. Ophthalmology 92:636-
disrupted with 1 to 4 mJ in only a few pulses. 640, 1985.
37. Short-Pulsed Nd:YAG Laser in Opthalmology 287

13. Channell MM, Beckman H: Intraocular pressure rise after neodymium-YAG laser capsulotomy.
changes after neodymium-YAG laser posterior Arch Ophthalmol 103:1538-1542, 1985.
capsulotomy. Arch Ophthalmol 102: 1024-1026, 23. Brown SVL, Thomas JV, Belcher CD, Simmons
1984. RJ: Effect of pilocarpine in treatment of intra-
14. Kraff MC, Sanders DR, Lieberman HL: Intra- ocular pressure elevation following neodym-
ocular pressure and the corneal endothelium after ium: YAG laser posterior capsulotomy. Ophthal-
neodymium-YAG laser posterior capsulotomy: mology 92:354-359, 1985.
Relative effects of aphakia and pseudophakia. 24. Richter CU, Arzeno G, Pappas HR, et al: Pre-
Arch Ophthalmol 103:511-514, 1985. vention of intraocular pressure elevation following
15. Ruderman JM, Mitchell PG, Kraff M: Pupillary neodymium-YAG laser posterior capsulotomy.
block following Nd-YAG capsulotomy. Oph- Arch Ophthalmol 103:912-915, 1985.
thalmic Surg 14:418-419, 1983. 25. Epstein DL, Steinert RF, Puliafito CA: Neodym-
16. Shrader CE, Belcher CD III, Thomas JV, Sim- ium-YAG laser therapy to the anterior hyaloid in
mons RJ: Acute glaucoma following Nd-YAG aphakic malignant (ciliovitreal block) glaucoma.
laser membranectomy. Ophthalmic Surg 14: 1015- Am J OphthalmoI98:137-143, 1984.
1016, 1983. 26. Irvine SR: A newly defined vitreous syndrome
17. Terry AC, Stark WJ, Maumenee AE, Fagadau following cataract surgery. Am J Ophthalmol
W: Neodymium-YAG laser for posterior capsul- 36:599-619, 1953.
otomy. Am J Ophthalmol 96:716-720, 1983. 27. Gass JDM, Norton EWD: Cystoid macular edema
18. Fastenberg DM, Schwartz PL, Lin HZ: Retinal and papilledema following cataract extraction.
detachment following neodymium-YAG laser Arch Ophthalmol 76:646-661, 1966.
capsulotomy. Am J OphthalmoI97:288-291, 1984. 28. Iliff CE: Treatment of vitreous-tug syndrome. Am
19. Parker WT, Clorfeine GS, Stocklin RD: Marked J Ophthalmol 62:856-859, 1966.
intraocular pressure rise following Nd-YAG laser 29. Katzen LE, Fleishman JA, Trokel S: YAG laser
capsulotomy. Ophthalmic Surg 15 103-104, 1984. treatment of cystoid macular edema. Am J
20. Knolle GE: Knife versus neodymium:YAG laser Ophthalmol 95:589-592, 1983.
posterior capsulotomy: A one year follow-up. Am 30. Gas~ JDM, Norton EWD: Follow-up study of
Intraocular Implant Soc J 11:448-455, 1985. cystoid macular edema following cataract extrac-
21. Epstein DL, Jedziniak JA, Grant WM: Obstruc- tion. Trans Am Acad Ophthalmol Otolaryngol
tion of aqueous outflow by lens particles and by 73:665-682, 1969.
heavy molecular-weight soluble lens proteins. In- 31. Jacobson DR, Dellaporta A: Natural history of
vest Ophthalmol Vis Sci 17:272-277, 1978. cystoid macular edema after cataract extraction.
22. Schubert HD, Morris WJ, Trokel SL, Balazs EA: Am J Ophthalmol 77:445-447, 1974.
The role of the vitreous in the intraocular pressure
38
General Anesthesia for N d: YAG
Laser Surgery
Kevin C. Moore

In spite of the high initial costs, an increasing class IV device, which attracts strict national
number of medical centers are installing laser safety regulations. In the United Kingdom these
facilities. The endoscopic use of the Nd:YAG are laid down by the Department of Health.s All
laser is well documented, and its multidiscipli- personnel involved in laser therapy should be
nary application has been described by Joffe et familiar with the potential hazards and fully
al. I A new generation of contact probes are now conversant with the safety requirements. The
available that have greatly extended the oper- anesthesiologist is perhaps ideally placed to su-
ative range of the Nd:YAG laser, and its use is pervise the correct operating room procedure.
currently being explored in a wide variety of
open operative procedures. The advantages of
these new probes and their possible applications Anesthesia for Endoscopy
have been highlighted by Joffe. 2
Anesthesiologists can therefore expect to be The endoscopic use of the N d: YAG laser to treat
increasingly involved in the provision of anes- lesions of the bronchial tree, gastrointestinal
thesia for laser surgery. To date, world anes- tract and urinary bladder is expanding. The
thesiajournals have carried a paucity of articles choice between general or local anesthesia
dedicated to the subject. It is hoped that this would appear in most cases to depend on user
chapter will stimulate interest and instigate val- preference, specific laser technique, and the
uable exchanges of clinical experience. availability of anesthesia services. Whenever
general anesthesia is administered for laser sur-
gery the potential fire risk precludes the use of
Laser Biophysics inflammable or explosive anesthetic gas mix-
tures.
As with any surgical procedure, a knowledge of
surgical technique and effect is of prime impor-
tance to the anesthesiologist. For Nd:YAG laser
Bronchoscopy
surgery, the anesthesiologist should make him- In chest medicine the Nd:YAG laser has pri-
self familiar with the basic biophysics of the marily been used for the treatment of inoperable
Nd:YAG laser including the physical properties malignant lesions of the tracheobronchial tree.
of the laser beam and its biologic effect on tis- In a report of 1000 endobronchial resections,
sues. All these have been well documented by Dumon et al. 6 preferred the use of a rigid bron-
Fulle~ and by Carruth and McKenzie. 4 choscope under general anesthesia with spon-
taneous ventilation. The use of the rigid scope
ensures proper ventilation, enables the prompt
Laser Safety and adequate treatment of hemorrhage, and al-
lows the removal of necrotic debris. The main
Accidents during laser use, although small in operative problems include hypoxemia, cardiac
number, can be devastating in effect. The arrhythmias, hemorrhage, and airway perfora-
Nd: YAG laser with a high power capacity is a tion. Toty et aC also recommend the use of a
38. General Anesthesia for Nd:YAG Laser Surgery 289

rigid bronchoscope under general anesthesia and ia, which allows the operator sufficient time to
describe their technique of maintaining anes- achieve a more complete result at one session,
thesia with an intravenous infusion of short-act- thus obviating the need for frequent initial treat-
ing agents, while producing muscle relaxation ments.
with a suxamethonium infusion and ventilating
via a modified Sanders injector using an equal
mixture of nitrogen and oxygen. More recently,
Gastroenterology
Dumon and Harre1l 8 have described a modifi- The endoscopic use of the N d: Y AG laser for
cation of their general anesthetic technique, in- the treatment of acute upper gastrointestinal
troducing the use of jet ventilation. hemorrhage and for the palliation of obstructive
Other workers, however, prefer the use of a and hemorrhagic tumors of the esophagus,
fiberoptic endoscope with topical analgesia and stomach, colon, and rectum is well established.
intravenous sedation. Unger and Atkinson 9 re- As in bronchoscopy, the choice between general
ported a series of 30 cases, all using a fiberscope anesthesia or topical analgesia with intravenous
under topical anesthesia. They cite the advan- sedation seems to be one of user preference. A
tages of useful patient cooperation, avoidance significant number of users are physician en-
of the risks of general anesthesia, and low pro- doscopists with presumably little or no access
cedure cost. McDougall and Cortese lO also rec- to regular anesthesia services.
ommend the use of a flexible fiberscope. Hetzel For the treatment of severe upper gastroin-
et al. II give a detailed account of their method testinal hemorrhage, general anesthesia with in-
of topical analgesia supplemented by intrave- tubation is recommended to avoid the danger of
nous sedation using diazepam and small doses aspiration and to ensure adequate oxygenation. 14
of diamorphine. A further technique is to intro- The one potential problem during anesthesia is
duce the flexible bronchoscope down the en- caused by the high coaxial CO 2 gas flow down
dotracheal tube of the anesthetized patient. The the laser fiber. This can cause rapid overdisten-
problems of obstruction to gas flow during in- sion of the abdominal viscera with consequent
spiration and expiration caused by this maneu- impairment of respiration. Venting of the gas can
ver have been reported by Bunnage and Ben- be achieved either by using a two channel en-
nett. 12 doscope or by introducing a small-bore naso-
It seems clear that one technique is not suit- gastric tube beside the scope. IS In practice,
able for all cases. With careful patient selection neither of these two methods are totally satis-
many can be treated with the fiberscope as an factory, and the answer must be constant vigi-
outpatient procedure under local anesthesia. lance and close cooperation between operator
Conversely, for large obstructive lesions of and anesthesiologist. Excepting this, the prob-
central airways the method of choice must be lems involved in general anesthesia are those
general anesthesia with a rigid scope. This is mainly associated with the elderly high-risk pa-
particularly so when the noncontact, high-power tient.
method of Nd:Y AG delivery is used. Smoke In Hira'sl6 series of Nd:YAG laser treatment
production is excessive, causing severe dis- of tumors of the esophagus, stomach, colon, and
comfort with coughing and struggling in the un- rectum all patients received general anesthesia.
anesthetized patient. This usually results in the This method allows the operator the necessary
abandonment of the procedure with the need for time to achieve a complete treatment in one
early retreatment. Heavy intravenous sedation session, thus reducing the need for early re-
is only partially successful in settling the patient operation. There were no problems relating to
and only serves to produce all the risks of gen- anesthesia and no operative mortality. General
eral anesthesia with none of its benefits. anesthesia can be safely administered for these
Hetzel et al. 13 now describe a technique com- endoscopic procedures to patients otherwise
bining the use of both the fiberoptic and rigid unfit for major operative surgery.
endoscope. The fiberscope allows the precise
control of the Nd:Y AG fiber tip for accurate
aiming, while the rigid scope promotes effective
Urology
suction and easy removal of necrotic debris. The Several centers now use the Nd:YAG laser for
technique is performed under general anesthes- the routine treatment of bladder tumors.
290 Kevin C. Moore

Sacknoffl7 recommends its use on an outpatient should be made in neurosurgery, otorhinolar-

basis. Hofstetter et al. 18 describe a large series yngology, and general surgery.
for the majority of which they employed topical
analgesia plus intravenous sedation. The main
Neurosurgery
reported danger during treatment is of bladder
perforation with possible damage to adjacent Takeuchi et al. 24 have described the use of the
intestinal tissues. All users admit to the pro- Nd:YAG laser via a focusing handpiece for de-
duction of bladder discomfort during laser bulking large vascular tumors such as menin-
treatment. Where this becomes a problem they giomas. A number of hand applicators are avail-
advocate the use of regional anesthesia or oc- able for use with the operating microscope. In
casionally general anesthesia. 1980 lain 25 described his techniques for vascular
Patient acceptance of laser treatment might welding using the Nd:YAG laser. General anes-
be promoted by the greater use of day case thesia is the method of choice for laser neuro-
anesthesia services which exist in most modern surgery. Cerrulo and Kohe 6 stress the need for
centers. the total immobilization of the patient. All
movements should be reduced to a minimum,
including the normal physiologic activities such
Anesthesia for Open Surgery as respiration and myocardial contraction. Their
technique involves muscular relaxation, high
The introduction of contact probes suitable for dosage of potent narcotic analgesics, and ven-
use with low-power Nd:Y AG laser energy has tilation with nitrous oxide and oxygen at a rate
provided laser users with a versatile new tool. 19 of 7 to 8 breaths per minute.
The advantages over the noncontact method of
usage include greater precision of use, less
damage to adjacent tissues, the elimination of
Otorhinolaryngology
laser light backscatter and virtually no smoke More has been written about anesthesia for CO 2
plume. The coagulating properties of the laser surgery of the larynx than about anesthesia
Nd: Y AG laser are retained at low power. Fi- for all the other forms of laser surgery put to-
nally, by attaching the probe to a handpiece the gether. It is potentially the most hazardous sit-
surgeon has a laser scalpel, which he can use in uation an anesthesiologist will face. Neverthe-
similar fashion to the conventional knife. 2 less, the benefits of laser surgery in the
The current use of the Nd:Y AG laser in all oropharynx and larynx are so great that its use
specialties is reviewed by Carruth and Mc- will increase and become standard practice
Kenzie. 20 Work in some of these is still exper- wherever laser facilities exist. 27 The fire hazard
imental and requires evaluation. In others, years that exists is a possible consequence of the im-
of experience have demonstrated a positive role pingement of a misdirected laser beam on a
for Nd:YAG laser surgery in certain procedures. combustible endotracheal tube. Several methods
In dermatology, the removal of tattoos and have been devised to avoid this catastrophe.
the excision of cutaneous lesions by the Most commonly, a red rubber endotracheal tube
Nd: YAG laser is performed mainly under topical is wrapped with an aluminum or copper adhe-
or local anesthesia. Only the more extensive or sive-backed metal tape. Inflammable or explo-
deep-seated vascular malformations and he- sive gas mixtures are avoided, and, wherever
mangiomas require general anesthesia. 21 The possible, the inspired oxygen concentration is
anterior segment of eye procedures of posterior maintained between 25 and 30%.
capsulotomy and peripheral iridotomy in oph- Several metal tubes have been devised that
thalmology are carried out under topical anes- are nonignitable. They have the disadvantage of
thesia. 22 In gynecology, endometrial ablation via being uncuffed, and most have a small internal
the hysteroscope under spinal or general an- diameter, which may give problems with gas
esthesia has been reported by Goldrath and delivery. In addition, they are a potential source
Fuller. 23 of laryngotracheal trauma and do not exclude
For the remaining specialties using Nd:YAG the possibility of reflective damage. Neverthe-
laser techniques, special reference to anesthesia less, in experienced hands they have a proven
38. General Anesthesia for Nd: YAG Laser Surgery 291

safety record. 28 A laminated cuffed silicone las- I have studied and reported on the benefits of
er-resistant endotracheal tube has been devised contact Nd: Y AG laser surgery and their effect
by Xomed. 29 Alternatives to endotracheal in- on the anesthetic management of patients. 36 The
tubation include the use of a nasopharyngeal increased precision of use, reduced instrumen-
airway with spontaneous respiration, which tation, and minimal damage to adjacent tissues
lacks good airway control, or the more popular resulted in a reduced level of intraoperative
method of Venturi ventilation. 30 Thode 3 ! has trauma. The coagulating effect of the laser
produced an excellent review of anesthesia for greatly reduced the operative blood loss, es-
laser surgery of the larynx. pecially in highly vascular tissues. Because of
While all the above comments refer to the CO 2 the foregoing, stable anesthesia was well main-
laser it seems reasonable to assume that they tained with minimal need for incremental dosage
would also apply to the use of high-power non- of analgesic or relaxant drugs. Cardiovascular
contact Nd:YAG laser energy. However, with stability was impressive with little variation in
the introduction of low-power contact probes for pulse rate and blood pressure, and the need for
Nd:YAG laser usage the attendant risks may not blood transfusion was virtually eliminated. In
be so great. There would certainly be a reduction this reported series of anesthesia for some 60
in the danger of both reflective damage and laser procedures, more than 50% ofthe patients
backscatter. Precision of use should be greater. were in the 70-90 years age group, with a pre-
If the contact Nd:YAG probe can match the CO 2 ponderance of Grades III and IV, according to
laser for operative ability and postoperative re- the American Society of Anesthesiologists clas-
sults, then the reduction in the anesthetic risk sification of physical status. The obvious ben-
would be welcomed by anesthesiologists. It is efits to these patients of laser surgery can be
too early to make valid judgments, but initial well appreciated by anesthesiologists. Imme-
results on tongue and buccal mucosa are en- diate postoperative recovery was rapid and un-
couraging. 32 complicated. As has been reported with CO 2
laser surgery, there appeared to be a definite
reduction in initial postoperative pain levels and
General Surgery early mobilization was achieved in most cases.
The fi~ld of general surgery offers the greatest Further experience in anesthesia for more
scope for the use and evaluation of low-power than 100 laser operations has supported these
contact Nd:YAG laser surgery. Areas of appli- impressions, which are currently being evalu-
cation include the body surface for such pro- ated by prospective comparative studies of laser
cedures as mastectomy, excision of cutaneous versus conventional operating techniques. With
and subcutaneous lesions, herniorrhaphy, hem- this in mind, I reported on a standard anesthetic
orrhoidectomy, and the debridement of in- technique suitable for the majority of laser and
fected ulcers and bedsores. Within the body conventional operative procedures. 37 Following
cavities its use is postulated for resection of the premedication with lorazepam, anesthesia is in-
gastrointestinal tract and for excision of solid duced with sodium thiopentone, muscular re-
organs and tumors.33 To date, reports of this laxation with alcuronium, and analgesia with
work are mainly limited to conference presen- fentanyl (or alfentanil in short procedures).
tations. Ventilation is by intermittent positive pressure
In their series of gastrointestinal tract surgery, with a gas mixture of oxygen and nitrous oxide.
Steger et al. 34 reported the use of contact Incremental doses of muscle relaxant and an-
Nd:Y AG laser in bowel resection, cholecystec- algesic are given when clinically indicated. Vital
tomy, and on solid vascular organs such as liver, parameters are monitored and recorded. Blood
spleen, and pancreas. Sultan et ae s used an loss is measured. All anesthesia is administered
Nd:YAG focusing handpiece and a combined by the same anesthesiologist. Postoperatively,
CO 2 and Nd: Y AG delivery system in their series recovery, analgesic requirements, mobilization,
of liver resections. Both reports stress the re- morbidity, and hospital stay are also recorded.
duced blood loss and excellent hemostasis The results of a small trial involving simple
achieved when operating on highly vascular or- mastectomy for malignancy and following this
gans. methodology is shown in Table 38.1. This
292 Kevin C. Moore

TABLE 38.1. Comparison of contact Nd: YAG laser 2. Joffe SN: Contact neodymium: YAG laser surgery
and conventional surgery: Breast surgery in gastroenterology: A preliminary report. Lasers
Factor Laser Nonlaser
Surg Med 6:155-157,1986.
3. Fuller TA: Fundamentals of lasers in surgery and
No. of cases 10 10 medicine. In Dixon JA (ed): Surgical Application
Age range (years) 49-92 49-84
of Lasers. Year Book Medical Publishers, Chi-
Blood loss (average in m!) 34 208
Wound drainage None All
cago, 1983, pp 11-28.
Postoperative analgesia 4. Carruth JAS, McKenzie AL: Medical Lasers,
(no. of cases requiring) Science and Clinical Practice. Adam Hilger,
Papaveretum 2 6 Bristol and Boston, 1986, pp. 36-38, 56-70.
Paracetamol 6 3 5. Department of Health and Social Security: Guid-
Nil 2 ance on the Safe use of Lasers in Medical Prac-
Mobilization tice. HMSO, London, 1984.
<12 hours 3 0 6. Dumon JF, Bourcereau J, Meric B, et al: Report
<24 hours 5 5
of 1000 YAG laser endobronchial resections. In
<48 hours 2 5
Joffe SN, Muckerheide MC (eds): Neodymium-
Complications
Inpatient stay (average in YAG Laser in Medicine and Surgery. Elsevier,
days) 5.5 8.5 New York, 1983, pp. 60-69.
7. Toty L, Personne C, Colchen A, Vourc'h G:
Brochoscopic management of tracheal lesions
using the neodymium yttrium aluminum garnet
showed reduced blood loss, reduced analgesic laser. Thorax 36: 175-178, 1981.
requirement, earlier mobilization, and shorter 8. Dumon JF, Harrell J: A universal rigid broncho-
hospitalization in the contact Nd: Y AG laser scope. (Abstract 244). Lasers Surg Med 6: 196-
group.38 197, 1986.
9. Unger M, Atkinson GW: Nd:YAG Laser Appli-
cations in Pulmonary and Endobronchial Lesions.
Conclusion In Joffe SN, Muckerheide MC (eds): Neodymium-
YAG Laser in Medicine and Surgery. Elsevier,
The anesthesiologist's contribution to endos- New York, 1983. pp 71-81.
copic laser therapy varies according to user 10. McDougall JC, Cortese DA: Neodymium YAG
preference. Nevertheless, general anesthesia is laser therapy of malignant airway obstruction.
safe and gives the operator and the patient the Mayo Clin Proc 58:35, 1983.
advantage of completing initial treatment in a 11. Hetzel MR, Millard FJC, Ayesh R, et al: Laser
single session. treatment for carcinoma of the bronchus. Br Med
In open surgery there is clear evidence that J 286:12-16, 1983.
12. Bunnage SM, Bennett MJ: Nd:YAG laser airway
technologic advances have initiated the use of
surgery: Resistance of tracheal tubes partially
contact N d: Y AG laser surgery in many spe- occluded by flexible bronchoscope. (Abstract
cialties and extended its use in others. Anes- 162). Anesthesiology 63:3A, 1985.
thesiologists will therefore be called upon to 13. Hetzel MR, Nixon C, Edmonstone WM, et al:
provide general anesthesia with increasing fre- Laser therapy in 100 tracheobronchial tumors.
quency. The opportunity exists to contribute to Thorax 40:341-345, 1985.
the assessment and evaluation of new laser pro- 14. Keifhaber P, Kiefhaber K, Huber F, Nath G: En-
cedures by the application of their own spe- doscopic applications of Neodymium-Y AG laser
cialized skills and experience. radiation in the gastrointestinal tract. In Joffe SN,
Currently the only clear conclusion is that for Muckerheide MC (eds): Neodymium-YAG Laser
the high-risk elderly patient requiring anesthesia in Medicine and Surgery. Elsevier, New York.
1983, pp. 5-14.
and surgery the contact Nd:Y AG laser is the
15. Swain CP: Endoscopic Nd:YAG laser control of
method of choice for both surgeon and anes- gastrointestinal bleeding. In Joffe SN, Mucker-
thesiologist. heide MC (eds): Neodymium- Y AG Laser in
Medicine and Surgery. Elsevier, New York, 1983,
References pp 15-28.
16. Steger A, Hira N, Moore KC: Inoperable gas-
1. Joffe SN, Muckerheide MC, Goldman L: Neo- trointestinal tract tumors. (Abstract 286). Lasers
dymium- YAG Laser in Medicine and Surgery. Surg Med 6:278, 1986.
Elsevier, New York, 1983. 17. Sacknoff EJ: Neodymium-YAG laser in urology.
38. General Anesthesia for Nd:YAG Laser Surgery 293

In Joffe SN, Muckerheide MC (eds): Neodymium- Safe anesthesia for endoscopic laryngeal laser
YAG Laser in Medicine and Surgery. Elsevier, surgery. (Abstract 27). Lasers Surg Med 6:203,
New York, 1983, pp 105-ll7. 1986.
18. Hofstetter A, Frank F, Keiditsch E, Bowering R: 29. Xomed Inc: Laser Shield Endotracheal Tube.
Endoscopic neodymium-YAG laser application Product Literature, Jacksonville, FL, 1983.
for destroying bladder tumors. Eur Urol 7:278- 30. Norton ML, Strong MS, Vaughn CW, et al: En-
282, 1981. dotracheal intubation and venturi (jet) ventilation
19. Joffe SN, Daikuzono N: MUltidisciplinary appli- for laser microsurgery of the larynx. Ann Otol
cations of contact Nd: YAG laser surgery. (Ab- Rhinol LaryngoI87:554-557, 1978.
stract 39). Lasers Surg Med 6:217, 1986. 31. Thode SA: Laryngo-tracheallaser surgery and
20. Carruth JAS, McKenzie AL: Medical Lasers, general anesthesia. Lasers Surg Med 6:369-372,
Science and Clinical Practice. Adam Hilger, 1986.
Bristol and Boston, 1986. 32. Hira N: Personal communication, 1986.
21. Rosenfeld H, Sherman R: Treatment of cutaneous 33. Joffe SN, Daikuzono N: Contact laser surgery in
and deep vascular lesions with the Nd: YAG laser. gastroenterology-An update on the endoscopic
Lasers Surg Med 6:20-23, 1986. and open surgical applications. (Abstract 20).
22. Jagger J, Dhillon BJ: Nd:YAG laser therapy for Lasers Surg Med 6:200, 1986.
the anterior segment of the eye. Lasers Med Sci 34. Steger A, Hira N, Moore KC: Use of laser in gas-
1:139-142, 1986. trointestinal disease and lasers in gastrointestinal
23. Goldrath MH, Fuller TA: Hysteroscopic ablation surgery. (Abstract 287:288). Lasers Surg Med
ofthe endometrium using Nd:YAG laser. Lasers 6:279, 1986.
Surg Med 3:186, 1983. 35. Sultan RA, Fallouh H, Lefebvre-Vilardebo M,
24. Takeuchi J, Handa H, Taki W, Yamagami T: The Ladouch-Badre A: Separate and combined use of
Nd: Y AG laser in neurological surgery. Surg Nd:YAG and carbon dioxide lasers in liver re-
NeuroI18:140-142, 1982. sections: A preliminary report. Lasers Med Sci
25. Jain KK: Sutureless microvascular repair with 1:101-105, 1986.
neodymium-YAG laser. J Microsurg 1:436, 1980. 36. Moore KC: Anesthesia for Nd: YAG laser surgery.
26. Cerrulo LJ, Koht A: Anesthesiological consid- Todays Anaesthesiol 1:6-7, 1986.
erations in laser neurosurgery. Lasers Surg Med 37. Steger A, Moore KC, Hira N: Anesthesia for laser
3: 1-35, 1983. surgery. (Abstract 290). Lasers Surg Med 6:280,
27. Carruth JAS, McKenzie AL: Medical Lasers, 1986.
Science and Clinical Practice. Adam Hilger, 38. Steger A, Hira N, Moore KC: Contact laser sur-
Bristol and Boston, 1986, pp 164-179. gery. (Abstract 289). Lasers Surg Med 6:279-280,
28. Anand VK, Herbert J, Robbett WF, Zellman W: 1986.
39
The Variable-Function Fiberoptic Laser
Apparatus Using Nd:YAG and Carbon
Monoxide Lasers
Tsunenori Arai, and Makoto Kikuchi

For laser apparatus used in medical treatments, glass fibers will realize a variable-function fi-
there are two major requirements that have not beroptic laser apparatus for medical treatments.
been completely met. One of them is the use of Figure 39.1 shows a schematic conceptual il-
a flexible optical transmitting line by which en- lustration of the variable-function fiberoptic
doscopic medical applications will be possible. laser apparatus. 3 The power delivery of CO and
The other is the possession of a variable function Nd: Y AG lasers and the variable tissue inter-
of cutting/coagulating performance similar to the action by the power-ratio control of CO and
electrical surgical unit. By solving these prob- Nd:YAG lasers are presented in this chapter.
lems, laser apparatus will be adaptable to treat The characteristics of the CO laser irradiation
complex medical conditions. The former re- on the living tissue is described in Chapter 42
quirement has been partially solved using of this book.
Nd:YAG or argon laser deliveries by a silica
glass fiber. Both of the interactions of the argon
and Nd:Y AG lasers essentially indicate thermal Principles of the Variable-
coagulation. The latter requirement has been Function Fiberoptic Laser
partially met using the combined irradiation of
Nd: Y AG and CO 2 lasers.' The variable function Apparatus
was realized by the power-ratio control of these
lasers, since the strong cutting interaction occurs The Variable Function and Fiber
by the CO 2 laser radiation. However, the laser Delivery
apparatus that simultaneously satisfies all of
The Variable Function by Combined
these requirements has not been realized yet.
One cause of this non-establishment is due to a Irradiation
lack of flexible optical fibers for the CO 2 laser The variable function to medical treatments, that
radiation, which indicates a strong cutting func- is cutting/coagulating capacity change, will be
tion. completely obtained by a wavelength change of
In this chapter we describe our own novel laser light source due to a change of the tissue
method for fulfilling these requirements. In order interaction between a laser light and tissue. In
to solve the lack of flexible fibers for cutting order to establish this function, it is necessary
lasers, CO lasers of oscillation wavelength 5-f.1m to change the wavelength of a high-power laser
band have been employed as cutting lasers.2 At from at least 1 to 3 f.1m. Although the tunability
this wavelength, chalcogenides and fluorides of \ of lasers has been attained in this region, they
infrared glass materials are available to make have reached neither high-power nor compact.
the flexible optical fibers. Moreover, even The employment of the tunable laser to medical
Nd:Y AG lasers can transmit some types of fi- treatment equipment is impossible. A unique
bers made from these glasses. Thus the com- method to practically obtain the variable func-
bination of Nd: Y AG and CO lasers with infrared tion has been by the employment of simulta-
39. Variable-Function Fiberoptic Laser Using Nd:YAG and CO Lasers 295

lnfrared-Gl ass Beam Blender

Optical Fibre Nd -YAG Laser

\ /.-----"'-
]

CO Laser

FIGURE 39.1. A schematic conceptual illustration of with Teflon cladding. In Katzir A (ed): Optical Fibers
the variable-function fiberoptic laser apparatus. [From in Medicine and Biology, SPIE, Bellingham, 1985, pp
Arai T, Kikuchi M, Sakuragi S, Saito M, Takizawa 24-31 , with permission.]
M, CO laser power delivery by AS 2 S 3 IR glass fiber

neous irradiation of coagulating and cutting la- beams, should employ two different power fi-
sers. A practical system using this method has bers. However, in the endoscopic application ,
been realized by the combined irradiation of it should be pointed out that the diameter of the
Nd:YAG and CO 2 lasers. The variable function biopsy hole (1.5 to 3 mm) is too small to insert
is realized by the power-ratio control of these two power fibers simultaneously. It would seem
lasers. The usefulness of this system has been that the combined power delivery of two dif-
particularly demonstrated in neurosurgery by ferent laser beams by a single power fiber is
this new tissue interaction. l However, its ap- necessary to develop the fiberoptic variable-
plications are quite limited since the manipulator function apparatus.
arms (i.e., reflector array) must be used to de- The wavelength of a coagulating laser is from
liver the laser beams in this system. Despite the visible to 1.5 /-Lm. The wavelength of a cutting
fact that endoscopic applications of laser treat- laser is over 3 /-Lm. There are many crystalline
ments have a great necessity for precise control fiber materials that cover both wavelengths.
of the laser interaction, , the use of the system However, the optical transmission of crystalline
for this application is impossible. The cause of fibers is decreased by repetitive bendings due
this defect of the system is not only a lack of to the increase of the scattering. s This growth
flexible optical fibers for the CO 2 laser light, but of scattering is attributed to the production of
also the difficulty of the combined delivery to scatterings by the destruction of the crystal
two different wavelength lasers. The flexible structures from plastic strain. Since the Rayleigh
optical delivery should be preferentially consid- scattering intensity is inversely proportional to
ered to design laser apparatus for endoscopic the fourth power of the wavelength, the trans-
application. mission of the crystalline fiber for the coagu-
lating laser is strongly affected by this scattering.
The medical fiber should resist tight repetitive
The Combined Power Delivery
bendings, so that the practical use of the crys-
The power delivery of laser beams by optical talline fiber for the combined power delivery will
fibers has been reported by many authors,4 al- be impossible. The brittle glass fiber is useful to
most all of them of the delivery of Nd:YAG la- prevent this scattering promotion by repetitive
sers or CO 2 lasers. In all these reports, a certain bendings.
kind of the fiber was selected for a certain kind Infrared glass materials have been studied to
of laser. Thus following, the variable-function make an ultra-low-loss fiber for optical com-
laser apparatus, which uses two different laser munications. 6 These materials have high me-
296 Tsunenori Arai and Makoto Kikuchi

chanical strength with brittleness. Their trans- materials have thus already been adapted for
mission range extends from 1 to 8 fLm, in medical applications as concerns the attenuation
general. However, they have not covered the of the fiber.
CO 2 laser wavelength. Therefore, it is necessary The infrared glass materials are classified into
to employ a new cutting laser that has a shorter three kinds of glasses, chalcogenides, fluorides,
wavelength than the CO 2 laser. CO lasers of and oxides. Their optimum transmission wave-
wavelength 5 fLm band have been selected as length becomes longer in the order: oxides,
cutting laser radiation. The power delivery of fluorides, and chalcogenides glasses. Figure 39.2
CO lasers by the infrared glass fiber has already shows their transmission spectrum reported with
been successfully demonstrated by the authors. 7 the silica glass fiber.~ll The most typical glass
This laser is a unique practical laser within cut- systems are selected in the figure. As shown in
ting range of infrared wavelengths. Please refer Figure 39.2, chalcogenide glasses in particular,
to our Chapter concerning both the choice of have a wide transmission range. Its transmis-
CO lasers and the interaction of CO lasers. sion range generally extends from 1 to 8 fLm.
The combined power delivery of CO and
Nd:YAG lasers is enabled by the wide trans-
Components of the Variable-Function mission wavelength range of chalcogenide
Fiberoptic Laser Apparatus glass fibers. In general, the bonding energy of
Infrared Glass Fibers optical transmission materials is related to a
transmission cutoff of a long wavelength side,
The transmission loss of the fiber made from so that chalcogenide glasses have a low me-
infrared glass has still been greater than desired chanical strength within infrared glasses. How-
for optical communications. However, since the ever, the fibers made from them indicate further
practical transmission length of the medical fiber flexibility than crystalline glass fibers. In the
is only up to 2 m, the transmission loss of up to near future, a fiber made from the fluoride
3 dB/m is allowable without considering the glasses will be important candidates for CO laser
heat-up of the fiber. The fibers made from these delivery by their high mechanical characteristics

10 2 r------,-------.-------r------.------.

30
40
50
60
70
80
~ 90
cc
~ E
(f)
(f) 95 ~
o--.l w
U
6 10- 1 z
«
(f) l-
(f) I-
~ ~
(f) (f)
z z
« «
a:
c::
I- I-
10 - 2

10 - 3L--L__-L______~____~~____~____~ FIGURE 39.2. Transmission spectrum of

1 2 3 4 5 6 typical infrared glass fibers reported
WAVELENGTH [~n l with the silica glass fiber.
39. Variable-Function Fiberoptic Laser Using Nd:YAG and CO Lasers 297

in spite of the discrepancy of wavelengths be- perature CO laser has focused on its sealed-off
tween their optimum transmission and CO laser type. 17
radiation. We have improved the performances of the
Infrared glasses are advantageous in mass room-temperature CO laser by high gas flow. 18
production, since the normal drawing method The gas flow (i.e., gas convection) extracts the
for production of the silica glass fiber is adapt- heat generated by the waste energy of the laser
able to manufacturing the infrared glass fiber to kinetics to outside of the laser discharge region,
reduce its cost. Hence, disposable use of the so that the temperature of the laser mixture is
infrared glass fiber might be possible, so that decreased. This effect promotes excitation by the
the disinfection of the medical fiber may be internal vibrational transfer of CO molecules and
eliminated. restricts the relaxation of CO molecules. The
performances of our CO laser were at the max-
Carbon Monoxide Lasers imum power of 40.7 W, the maximum efficiency
of 20.3% from the laser tube of 1.06 m in
Performance of CO Lasers length. 19 They indicated a 30% improvement in
The CO laser, a kind of electrically excited gas performance against previous reports.
laser, was discovered by Patel in 1964 using the There are few production models of CO lasers
same apparatus that was used for the first CO2 available in the world. Almost all of them are
laser. 12 The quantum efficiency which indicates not immediately adaptable for medical treat-
the maximum theoretical efficiency is estimated ment. However, since CO lasers can be man-
at as high as 98.8% in spite of the impossibility ufactured by the same technique as CO2 lasers,
of a precise definition of the efficiency of CO it will be easy to manufacture practical CO lasers
lasers. The cause of this high efficiency origi- to satisfy the medical application needs.
nated from the small friction of CO molecules.
CO lasers are characterized by this high effi-
ciency. Electrical efficiencies of 47 and 63% are Fundamental Experiments of the
reported in continuous and pulse mode opera- Variable-Function Fiberoptic
tions, respectively.I3·14 However, in general it
appears only when the temperature of the laser Laser Apparatus
mixture is kept at a low value (for example, liq-
uid nitrogen temperature), since the pumping Experiments of the Combined Power
process of this laser is strongly dependent on Delivery
the gas temperature.
Experimental Setup for the Combined
Power Delivery
Room-Temperature CO Lasers
AS 2S3 Chalcogenide Glass Fiber
Room-temperature operations of CO lasers have
been reported by many authors using a xenon The chalcogenide glass fiber used in this ex-
additive in the laser mixture. The room-tem- periment has been made by AS 2S 3 glass, 400 j.Lm
perature operation is extremely important due in core diameter. The cladding is made of FEP
to its usefulness for easy handling and mainte- Teflon resin, which protects the core surface
nance, which are necessary for medical equip- from scratching. The core and the cladding are
ment. The role of xenon in CO laser kinetics is optically attached to form a core-clad structure.
estimated to optimize electrical excitation effi- The allowable bending radius of this fiber is less
ciency to cover the low pumping speed at room than 30 mm. The transmission losses of this fiber
temperature. 15 The room-temperature CO laser for CO and Nd:YAG laser radiation are less than
is less efficient than CO2 lasers, so that the room- 1 dB/m. 20 The refractive index of the core ma-
temperature CO laser is not popular in the mar- terial is 2.41 at 5 j.Lm, so that approximately 30%
ket. The room-temperature CO laser was de- of incident laser energy is reflected backward.
veloped for use with spectroscopic applications, In other words, the coupling efficiency is limited
so that there was little interest in the improve- to 70%. To improve the coupling efficiency in
ment of the power and efficiency of of this kind the future, antireflection coatings will be avail-
of laser. 16 Currently, research of the room-tem- able. The refractive index of cladding material
298 Tsunenori Arai and Makoto Kikuchi

is 1.3. This fiber transmits all incident light col- Results and Discussion of the Combined
limated on the incident surface. The solubility Power Delivery
for water of AS ZS3 is 6 X 10- 5 g/100 gH 2 0. This
The transmission loss under the power delivery
solubility suggests a low toxicity of AS 2 S 3. The
was measured by an angle of line inclination, in
termination of the fiber was polished using fine-
a graph of the dependence of the fiber length on
grade sandpaper, so to suppress the scattering
the fiber transmittance. The transmission loss
of measured data for maximum power delivery.
for the Nd: YAG laser delivery was measured to
2.6 dB/m. The transmission loss for the CO laser
Setup of Optical Components
delivery was 1.2 dB/m. Since the wavelength of
We have demonstrated the combined power de- the Nd:Y AG laser, 1.06 fLm, is near the low-
livery of CO and Nd: Y AG lasers by As ZS 3 • The wavelength cutoff for this fiber, the attenuation
setup for the combined power delivery of the for Nd:YAG lasers is larger than that for CO
CO and Nd:YAG laser is illustrated in Figure lasers.
39.3. 11 The chalcogenide glass fiber made from In order to determine the capacity of the
AS 2 S 3 used in the experiment is as described power delivery, the incident laser power was
above. Two laser beams were aligned into one increased until the fiber was destroyed. This
beam on a ZnSe plate. The ZnSe plate was set experiment was undergone at various combined
at the Brewster angle for a liner polarized CO ratios of the N d: Y AG and CO lasers. In a pre-
laser beam. The Nd: Y AG laser beam reflected vious paper3 we revealed that the maximum ca-
on the ZnSe plate was combined with the CO pacity of the power delivery for a CO laser by
laser beam. The coupling efficiencies were 100% the same AS 2 S3 glass fiber was over 15 W. The
and 30% for CO and Nd:YAG lasers, respec- light intensity at the output end of the fiber was
tively. This combined technique is appropriate in excess of 12 kW/cm 2 • 3 By the experiment of
only for laboratory use. In the actual application, the combined power delivery, it is evident that
multicoated dielectric beamblenders will be the maximum delivered power is decreased by
available to improve the coupling efficiency of increasing the Nd:Y AG laser power ratio. Since
both lasers. The combined beam was collimated the destruction of the fiber by the laser power
into the incident end of the fiber by a CaF2 lens results by melting down the fiber, it is well
of 75 mm of focal length. The beam diameter of understood by the measured transmission loss
the combined beam was 6 mm, so that the nu- which induces the heat generation. Neverthe-
merical aperture of incident optics was approx- less, the fiber could transmit over 8 W laser
imately 0.1. The fiber output was measured by power with an output intensity of 6.4 kW/cm 2 ,
a thermal power meter. even though the entire delivered light power

Absorber
He-Ne Laser Total Reflector
for Fiber f or Fibe r
AI ignment Alignment
~
AS,S, Gloss Fiber
Coredlo. - 400~111
t CO Output
CouPI[r ~
COlXe Laser

~~~----------~~~~~~~
U
I ___~
Mechanical
0 11 Power' Meter
(Coherent P210 )
Shutter

FIGURE 39.3. Schematic illustration of the setup for the combined power delivery of CO and Nd: YAG laser.
FIGURE 39.4.
Microphotographs of
manufactured
specimens of combined
irradiation samples.
Irradiation power ratio
(CO/Nd:Y AG): (A) 01
100, (B) 5/95, (C) 10/90,
(D) 25/75. Average
light intensity: 1.2 kWI A
cm'. Irradiation time:
15 seconds. Sample:
cow liver.

.",tJ . . ...

299
300 Tsunenori Arai and Makoto Kikuchi

consisted of a Nd:YAG laser. l1 It is noted that Figure 39.4C,D show the strong cutting inter-
these performances were carried out by the 400 action. It is evident that the function variability
/-Lm diameter fiber without any cooling of the is easily attained by the power ratio control of
fiber. This capability for power delivery will be lasers. The depths of the cutting grooves in this
sufficient to realize the variable-function fiber- experiment were not proportional to the CO
optic laser apparatus. When forced cooling by laser power. In other words, the tissue inter-
air convection was applied to the ends of the action was sensitively varied to the addition of
fiber, the maximum delivered power was in- cutting laser power. This result may be attrib-
creased. However, since in practical endoscopic uted to a rapid change in the composition of the
applications there are many geometric restric- tissue surface by cutting laser irradiations. This
tions to attain forced cooling of the fiber, the fact suggests that the power of the CO laser
power delivery fiber should be used without the which is necessary for the combined laser ap-
cooling. paratus might be smaller than that of the
Nd:YAG laser.
The Variable Function by the Power
Ratio Control of the Nd:YAG and CO
Summary
Lasers
Experimental Setup The variable-function fiberoptic laser apparatus
for medical treatment was described in this
The tissue interactions by the combined irra-
chapter. The discussion of its conceptual design
diation of CO and Nd:YAG lasers were exper-
was described. The laser apparatus for medical
imentally measured in vitro. To demonstrate the
treatment should be designed from a standpoint
usefulness of the simultaneous delivery by the
of flexible optical delivery, since endoscopic
fiber, the fiber output beam was used in this in-
applications of the laser apparatus are both
vestigation. The exsanguinated livers of pigs
unique and the most important laser treatments.
were used as subjects. The total fiber output was
In addition, variable-function similar to the
fixed to 5 W. The fiber which was bent down
electrical surgical unit will be necessary. The
to the sample in 80 mm of curvature was ap-
employment of a new cutting laser and an in-
proximately 400 mm in length. A preliminary
frared fiber made of new material make it pos-
experiment was done to indicate that the fiber
sible to construct this apparatus. A brief ex-
output originating two different lasers was con-
planation of the infrared glass fiber and the
structed in a concentric configuration. The fiber
room-temperature CO laser was given. The
output was directly irradiated on the liver sample
experimental results of the fundamental com-
of which the surface was separated 5 mm from
the fiber termination. The averaged light inten- bined power delivery of the Nd:YAG and CO
sity on the sample was 1.2 kW/cm2 • The power laser by the flexible As Z S3 glass fiber appealed
ratio of the CO and Nd:YAG laser was varied to the validity of our approach. The tissue inter-
five steps within from 0/100 to 50/50. The irra- actions by combined irradiation with a varying
diated livers were manufactured to tissue spec- power ratio successfully demonstrated the vari-
imens. ability ofthe function of this system. This appara-
tus will be useful for entire endoscopic appli-
Results and Discussion cations including vascular recanalizations. The
authors believe that this apparatus will be manu-
Figure 39.4 shows microphotographs of manu- factured for actual application in the near future.
factured specimens of irradiated samples. The
irradiation power ratio (CO/Nd: YAG) increases
from Figure 39.4A-D.22 Despite the interaction References
of the thermal coagulation not being obviously 1. Tsuyumu M, Yamazaki S, Takei H, Suzuki K, et
indicated in the microphotographs, the cutting al: Experimental study of combined coaxial ir-
interaction was completely investigated. Figure radiation by high-peaked pulse wave form CO2
39.4A,B show the increase in temperature on and Nd:YAG laser on the brain. J Jpn Soc Laser
the sample surface; still there was no cutting. Med 4:141-142, 1984.
39. Variable-Function Fiberoptic Laser Using Nd:YAG and CO Lasers 301

2. Arai T, Kikuchi M: A study for development of vibrational-rotational transitions of CO. Appl Phys
CO laser scalpel (1) Investigation of the effect of Lett 5:81-83, 1964.
CO laser light on living tissue. J Jpn Soc Laser 13. Bhaumik ML, Lacina WB, Mann MM: Charac-
Med 3:223-230, 1982. teristics of CO laser. IEEE J Quant Electron QE-
3. Arai T, Kikuchi M, Sakuragi S, et al: CO laser 8:150-160, 1972.
power delivery by AS OS 3 IR glass fiber with Teflon 14. Mann MM, Rice DK, Eguchi RG: An experi-
cladding. In Katzir A (ed): Optical Fibers in mental investigation of high energy CO lasers.
Medicine and Biology. SPIE, Bellingham, 1985, IEEE J Quant Electron QE-IO:682-683, 1974.
pp 24-31. 15. Murray GA, Smith ALS: The efficacy of xenon
4. Pinnow DA, Gentile L, Standlee AG, Timper AJ: as an additive gas in carbon monoxide lasers. J
Polycrystalline fiber optical waveguides for in- Phys D 11 :2477-2487, 1978.
frared transmission. Appl Phys Lett 33:28-29, 16. Peters PJM, Witteman WJ, Zuidema RJ: Efficient
1978. simple sealed-off CO laser at room temperature.
5. Mimura Y, Ota C: Transmission of COo laser Appl Phys Lett 32:119-121,1980.
power by single-crystal CsBr fibers. Appl Phys 17. Browne PG, Smith ALS: Efficient long life sealed
Lett 40:773-775, 1982. CO lasers at room temperature. J Phys E 8:870,
6. Miyashita T, Manabe T: Infrared optical fibers. 1975.
IEEE J Quant Electron QE-18:1432-1450, 1982. 18. Arai T, Kikuchi M: High power coaxial-flow
7. Arai T, Kikuchi M: Carbon monoxide laser power room-temperature CO laser. In Kaye AS, Walker
delivery with an AszS, infrared glass fiber. Appl AC (eds): Gas Flow and Chemical Lasers. Adam
Opt 23:3017-3019, 1984. Hilger, Bristol, 1984, pp 29-34.
8. Horiguchi M, Osanai H: Spectral losses of low- 19. Arai T, Kikuchi M: High-power room-temperature
OH-content optical fibers. Electron Lett 12:310- CO laser. Appl Phys Lett 45:362-364, 1984.
312, 1976. 20. Saito M, Takizawa M: Teflon clad As-S glass IR
9. Takahashi H, Sugimoto I, Sato T: Germanium- fiber with low absorption loss. J Appl Phys
oxide glass optical fiber prepared by V AD meth- 59: 1450-1452, 1986.
od. Electron Lett 18:398-399, 1982. 21. Arai T, Kikuchi M, Tomita Y, et al: Combined
10. Mitachi S, Miyashita T: Preparation of low-loss laser power delivery of CO laser and Nd:YAG
fluoride glass fiber. Electron Lett 18: 170-171, laser by IR glass fiber. J Jpn Soc Laser Med 6:355-
1982. 358, 1986.
11. Miyashita T, Terunuma Y: Optical transmission 22. Arai T, Kikuchi M, Tomita Y, et al: Simultaneous
loss of As-S glass fiber in 1.0-5.5 f.Lm wavelength laser irradiation of fiber delivered CO and
region. Jpn J Appl Phys 21:L75-L76, 1982. Nd: YAG laser on living tissue. J Jpn Soc Laser
12. Patel CKN, Kerl RJ: Laser oscillation on X'~+ Med 6:283-286, 1986.
40
Computer-Controlled Contact N d: YAG
Laser System for Interstitial Local
Hyperthermia
Norio Daikuzono, Masaru Ohyama, Stephen N. Joffe,
Soutaro Suzuki, Hisao Tajiri, and Hiroshi Tsunekawa

Contact N d: Y AG laser surgery is assuming a laser energy and causes a very limited localized
greater importance in endoscopic and open sur- high temperature, which is difficult to control
gery, allowing coagulation, cutting, and vapor- properly and is too unstable for use in hyper-
ization with greater precision and safety. A new thermia. We have introduced several kinds of
contact probe allows a wider angle of irradiation sapphire contact probes 2 . 3 for attachment to the
and diffusion of low-power laser energy (< 5 W) Nd:YAG laser optical fiber (Figure 40.1 and
using the interstitial technique for local hyper- 40.2). Contact probes delivering different kinds
thermia. Continuously monitoring temperature of beam patterns can be used for coagulating,
sensors are placed directly into the surrounding vaporizing, and cutting tissue with much lower
tissue or tumor. Using a computer program in- power than conventional noncontact methods
terfaced with the laser and sensors, a controlled (Figure 40.3). The interstitial contact probe has
and stable temperature (e.g., 42°C) can be pro-
duced in a known volume of tissue over a pro-
longed period of time (e.g., 20-40 minutes).
Several kinds of energy resources have been
used for hyperthermia.
1. Heat flow Hot water
2. Electromagnetic energy RF, Microwave
3. Sonic energy Ultrasonic induction
4. Scattered light Infrared light
5. Laser Nd:YAG Laser
For hyperthermia, greater and more uniform
heating, easier and more precise control for
temperature, and no invasive methods are de-
sired. For certain clinical purposes, localized
hyperthermia and a means of transmitting energy
are very important. The Nd:YAG Laser can be
transmitted by a flexible optical fiber; it can
penetrate tissue deeper than other kinds of
medical lasers.
S.G. Bown' tried to use the Nd:YAG Laser
for hyperthermia by the interstitial method-
sticking bare fiber into a tumor. However, high-
power density at the distal end of the fiber caus-
es damage at the tip of the fiber and vaporizes
the tissue. Burnt tissue, including char, absorbs FIGURE 40.1 Contact laser scalpel.
40. Contact Nd:YAG Laser for Interstitial Local Hyperthermia 303

FIGURE 40.2. Contact endoprobes.

the ability to diffuse the laser beam on the probe Interstitial Probes
surface because of its optical design (Figure
40.4). It can withstand higher temperature and N oncontact laser irradiation can lose 30-40% of
is much harder than the bare quartz fiber, which beam energy to backscatter. The contact meth-
assures thermal and mechanical stability. In this od, especially the interstitial method, can deliver
chapter, we will describe local hyperthermia the laser beam more effectively and quantita-
controlled by a computer, using a thermocouple tively into tissue. This is very important for
as monitor for temperature and an interstitial clinical procedures requiring a total dose of laser
probe to transmit diffuse low power through the energy. The probe's conical shape facilitates
Nd:YAG laser. We call this method laserther- mechanical penetration of the tumor (Table
mia® which is a registered trademark of Surgical 40.1). Diffused laser light on the surface of the
Laser Technologies Inc. (Malvern, PA) probe has lower power density, less than 0.05

Coagulation Gallstone Incision/Excision Incision/Excision

High.... Power Density ~

FIGURE 40.3 Beam divergence of endoprobe.

304 Norio Daikuzono et al.

i:lative Power Density

~ 0.4

0 .2
o

-+Relative Power Density

o 0 .2 0.4 0.6

FIGURE 40.4 Interstitial endoprobe local hyperther-

mia/Photodynamic therapy: Distribution of power
density.

W/cm 2 for 1 W of total irradiation from the

probe, having 3 mm length, in contrast to the
bare fiber, 3.6 W/cm 2 for 1 W of 600 J-lm. With
a longer probe it is possible to have longer ir- FIGURE 40.5 Thermocouples.
radiation time so that different probe lengths can
be applied based on the tumor volume. Due to
low power density on the surface and charac-
teristics of the probe, the probe has less damage face of the needle is well polished for laser beam
than bare fiber under more energy delivery. reflectance. Different length of needles are
available for different clinical cases (Figure
40.5). It was confirmed by a comparison of
Thermocouple measured temperatures from the thermocouple
and thermograms that there was no temperature
For the practical purpose of inserting the ther- interference from exposure of the laser beam
mocouple into the tumor, the needle-shaped directly onto the thermocouple during low-
stainless steel thermocouple has stopperlike power laser irradiation from the probe in the tis-
flange to control the depth of insertion. The sur- sue (Figure 40.6).

TABLE 40.1. Characteristics of single crystal artificial sapphire

Property Sapphire Quartz
Material/formula AI 2 0 SIO
Melting point 2030-2050°C I 600°C
Specific heat 0.18 (25°C) 0.17 (25°C)
Thermal Conductivity (gOcal. cm s) 0.0016-0.0034 (40°C) 0.0158 0.0299 (40°C)
Coefficient of thermal expansion (\0 cmrC) 50-67 80
Elastic Coefficient (10 kg/cm) 5.0 0.76
Specific gravity 4.0 2.2
Hardness (mohs) 9 7
Compressive strength (kg/cm) 28000 20000
Tensile strength 2000 900 1200
Index of refraction 1.76 1.54
Absorption degree of water 0.00 0.00
Chemical characterstic appearance Acid- and bace-proof clear Acid- and base-proof clear
Crystal form hexagonal system hexagonal system
Transmittance for Y AG laser More 90% More 90%
 40. Contact Nd:Y AG Laser for Interstitial Local Hyperthermia 305

FIGURE 40.6 Thermogram

during laserthermia.

Computer System
The delivery of laser energy from the probe to
increase the temperature of tumor is controlled
by computer, monitoring 'o ne representative
temperature at the certain distance from the
probe to the thermocouple. Feedback system of
measured temperature to laser delivery is pos-
sible to keep the programmed temperature at the
point where the thermocouple is located (Figures
40.7 and 40.8). Currently the medical laser gen-

Stable
Nd : Vag Laser
HlgnResponse
( ~;:e~on ..ct ) Optical Snuner t=== ======iI
Interstitial
Tilermoeouple

_ _ Control Sy"Slem

_ _ Computer System

Computer
(NEe PC9801 )

FIGURE 40.7 Computer-controlled Laserthermia sys-

tem-single channel. FIGURE 40.8 Single-channel control system.
306
Norio Daikuzono et al.

Temp.
( C] A Original temperature ( Stomach)
B 9mm control ( Stomach )
C 6mm control (Stomach)
D 9mm control ( SpI""n)
E 6mm control ( Serosa )

10

12 9 6 3 3 6 9 12
(mm] Distance from
probe

• Probe

o Ttlermocoupie

FIGURE 40.10 Temperature distribution in canine

stomach and spleen.

FIGURE 40.9 SLT Contact Laser.

Laser delivery ~~ON-*-OFF...,.J

I I CW I I
Control mode CW ---+I!--t I' II' II
f IPube I I I Pulse I
Temperature I I I I I
( e] I I I - Abnormal Upper Temp.
46 I I I (Interlocking)

44 - _: - _: _ - _I ___ : _ _ Upper Control Temp.

I _ 1__ _ _ _ _ _ __
1 Lower ContrOl Temp.
42
40

36
- - - Abnormal Lower Temp.
34 (Int",locking)

Time (min ) ....

FIGURE 40.11 Control method for temperature with laser delivery.

40. Contact Nd:YAG Laser for Interstitial Local Hyperthermia 307

erator is manufactured for the purpose of high sible by using the pulse mode. If the temperature
power and noncontact methods, so we require is over the "upper control temperature," it will
a very stable laser generator such as the SLT stop the delivery of laser energy. For safety
Contact Laser, especially using low powers considerations, the system will stop delivering
(Figure 40.9). If the probe is not changed, the laser energy if the temperature is over the "ab-
temperature distribution will differ with the color normal upper temperature," suggesting local
of the tissue and the distance between the probe overheating, or lower than "abnormal lower
and the thermocouple. The temperature on the temperature," suggesting disconnection of
surface of the probe has the highest temperature. thermocouple from tissue. The system allows
But to get wider heating and controllable tem- various input ranges and conditions for con-
perature, it is important not to obtain more than trolling the system so that it has versatility for
100°C on the surface of the probe. Otherwise a wide variety of clinical purposes (Table 40.2
burning of the tissue occurs with a great energy and Figure 40.12).
loss leading to damage of the probe. For this
reason, in this method a suitable power level is
required, normally less than 5 W. This depends TABLE 40.2. Input ranges for controlling system
on the duty cycle of laser delivery and also limits
1. Input power 0.1-100 w
the heated area to a 1-2 em diameter (Figure
2. Total time 0.01-30 min
40.10). A cross sectional view of temperature 3. Totaljoules 0.1-10,000 J
distribution is almost semicircular, so that it is 4. Upper temperature 3S.I-SS.0°C
possible be easily get a known volume of tissue (Upper temperature controlled)
heated adequately. S. Lower temperature
(Lower temperature controlled)
6. Ab.-Up. temp. 3S.1-SS.0°C
(Abnormal upper temperature)
Control Method for Temperature 7. Ab.-Lo. temp.
(Abnormal lower temperature)
At the beginning of the laserthermia procedure, 8. Laser output mode Continuous or
laser energy must be delivered rapidly in a con- (Control mode) pulse
8-I.C 0-30 min
tinuous mode, since the tissue temperature is (Continuous)
lower than "lower control temperature" set at 8-2. P Programmable
42°C (Figure 40.11). However, if the tissue tem- (Pulse)
perature is within the control range between the 8-2-1. Pulse on O.I-S.O sec
"lower control temperature" and the "upper (Pulse width)
8-2-2. Pulse off 0.I-S.0 sec
control temperature" such as 44°C, the system
(No pulse width)
delivers the laser energy slowly, which is pos-

Operat i ng data (Data I nput End => f· 5 i'<ey ento:>r)

Date - - - - - - 85/04/25
Time - - - - - - ., 12:48:00
Patient - - - -
I'lImber - - - - 0aBJl01
Name----- H.()I-t:.lSHI////////////
Birthday - - - ., 23d~Jg/ 1949// //
Sex - - - - - . , Female
Doctor Name- - - - ========================================
I'lIrse Name - - - - .,
Operation
I nput Power (w) - - ., 10.0
Total Joule(j)- - ., lOOl0.0
Total Time (m)- - 20.00
Upper. Temp. (OC) - 44.5
Lower Temp. ("C) - 4:;.5
Hb.-Up Temp. (oC)- 45.5
Ab.-Lo Temp. (OC)_ 35.0
FIGURE 40.12 Operating data input. Laser Output Mode- ., Cont i nuous
308 Norio Daikuzono et al.

Date : ~05~2 Time: 14:25: 38 Sta.Tlme: 13:59:06 Ope.Stop Las .OFF Ope.T ~p.= 33 . 3·C
Pat. i'llm.: Name : 8, r. : 5e,: Fema I e
Doc.:---------------------------------------- i'llr. :----------------------------
In . Pow . (w) =10.0 Tot.Jvu. Ij )= I0000 .0 Tot .Time (rn)=20.0e PuI.on=0.5s/ off=0.5s
Upper Temp.=43.5°C Lower T~p.=4 3 .2° C Ab.Upp.Temp.=4S.0°C Ab. Low . Temp. =35 .0·C
Temp. (°0 Jou Ie(Xl0000)
~ I

50
.,.. control
4-------------------------.. 4.~--------------------_.

45 .5
,/Ia....j'....I;.-~4~:.....':........~. .:~..... -· '.,......r.:~·. .·.L.-...r.!:i-4~~.i~2~~~
.;:.¥-V:..V..\;-,••,"..V .J..\ .."'~...
41;.•

,
--... . ~ ..... -
40 ....,../ --_ .. --- . ..... ---
~--

-- "" ---
_a""·"' -
----~

35 .-' 0
o 5 10 15 Time(rnin.) FIGURE 40.13 Data out-
Ela.Time:20n 0s as. Time: ~ 0s ;Urn JOI.I .= '320 1.6 r ..m.Jou . = 6798.4 put.

FIGURE 40.15 Multiple-channel control system for

FIGURE 40.14 MUltiple-channel laser system. Laserthermia.
40. Contact Nd:YAG Laser for Interstitial Local Hyperthermia 309

FIGURE 40.16 Computer-controlled Laserthermia

system-multiple channels. Stable Multiple
Nd: Vag Laser Laser
~ Distribution
(SlT Contact I r-- System
la ....

--
Multipul 1-
Temperature
Controller

1
..:::: .::::: ..:::: :::::!J
Computer y
,,

• Probe x-- ·
o Thermocouple
,
I
4 Channels
Independent Control

Suitable Power Ranges and Pulse the temperature with less flexibility to respond
Delivery the change of tissue conditions such as blood
flow. The suitable power range seems to be from
1 to 5 W. This will be clearer with more exper-
From experiments in vivo it is clear that higher iments. The system allows the use of continuous
power causes overshooting the "upper control wave or pulse mode for laser delivery during
temperature" so the controlled range of tem- the raising of temperature between "lower and
perature is wider and not precise. Contrary to upper control temperature." But the proper
that, lower power takes a longer time to increase condition with the pulse mode makes more pre-

laserthermia
System ~=:::::~

Endoscope

FIGURE 40.17 Endoscopic Laserthermia.

310 Norio Daikuzono et al.

cise control than the continuous wave mode scopic Laserthermia, 4 using a two-channel en-
(Figure 40.13). doscope (Figure 40.17). Obviously, a mUltiple
Laserthermia system will be used for larger tu-
mor located on an open surgical field. Recent
Multiple Laserthermia System biomedical and clinical studies of Laserthermia
shows that in addition to normal efficacy of hy-
The single-probe Laserthermia System is limited perthermia, it may have additional advantages
for heating a large volume of tissue. To get larger based on the interaction between laser energy
tissue volumes with more uniform temperature and cancer cell with a direct effect with laser
heating we have developed Multiple Laserther- light on the cancer cells. 5 Damage to normal tis-
mia system,® consisting of a SLT contact laser sue with Laserthermia is minimum as shown by
with multiple laser distribution system (Figure studies measuring arachidonic acid metabolites
40.14) and a computer (Figure 40.15). Consid- in vivo. This method has been evaluated by dif-
ering the rapid localized change of temperature ferent specialties. 6 Further study will be focused
in the tumor, each probe is independently con- on this point and on the influence of Laser-
trolled by its own thermocouple. In this report thermia, especially on normal tissue.
a four-channel system is shown. There are no
known technical problems to using more chan-
nels, which would be determined by the volume Reference
of tissue to be treated. The temperature around
the probe in the tumor is higher. This is not of 1. Brown SG: Tumor therapy with the Nd: YAG laser.
In Joffe SN, Muckerheide M, Goldman L. (eds):
much concern as long as the probe does not
Neodymium-YAG Laser in Medicine and Surgery
cause tissue vaporization. The temperature Elsevier, New York, 1983, pp. 59-70.
should be controlled strictly and precisely at the 2. Daikuzono N: Introduction of a newly developed
border between normal tissue and tumor. A contact ceramic probe connected to a laser optical
monitoring thermocouple should be placed at quartz fiber for wide applications in medicine and
this junction and the probes should be directed surgery. Proceedings for 2nd International
to the center of the tumor (Figure 40.16). Nd:YAG Laser Conference in Springer-Verlag,
Munich, 1985. pp 302-306.
3. Daikuzono N: Artificial sapphire probe for contact
Conclusion photocoagulation and tissue vaporization with the
Nd:YAG laser. Med Instrum 19(4):173-178,1985.
We have successfully developed both a Single 4. Suzuki S: Endoscopic local hyperthermia with Nd-
and Multiple Laserthermia System, which make YAG laser. Gastroentererology (Japan) 4(4):363-
370,1986.
it possible to control temperature precisely.
5. Tajiri H: Experimental studies of local hyperther-
These therapeutic modalities are very easier to mia using Nd-YAG laser. Oncologia 17:161-163,
operate, safer and have more precise tempera- 1986.
ture control than currently used laser system 6. Ohyama M: Treatment of head and neck tumors
with their high power and short therapeutic du- by contact Nd-YAG laser surgery. Auris Nasus
rations. The single system is useful for endo- Larynx (Tokyo) 12 (Suppl 11):S138-S142, 1985.
41
Safety Procedures for N d: YAG
Laser Surgery
R. James Rockwell, Jf.

Understanding the specifics of laser safety is cedure. The same laser system is used in both
absolutely essential to the medical community. cases but there are significant differences in the
In the past there has been uncertainty over the potential hazards. Safe use of lasers-in partic-
regulations that apply in laser surgery. This can ular, Nd:YAG lasers-requires procedures and
create unnecessary concerns, particularly at the practices based on knowledge and understand-
time the first laser is acquired. Therefore, it is ing.
the goal of this chapter to provide a review of
the various hazards associated with the surgical
use of lasers and an understanding of the ap- Laser Hazards to the Eye
plicable standards, with suggestions for several
specific safety procedures that can be applied The hazards of lasers that represent a potential
when using the Nd: Y AG laser in a surgical set- for injury to the eye generally depend upon the
ting. wavelength of the laser and which part of the
Some of the primary factors that must be eye absorbs the most radiant energy per unit
considered when implementing the Nd:YAG volume of tissue at that wavelength. Retinal ef-
laser in surgery are (1) the operational charac- fects are generally considered the most serious
teristics of the specific Nd: Y AG laser; (2) the and are possible when the laser wavelength falls
adaptability to desired accessories (e.g., endo- in the visible and near-infrared spectral regions
scopes, fiber optics, sapphire tips, handpieces); (0.4-1.4 f.Lm). Hence the Nd:YAG laser with
(3) education and training, including inservice emission at 1.064 f.Lm (or 1.32 f.Lm in some ex-
training; (4) ongoing service and maintenance of perimental systems) represents a definite retinal
the equipment; and (5) the level of anticipated hazard.
use. The Nd:YAG laser beam entering the eye
It should not be surprising that there are safety either directly from the laser, or from a specular
considerations involved in each of these areas. (mirror), or diffuse (scattered) reflection can be
In fact, virtually all aspects of activity associated focused to an extremely small spot-image on the
with medical laser usage involve some safety retina. This causes an excessive irradiance (WI
factors that require continuing attention. For cm 2) or radiant exposure (J/cm 2 ) incident on the
example, it is often desirable to purchase the retinal tissues even for modest corneal exposure
most advanced laser system design to meet the levels. The absorbed energy is converted into
changing needs of mUltiple discipline use. This heat, and, if the incident laser energy is too
may mean that one surgical team uses the laser great, it causes an irreversible retinal burn. The
in an open-beam configuration, which usually process is due to tissue proteins being denatured
requires the maximum safety requirements. by the rise in tissue temperature following ab-
Others may use the same laser endoscopically sorption of laser energy (Figure 41.1).
with no "open-beam" hazards during the pro- The principal thermal effects of laser expo-
312 R. James Rockwell, Jr.

DANGEROUSLY FOCUSED

FIGURE 41.1. Focused intrabeam condition. Focused ance at the cornea. For example, the retinal irradiance
spot can be 20 fLm or smaller. Retinal irradiance will produced by a I-mW laser, just filling the worst-case
be approximately 140,000 times greater than irradi- 7 mm pupil size, will be about 440 W/cm'.

sure, therefore, depend upon the following fac- diation (0.4-0.55 f.Lm) when exposures are
tors: greater than 10 seconds.
1. Absorption and scattering coefficients of the
tissues at the 1.064-f.Lm Nd:YAG laser wave- Intrabeam Viewing
length
A retinal injury occurring in the macular region
2. lrradiance or radiant exposure of the laser
is very serious, since the visual functions are
beam
most highly developed in this area. Blindness
3. Exposure duration and pulse repetition char-
can result from a laser exposure that lasts only
acteristics
an infinitesimal fraction of a second. Similar
4. Local vascular blood flow
damage, on the other hand, in the periphery of
5. Size of the irradiated area
the retina will often have minimal effect, usually
The mechanism of tissue damage caused by without functional significance.
repetitively pulsed or scanned Nd:YAG laser A macular burn would probably result if the
exposures is still being investigated. The current individual is viewing the beam under conditions
evidence indicates that the major mechanism is where the eye is resolving the laser source or a
a thermal process with an additive effect related diffuse reflection . The latter could occur, for
to the accumulated energy of the individual example, while viewing the focused spot without
pulses. protective filters either directly or through a
Tissue damage may also be caused by ther- binocular microscope or endoscope. A periph-
mally induced acoustic-shock waves and/or eral burn might occur through an accidental ex-
photodissociation (electric field effects) follow- posure when the eye is not directly viewing the
ing exposures to submicrosecond Q-switched or beam and the eye is not "relaxed" but rather
mode-locked Nd:YAG laser pulses. focused on something other than the laser point
Other mechanisms of tissue damage have also source.
been demonstrated for other specific wavelength
ranges and/or exposure times. For example,
Diffuse Reflections
photochemical reactions are the principal cause
of tissue damage following exposures to either Viewing a large beam area which has been re-
actinic ultraviolet radiation (0.200-0.315 f.Lm) for flected from a diffuse surface will usually pro-
any exposure time or "short-wave" visible ra- duce a much larger retinal image spot size than
41. Safety Procedures for Nd:YAG Laser Surgery 313

direct (intrabeam) viewing. This provides, at first region, as in the ultraviolet "A" and "B" re-
consideration, some degree of protection, since, gions, the threshold for damage to the cornea is
at distances close to the reflecting surface, the comparable to that of the skin. Damage to the
retinal irradiance can be significantly lower due cornea, however, is much more disabling and
to the larger spot size. of much greater concern.
Most surgical Nd:YAG lasers are, however,
of sufficient power (Class IV) as to be diffuse
reflection hazards. The resulting degree of ret-
inal damage would be significant due to the Maximum Permissible
larger retinal spot sizes associated with a typical Exposure Limits
extended source viewing condition. Also, larger
image sizes (typically 100 f,Lm or greater) of The safe exposure limits provided in the various
longer exposure times (> 10 seconds) do not standards seem to be set about a factor of 10 or
dissipate the heat buildup as rapidly as smaller more lower than the actual retinal damage
image sizes. Consequently, the retinal irradiance threshold levels reported in the biologic litera-
threshold level that produces a minimal burn on ture. This factor of 10 is sometimes erroneously
the' retina will be about 10-20 times lower for referred to as a "safety factor." In fact, the val-
larger image sizes than for the smaller (20 f,Lm) ues called thresholds are actually so-called
point-source image sizes. Hence different safety "EDso" doses; that is, doses where 50% of the
limits are needed for the two different exposure exposures resulted in injury and 50% of the ex-
conditions resulting from point and extended posures did not result in changes which were
sources. visible by an ophthalmoscope. Obviously, safety
limits must be concerned with whether there
Eye Exposure to Infrared may be permanent or delayed visual loss or tis-
sue damage, and not whether damage is simply
Wavelengths ophthalmoscopically visible.
A transition zone between retinal effects and ef- Many studies have been performed to deter-
fects on the front segments of the eye (cornea, mine at what levels below the so-called EDso
lens, aqueous media) begins at the far end of the dose some loss of visual function or morphologic
visible spectrum and extends into the infrared change in the retinal tissue will be encountered.
"A" region (0.700-1.4 f,Lm). The Nd:YAG laser These studies generally suggest that for expo-
operates in this so-called near-infrared region. sure durations of 10 microseconds to 10 seconds,
Although the 1.064-f,Lm wavelength does not changes are still observed by histologic evalu-
evoke a visual response, this frequency still ation at power/energy levels reduced from the
transmits back to the retinal surface. There will EDso value by a factor in the range of 2 to 5.
be some significant absorption and scattering Hence the apparent safety factor of 10 based on
losses and the laws of physical optics dictates ophthalmoscopic visible burn criteria is, in real-
that the eye of the lens will not focus a longer ity, only a vaJue of 2 above the level of actual
invisible wavelength to as small a spot as a vis- morphologic or histologic change.
ible frequency. Nonetheless, the Nd:YAG laser The most accepted safety limits are the max-
must still be considered one of the most dan- imum permissible exposure (MPE) limits ob-
gerous laser types simply because of the high tained from the Z-136.1 (1986) standard pub-
power (typically 100 W in a surgical laser) and lished by the American National Standards
also because the beam is not visible. These two Institute (ANSI); an organization for which ex-
factors present a situation where even a small pert volunteers participate on committees to
reflection can cause irreversible retinal damage. determine industry consensus standards in var-
In the infrared "B" region 0.4-3.0 f,Lm) dam- ious fields. The MPE limits are determined as
age is observed to both the lens and cornea. The a function of laser wavelength, exposure time,
ocular media becomes opaque to radiation in the and pulse repetition frequency (prf). Table 41.1
infrared "C" region (3.0 f,Lm-1 mm), as the ab- gives MPE limits for various Nd: YAG laser ex-
sorption by water (a major portion of all body posure criteria and compares them to other laser
cells) is high in this region. In the infrared "C" types.
314 R. James Rockwell, Jr.

TABLE 41.1. Maximum permissible exposure (MPE) levels

Wavelength Exposure time
Laser (ILm) (s) MPE
Helium-neon 0.633 cw: 3 x 10' 17 ILW/cm'
Helium-neon 0.633 cw: 0.25" 2.5 mW/cm'
Argon 0.514 cw: 3 x 10' 1.0 ILW/cm'
Nd:YAG 1.064 cw: 3 x 10' 1.6 mW/cm'
Nd:YAG 1.064 pulsed: I x 10-' 5.0 f.d/cm'
Ruby 0.694 pulsed: I x 10-' 0.5 ILJ/cm'
Carbon dioxide 1O.6 b 3 x 10' 100 mW/cm'

cw = continuous wave.
aO.25 second is considered aversion response time.
bFar-infrared radiation is not a retinal hazard.

Safety Controls for Laser Surgery will be designated ANSI Z-136.3 "Safe Use of
Lasers in Health Care Facilities" (1987). This
Laser safety practices are commonly effected in document will provide guidance specific to the
laser surgery by implementing specific safety medical use of lasers but will be based upon
procedures that are designed to either eliminate specific requirements of the Z-136.1 (1986)
ocular and skin exposures to direct or scattered "parent" standard as detailed in this chapter.
laser radiation. In cases where a hazard analysis The ANSI Z-136.1 standard has been univer-
has been done, controls can be implemented to sally adopted by industry, medicine, and gov-
reduce potentially hazardous laser exposures to ernment departments as the "user require-
acceptable levels. ments" of lasers. The requirements are easily
Safety controls are also needed for the hazards implemented by the designated Laser Safety
associated with toxic fumes, electrical power Officer (LSO) of the facility.
supplies, laser induced-plasma by-products, and
fire, which are often associated with the laser
devices. Important in this area are the problems The Laser Hazard Classes
associated with anesthesia and, particularly,
fires produced by an accidental laser exposure Both the ANSI and FDA standards divide all
of a tube supporting high oxygen levels. lasers into four major hazard categories called
Four basic categories of safety controls are the laser classifications. These are summarized
useful in laser environments. These are engi- as follows:
neering, personal protective equipment, admin-
istrative and procedural controls, and special Class I: Cannot emit laser radiation at known
controls. hazard levels (typically cw: 0.4 mW). Users
The recommendations in this chapter are of a Class I laser are generally exempt from
based on the contents of the recently revised Z- radiation hazard controls during operation and
136.1 (1986) standard of the American National maintenance (but not necessarily during ser-
Standards Institute (ANSI). It should be noted vice). Since lasers are not classified on beam
that the existing Federal Laser Product Perfor- access during service, most all Class I lasers
mance Standard (FLPPS) of the FDA that reg- will consist of a higher class (high-power) laser
ulates laser manufacturers (CFR: Part 1040.10 enclosed in a properly interlocked and labeled
and 1040.11), and the Suggested State Regula- protective enclosure.
tion for Lasers (SSRL), which is being consid- Class II: Low-power visible lasers that emit
ered for adoption at this time by several states, above Class I levels, but not above 1 mW.
have terminology and concepts nearly identical The concept is that the human aversion re-
to the ANSI Z-136.1 standard. action to bright light will protect a person.
An ANSI standard specific to the medical en- (Note: Class IIA is a special designation that
vironment is also in preparation. This standard is based upon a 1000-second exposure and
41. Safety Procedures for Nd:YAG Laser Surgery 315

applies to lasers that are "not intended for investigation of the laser's "safety and effec-
viewing. ") tiveness." Once an IDE has been done and ap-
Class IlIA: Intermediate-power lasers (cw: 1-5 proved, the manufacturer may market the device
mW). Only hazardous for chronic intrabeam for that specific use only.
viewing. Some limited controls are usually
recommended.
Class IIIB: Moderate-power lasers (cw: 5-500
mW, pulsed: 10 J/cm2 : or the diffuse reflection Nominal Hazard Zone
limit). In general, Class IIIB lasers will not
produce a hazardous diffuse reflection unless There are some laser uses, such as surgery,
intentional staring is done at close distances. where it is useful to define the area where the
Specific controls are recommended. possibility exists for potentially hazardous ex-
Class N: High-power lasers (cw: >500 mW) are posure. The nominal hazard zone (NHZ), by
hazardous to view under any condition (di- definition, describes the space within which the
rectly or diffusely scattered). Significant con- level of direct, reflected, or scattered radiation
trols are required of Class IV laser facilities. exceeds the level of the applicable maximum
permissible exposure (MPE). Consequently,
Important in the classification and implemen- persons outside the NHZ boundry would be ex-
tation of safety controls is the distinction be- posed below the MPE level and are considered
tween the functions of operation, maintenance to be in a "safe" location. The NHZ boundry
and service. First, most laser systems are clas- may be defined by direct laser beams, diffusely
sified on the basis of the laser radiation acces- scattered laser beams, and beams transmitted
sible during operation and maintenance, where from fiberoptics and/or lenses, special contact
the latter is considered as those tasks required tips, etc. The NHZ perimeter is the envelope of
to maintain routine system operation (e.g., MPE exposure levels from any laser in a given
cleaning a lens, changing gas bottles). Service application or installation geometry (Figure
functions are usually performed with far less 41.2).
frequency than maintenance functions (e.g., re- The principal use of the NHZ evaluation is to
placing the laser resonator mirrors, repair of define that region where control measures are
faulty components) and often will require access required. Thus, as the scope of surgical laser
to the laser beam. has expanded, the classic method of controlling
The Federal Government does not "approve" lasers in an interlocked room has become lim-
laser systems. The manufacturer of the laser iting and, in many instances, can be an over-
system first classifies the laser and then certifies reaction to the real hazards present.
that it meets all performance requirements of
the FLPPS. This is reviewed by the laser divi-
sion within the Center for Devices and Radio- Intrabeam Nominal Hazard Zone
logical Health (CDRH) of the Food and Drug
Administration (FDA). One of the first respon- The intrabeam nominal hazard zone can be de-
sibilities, then, of the hospital's Laser Safety termined by the so-called laser range equation.
Officer (LSO) is to assure that the lasers are, in This is useful in calculating the distance the
fact, manufacturer-certified and classified. beam must travel before the beam size has
In addition, the CDRH also has the respon- grown large enough so that the irradiance is re-
sibility for enforcing compliance of the Medical duced to the maximum permissible exposure
Device Regulations. All surgical laser manufac- (MPE) level. In this case, the range (r) is ex-
turers must, therefore, obtain premarket ap- pressed as
proval of their laser surgical devices from CDRH
before they can be sold. The CDRH sanctions
the investigational use of lasers for specific sur-
gical procedures through a process referred to
where
as an Investigational Device Exemption (IDE).
Approval of an IDE allows the limited use of a <I> the laser beam divergence (rad),
laser expressly for the purpose of conducting an <I> = the laser power (W),
316 R. James Rockwell, Jr.

L--L_A_SE_R-.lrf°PTI~
I~ r NOHD -I
(A) Intrabeam vielVing (c) Fiber optic on laser

[LASER

(8) Lens - on-laser (D) Di ffuse Reflection

FIGURE 41.2. Nominal hazard zone (NHZ) geometry. dition. NHZ range measured from focal plane of lens.
(A) Intrabeam (direct) viewing condition. NHZ range (C) Fiberoptic on laser condition. NHZ range is mea-
(nominal ocular hazard distance) measured from laser sured from fiber tip. (D) Diffuse reflection condition.
to point where beam has grown large enough so that NHZ range is measured from target point on diffuse
MPE irradiance is attained. (B) Lens-on-Iaser con- surface.

Es the irradiance at the range (r) (W/cm 2 ), The intrabeam hazard extends to a distance
and of 1.4 km from the laser, and certainly extends
r range from the laser to target (cm). beyond the surgical operating-room limits. This
implies, therefore, that uses of a Nd:Y AG laser
If the value of the irradiance at a distance (r)
in this "natural" state may require entry way and
away from the laser is maintained at (or below)
personnel controls more detailed than in those
the MPE, then the distance is considered the
cases where the delivery optics , fibers, or fiber
intrabeam nominal hazard zone range (R~HZ) or
tips cause rapid beam expansion.
"safe range" value. That is, substituting Es
MPE in Equation I we have
lB 1 4<1> )0'5]
[(1T(MPE)
R NHZ = ~ - a . (2)
Diffuse Reflections
For example, consider the case of a typical 100-
W Nd:Y AG surgical laser with a beam diver- In practice, most partially roughened nonglossy
gence of 2.0 m rad and an exit beam diameter surfaces act as diffusing surfaces to incident
of 0.2 cm. Using Equation 1 and assuming the visible or near-infrared lasE\r beams. Tissues, for
"worst-case" (8-hour) MPE = 1.6 mW/cm 2 , we example, are an excellent diffuse reflecting me-
find that dia. Such a diffusing' 'rough" surface acts as a
plane of very small scattering sites that reflect
the beam in a radially symmetric manner. The
2 X 10 - 3 roughness of the surface is such that the scat-

[(
4 x 100 )0.5 _ 0 2] tering sites are larger than the laser wavelength.
Consequently, the reflected radiant intensity
3.14 x (1.6 x 10- 3 ) •
(power per unit solid angle), denoted by I(e),
1.41 x 103 meters. can be shown to be dependent upon the cosine
41. Safety Procedures for Nd:YAG Laser Surgery 317

of the viewing angle (6) as measured from the length; which for the Nd:YAG laser isjust over
normal to the surface. That is, 1 J.Lm.
Most partially roughened surfaces may still
1(6) = 10 cos (6), (3) have properties that contribute specular reflec-
where tion. This may occur when a low percentage of
the incident radiation is specularly reflected and
1(6) radiant intensity occurring at an angle the remainder diffusely reflected. This behavior
from the normal [W/sr], is generally the rule , and not the exception, for
10 radiant intensity [W/sr] reflected most common surfaces. As a result, the reflected
along the normal to the surface, and radiation is not exactly radially symmetric, but
6 angle measured from the normal to skews toward the specularly reflected compo-
the surface. nent.
This relationship is known as Lambert's Cos-
ine Law. A surface behaving in this manner is
Inverse Square Law and Diffuse
usually referred to as a lambertian surface. This
relationship defines an ideal plane diffuse re- Reflections from Point Sources
flector (Figure 41.3). The diffusely reflected irradiance (E) or radiant
It should be stressed that "rough" surfaces exposure (H) resulting when a point source beam
do not act as diffuse reflectors at all) wave- is incident upon a lambertian surface, which is
lengths. For example, brushed aluminum (which inversely related to the square of the distance
is partially diffuse for visible wavelength laser (r) from the surface, is expressed by the follow-
radiation) is a good specular mirrorlike reflector ing equation for continuous wave sources:
for far-infrared wavelength lasers such as the
CO 2 laser (10.6 J.Lm) . Nonpolished metals such _ p<l> cos 6
E (r,6 - 2 (4)
as brushed aluminum and stainless steel, as 'ITr
would be found in some "sand-blasted" surgical or for pulsed lasers by
instruments, will produce a more diffuse reflec-
tion than polished metals. The average surface pQ cos 6
H(r,6) = 2 [J/cm 2 ],
roughness should be larger than the laser wave- 'ITr

FIG URE 41.3. Diffuse reflection oflaser beam emitted an extended source to retina and for Class IV lasers
from fiberoptic. System shown with visible argon laser (> 0.5 W) can produce a condition of hazardous diffuse
to depict situation produced by invisible Nd:YAG reflection viewing throughout the diffuse nominal
laser under similar conditions. Spot produced can be hazard zone. This can include an entire surgical room.
318 R. James Rockwell, Jf.

where Extended Source Diffuse Reflections

Q the energy incident upon the surface (J), In cases where the laser creates large spot di-
p the surface reflectivity (fraction), ameters on the diffuse target relative to the
8 viewing angle measured relative to the viewing distance, the diffuse surface is said to
normal to the reflecting surface (de- create an "extended source" relative to the eye.
grees), and In this case, the retinal image size of the focused
r - distance from diffusing surface to viewer laser light will usually exceed 100 J.Lm, and the
(cm). viewer can resolve the details of the diffuse tar-
All other terms are as previously defined. get source. Such larger area retinal images are
The inverse square distance relationship is of special concern because the threshold for bi-
valid, provided the distance (r) is much greater ologic damage for the larger retinal images is at
than the spot diameter D L . Consequently, a dif- least ten times lower than for point-source im-
fuse surface acts as a distance-dependent atten- ages.
uator that permits indirect viewing of some low- A laser beam reflected from a diffuser is often
powered laser beams when the reflecting spot expressed in radiant energy units, which com-
is small. lfthe laser power is sufficient, that is, bine the reflected radiant power or energy with
>0.5 W, even a diffuse reflection is hazardous the geometry of a solid angle "cone" and the
to view. This is an important consideration for reflecting "source" area. This is referred to as
those working with high-powered visible or near- the radiance (L) of a plane diffuse lambertian
infrared Class IV lasers. surface, and it is related to the irradiance inci-
dent on the surface by the equation

Diffuse Reflection Nominal Hazard L = pEs (6)

'IT
Zone Range
There are some instances where it is useful to
where
calculate the distance away from a "point
source" diffuse reflector at which a specific ir- L radiance of the diffuse reflector [W cm - 2
radiance occurs. Solving Equation 4 for dis- sr- I ],
tance, we find that the diffuse reflection nominal Es irradiance incident upon the surface [WI
hazard zone (R~~d can be written as cm 2], and
05 p reflectivity of the surface.
RDR
NHZ -
_ (P<P cos 8)
'IT(MPE) (5) Equation 6 allows us to calculate the radiance
of a diffusely reflected laser beam while knowing
For example, assume a normal (8 = 0 view- 0
)

only the irradiance incident upon the surface and

ing of a 100-W Nd:YAG surgical laser directed the reflectivity of the surface.
upon a surface with a 100% reflectance. At what For example, assume that a 100-W Nd:YAG
distance does the MPE irradiance of 1.6 mWI surgical laser beam is expanded to a size of 1.0
cm 2 occur? Solving Equation 5 and inserting nu- cm onto a nearby 100% diffusely reflecting sur-
merical values, we find that face. The irradiance incident on the surface will
005 be 127 W/cm 2 • Assuming the reflectivity of the
1.0 x 100 x 1.0 )
(
surface to be 100% (p = 1.0), we find from
3.14 x (1.6 x 10- 3) Equation 6 that the radiance of the reflected
1.41 meters. beam (L) is
Thus, the maximum NHZ range for a 100% 1.0 x 127
point -source diffuse reflection from aNd: Y AG L
3.14
laser will be only 141 cm or about 4.6 ft! The = 40.5 W cm- 2 sr- I •
diffuse hazard exists around the laser surgical
operating site and eye protection, for example, Note that this term is given in units ofradiance,
would be required in this zone. expressed in terms of the power (watts) reflected
41. Safety Procedures for Nd:YAG Laser Surgery 319

from the source area (cm 2) into a solid-angle angle, called amiD which corresponds to the
cone (steradian). maximum viewing distance (RmaJ for which ex-
For comparative purposes, note that staring tended source MPE values apply. In this case,
directly at a standard 100-W frosted light bulb Rmax is given by
at close range is equivalent to viewing a diffuse
light source with a radiance of about 0.04 W DL cos 6v
Rmax = --==----'- (8)
cm - 2 sr - 1. Hence the radiance from the diffuse Umin

reflection of the 100-W Nd:YAG laser is over For example, the ANSI Z-136 standard indicates
1000 times greater than directly viewing a 100- that for exposures of 10 seconds or more, the
W diffused light bulb! value of amiD is 24 mrad. Hence, for the diffused
Since the ANSI Z-136.1 long-term (8-hour) beam spot diameter of 1 cm in the previous ex-
MPE for Nd: YAG laser extended sources is 3.2 ample, the extended source criteria will apply
W cm - 2 sr -1, the 100-W laser produces an ex- for a distance of Rmax = 1.0 x 1.0/(24 x 10- 3)
tended source diffuse reflection that is over 12 = 41.7 cm or nearly 1.4 ft. In this range, a 10-
times greater than the allowed extended source second MPE of 10.8 W cm -2 sr- 1 applies and,
exposure. Note that the dividing point between at 1.4 ft, produces a corneal irradiance of 5 mW/
hazardous and nonhazardous diffuse reflections cm2 • Beyond 1.4 ft, point-source criteria apply.
is considered to be at 0.5 W, the cuttoff between
continuous wave Class IIIB and Class IV lasers).
Lens-on-Laser Nominal Hazard Zone
Also important is fact that the resulting retinal
irradiance produced while viewing an extended Range
source at close range is independent of the dis- Most surgical Nd:YAG lasers incorporate a lens
tance between the source and viewer. This is as the final component in the beam path. This
due to the fact that, as one moves away from not only provides the increased irradiance in the
such an extended source, the inverse square law focal plane of the lens to do the work intended
reduces the amount of irradiance incident upon of the laser, but it also forces the beam to spread
the cornea but, at the same time, the spot size with an angle usually many times larger than the
of the focused beam gets proportionally smaller. beam divergence angle in the space beyond the
The result is a retinal irradiance that remains focal plane. The result is that the MPE irradiance
constant and is independent of the distance from is reached in a distance much less than the in-
the diffuser to the eye. In general, Equation 6 trabeam nominal hazard zone range. This can
applies up to that point where the source is suf- be referred to as the lens-on-the-Iaser nominal
ficiently close that it can still be resolved by the hazard zone range (R~tz):
viewer. Beyond that point, point-source char-
acteristics apply as described by Equations 4 RLL _ f2. x ( 4<1> ) 0.5 (9)
NHZ - b 1T(MPE) ,
and 5.
In practice, the evaluation of the point source/ where
extended source dilemma has been addressed in
the ANSI Z-136 standard by requiring an eval- fo = the lens focal length (cm), and
uation of the subtense angle (a) between the b = the diameter of the beam at the lens (cm).
viewer and the extended source target. For For example, consider a 100-W surgical
lambertian (diffuse) viewing, this angle is also a Nd: YAG laser with a 2.54-cm focal length lens
measure of the resultant retinal image size (dr in the beam path and a 6.3-mm beam size as the
= fa) and may be expressed in terms of the so- beam strikes the lens. Substituting into Equation
called viewing angle (6 v ) and the extended 9, we have
source diameter (D L ) by the relationship

(7)
R~tz ~:~: x
= (3.14 x4 (:.;o~ 10_ 3»)0.5
= 11.4 meters.
The cutoff between point source and extended Thus, in the direction defined by the cone of
source occurs at a defined "minimum" viewing laser light directed through the lens, the hazard
320 R. James Rockwell, Jr.

TABLE 41.2. Nominal hazard zone distance values for

typical surgical lasers
Hazard range (m)
Laser Exposure
type criteria Diffuse Lens-on-laser Direct
Nd:YAG 8h 1.4 11.4 1410
lOs 0.8 6.3 792

CO2 8h 0.18 2.4 168

lOs 0.18 2.4 168

Argon 8h 12.6 1.7 x 103 25.2 X 103

0.25 s 0.25 33.3 240

zone extends up to a distance of II.4m, at which NA = the fiberoptics numerical aperture (typ-
point the beam has expanded to a diameter of ically in the range of 0.20).
282 cm or slightly over 9 ft. At that distance,
The NHZ for a multimode fiberoptic with a
the irradiance will be 1.6 x lO-3 W/cm2 , which
is theMPE level. Thus, addition of a lens in the
numerical aperture (NA) of 0.20 attached to a
lOO-W Nd:YAG laser can be computed as
beam path reduced the hazard range from 1.4 0.5
km to about 38 ft. FO 1.7 ( lOO )
R NHZ = 0.2 x 3~ 14 x (1.6 x lO-3)
= 12 meters.
Fiberoptic-on-Laser Nominal Hazard
Zone Range Thus, the fiberoptic hazard range is nearly op-
tically equivalent to a system with a lens in the
Similar to the lens-on-Iaser example, a muIti- beam path.
mode fiber optic attached in the beam path also A summary of all of the NHZ distances is giv-
provides a beam expanding element that shrinks en in Table 41.2 and 41.3 for the Nd:YAG laser.
the hazard range depending upon the charac- In addition, comparative values are also given
teristics of the fiber. For a typical multi mode for a 100-W CO 2 and a 5-W argon laser, which
fiber, such as would be used in laser endoscopy, are two commonly used surgical laser units.
the fiberoptic nominal hazard zone range
(R~~z) is given by
Beam-Path Controls
R~~z ~~ x (1T(:PE»)
= 0.5, (10)
Class IIIB and IV lasers are sometimes used in
where situations where the entire beam path is totally

TABLE 41.3. Laser criteria used for nominal hazard zone

distance calculations
Laser parameter Nd:YAG CO 2 Argon
Wavelength (/Lm) 1.064 10.6 0.488
Beam power (W) 100.0 100.0 5.0
Beam divergence (mrad) 2.0 2.0 1.0
Beam size at aperture (mm) 2.0 20.0 2.0
Beam size at lens (mm) 6.3 30.0 3.0
Lens focal length (mm) 25.4 200.0 200.0
MPE: 8 h (/LW/cm2) 1.6 x 103 1.0 X 105 1.0
MPE: 10 s (/LW/cm2) 5.1 x 103 1.0 X 105
MPE: 0.25 s (/LW/cm2) 2.5 x 103
MPE = maximum permissible exposure.
4l. Safety Procedures for Nd:YAG Laser Surgery 321

enclosed. Other uses may find a beam path with enclose the immediate area of beam delivery al-
extremely limited access. In some uses, such as most completely. Such a system would not meet,
surgery, the beam path is totally open. In each perhaps, the stringent "human access" require-
case, the controls required will vary. ments of the FLPPS for a Class I laser, but the
real laser hazards are well confined.
Totally Enclosed Beam Path Such a design provides what can be called a
limited open-beam path. In this situation, the
Perhaps the most common form of a Class I laser
ANSI Z-136.1 standard recommends that the
system is a high-power laser that has been totally
LSO shall effect a laser hazard analysis and es-
enclosed (embedded) inside a protective enclo-
tablish the extent of the nominal hazard zone
sure equipped with appropriate interlocks on all
(NHZ). In many system designs, such as de-
removable panels and access doors. This pre-
scribed above, the NHZ will be extremely lim-
vents beam access during operation and main-
ited and procedural controls rather than elab-
tenance. Such a completely enclosed system, if
orate engineering controls will be sufficient.
properly labeled and safeguarded with protective
Protective equipment (eye protection, tem-
housing interlocks and all other applicable en-
porary barriers, clothing and/or gloves, respir-
gineering controls, will fulfill all requirements
ators, etc.) would be recommended, for exam-
for a Class I laser and may be operated in the
ple, only if the hazard analysis indicated a need
enclosed manner without the requirement for
or if the Standard Operating Procedure (SOP)
additional controls for the operator. For ex-
required periods of beam access, such as during
ample, during actual operation, a Nd:YAG laser
setup or infrequent maintenance activities.
used endoscopically could be considered op-
Temporary protective measures would be han-
erationally a Class I system. During use the laser
dled in a manner similar to operation of any
beam can be contained within the laser, the fiber
Class IV surgical laser.
delivery system, the endoscope and, finally, the
patient. If the system were designed to preclude
operation except when the system was com- Totally Unenclosed Beam Path
pletely enclosed and the endoscope placed
Most surgical laser uses are used in an unen-
within the patient, it could be considered a Class
closed beam condition. Such laser uses will re-
I device by FDA. Endoscopic systems manu-
quire that a complete hazard analysis and NHZ
factured to date do not have such a classification
assessment be effected by the LSO if such in-
due to the difficulty and expense of assuring
formation is not furnished by the manufacturer
such a Class I condition.
of the laser. Then, the controls implemented will
However, the Laser Safety Officer (LSO)
reflect the magnitude and extent of the acces-
could decide, using the ANSI Z-136.1 standard,
sible beam.
that an endoscopic Nd:YAG laser was Class I
A 100-W Nd:YAG surgical laser system will
operationally, provided certain procedural con-
require beam path controls during surgical use.
trols were met. This would eliminate many of
As summarized in Table 41.2, the intrabeam
the Class IV controls that would be required for
(direct) hazard extends from 792 to 1410 ill, de-
this system. The major concern would be related
pending upon whether the 10-second or 8-hour
to assuring that the fiber does not break during
MPE criteria are used during the NHZ calcu-
the procedure.
lations. Simularly, with a lens on the laser, the
It should be noted that during periods of ser-
hazard exists over a range from 6.3 to I 1.4 m.
vice, controls appropriate to the class of the
The diffuse reflection zone is, however, mark-
embedded laser are required, perhaps on a tem-
edly smaller, ranging from 0.8 to 1.4 m. This
porary basis, when the beam enclosures are re-
suggests that surgeons and support staff close
moved and beam access is possible. Beam ac-
to the operative site would still need laser eye
cess during service will not change the Class I
protection, even for diffuse reflections from the
status of the laser during operation.
surgical area.
If the LSO provides a detailed procedural
Limited Open-Beam Path control to limit the "beam on" condition only
Some surgical laser uses, particularly those us- to situations where the lens was in place and the
ing fiberoptic intrapatient delivery may, in fact, beam was focused only onto the surgical site,
322 R. James Rockwell, Jr.

then the zone of potential beam hazard would

be limited to that resulting from diffuse reflec-
tions and , in an absolute "worst-case" scenario,
to the specular reflections of the focused beam.
This implies a maximum hazard region that ex-
tends no greater than about 30 ft. This certainly
would project outside a surgical room. The LSO
would be correct to require a barrier be placed
just inside the entrance way to prevent an un-
likely stray beam from going out a doorway. Al-
though entry way interlocking is also an alter-
native, it is limiting in most surgical settings.
Entryway controls such as interlocking may,
however, be more strongly considered by the FIGURE 41.4. Laser danger warning sign. Typical

LSO in areas such as outpatient clinics and re- posting for a medical laser installation. Signs are rec-
search laboratories where one cannot closely ommended for Class IIIB and Class IV lasers. Lighted
sign is connected to laser system so that light is on
monitor personnel flow in and out of the laser
when laser is activated. Some facilities install flashing
area. light capability. Design and colors are specified in
Similar analyses are provided in Tables 41.2 ANSI-Z136 standard .
and 41.3 for a 100-W CO 2 laser and a 5-W argon
laser. Note that the NHZ distances do not vary
for the CO 2 laser (because the MPE values are
nearly identical for the 10-second and 8-hour
If the LSO chooses to post Class II or Class
exposure times). Also note that the diffuse re-
IlIA areas, then all signs (and labels) asso-
flection NHZ distances are very small except
ciated with these lasers (when the beam ir-
for the 8-hour criteria for the argon laser. In most
radiance for Class IlIA does not exceed 2.5
cases, the 0.25-second criteria can be used with
mW/cm 2 ) will use the CAUTION format:
visible frequency lasers unless intentional staring
yellow background, with black laser symbol
is possible.
and letters.
2. Operation by qualified and authorized per-
sonnel:
Laser-Controlled Area This includes appropriate training of the in-
dividuals in aspects of laser safety.
When the entire beam path from a Class IIIB 3. Transmission from indoor controlled area:
or IV laser is not sufficiently enclosed and/or The beams shall not, under any circumstan-
baffled such that access to radiation above the ces, be transmitted from an indoor laser con-
MPE is possible, a "laser-controlled area" is trolled area unless for specific purposes (such
required. During periods of service, the con- as atmospheric testing). In such cases, the
trolled area is established on a temporary basis. operator and the LSO must assure that the
The controlled area will encompass the NHZ. beam path is limited to controlled air space.
Those controls required for both Class IIIB and
Those items recommended for Class IIIB but
Class IV installations are as follows:
required for Class IV lasers are as follows:
I. Posting with appropriate laser warning signs: I. Supervised directly by of an individual
Class IlIA (beam irradiance >2.5 mW/cm 2 ), knowledgeable in laser safety.
Class IIIB and Class IV lasers require the 2. Require approved entry of any noninvolved
DANGER sign format: white background, red personnel.
laser symbol with black outline and black let- 3. Terminate all potentially hazardous beams in
tering. Note that area posting is required only a beam stop of an appropriate material.
for Class IIIB and Class IV lasers and laser 4. Use diffusely reflecting materials near the
systems (Figure 41.4). beam, where appropriate.
41. Safety Procedures for Nd:YAG Laser Surgery 323

5. Personnel within the laser controlled area are

provided with appropriate laser protective
eyewear.
6. Secure and locate the laser such that the beam
181 " PANIC" BUTTON
path is above or below eye level in any stand-

l-ccASS'
ing or seated position.
7. Have all windows, doorways, open portals,
and so on from an indoor facility covered or
restricted thus reducing transmitted beams f - - - -----l1-8ARR I ER,
below the appropriate ocular MPE level. SCREEN,
CURTAIN
8. Require storage or disabling of lasers when APPLICABLE MPE
not in use. 181 "PAN IC" BUTTON

~'ND'CATOR
In addition, there are specific controls re- (VISIBLE OR AUDIBLE)
quired at the entryway to a Class IV laser con-
trolled area. These can be summarized as fol- FIGURE 41.5. Procedural entryway control. A barrier
lows: can be used to prevent beam from exiting laser room.
Barrier design should be such as to withstand direct,
1. All personnel entering a Class IV area shall lens-on-Iaser and/or scattered laser light for a specified
be adequately trained and given proper laser period (nominally 60 seconds) and not produce a fire
protective eyewear. hazard.
2. All personnel shall follow all applicable ad-
ministrative and procedural controls.
3. All Class IV area area/entryway controls shall 3. Procedural entryway controls:
allow both rapid entrance and exit under all Controls such as blocking barrier, or screen,
conditions. or curtain which can block or filter the laser
4. The controlled area shall have a clearly beam at the entryway may be used inside the
marked "Panic Button" (disconnect switch) controlled area to prevent the laser light from
that allows rapid deactivation of the laser. exiting the area at levels above the applicable
MPE level. In this case, a warning light or
In addition, Class IV areas also require some sound is required outside the entryway that
form of area/entryway controls. In the past, operates when the laser is energized and op-
doorway interlocking was required for all Class erating. In addition, all personnel shall re-
IV installations. In the revised ANSI Z-136.1 ceive training (Figure 41.5).
(1986) standard, a set of options is provided that
allow the LSO to provide an entry way control
suited for the installation. The options include:

1. Nondefeatable entryway controls: Administrative and Procedural

Controls such as a magnetic switch built into Controls
the entryway door. In this case, training is
required only for those persons who regularly One of the more important of the so-called ad-
require access into the laser area. ministrative and procedural controls is the
2. Defeatable entryway controls: Standard Operating Procedure (SOP). This is
Controls such as may be required, for ex- required for a Class IV laser and is recom-
ample, in long-term testing in a laser area or mended for a Class IIIB laser.
for some surgical laser environments. In this The key to a written SOP is that those indi-
case the controls may be overridden if it is viduals who operate, maintain, and service the
clearly evident that there is no hazard at the equipment should be involved in the preparation
point of entry. Training is required for all with guidance from the LSO. Most laser equip-
personnel who may require entry into the ment will be provided with instructions for safe
area. operation by the manufacturer. However,
324 R. James Rockwell, Jr.

sometimes these are not well suited to a specific include delicate optics that are sensitive to
use due to special conditions of use. moving.
Other administrative and procedural controls
include:
1. Alignment procedures:
Education and Training
One of the highest rates of laser eye accidents Frequent presentations to the medical staff on
occurs during laser alignment. Such proce- laser applications and the correct safety pro-
dures must be done with extreme caution. A cedures are recommended, especially when new
written procedure is recommended for re- procedures are introduced. These are in addition
curring alignment tasks. to the detailed initial laser inservice training.
2. Limitations on spectators: An extensive hands-on and theory training of
Persons unnecessary to the laser operation the Medical Laser Specialists to run and be re-
should be kept away. For those who do enter sponsible for laser equipment and procedures is
the laser area, appropriate eye protection and also recommended.
instruction is recommended. A vailability of a dealer's or manufacturer's
agent for technical assistance is important to the
As mentioned, the overall laser safety pro-
purchase decision as is the availability for on-
gram is administered by the LSO. Some of the
going educational presentations for the staff and/
main LSO duties are to monitor and enforce the
or medical community.
control of laser hazards and, when needed, ef-
fect the knowledgeable evaluation and control
of laser hazards. In addition, the LSO estab-
lishes and periodically reviews appropriate con-
Service and Maintenance
trol measures, avoids needless duplication of All lasers malfunction. Even the best instrument
controls in cases where several alternate but is of little value when it is not working properly.
equally effective means may be used to limit ex- The availability of a dependable, qualified ser-
posure, and effects laser safety training, when vice team is essential.
appropriate. The quality of education and service personnel
must be considered with the same emphasis that
is given to choosing laser technology. In a rap-
idly evolving technological field, the ability to
Laser Factors
modify equipment, adjust to new developments,
In the selection of any laser, one must consider and learn the new scientific material is very im-
the applications intended by the various spe- portant.
cialties. The more versatile laser can be used In order to assure a smooth implementation
by many of the hospital services and, therefore, of new laser technology, several steps should
justify the initial financial investment. This usu- be taken before initiating the clinical use of the
ally requires SOP's for each specialty, since dif- laser. A laser safety committee should be es-
ferent delivery systems and procedures are re- tablished, nurses appointed to receive training
quired. as Laser Medical Specialists, and educational
The safety protocols will usually be adapted presentations planned.
to the different delivery systems such as hand-
pieces, mictoscopes, endoscopic couplers, and
fiberoptic couplers.
Laser Safety Committee
Mobility is also important in permitting in- A laser safety committee should be established
creased usage. Although it is best to move any even before a laser is delivered to the hospital.
laser system as infrequently as possible, the re- This committee is essential for planning, legal,
quirement for mobility should be considered and safety purposes. The committee is often
when developing the SOP's, since a complete comprised of physicians from various special-
system checkout will be required prior to use to ties, chief of surgery, operating room director
assure optimum performance. Laser systems and head nurse, primary laser nurse, and an ad-
41. Safety Procedures for Nd:YAG Laser Surgery 325

ministrator. This committee will establish writ- Patient Concerns and Safety
ten guidelines for laser procedures, protocol on
its use, and credentials standards for laser priv- A medical laser safety discussion would not be
ileges. The purpose of this committee is to pro- complete without some comments about patients
mote the safe and frequent use of the laser. who undergo treatment. Medical personnel
should not dismiss psychological concerns or
Medical Laser Specialists fears their patients could have when faced with
laser surgery. For patients, the concern over
It is essential that the responsibilities for op- "Star Wars" may be difficult to resolve . In ad-
erating and controlling the laser be limited to a dition, sounds and smells of laser surgery can
few well-trained individuals. A minimum of two be very frightening. Moreover, since everyone
or three nurses or technicians should receive in the room may be wearing safety glasses (Fig-
thorough training in lasers in general and the ure 41.6), the impact can be potentially upset-
hospital's unit in particular. A manufacturer's ting, since such safety equipment and proce-
inservice program on how to "push the button dures implies a dangerous procedure. In order
and turn the dials" is not sufficient to make the to reduce such fears, medical personnel can do
unit operative and ensure safe use. the following:
1. Take the patient step-by-step through the
Inservice and Trial Run procedure and carefully explain what to ex-
pect.
A trial laser case should be scheduled if the laser 2. Explain what a laser is, how it works, and
is a new piece of equipment. This procedure how it is used.
would involve the primary physician, laser 3. Remind the patient about smells and sounds,
nurse, and operating room personnel. All other and the need for safety glasses.
equipment such as microscopes, bipolars, video 4. Help patients understand the concerns about
equipment, and so on that will be used in the having "excessive expectations" of laser
laser case should also be activated. Such a trial treatments.
procedure allows one to learn beforehand the
best physical setup of the room, how to appro-
priately drape the new equipment, whether there
are ample electrical outlets, and whether suffi-
cient current is available in the operating area.
All safety protocols should be developed and
practiced at this session.
A general in service session should be sched-
uled for the entire surgical staff. This is an in-
troductory session designed to acquaint all per-
sonnel with the new instrumentation. A medical
presentation on the medical applications of las-
ers may enhance interest and promote increased
use of the instrument by diverse physicians.

Continuing Education
Periodic refresher courses are recommended for
all laser personnel. Emphasis should be placed FIGUR E 41.6. Patient eyeshields. Special reflecting
on new techniques, procedures, and methods to eyeshields can be applied to completely cover eye.
assure safety. The laser safety personnel, laser Such protection is especially important in dermato-
nurses, and technicians should undergo contin- logic procedures around the eye, such as port-wine
uing training on at least a biyearly basis. nevi treatment.
326 R. James Rockwell, Jf.

Personal Protective Equipment by first determining the value of H o• From the

above, we calculate the worst-case exposure
Personal protective equipment for laser safety spread over the 7-mm limiting aperture and not
generally means eye protection in the form of the 2-mm laser beam diameter. Thus the effec-
goggles or spectacles. This can include special tive "area" is found: A = 'IT~/4 = 'IT(0.7)2/4 =
prescription eyewear using special high optical 0.385 cm 2 • The radiant exposure H o = 100/0.385
density filter materials or reflective coatings to = 259.7 W/cm2. Calculation for the OD is done

reduce the potential ocular exposure below MPE as follows:

limits. Some applications, such as use of high-
power excimer lasers operating in the ultravi- OD = 10glO ( 1.6259.7
X10- )
3 = 5.2.
olet, may also dictate the use of a skin cover if
chronic repeated exposures are· anticipated at Thus a filter with OD = 5.2 for the 1.064-/.Lm
exposure levels at or near the maximum per- Nd:YAG laser wavelength would provide ade-
missible exposure (MPE) limits for skin. quate protection.
In general, it is recommended that, if possible,
other means of controls be employed rather than Optical Density When a Fiber is
reliance specifically on the use of protective
eyewear. This argument is predicated on the fact Used
that so many accidents have occurred when
eyewear was available but not worn. There are A hazard analysis of a typical Nd: Y AG surgical
many reasons for this lack of use, but the most laser (1.06 /.Lm) with a fiberoptic delivery could
common are, most probably, that the eyewear be based upon the following parameters using a
is dark and uncomfortable to wear and limits maximum of 100 W of continuous wave laser
vision. power with a beam divergence of 210 mrad (12
Laser protective eyewear filters are specified degrees) from the fiber tip and an exposure time
in terms of the logarithmic units of optical den- of 10 seconds.
sity (usually referred to as "OD"). Optical den- Using these parameters, a mathematical haz-
sity (OD) is a logarithmic function defined by ard analysis can be done to estimate the general
the equation region around the surgical site where hazardous
exposures may be possible. The following anal-
OD = 10glO (;OE) , (11)
ysis is representative of Nd: YAG surgical lasers.
The worst-case MPE value for a direct intra-
beam or point source diffuse reflection with a
where Nd:YAG laser exposure of 10 seconds is 50.6
Ho anticipated worst-case exposure (J/cm2 mJ/cm 2 • The MPE for a long-term (>8-hour) ex-
or W/cm 2), and tended source diffuse reflection of this laser is
MPE = maximum permissible exposure level 3.2 W cm -2 sr- 1 contained within an apparent
expressed in same units as H o. visual angle (amin) which is not smaller than 24
mrad. The lO-second MPE value for skin ex-
It should be noted that, since the MPE values posure is 10.5 J/cm2.
have, in effect, been normalized to the area of To estimate a diffuse reflection from the site,
the so-called limiting aperture, which is the 7- one must first estimate the approximate scat-
mm pupil size for visible and near-infrared, the tering distance from the target site on the tissues
calculation for H o for beams smaller than the to the surgeon's eye. This is about 40 cm (ap-
limiting aperture requires that the limiting ap- proximately 16 in.). The ANSI Z-136.1 point-
erture be used instead of the smaller beam size. source MPE criterion is used in this case be-
Thus, the calculation is made as though the cause, using Equation 7 and applying an a min of
beam were spread over the limiting aperture. 24 mrad, one can show that point-source con-
As an example, consider the case of a 100-W ditions exist when the laser spot size is less than
Nd:YAG laser emitted in a 2-mm beam diam- 1 cm diameter (e.g., DL = 40 x 24 X 10- 3 =
eter. This would be a Class IV laser with an 0.96 cm). Since beam diameters less than 1 cm
MPE = 1.6 mW/cm 2 • Thus the OD is calculated are anticipated in the fiberoptic procedure, the
41. Safety Procedures for Nd:YAG Laser Surgery 327

beam acts as a point source. Solving Equation an open beam fiberoptic. Diffuse viewing will
4 , the irradiance at the eye will be 19.9 mW! require optical density values of 1.1 or smaller,
cm 2 • This produces a radiant exposure of nearly depending on viewing time and beam spot size.
200 mJ!cm 2 during a lO-second exposure. A wide variety of commercially available op-
Based upon these typical exposure conditions, tical absorbing filter materials either of glass or
the optical density required for a suitable filter plastic and various coated reflecting "filters,"
can be determined. Using a worst-case exposure including dielectric coatings and some experi-
condition outlined above, one can determine the mental holographic designs, are available for
optical density recommended to provide ade- laser eye protection . Some are available in
quate eye protection for this laser. Using Equa- spectacles ground to prescription specifications.
tion 11, the minimum optical density at the 1.064 One filter type may be applicable to more than
J..Lm Nd:YAG laser wavelength for a lO-second one wavelength. Some filters have a high optical
direct intrabeam exposure (MPE = 50.6 mJ!cm 2) density below a certain "cutoff' wavelength,
to the 100-W maximum laser output (H 0 = 2597 usually limiting overall visibility (Figure 41. 7).
J!cm 2 ) would be OD = 4.7. One of the more superior eye protection filters
The more conservative approach reviewed for the Nd: Y AG laser is the near-infrared ab-
previously would be to consider the full-day 8- sorbing glass designated KG-3 or KG-5 from the
hour occupational exposure . In this case, (MPE Schott Optical Company. These two glass types
= 1.6 mW!cm 2 , Ho = 259.7 W!cm 2 ) the optical have optical density values sufficient to meet
density at 1.06 f.Lm is OD = 5.2 for the IOO-Watt almost all surgical Nd:YAG situations and yet
intrabeam viewing condition. has nearly 95% luminous (visible light) trans-
The optical density required for safe viewing mission.
of the diffuse reflection off tissues is substan- The typical optical density and internal trans-
tially reduced from the 100-W intrabeam case. mittance values for various filter thickness val-
Using the 40-cm "viewing distance" described ues from 1 to 5 mm for the KG-3 and KG-5 are
above, the required optical density at 1.06 f.Lm given in Table 41.4. Eye protection usually is
(Ho = 200 mJ!cm 2 , MPE = 50.6 mJ!cm 2 ) would done with filter thickness no less than 3 mm.
be OD = 0.6 for a lO-second exposure and (Ho Unless the glass is thermally treated, eye pro-
= 19.9 mW!cm2 , MPE = 1.6 mW!cm2 ) an OD tection using KG-3 and KG-5 filters will require
= 1.1 for the occupational 8-hour exposure. additional clear coverage to provide impact re-
These worst-case conditions suggest that an sistance using, for example, a high-impact re-
optical density in the range from 4.7 to 5.2 at sistant plastic.
the 1.064-f.Lm wavelength is recommended for The need for protection for multiple laser
100-W Nd:YAG laser surgical situations using wavelengths is becoming more common in the

FIGURE 41.7. Laser protective eyewear. Protective have high optical density values at the laser wave-
filters can be obtained in a range of designs, including length and reduce worst-case exposure to the MPE
prescription spectacles and traditional goggles. Filters level.
328 R. James Rockwell, Jr.

TABLE 41.4. Optical density and internal beams from reflections should be appropriately
transmittance for Schott KG-3 and KG-5 glass as a terminated in an absorbent material. Periodic
function of glass thickness inspection is required of the absorbent materials,
Thickness Transmission since they degrade with use.
Glass type (mm) at 1060 nm Optical density Firebrick materials containing beryllium or
KG-3 1.0 0.24E-OI 1.6 other hazardous substances should not be used.
1.5 0.3SE-02 2.4 An optical-wedge absorber is recommended for
2.0 0.60E-03 3.2 beam termination.
2.5 0.94E-04 4.0
3.0 0.15E-04 4.S
3.5 0.23E-OS 5.6
4.0 0.36E-06 6.4 Engineering Controls
4.5 0.56E-07 7.2
5.0 O.SSE-OS S.I The most universal controls are referred to as
KG-5 1.0 0.55E-02 2.3
engineering controls. Usually, these are items
1.5 0.4IE-03 3.4 built into the laser equipment that provide for
2.0 0.30E-04 4.5 safety. In most instances, these will be included
2.S 0.22E-05 5.7 on the equipment provided by the laser manu-
3.0 0.16E-06 6.S facturer as so-called "Performance Require-
3.5 0.12E-07 7.9
4.0 0.90E-09 9.0
ments" mandated by the FDA. The systems will
4.5 0.67E-1O 10.2 have, for example, built-in beam shutters, laser
5.0 0.49E-II 11.3 power monitors, maintenance panel interlocks,
"beam-on" indicator lights or tones, key-
operated control switches, and numerous labels
related to safety (Figure 41.8).
All of these features do provide a baseline for
surgical environment, as procedures may in- safe operation, but do not replace the need for
volve several laser wavelengths or different laser evaluation of the hazards during use and the im-
types. In this case, dual filters are often the de- plementation of adequate area and personal
sign of choice, frequently mounted in a "flip- controls and adopting proper standard operating
up" -style goggle or spectacle frame. procedures (SOP's) for each type of surgical
Of special concern is the management of eye procedure.
protection in such multiple laser environments
to assure that proper protection is being used
for each laser type and wavelength. Some med- DANGER
ical facilities have color-coded the eyewear to INVISIBLE LASER RADIATION WHEN OPEN
aid in proper selection. Then the LSO or nurse AVOID EYE OR SKIN EXPOSURE TO
responsible for safety practices during a pro- DIRECT OR SCATTERED RADIATION
cedure can quickly check that proper eyewear
is being used.
FIGURE 41.8. Laser protective housing label. Required
by FDA and AN SI standards for portions of the laser
housing that, when removed for servicing, permit ac-
Invisible Beam Control cess to the beam.

Infrared (0.7-10 3 /Lm) and ultraviolet (0.2-0.4

/Lm) laser radiation are "invisible" radiations,
and special controls are often necessary. For Training Programs
example; The beams from Class IIIB and Class
IV lasers should be terminated in highly ab- Detailed training is recommended for those
sorbent, non specular reflecting materials wher- working with Class III and Class IV lasers, in-
ever practicable. Many metal surfaces that ap- cluding the technical support staff and techni-
pear "dull" visually can act as a specular cians. The training should provide a complete
reflector of infrared radiation. All secondary understanding of the requirements of a safe laser
41. Safety Procedures for Nd:YAG Laser Surgery 329

environment. Emphasis should be placed on Bibliography

practical, safe laser techniques and procedures,
American National Standard for the Safe Use of Las-
as well as safety devices that provide an overall
ers. ANSI Z-136.1 (1986). Laser Institute of Amer-
safe environment. ica, Toledo, OH, 1986.
The need for frequent update training ses- Comment: It could happen to you. Laser Focus p 10,
sions, particularly for the laser professional, was Apr 1982.
well shown in a published account by an indi- Goldman L, Rockwell R Jr: Lasers in Medicine. Gor-
vidual who lost the sight of one eye when pro- don & Breach, New York, 1971.
tective eye wear was not used. This article con- Ham WT Jr: The eye problem in laser safety. Arch
cluded: "But more important than the actual Environ Health 20: 156, 1970.
event is the idea that this incident could have Laser Safety Guide, 6th ed. The Laser Institute of
been avoided. Don't let it happen to you or a co- America, Toledo, OH, 1986.
worker. Take time to assess safety conditions, Meyer Arendt JR: Radiometry and photometry units
and conversion factors. Appl Opt 7:2081, 1968.
and do it again in 6 months or a year; addition-
Performance Standard for Laser Products. Center for
al hazards arise in an ever-changing research Devices and Radiological Health, Food and Drug
environment. Safety deserves your thought- Administration (DHHS), CFR 50 (161):33682-33702
ful considerations, now, before your accident." Tuesday, Aug 20, 1985.
Often each training session will need to be Rockwell RJ Jr: Ensuring safety in laser robotics.
tailored for the different groups working with Lasers Applications 3(11):65-70, Nov 1984.
specific lasers in the facility. The type of laser(s) Rockwell RJ Jr (ed): Laser Safety in Surgery and
and locations will impact the content of the Medicine, 2nd ed. Rockwell Associates, Cincinnati,
training program. For example, the hazards and OH, 1985.
controls recommended for the far-infrared car- Rockwell RJ Jr: Analyzing laser hazards. Lasers Ap-
bon dioxide lasers are usually different than plications 5(5):97-103, May 1986.
Rockwell RJ Jr: Controlling laser hazards. Lasers
those for a near-infrared Nd:YAG laser or a vis-
Applications, 5(9):93-99, Sep 1986.
ible argon laser. Rockwell RJ Jr, Moss CE: Optical radiation hazards
In addition, the use of several laser types at in laser welding processes. Part I: Neodymi-
the same facility will require review of each um-YAG Industrr Hyg Assoc 44(8):572-579, Aug
system in the training sessions. Special analysis 1983.
will be necessary in the event that two or more Safety of Lasers and Other Optical Radiation Source.
lasers are used in the same location at one time. Rockwell Associates, Cincinnati, OH, 1986.
In this event, the protective eyewear and op- Sliney DH, Freazier BC: The evaluation of optical
erational precautions may need to be adjusted radiation hazards. Appl Opt 12:1, 1973.
for the presence of multiple laser wavelengths. Sliney DR, Wolbarsh ML: Safety Manual for Lasers
and Other Optical Sources. Plenum, New York,
1978.
Conclusions
The Nd:YAG laser used in surgery has the po-
tential of providing hazards to the eye and skin
of the surgeon, support staff, and patient. The
hazard evaluation methods described can allow
for analysis of the zone within the surgical area
where direct and scattered beam hazards exist.
Implementation of the protective procedures and
use of proper safety equipment can provide ad-
equate safety to all involved in the surgical pro-
cedure.
42
Tissue Interactions of Carbon Monoxide
and Carbon Dioxide Lasers
Tsunenori Arai, and Makoto Kikuchi

The principle and the practical experimental re- tissue is generally small compared with the cut-
sults for the tissue interaction of CO and CO 2 ting laser wavelength.
lasers are described in this chapter. The high- Since the tissue optical characteristics and the
intensity irradiation of these lasers indicates irradiation conditions have been continuously
strong cutting to the living tissue. Despite the changed by the irradiation, a definite statement
fact CO 2 lasers have been used as the unique about tissue interaction cannot be made. For in-
light source for the laser scalpel, one problem stance, even Nd:YAG laser irradiation can be
remaining unsolved is the lack of available flex- used for cutting and vaporizing, in spite of this
ible optical fibers that can deliver CO 2 laser ra- radiation essentially indicating strong coagula-
diation of 10.6 J-Lm in wavelength. The CO laser tion. The low intensity with long-term irradiation
radiation of wavelength 5 J-Lm indicates similar of CO 2 lasers coagulates the surface of the tis-
tissue interaction to the CO 2 laser radiation. sue. Moreover, a contact irradiation method was
Moreover, the flexible glass fibers made from currently developed as an irradiation technique
infrared glasses can be available for CO laser of the Nd: Y AG laser.' This contact irradiation
delivery. We have recommended using CO la- of Nd:Y AG laser using the sapphire tip attach-
sers for cutting instead of CO 2 lasers. ment indicates fine cutting injuries, due to high
heat deposition on the boundary between the
tip and the tissue and/or mechanical pushing by
the tip.
Principles of Cutting Interactions In this chapter the essential interaction of tis-
to Living Tissue sue is only described in order to present the
fundamental characteristics of CO and CO 2 ir-
General Principles radiations to the tissue.
The tissue interaction against an incident laser
beam can be essentially explained by the ab- Tissue Light Absorption
sorption and the scattering characteristics of the
The absorption characteristics are particularly
living tissue. A light that is strongly absorbed
important in describing the cutting phenomenon
by the tissue indicates cutting capacity as the
to tissue. The absorption characteristics of the
tissue interaction. On the other hand, a light that
living tissue in the light region of electromagnetic
is weakly absorbed by the tissue induces strong
waves is characterized mainly by water, hemo-
coagulation capacity to the tissue. The scattering
globin, and protein absorption.
process is not dominant for the cutting phenom-
enon so that the extinction length of the tissue
Tissue Light Absorption by Water
for the cutting laser light is extremely short.
Moreover, the scattering process may be weak Water is the major constituent of living tissue,
since the diameter of the scatterer in the living the maximum component excluding the fat and
42. Tissue Interactions of CO and CO 2 Lasers 331

bone. Approximately 50 to 60% of the whole a broad absorption band. Particularly as water
human body in weight consists of water. In the is composed by hydrogen bonds, this tendency
muscle, this rate is increased to 75%. The strong is obviously enhanced.
absorption of water appears in the wide wave-
length region of the electromagnetic wave. Fig-
Tissue Light Absorption by Proteins
ure 42.1 shows the absorption spectrum of liquid
water in the infrared.2 In general, this absorption Living tissue contains less than 10% protein on
within the light region decreases with the wave- an average. This content is as high as 12% in
length in spite of the existence of some absorp- muscles. Despite absorption by proteins ap-
tion peaks. In the visible and ultraviolet region, pearing from ultraviolet to far-infrared, they play
the absorption coefficient is less than 10- 1 cm - I; an important role at ultraviolet and mid-infrared
in other words, the extinction length which is regions. In the ultraviolet , since water is almost
defined as a length at one-tenth of the atten- a window material, the protein absorption will
uation of light intensity is in excess of 23 cm. be effective. Protein absorption near 280 nm is
Therefore, water is almost transmitting material due to the electronic state of aromatic amino
for visible and ultraviolet light, and the water acids. Currently, excimer lasers that oscillate
absorption is merely important for infrared light ultraviolet laser radiation with high average
to discuss the cutting interaction. For wave- power are used for preliminary medical appli-
lengths over 2.3 fA-m, water indicates a strong cations to obtain nonthermal cutting by de-
absorption of which the coefficient is over 102 struction of the structure of proteins. 3 This cut-
cm - I. The extinction length h of this wavelength ting has a useful advantage for the restriction of
region is less than 230 fA-m. The kinetics of this thermal injuries; however, simultaneously it has
absorption range is attributed to the stimulated harmful cytotoxicity and mutagenicity due to the
absorption of the vibrational mode of water, for destruction of the inherited information in the
instance, as in a strong absorption peak of ap- cell. In mid-infrared, proteins have strong ab-
proximately 3 fA-m ascribed to the vibrational sorption peaks caused by amino acids which are
absorption of OH radical. In the liquid phase, a the fundamental component of proteins ., These
certain internal energy mode can be strongly af- peaks appear 1660-1610 cm - I and 1550-1485
fected by the interaction force, so that it forms cm - I , generally called amino acid I and amino

10- 4
;- 10 4
e
!:!. 10- 3
I-
:z 10 3 Ii
UJ
!:!.
'--' 10- 2 :::I::
u..
LL
UJ
10 2 l-
~
2:
0 UJ
'--' .:z: 10- 1 ---'
:z 10 '"0< 2:

..,
0 Ul 0
I- I-
CL
c::
0 1 '--'
2:
0
(/) 1 U I-
<0 ><
« UJ

:;;; 10- 1 10
UJ •
<0
:E:
« 10 2
---' 10- 2
2 4 6 8 10 12 14
WAVELENGTH ( 11m )
FIGURE 42.1. Absorption spectrum of liquid water in infrared with the oscillation wavelength of infrared
high-power lasers . The extinction length (Le) is expressed as; Le = 1I0.434f,Lm, where f,Lm is the absorption
coefficient.
332 Tsunenori Arai and Makoto Kikuchi

acid II, respectively. These peaks are attributed with the existence of air. This burning enhances
to the vibrational state of the NH3 + bending the disappearance of the tissue. These descrip-
mode. tions are general explanations of the tissue cut-
ting by light irradiation which is strongly ab-
sorbed by the tissue. Since the complex
Tissue Light Absorption by Dyes
processes simultaneously occurred under the
Dyes in the living tissue strongly affect tissue light irradiation, the precise estimation method
absorption in the visible and near-infrared re- of cutting interaction has not been reported.
gions. Dyes have efficient kinetics for light ab- The resulting damaged layer aside from the
sorption, and the existence of small amounts of cutting groove is thinner than other cutting
dyes indicates strong absorption. The most im- methods due to the short extinction length of
portant dye in living tissue is hemoglobin, which the irradiated light and the short time period of
composes a third of the red blood cell in weight. cutting. This thin damaged layer induces an ad-
Melanin in the skin is effective when discussing vantage in the healing of injuries. Moreover, an
the surface optical characteristics of black skin. advantage against infection is this noncontact
The absorption spectrum of hemoglobin is process of cutting. However, the thin damaged
changed by oxidation. 4 If the tissue contains a layer can also imply a poor capacity of hemo-
density of 2 x 10- 3 mollL oxyhemoglobin (over stasis. The high rate of heat generation in a small
estimation), the absorption by oxyhemoglobin volume is necessary for this cutting, produced
becomes larger than by water at least from 1 /-Lm by the high intensity of light irradiation and/or
of wavelength. The absorption of the oxyhem- strong absorption of the tissue. To obtain such
oglobin is important in describing tissue inter- high light intensity, the use of the coherent laser
action by argon and Nd:YAG lasers. However, source is necessary. That is the reason why mid-
in normal tissue, absorption by oxyhemoglobin infrared lasers are employed for the non contact
is not effective for cutting lasers, that is, CO tissue cutting.
and CO 2 lasers.

Mechanism of Tissue Cutting Tissue Interaction of CO and CO 2

The absorbed light energy is delivered into the
Lasers
internal mode (vibrational or electrical) of mol-
ecules, then it rapidly relaxes to the lowest in-
A vailable Infrared Lasers
ternal mode within a few microseconds. The Since lasers are oscillators that use the inter-
energy of the lowest mode, that is, the trans- action between the internal energy mode of
lational mode, is called thermal energy. The in- molecules/atoms and the electromagnetic field,
crease of the thermal energy is characterized by lasers have essentially a poor tunability of os-
an increase of translational temperature which cillation wavelength. Moreover, there are few
can be directly measured by a thermometer. By lasers which can extract high power with prac-
irradiation of high absorption light to the tissue, tical efficiency. In the wavelength range over
the rapid increase of the temperature in the tis- 2.3 /-Lm, they are CO 2 , CO, HBr, DF, and HF
sue induces the evaporation of water. The ir- lasers. HBr, DF, and HF lasers being chemically
radiated portion of the tissue disappears with pumped lasers, are not practical because of the
this evaporation. The evaporation heat is ex- problem of the treatment of exhaust gases. CO
tracted from the irradiated portion by the evap- and CO 2 lasers are electrically excited (i.e., dis-
oration. The heat conduction also stimulates charge excited) lasers with high efficiencies. s ,o
heat extraction from the irradiated portion. The sealed-off operation of laser gases has been
However, since the rate of the heat generation established in these lasers. 7 . 8 Therefore these
by the light irradiation is set extremely higher lasers are extremely useful for cutting applica-
than this heat extraction, the continuous evap- tions.
oration by the radiation is steadily kept. In ad- To apply cutting lasers to endoscopic appli-
dition, under the high temperature condition, cations, it is important to select a wavelength
proteins of which the tissue is composed burns with a transmission range of flexible fibers. De-
42. Tissue Interactions of CO and COo Lasers 333

spite CO 2 lasers having been applied to a laser collimated laser beam at a focal point was 0.2
scalpel, the optical transmission line of all pro- mm with a focal depth of 16 mm. The refractive
duction models of the CO 2 laser scalpel have optics were used for collimation, so that the
been made by a series of reflectors in the ma- collimated beam geometry was slightly changed.
ni~ulator. It was not until recently that an in- However, since the incident angle to the con-
flexible crystalline fiber was equipped in the cave mirror was limited up to tOO this transfor-
production model of the CO 2 laser scalpel for mation was quite small. In order to express the
the first time. 9 This defect of the CO 2 laser scal- intensity of the light beam, the average light in-
pel is due to the lack of available glass materials tensity was defined to use;
with long oscillation wavelengths of CO 2 lasers.
CO lasers have not been applied in practical use, lay = PI'IT X R/
however they have an attractive wavelength for
light delivery by flexible optical fibers. The au- where
thors predict that CO lasers might be used as lay = the average light intensity;
cutting lasers instead of CO 2 lasers. Please refer
to Chapter 39 for further details. P = the beam power; and
Rs = the spot radius.
Experimental Setup
lay is half the intensity as the peak intensity
The interaction of the cutting laser should be within the beam at TEMoo transverse mode. The
determined by this experimental investigation sample surface was aligned at 120 mm from the
because of the difficulty of giving a precise de- concave mirror, so the spot diameter on the
scription of the laser cutting. 10 The interactions sample surface was 0.5 mm. The irradiated area
of CO and CO2 laser irradiations to the tissue was scanned automatically by moving the sam-
were experimentally investigated. 11.12 The in- ple by a servo mechanism. This action was co-
teraction of the CO laser has been preliminarily ordinated to move the collimated beam in actual
reported by Karbe et al., 13 however the authors applications to cut the tissue. In the case of the
could not find quantitative information from the low-intensity irradiation, the laser beam oscil-
prior report. A small laser device was con- lated was directly delivered to irradiate on the
structed for this purpose. This laser device had sample. The sample position was fixed in this
a laser tube of 7 mm inside diameter and 60 cm case.
in length. By changing laser gases, optical com-
ponents, and cryogens, the device could oscil-
late both CO and CO 2 lasers. The oscillation Results and Discussion
transverse mode was TEMoo with a spot di-
High-Intensity Irradiation
ameter of 3.5 mm. The oscillation wavelengths
were measured by a grating monochrometer. The high-intensity laser beams of CO and CO 2
The measured wavelength of the CO laser was lasers irradiated on the surface of the moving
distributed from 5.0 !-Lm to 5.4 !-Lm (5.2 !-Lm in samples. The average light intensity was set to
an average). The measured wavelength of the 2.6 kW/cm 2 • The moving speed was varied
CO 2 laser was approximately 10.6 !-Lm [the within 0.1 to to mm/second. These results are
branches of P(16), P(20), or P(22)]. All laser ir- shown in Figure 42.2.11.12 The results show that
radiations were carried out in vitro. The samples the high-intensity irradiation of these lasers in-
for laser irradiations were exsanguinated dog dicates strong cutting performance, although the
and cow livers. Since the interactions by CO cutting depth by the CO laser irradiation is
and CO 2 irradiations are mainly attributed to slightly less than that by the CO 2 laser irradia-
water absorption in the tissue, the content of tion. The incised depth is proportional to the
blood (i.e., hemoglobin) does not seriously affect incision speed (i.e., the movement speed of the
the interaction. sample). In the case df 1.3 kW/cm 2 irradiation,
To irradiate a high-intensity laser beam, a gold the incised depth was decreased to a half of that
concave mirror of 250 mm in curvature was used of 2.6 kW/cm 2 for both lasers.
to collimate the laser beam. The diameter of the To investigate the damage of the tissue by
334 Tsunenori Arai and Makoto Kikuchi

.,
and CO 2 lasers. II The thermal necrotic layer be-
side the cutting groove by CO laser irradiation
~~o
10 -
is 50% thicker than that by CO 2 irradiation. That
>: is because the extinction length of the CO laser
-5
light by water absorption is 0.1 mm, three times
.....
:I:
~ ,,~ larger than that of the CO 2 laser light. Moreover,
lLI
Cl
~, the scattering of vaporized debris (i.e., smoke)
Cl

~e
I..LJ
(/) under the CO laser irradiation with high intensity
'-'
z 1.0 was stronger than that by the CO 2 laser irradia-
tion due to the wavelength dependence of the
Rayleigh and/or Mie scattering process. This ef-
0: CO 2 LASER , S H. fect might promote this tendency. This promoted
~: CO LASER,S W. thermal necrotic layer might be available for he-
DOG LIVER mostasis bleeding from the cutting injuries. De-
spite the enhanced thickness of the thermal
0.10. 1 1.0 10 necrotic layer to the CO laser cutting, the thick-
I CISlO I SPEED <MM/SEC) ness is still thinner than the injuries by the elec-
trosurgical unit.
FIGURE 42.2. Dependence of the incision depth on
the incision speed of high-intensity CO and CO 2 laser
Low-Intensity Irradiation
beams. Average light intensity: 2.6 kW/cm 2 • .6.: CO
laser irradiation. 0: CO 2 laser irradiation. Sample: dog To investigate the interaction for the low-inten-
liver. [From Arai T, Kikuchi M, Sakuragi S, Saito sity irradiation, a 10 to 45 W/cm 2 laser beam was
M, Takizawa M: CO laser power delivery by As 2 S, irradiated on the sample. This intensity corre-
IR glass fiber with Teflon cladding. In Katzir A (ed): sponds to the laser hemostasis by cutting laser
Optical Fibers in Medicine and Biology. SPIE, Bel- irradiation for liver and/or kidney hemorrhages.
lingham, 1985, pp 24-31, with permission.]
The thermal coagulated layer and carbonized
layer thicknesses were measured as a function
laser cutting, specimens of the sectional view of of the average light intensity and the irradiation
the cutting samples were made. The light inten- duration time. The result of this experiment is
sity and the beam scanning speed were 2.6 kW/ shown in Figure 42.4."·12 Since the difference
cm 2 and 0.33 mm/second, respectively. Figure of the extinction length of the CO and CO 2 lasers
42.3A,B shows the groove specimens for CO is approximately 100 !-Lm, for the irradiation time

FIGURE 42.3. The sectional view

of the specimens of the cutting
samples. Average light intensity:
2.6 kW/cm 2 • Beam scanning
speed: 0.33 mm/second. Sample:
dog liver. (Top) For CO laser cut-
ting. (Bottom) For CO 2 laser cut-
ting.
42. Tissue Interactions of CO and COo Lasers 335

0.5 .-----.-----.-~---.----~
method of optical delivery by flexible fibers,
endoscopic applications via soft endoscopes are
0.,4 impossible. In this chapter, we showed the sim-
u>
(/)
o....J t!. ilarity of the tissue interaction of the CO laser
:z:
""
u
0.3 ... and CO 2 laser. The CO laser is a profitable can-
:t:
I- ... didate for the cutting and vaporizing laser for
0::
LLJ
endoscopic applications in the near future.
>-
C( 0.2
....J
t!. t!.
Q

~ 0.1
References
:::>
C!:I
C(
1. Joffe SN, Daikuzono N, Osborn J, et al: Contact
8 o~--~~------~----~~----~ probes for the Nd:Y AG laser. In Katzir A (ed):
10 20 30 40 50 Optical Fibers in Medicine and Biology. SPIE,
AVERAGED LASER POWER DENS ITY (W/cMf) Bellingham, 1985, pp 42-50.
FIGURE 42.4. The thermal coagulated layer thickness 2. Downing HD, Williams D: Optical properties of
on the sample surface for low-intensity irradiation of water in the infrared. J Geophys Res 80: 1656-
CO and CO 2 lasers as a function of the average light 1661, 1975.
intensity. 6: CO laser irradiation . .&.: CO 2 laser ir- 3. Trokel SL, Srinivasan R, Braren B: Excimer laser
radiation. Irradiation time: 2 seconds. Sample: cow surgery of the cornea. Am J Opthalmol 96:710-
liver. [From Arai T, Kikuchi M, Sakuragi S, Saito 715, 1983.
M, Takizawa M: CO laser power delivery by As 2 S, 4. Gordy E, Drabkin DL: Determination of the ox-
IR glass fiber with Teflon cladding, In Katzir A (ed): ygen saturation of blood by a simplified technique,
Optical Fibers in Medicine and Biology. SPIE, Bel- applicable to standard equipment. J Bioi Chern
lingham, 1985, pp 24-31, with permission.] 227:285-299, 1957.
5. Bhaumik ML, Lacina WB, Mann MM: Charac-
teristics of CO laser. IEEE J Quant Electron QE-
over 2 seconds, the coagulated and carbonized 8: 150-160, 1972.
layer thicknesses of these lasers were the same 6. Cheo PK: CO 2 lasers. In DeMaria AJ (ed): Lasers.
due to the thermal conduction. The interaction Marcel Dekker, New York, 1971, pp 111-267.
difference was then studied under 2 seconds du- 7. Browne PG, Smith ALS: Efficient long life sealed
ration. The measured thickness of the thermal CO lasers at room temperature. J Phys E 8:870,
coagulation layer by the CO laser irradiation 1975.
is 0.2 to 0.3 mm thinner than that by the CO 2 la- 8. Witteman WJ: High-output and long lifetimes of
ser. sealed-off COo lasers. Appl Phys Lett 11 :337-338,
1967.
9. Ikedo M, Ishiwatari H, Watari M, et al: Infrared
optical fiber for energy transmission. Rev Laser
Summary Eng (Jpn) 11:834-841, 1983.
10. Halldorsson T, Langerhole J: Thermodynamic
In general, the cutting process by the light ir- analysis of laser irradiation of biological tissue.
radiation is essentially explained by the thermal ApplOpt 17:3948-3952, 1978.
process. The optical process affected the cutting 11. Arai T, Kikuchi M: A study for development of
mainly by the absorption of light by the material CO laser scalpel (1) Investigation of the effect of
of the tissue. Thus, the absorption coefficient CO laser light on living tissue. J Jpn Soc Laser
and the intensity of the irradiation beam are im- Med 3:223-230, 1982.
portant for cutting. The incision had been easily 12. Arai T , Kikuchi M, Sakuragi S, et al: CO laser
controlled by the light intensity and the move- power delivery by AsoS, IR glass fiber with Teflon
cladding. In Katzir A (ed): Optical Fibers in
ment speed of the beam with the great advan-
Medicine and Biology. SPIE, Bellingham, 1985,
tages by noncontact cutting. The interactions of pp 24-31.
the CO and CO 2 lasers applied to living tissue 13. Karbe E, Beck R, English W, Experimental sur-
were experimentally investigated. CO 2 lasers are gery with neodymium, holmium, CO and CO 2
the most popular and unique lasers for cutting lasers. In Kaplan I (ed): Laser Surgery. Jerusalem
applications. However, as they do not have a Academic Press, Jerusalem, 1976. pp 174-177.
43
Tissue Interactions of Nd:YAG Lasers
Kim A. Brackett

The primary mechanism of action of the stand- matrix causes a high degree of scattering within
ard lO64-nm wavelength Nd:YAG laser on bi- a relatively short distance below the surface of
ologic tissue is dependent upon the conversion the tissue, making this the more significant pa-
of radiant optical energy into thermal energy. rameter. Scattering converts the coherent col-
However, there are some exceptions to this rule. umn of photons into a diffuse oblate spheroid
The major exception to the thermal mechanism of radiation 2 .3 in agreement with the results of
is the Q-switched or mode-locked laser, which the Monte Carlo method of calculation of mul-
is capable of producing short bursts (10- 9 to tiple scattering events within a solid. A signif-
lO -12 seconds) of high power levels, inducing icant proportion of these events results in back-
mechanical as well as thermal damage to the tis- scattered energy from the incident surface
sue, as will be briefly described later. There is toward the source and operator. In a hollow
also some evidence of a reduction in collagen viscus with a wall thickness of 2 to 3 mm, 30 to
synthesis by fibroblasts exposed to Nd:YAG 40% of the power applied will be backscattered,
laser irradiation in vitro, which was not dupli- compared to 25 to 30% scattered forward
cated by equal heating of cultures with an al- through the opposite surface of the wall. 2 This
ternative light source. 1 The mechanism behind scattering within a thin-walled viscus causes a
this inhibition and whether it is wavelength-spe- doubling of beam diameter at the incident sur-
cific remains to be elucidated. This chapter will face and a fourfold increase at the rear wall.
be mainly concerned with the primary thermal Thus, the area irradiated is 4 and 16 times as
effects. great, respectively, as that of the original beam
profile. 2 The forward-scattered energy is very
diffuse, with a resultant low-power density due
Theoretical Considerations to the multiple scattering events within the tis-
sue.
The conversion of light energy to thermal energy The magnitude of the absorption and scatter-
depends upon absorption and scattering of the ing coefficients is dependent upon wavelength
beam within the tissue. Halldorsson et al. 2 have and duration of exposure. As the wavelength of
established an absorption coefficient (a) of 0.11 the laser decreases, its absorption increases,
and a scattering coefficient (13) of 9.89 per cen- accompanied by a decrease in scattering. This
timeter of tissue traversed by the beam. Thus, phenomenon offers possibilities for the use of
if absorption alone were responsible for dissi- the 532- and 266-nm harmonics of the Nd:YAG
pating the energy of the beam, penetration would laser to achieve effects for which the funda-
reach approximately 9 em, as is the case with a mental 1064-nm wavelength is not well suited.
sample composed of water. However, the com- The coefficient of scattering, in particular, also
plex and nonhomogeneous three-dimensional changes with increasing exposure time due to
array of proteins within the cells and intercellular changes in the optical properties of the tissue
43. Tissue Interactions of Nd:YAG Lasers 337

as necrosis proceeds. Initially, coagulation of Acute Effects of 1064-nm

tissue proteins causes an increase in scattering. 2
This increase in the value of 13 results in a rising
Exposure
proportion of backscattered energy, with an ac-
When tissue that has been subjected to laser ir-
companying decrease in forward scatter. As the
radiation is examined histologically immediately
temperature of the tissue reaches 100°C, there
after exposure, one finds the development of
is a sharp increase in backscattering, which re-
zones of tissue damage, which is in agreement
mains at this elevated level until tissue water is
with the described theoretical considerations
boiled off. At the point of tissue dehydration and
(Figure 43.1). The degree of tissue effect is de-
carbonization there is a sharp decrease in back-
pendent upon both the power level applied and
scattering and an increase in forward transmis-
the duration of application. Short pulses of
sion of beam energy.
higher power will cause a narrower, deeper, and
more localized effect than the same total energy
applied as longer pulses at a lower power level. 3
Correlation of Temperature Rise In other words, the defect caused by high power
levels is more dependent on the distribution of
With Tissue Damage beam energy within the tissue, while lower
power, longer duration exposure allows more
The initial phase of absorption of energy raises
time for thermal conduction to adjacent cells and
the tissue temperature from 37°C to approxi-
produces a shallower but wider defect.
mately 60°C, with some accompanying hyper-
At very low energies temporary hyperemia
emia and swelling but no permanent structural
and mild edema of the tissue may occur. As
damage. As the temperature increases beyond
more energy is applied, the tissue temperature
60°C, protein denaturation and coagulation oc-
increases, with the greatest rise occurring below
cur. 3.4 This phase is signaled by blanching of the
the surface at a depth of 0.7 to 1.3 mm, as de-
exposure site and an increase in the scattering
termined by Marchesini et al. 5 Thus subsurface
properties of the tissue, as previously described.
coagulation is achieved before surface damage
At this point, shrinkage of the tissue is also ob-
served. Further absorption of energy raises the
tissue temperature to 100°C and begins to boil
the water in the cells and intercellular matrix.
The conversion of water to steam has two ef-
: - - - - - Tissue Surface
fects. The first is related to the thousandfold in-
crease in volume of the water as it changes from oagulum
cav ita tion
a liquid to a gas, with resultant rupturing of cells
and cavitation of the tissue as this expansion Cldophilia
occurs. The second effect is the action of water
as a heat sink because of its high latent heat of
vaporization during this phase transition. Once nsition

all the water has been driven out, a rapid rise

in temperature occurs. Carbonization takes plane 01 resection
place when the temperature has reached a level
between 300 and 400°C. This stage is made ev- FIGURE 43.1. Schematic representation of the volume
of tissue affected by scattering and thermal conduc-
ident by the production of smoke. Absorption
tion from the point of beam contact. Zones of tissue
of energy increases as the tissue blackens and
damage corresponding to the amount of energy ab-
if temperatures exceed 500°C the tissue c~n ig- sorbed are indicated but not drawn to scale. (From
nite. This increased absorption of energy with Brackett KA, Sankar MY, Joffe SN: Effects of
attendant scattering and thermal conduction Nd:YAG laser photoradiation on intra-abdominal tis-
before the ignition point is reached, will greatl; sues: A histological study of tissue damage versus
extend the total volume of tissue affected around power density applied. Lasers Surg Med 6: 123-130,
the area of beam contact. 1986. With permission.)
338 Kim A. Brackett

is visible. In a highly cellular organ such as the as a thermal sink. Higher power densities (up
liver, stained with azure-eosin, a small spheroid to approximately 2500 J/cm 2 ) are required to in-
of acidophilic, necrosed cells will be seen below crease the depth of this effect up to 3 mm, which
a surface minimally affected by the beam (Figure is about the limit after which vaporization of su-
43.2). Tissue with a thin epithelium or mucosa perficiallayers of cells begins. 5 However, this
often shows a condensation of collagen in the maximum depth may be increased into the range
submucosa, accompanied by swelling, again of 4 to 6 mm by artificial cooling of the surface
under a normal-appearing surface. Such tissues of the tissue with saline irrigation. 6J Here, water
stained with Masson's Trichrome sometimes acts as a heat sink at the surface without af-
show a homogeneous analine blue staining of fecting the thermal characteristics of the deeper
the submucosa, resulting in a vitrified appear- layers of the tissue.
ance. These connective tissue effects are im- Application of increasing amounts of energy
portant in the mechanism of Nd:YAG laser-in- until vaporization of the superficial layers occurs
duced hemostasis. Swelling of the matrix results in the appearance of distinct zones of
surrounding small blood vessels provides oc- damage related to the proportional intensity of
clusive pressure. The total energy required to energy absorbed at that point in the tissue. 8
achieve this effect varies with technique and the Again using liver as an example, four zones can
volume of blood flow to the tissue, which acts be distinguished (Figure 43.3). The most super-

FIGURE 43.2. Liver sUbjected to low

dosage of noncontact Nd: YAG laser ir-
radiation. Tissue in the center of the
field displays heat necrosis and coag-
ulation, while the overlying hepatocytes
are normal. Dosage was sufficient to
cause capsular swelling at the surface.
Azure-eosin, x 90.
43. Tissue Interactions of Nd:YAG Lasers 339

FIGURE 43 .3. Liver resected by SLT

contact Nd:YAG laser probe. Four
zones of tissue damage can be ob-
served. 1, surface coagulum ; 2, cav-
itation; 3, acidophilia; 4, transition.
Noncontact resected liver would
demonstrate the. same four zones,
but the acidophilic zone would oc-
cupy 3 to 5 times the volume of tissue
affected here . Azure-eosin, x 180.

ficial zone is composed of a thin « 100 /-Lm) layer corresponds to the spheroid exposed to scat-
of intensely stained coagulated proteins and is- tered photons and thermal diffusion. A transition
lands of carbonized debris. Beneath this layer, zone, located between the acidophilic cells and
cavitation occurs from the formation of steam normal tissue, in which the cytoplasm of the
within the tissue. The depth to which cavitation cells is more acidophilic than normal but retains
can occur is variable but is usually restricted to the basophilic staining of the rough endoplasmic
the upper 500 /-Lm. The bulk of the tissue affected reticulum, is generally present but often difficult
by the laser lies under the cavitation layer. Here to distinguish. These cells appear to have swol-
cells are characterized by acidophilic cytoplasm len mitochondria and activated lysosomes when
with nuclei varying from densely pyknotic near examined with the electron microscope. This
the surface to normal or slightly swollen as the layer represents the minimum detectable struc-
transition to normal tissue is approached. Many tural effect of the laser and/or thermal energy
of these cells do not appear to be structurally on the cells. The normal tissue below this level
damaged, but coagulation and heat inactivation is hyperemic. Similar zones are identifiable in
of the basophilic cytoplasmic ribosomal nucleo- other, more heterogeneous, organs as well.
proteins have rendered them nonviable. This When the stomach is exposed to a power density
zone can extend up to 5 mm into the tissue and high enough to vaporize the mucosa, the defect
340 Kim A. Brackett

is surrounded by a coagulum, a thin layer of ating a precise incision when used in the con-
cavitation and a broader zone of condensed ventional noncontact mode. Such incisions are
necrotic cells and connective tissue (Figure accompanied by a band of necrotic tissue show-
43.4). The smooth muscle of the wall responds ing the described zones of damage arrayed par-
with shrinkage of individual fibers, pyknosis of allel to the plane of resection. The width of the
the nuclei, and the formation of intercellular zone of necrosis (acidophilic cells) appears to
clefts. These zones are analogous to those seen be independent of the power applied when op-
in the liver. Generally, no specifically identifi- erating in the range of 50 to 100 W. 8 The primary
able transition zone can be recognized. A raised reason for this independence is the reduction in
ring can often be found on the surface sur- the amount of time the beam is in contact with
rounding the site of laser application, caused by any unit volume of tissue as a result of the higher
swelling of the surrounding vital tissue. Often rate of excavation with increased power, thus
the adjacent normal tissue is hyperemic and fo- allowing less thermal diffusion.
cal hemorrhages are common. The recent development of a variety of SLT
This broad spheroid of damage caused by the contact sapphire laser probes permits the use of
low absorption and high degree of scattering 1064-nm radiation to be used to create a much
makes the Nd:YAG laser less than ideal for cre- more precisely localized coagulation and/or

FIGURE 43.4. Gastric wall exposed to

Nd:YAG laser radiation. Zones of
damage include regions correspond-
ing to 1, surface coagulum; 2, cavi-
tation; 3, acidophilia. Damage ex-
tends through the smooth muscle of
the externa. Masson's Trichrome,
x90.
43. Tissue Interactions of Nd:YAG Lasers 341

cutting effect than was previously possible. tissue subjected to a single pulse. 14 The disrup-
Contact techniques are effective at greatly re- tion appears to be caused by the creation of a
duced power levels, typically between 5 and 25 bubble of vapor at the site, or possibly by the
W, and result in an average fivefold decrease in propagation of a nonlinear shock wave. A train
the volume of tissue damaged when used for of lower energy pulses at this wavelength results
cutting. 9 This tissue damage is qualitatively in thermal damage to the photoreceptors and
similar to that seen with the noncontact mode, pigmented epithelium of the retina whose cells
but is reduced quantitatively to the range typi- were highly vacuolated with accompanying nu-
cally encountered with the CO 2 laser or Bovie clear pyknosis. Rapidly pulsed 266-nm photo-
electrocautery. An additional difference seen in radiation has been used experimentally to pro-
preliminary studies is the reduction, or complete duce fine, precisely controlled cuts in cadaver
elimination, of the raised ring of tissue sur- corneas. 15 At this wavelength the tissue absorbs
rounding the exposed area. Scanning electron- most of the energy with greatly reduced scat-
microscopic examination of contact versus tering. Further study of this wavelength is nec-
non contact lesions in the trachea shows an ab- essary, but scanning electron microscopy dem-
rupt transition to normal tissue at the edge of onstrated minimal coagulation and carbonization
the crater, in contrast to coagulated debris in- along the incision. The 260-nm ultraviolet ra-
terposed in the noncontact lesions (Figure 43.5). diation has long been known to have mutagenic
Early measurements also indicate a reduction in effects on DNA, and the carcinogenic effects of
backscattering when the contact probe is used, 266-nm radiation and what degree of thermal
which may be related to this phenomenon as spread may occur remain to be investigated.
well as to the use of lower power densities. 10 A fourth area of laser-tissue interaction that
remains to be developed involves the use of one
or more of the available Nd:YAG wavelengths
in photodynamic therapy. Such applications
Acute Effects of Alternate Modes await the development of suitable photochem-
and Wavelengths ically active substances responsive to Nd:YAG
laser radiation.
The use of Q-switched or mode-locked Nd:YAG
lasers allows the storage of high levels of energy
during optical pumping, which is then released
in extremely short pulses. ll This high-density Healing of Nd:YAG Laser-
energy has an explosive effect on atoms within Induced Lesions
the target tissue. 12 Electrons are inelastically
scattered from the atoms and form a plasma The pattern of healing following Nd:YAG laser
shield that helps to screen deeper structures exposure is typical of that seen following any
from the beam. After the pulse, released elec- thermal injury. Subsurface areas of photoco-
trons are recaptured, giving off the energy which agulation following low exposure levels are rap-
they gained from the photon pulse. This mi- idly invaded by fibroblasts, macrophages, and
crodischarge of energy creates a shock wave'that capillary buds from adjacent tissues and heal
disrupts and vaporizes the local tissue. This with the formation of a connective tissue scar.
technique is often employed in ophthalmologic Craters and resected surfaces undergo a slightly
surgery for penetrating and incising the nonpig- more complex process, which can result in the
mented structures such as the cornea and lens. formation of a scar or in segregation of the dam-
The alternative Nd:YAG laser wavelengths aged area by connective tissue encapsulation
investigated thus far include 1340 nm and the with eventual sloughing or resorption of the
second (532 nm) and fourth (266 nm) harmonics necrotic mass, depending upon the extent of the
of the 1064-nm wavelength. The 1340-nm radia- original injury. The connective tissue arises from
tion has been found to result in increased depth the capsule of the organ, its stroma, or peri-
of penetration and tissue damage, particularly vascular connective tissue sheath, and invades
in hemoglobin-rich tissue. 13 As tested on retinal the mass along the transition zone. Regeneration
tissue, 532 nm causes mechanical disruption of of normal tissue occurs concurrently in those
342 Kim A. Brackett

FIGURE43.5. (A) Scanning electron micrograph (SEM) mucosa, 15-W SLT contact probe laser lesion. Tran-
of tracheal mucosa, 100-W, noncontact laser lesion. sition from normal surface mucosa to crater is abrupt,
Crater is surrounded by a raised ring of coagulated, lacking the coagulated rim seen in noncontact lesions.
necrotic tissue (arrows). X 50. (B) SEM of tracheal x50.
43. Tissue Interactions of Nd:YAG Lasers 343

organs capable of regeneration. In most in- 5. Marchesini R, Andreola S, Emanuelli H, et al:

stances, little inflammatory cell infiltrate is ob- Temperature rise in biological tissue during
served. Presumably, the creation of a sterile Nd: YAG laser irradiation. Lasers Surg Med 5:75-
area, coinciding with the necrotic zone as a re- 82, 1985.
sult of absorption of thermal energy, eliminates 6. Kroy W, Halldorsson Th, Langerholc J: Practical
advice in laser coagulation from a theoretical
exogenous stimulation of inflammation. By the
viewpoint. Appl Opt 196:6-9, 1980.
same token, heat denaturation of cellular en- 7. Frank F, Keiditsch E, Hofstetter A, et al: Various
zymes and other proteins suppresses endoge- effects of the CO 2 - , the neodymium: YAG-, and
nous stimulation. the argon-laser irradiation on bladder tissue. Las-
One exception to the pattern of healing has ers Surg Med 2:89-96, 1982.
been found in experimental pancreatic resec- 8. Brackett KA, Sankar MY, Joffe SN: Effects of
tions. Resections involving the use of noncon- N d: YAG laser photoradiation on intra-abdominal
tact and contact techniques have been found to tissues: A histological study of tissue damage
produce acute and chronic pancreatitis in rats versus power density applied. Lasers Surg Med
and dogs. 16 However, similar results were ob- 6:123-130, 1986.
tained using Bovie electrocautery, indicating 9. Joffe SN, Brackett KA, Sankar MY, Daikuzono
N: Liver resection with the N d: Y AG laser. A
that the results were not necessarily related to
comparison of a new contact probe, the laser
the instrumentation and are probably related to scalpel, with the conventional non-contact meth-
leakage of pancreatic secretions into the sur- od. Surg Gynecol Obstet 163:437-442, 1986.
rounding parenchyma and into the abdominal 10. Daikuzono N, Joffe SN: Artificial sapphire probe
cavity from unclosed ducts. Further refinements for contact photocoagulation and tissue vapori-
in operating technique should eliminate this zation with the Nd:YAG laser. Med Instrum
problem. 19:173-178, 1985.
Thus, current investigations hold promise for 11. Fuller TA: The physics of surgical lasers. Lasers
the development of a highly versatile system of Surg Med 1:5-14, 1980.
multimode Nd:YAG lasers capable of producing 12. Osher RH: The neodymium:YAG laser in oph-
a variety of complementary tissue effects. thalmology. In Joffe SN, Muckerheide MC,
Goldman L (eds): Neodymium-YAG Laser in
Medicine and Surgery. Elsevier, New York, 1983,
References pp 164-169.
13. Stokes LF, Auth DC, Tanaka D, et al: Biomedical
1. Abergel RP, Meeker CA, Dwyer RM, et al: Non- utility of 1.34 fLm Nd:YAG laser radiation. IEEE
thermal effects of Nd:YAG laser on biological Trans Biomed Eng BME-28(3):297-299, 1981.
functions of human skin fibroblasts in culture. 14. Mosier MA, Champion J, Liaw L-H, Berns MW:
Lasers Surg Med 3:279-284, 1984. Retinal effects of the frequency-doubled (532 nm)
2. Halldorsson Th, Rother W, Langerholc J, Frank YAG laser: Histopathological comparison with
F: Theoretical and experimental investigations argon laser. Lasers Surg Med 5:377-404, 1985.
prove Nd:YAG laser treatment to be safe. Lasers 15. Berns MW, Gaster RN: Corneal incisions pro-
Surg Med 1:253-262, 1981. duced with the fourth harmonic (266 nm) of the
3. McKenzie AL, Carruth JAS: Lasers in surgery YAG laser. Lasers Surg Med 5:371-375, 1985.
and medicine. Phys Med Biol29(6):619-641, 1984. 16. Schroder T, Brackett K, Joffe SN: Proximal
4. Sacknoff EJ: Neodymium-YAG laser surgery in pancreatectomy: A comparison of electrocautery
urology. In Joffe SN, Muckerheide MC, Goldman with the contact and non-contact Nd: YAG laser
L (eds): Neodymium-YAG Laser in Medicine and techniques in the dog. Am J Surg (In Press),
Surgery. Elsevier, New York, 1983, pp 106-117. 1987.
44
Setting Up Ambulatory Laser Centers
Carolyn J. Mackety

As cost-effective, multidisciplinary laser centers after their laser treatment is completed. This unit
become a strategic goal for many health care has its own personnel and may administratively
facilities, many elements must be taken into report to the ambulatory services or chief op-
consideration during the development. erating officer of the facility. This unit can be
set up either as a for-profit department or as a
part of the hospital's not-for-profit structure. An
Types of Laser Centers example of a contained unit is the Grant Hospital
Laser Center, Columbus, OH.
Conceptually, a "Laser Center" is a cluster of
laser systems used for outpatient treatment.
General anesthesia is not required. There are Integrated Unit
three types of laser centers:
The integrated unit is physically contiguous to,
1. A contained unit; a space within a hospital or is a part of, an operating room or ambulatory
but not contiguous to an operating room or surgery unit. Since the operating room depart-
ambulatory surgery clinic ment and the ambulatory surgery clinic have
2. A unit integrated into an operating room or their own laser-trained staff, the laser center that
ambulatory surgery clinic or contiguous to is within these departments can schedule and
them in a medical facility, with the laser cen- use all the laser systems as they are needed. The
ter reporting to the administrative manager laser center can be designed as treatment rooms
of the parent department in an area that is contiguous to the OR or the
3. A free-standing building that is owned and ASC, and in this setting the unit can provide
operated by a medical facility or in a joint outpatient laser treatment without general anes-
venture with the facility and a group of phy- thesia. This type of laser center has its own per-
sician users sonnel, however, and when the laser is used in
the main operating room or ambulatory surgery,
the laser center personnel must be available
Contained Unit during laser treatment. In view of the fact that
The contained unit is constructed as a "mini" staff, and the scheduling of patients for the laser
ambulatory surgery department, where patients center is integrated with the regular operative
are scheduled to have their laser treatment and schedule, the laser equipment, accessories are
are admitted to the unit in a prescribed manner. used in both surgical units, as well as the laser
The admission process is expedited, as these center. This type of center is very cost-effective,
patients require little or no preadmission testing as there is minimal duplication of equipment or
or assessment. They are usually in good health personnel. The patients treated in this unit are
and will require little or no anesthesia for their low-risk outpatients who do not require general
procedure. The patients usually do not have to anesthesia and can be discharged immediately
change their clothes, and they can leave shortly after treatment. An example of the integrated
44. Setting Up Ambulatory Laser Centers 345

unit is the Wenske Laser Center, Ravenswood be physicians who use lasers, laser nurses, hos-
Hospital Medical Center, Chicago, IL. pital administrators (C.O.O. or V.P. for Am-
bulatory Services), planners, marketing direc-
tors, and biomedical engineers. Other experts
Free-Standing Center can be asked to participate on the task force as
The free-standing laser center is a separate needed during the design, development, and
building that contains all types of laser systems, implementation phase. The task force should set
with related accessories, supplies, and personnel realistic goals and workable time frames. Meet-
to administer laser treatments to all indicated ings should be held frequently at first; then as
patients. The facility is designed and constructed the ALC develops, a regular schedule should be
to meet all ambulatory surgical care guidelines, maintained. The task force should have an
including general anesthesia, if required, and agenda and the responsibility and authority to
postoperative recovery. Physicians must apply make decisions and recommendations.
for privileges as described in the bylaws of the
center, and nursing and ancillary staff are avail-
able for patient care and the general management Feasibility Study
of the center. Administratively, the center has The feasibility study, to ensure a successful
a manager who reports to a board of directors program, will have multiple components:
or the chief executive officer of the corporation.
Inasmuch as this center owns all of its laser sys- Medical staff commitment
tems and related equipment and has its own Case-mix (medical/surgical) analysis
personnel, it is usually run as a for-profit or- Financial considerations
ganization. An example of a free-standing laser Acquisition
center is the Beckman Institute, Irvine, CA. Evaluation
Reimbursement factors
Operating budget
Development of Ambulatory When these elements have been considered, a
Laser Centers go-no go decision is made and the implemen-
tation phase commences.
This section will discuss the following topics that
should be considered in the development of am-
bulatory laser centers (ALC): Medical Staff Commitment
A survey form should be devised and sent to the
1. Task force
2. Feasibility Study medical staff to assess interest, motivation, and
commitment to use lasers in their daily practice.
3. Construction parameters
Why survey the medical staff? The survey anal-
4. Policies and procedures
ysis will document interest and commitment,
5. Staffing
identify laser-specific patient populations, as-
6. Marketing strategies
certain the extent of attendance in laser edu-
Each element should be addressed in relation to cation programs, and it will generate interest
implementing the laser center concept, to op- where it may have been minimal. Physician
timize the overall success of the program. commitment to significant use of the laser en-
sures maximum laser usage.

Task Force Case-Mix Analysis

A laser task force should be appointed as a basic
The case-mix analysis will give the facility a po-
work group to expedite the coordination and
tential utilization base and case load projection.
management of the overall program. If the fa-
There are three methods to analyze this infor-
cility has an ongoing laser program with a Laser
mation:
Committee in place, the work group can be an
ad hoc committee reporting to the Laser Com- 1. Identify types of procedures that could be
mittee. The composition of this task force should converted into laser cases.
346 Carolyn J. Mackety

2. Review those procedures in relation to the est rates, leasing equipment, using revenue to
ICD-9-CM codes within the DRG's. pay the lease rates would be advantageous. The
3. Compare those codes and DRG's with each option to purchase by the pay-per-use method
physician's profile indicating those potential initially seems advantageous; however, the
"gainers or loss leaders." vendor usually profits excessively from this ar-
rangement. A suggestion would be to have a
Most facilities have their case-mix information
portion of the payment put in escrow as an eq-
computerized and readily available for data and
uity investment and at the end of a specific time
current trends analysis. There are several ways
period convert the "deal" to purchase or, if
to request this information from the computer:
there is not enough use, return the product. Al-
physician, procedure, DRG, ICD-9-CM code,
though current tax advantages are in a state of
inpatient, and outpatient. Experience shows
flux, joint ventures with physicians are still a
that, after identifying procedures from the case-
viable option. Entering into ajoint venture with
mix of the facility, approximately 10% of the
physicians represents a commitment for utili-
yearly operative base can convert to laser pro-
zation.
cedures.
After all these data are collected and analyzed,
the appropriate laser systems and accessories Evaluation
will be recommended for acquisition. There are Lasers represent significant capital outlay for the
many laser manufacturers in the medical indus- facility and as the market for lasers is changing
try today, with laser systems varying in power, it becomes very competitive. An evaluation
mode, type, and installation requirements. La- process should be developed, considering the
sers are available across the broad spectrum of following elements:
wavelengths to meet most of the medical indi-
cations for laser usage in today's medicine. System type and power to meet needs
Once the facility makes the decision to pur- Advantages/reliability/cost
chase the lasers recommended the acquisition Manufacturing history
process begins. Technical services available
Education process for physicians and nurses
Financial Considerations The evaluation process should be structured
Acquisition so each laser system is on site, usually no longer
than a week. The evaluation process should take
It would be advantageous to add the Materials place in an area that can accommodate a safe
Manager or Purchasing Agent to the laser task demonstration, that is accessible for physicians,
force at this time. Bid letters are sent to the and that can be reached by the greatest number
vendors with specifications for each laser system of potential laser users at convenient times.
noted. Within a specific time period after the Completion of the evaluation process is impor-
quotations are returned, the bids are reviewed tant. Documentation of the evaluation will be
to negotiate the "best deal" for the facility. As summarized for the decision-making process.
the ALC mayor may not be a specific geo- When the evaluation process is complete, the
graphic location, the Materials Manager may decision made, the price negotiated, accessories
need to purchase contracts for new construction identified, and delivery date decided, all policies
or renovation, equipment, and accessories and procedures should be developed and be ap-
needed as the program expands to continually proved to provide the facility with the appro-
meet the needs of the physicians and commu- priate medical-legal standards for laser practice.
nity. During this process the biomedical de-
partment should become involved in a discus-
Reimbursement Factors
sion of installation requirements.
In today's health care economy, creative To identify reimbursement factors, all financial
methods of acquisition will become necessary. data should be reviewed, including medicare,
Outright purchase of the laser systems gives the third-party payors, other payors, bad-debt fac-
facility the opportunity to immediately capitalize tors, and any other financial information that will
and depreciate the equipment. At current inter- affect income and the operation of the center.
44. Setting Up Ambulatory Laser Centers 347

The development of laser usage charges will be When this proforma is complete the facility
based on all those factors, to include reimburse- will be able to establish an incremental charge
ment under the DRG's. Other factors taken into (see Table 44.1).
consideration will be the facility's demographic
information for their core and service area.
Looking at the demographics will have other Construction Parameters
ramifications, such as age groups, which will af- This section will discuss the parameters for the
fect patient population, potential laser proce- development of an integrated and self-contained
dures, and the types of lasers needed. unit. There are similar considerations, so this
Next, the operation proforma will need to be information should be read in that context. The
developed for budgetary purposes. The elements laser task force should now be expanded to in-
for developing laser usage are as follows: clude the construction project engineer, archi-
1. How the local third-party payors will handle tects, and the significant persons involved with
charges for laser procedures. administration to plan, design, and develop the
2. Can equipment be charged to the patient in center.
a particular state. Financing the project is an administrative de-
3. Develop cost/charge ratios that are realistic. cision; however, the following options can be
4. Develop ongoing budgetary information for considered:
the center. 1. Use of operational funds: Develop the ALC
5. Make sure all procedures have the correct as a center of excellence and a for profit de-
codes assigned (both ICD-9-CM and DRG). partment. Enter into joint ventures with the
6. Charges for outpatient surgery should be de- facility and the physicians.
veloped as procedural charges that are rea- 2. Venture capitalization: This decision is based
sonably competitive in the community mar- on the strategic goals of the facility and the
ketplace. support of the Board of Trustees.
7. A flat-rate user charge can be developed using
the facility's usual formula for equipment The design phase will be important for the ef-
charging. An alternative is pricing on an in- ficient operation of the center and the following
cremental cost base, that is, based on volume should be considered:
and competitive cost using the center vs office Location
pricing. Convenient for patients and physicians
Again, using the case-mix history, the pro- Parking/access to the facility
cedure analysis by physicians should give the Adequate space to accommodate all the
overall average time for all procedures. Based equipment
on yearly potential patient population, amorti- Logistics for patient flow
zation time, and profit margin, an incremental Access to needed utilities
cost base can be established. Patient comfort area
Space Planning
Patient waiting/reception
Operating Budget
Patient/staffllockers/toilet facilities
The operating budget of the center is simulta- Treatment rooms
neously developed and is crucial to the Recovery rooms
cost:charge ratio. The factors to be addressed Instrument clean/set-up areas
in this process are as follows: Office/conference space
Nursing stations
Construction/renovation Reception/scheduling area
Equipment/furniture Storage space
W agel salarieslbenefits
Consumable supplies/maintenance costs Access to the building should be convenient
Marketing/education materials for patients and physicians. The parking or drop-
Utilities/environmental services off area should have accommodations for hand-
Service contracts/insurance icapped patients. The signs should be easy to
348 Carolyn J. Mackety

TABLE 44.1. Cost of gynecological laser surgery

Service ICD-9-CM Cost ($)
Gynecological procedures by DRG
DRG 360 Reimbursement $1691.00
LOS
1982 4.2
1985 1.8
Excision cervical lesion 67.39
Hymenotomy 70.31
Marsupialization Bartholin cyst 71.24
Partial vulvectomy 71.61
Ablation herpes lesion 70.33
Excision vaginal septum 70.33
Excision vaginal warts/condyloma 70.33
Inpatient consumption
OR Time 375
Anesthesia supplies 82
Pharmacy 24
Suture 40
Laser drape pack 53
Miscellaneous 20
Laser (flat fee) 269
Recovery 100
Total 963
Per diem 1.8 754
Nursing care 1.8 484
Total cost 2201
Loss -510
Outpatient Procedure DRG 360/above codes
Procedure charge 375
Facility fee 100
Laboratory 30
Recovery 50
Laser*(incremental) 180
Total 735
Reimbursement +956
*First 15 m = $100.000; each subsequent 15 m $80.00.

read, as many patients may be visually impaired. adequately meet the installation requirements.
The patient treatment areas should be semires- Most CO 2 lasers have no added requirements.
tricted to allow patients to have their procedure Continuous wave Nd:YAG lasers have special
in a clean environment without crossover of requirements such as 208 three-phase electricity
sterile and nonsterile techniques. and flowing water at 45 psi. The newer cw
Patient flow through the ALC may present Nd:YAG lasers are air-cooled; however, air ex-
logistical problems. The patient should fall changes in the treatment rooms should be at
within the anesthesia classification I and II, be least 12 to 15 exchanges per hour. Argon lasers
healthy, or have minor health problems under can be fixed or mobile. The pulsed Nd:YAG for
control. Access and egress through a common ophthalmology does not have additional instal-
admitting and discharge area conserves space. lation requirements.
Patient mix in a common change area with lock- The patient and family waiting area should be
ers and toilet facilities does not present a prob- comfortable, and soft lighting and warm colors
lem. Toilet facilities should have panic hardware will assist in reducing anxiety. For diversion
installed. there should be light music, television, patient
Utilities will have to be identified to include education information, and current quick read-
electricity, water, heating, and air contidioning. ing material. Personnel should be available to
All laser systems will need to be identified to answer questions. A nourishment station should
44. Setting Up Ambulatory Laser Centers 349

be provided for patients and family, as many of 5. Troubleshooting and maintenance docu-
them may have come from a distance and may mentation
have been on restricted fluids prior to their pro- 6. Education for laser support personnel
cedure. 7. Orientation of personnel to laser safety
The treatment rooms will need sufficient space 9. Operational safety procedures:
to accommodate the laser systems, treatment a. Eye protection
tables, modular storage, and emergency equip- b. Controlled access
ment. Treatment rooms should be approximately c. Signage
200 square feet and should have the functional d. Endotracheal tube safety
capacity to accommodate all laser systems, in- e. Instrumentation
cluding installation. The ophthalmologic laser f. Laser shutdown
center is a good example of how the center can g. Smoke evacuation
be set up. h. Care of all laser accessories
Supplies needed for each room can be stored 9. Setup and Shutdown procedures
in modular units, either as an exchange cart or 10. Moving the lasers
"topped-out" by the staff or central supply. All 11. Consent forms
drugs used in the unit can be consumed and re- 12. Documentation
placed or availability can be on an exchange ba- 13. Laser safety officer
sis with the pharmacy.
The physicians' offices and conference rooms These policies and procedures are developed
can be combined by using modular office con- and approved in accordance to institutional
cepts. The Scheduling/Receptions area can be protocol.
planned in a modular concept, able to be ex-
panded as needed. Space should include a com-
puter station for data entry and retrieval. Staffing
Nursing work stations should be installed in
Whatever type of ALC is developed, staff se-
each treatment room; however, a central nursing
lection is important for the ongoing management
work area should be considered for intraoper-
and viability of the center. The person selected
ative documentation, care planning, discharge
to direct the program must demonstrate effective
summaries, and preoperative assessment.
management skills, for both people and material,
Stations for decontamination and setting up
and he or she must have basic understanding of
of accessories and instruments for reprocessing
all medical and surgical procedures, as well as
will be necessary. Some laser accessories are
the motivation and dedication to expend con-
cleaned immediately and stored appropriately.
siderable energy to participate in the growth of
the center.
The general staff will include nurses, ancillary
Policies and Procedures
personnel (e.g., secretary/receptionist), and
For medico-legal purposes, policies and pro- technicians, both clinical and biomedical (Table
cedures should be developed, approved, and 44.2). Staffing decisions will be depend on the
implemented for safe laser practice. There is no following:
bureaucratic body that has dictated what these
should state; however, the American National Number of laser systems
Standards Institute will be publishing their Where the lasers are geographically placed
Z136.3 addendum for "Safety in Medical Fa- Number of procedures
cilities", soon. The following is a suggested list Number of credentialed physicians
that should be developed prior to laser program ALC staff utilization
implementation: Patient/staff education·
Marketing
1. Function of the Laser Committee
2. Job descriptions for laser personnel The director's responsibilities will depend on
3. Education criteria how the department is developed within the or-
4. Accident and malfunction report ganizational structure.
350 Carolyn J. Mackety

TABLE 44.2. Recommended staff for a typical laser tation of nursing care for the laser patients.
center 2. Assumes the perioperative role.
Position FTE Salary (K) 3. Day-to-day management of the Laser Sup-
Director 1 35-40 port team.
RN 2 25-28 4. Assists in the development and implemen-
Technician 1 18-22 tation of continuing education laser pro-
Secretary/Receptionist 1 12-15 grams.
Biomedical technician .5 8-12
Marketing .25 5-8 5. Participates in the orientation of new em-
ployees regarding laser safety and laser pol-
icy and procedures.
6. May assume responsibility for the laser dur-
Integrated Laser Unit
ing the surgical procedure.
The director of the integrated unit would report 7. Monitors safe laser practice.
to the Vice-President of Operations of Ambu- 8. Maintains the lasers and the laser accesso-
latory Care as a middle manager. The duties of ries.
the director would be, however, not all-inclu- 9. Documents all laser procedures.
sive: 10. Participates in clinical laser research proj-
ects.
Direct daily activities of the ALC
11. Participates in nonlaser procedures as as-
Budget maintenance signed.
Liaison between physicians and administration
Designated Laser Safety Officer
Responsibility for all equipment and accessories LASER SAFETY TECHNICIAN
Marketing liaison
Educational activities to include, hands-on Responsibility
training, in service and continuing education To the Clinical Nurse/Laser, or to the appro-
priate designated person in the area where laser
SelJ-ContainedIFree-Standing Laser Unit treatments are being performed.
The director of the free-standing unit, as a part
of independent departments and for-profit cen- Typical Responsibilities
ters, would have added responsibilities, includ- 1. Sets the laser up and does the check proce-
ing all the duties listed for the director of the dure prior to each laser case.
integrated unit, and the following additional ac-
2. Assumes responsibility for the laser and ac-
tivities:
cessories during each laser procedure.
Trends analysis 3. Assists in the orientation of new employees
Statistical utilization with regard to laser safety and policy and
Revenue tracking procedures.
Community education 4. Assists in the monitoring of safe laser prac-
Laser research tice.
5. Assists in the documentation of all laser pro-
Job Descdptions cedures.
6. Assists in research projects as needed.
CLINICAL NURSE SPECIALIST/LASER
7. Performs other duties as requested or as-
signed.
Responsibility
To the Head Nurse, Assistant Supervisor or Di- Note
rector of Operating Room Service or the des-
The above statements are intended to describe
ignated Director of the Laser Program:
the general nature and level of the persons as-
signed to the job classification. They are not to
Typical Responsibilities
be considered as an exhaustive list of all job du-
1. Participates in the planning and implemen- ties performed by personnel in this classification.
44. Setting Up Ambulatory Laser Centers 351

BIOLASER TECHNICIAN community. Marketing to the physicians will be

essential for the viability of the center, a referral
Responsibility base will need to be established. A laser "hot-
line" can be the connection from the center to
To the Clinical Nurse/Laser, Director of Op-
the community, information should be available,
erating Room services or the designated super-
a speaker's bureau established, local media in-
visor where laser treatments are being per-
formed regarding the efficacy of laser proce-
formed, or the Medical Director of the Laser
dures, and publication in various journals and
Program.
other media.
Marketing attempts to identify first the needs
Typical Responsibilities of consumers and then to provide a product or
service that so closely matches these needs that
1. Operates, maintains, and troubleshoots all the exchange process is made from the consum-
laser and assessories. er's perspective. Selling is concerned with help-
2. Has the responsibility, with approval, to call ing the potential consumers understand their
the manufactures service representative. needs, and then to provide support to facilitate
3. Performs preventive maintenance on a pre- the purchase decision.
scribed schedule an all lasers and related Marketing and selling are not mutually exclu-
equipment. sive, but there is a difference in their orientation.
4. May assume responsibility for the operation Marketing identifies potential users of a product
of the laser and assessories during laser pro- or services, while selling focuses on the pur-
cedures. chase transaction. In the marketing and selling
5. Assists in the orientation and continuing ed- of health care services, both must be market-
ucation of the employees. driven, that is, allowing consumers' needs to
6. Remains current in the field of all laser mo- determine what services will be provided and
dalities and equipment. the levels of usage.
7. Participates in clinical laser research projects. The goal of marketing the Laser Center is to
8. Assists in the evaluation of laser and related track the changing needs and desires of con-
equipment for upgrade in the current available sumers and constantly adjust the hospital's
laser modalities mix of services to meet these needs. The mar-
9. Performs other duties as assigned or request- keting program will continue to produce value
ed. for the consumers through the services provid-
ed.
SECRETARy/RECEPTIONIST Another critical factor in marketing of the
services provided by the Laser Center is to cor-
Responsibility rectly identify the persons who playa key role
Major responsibilities will be scheduling, ad- in the purchase decision. It is at this point that
mission, logistic patient flow, record keeping, the marketing of health care services differs
and following through with patient appoint- from the marketing of the other professional ser-
ments. This person should be efficient and per- vices.
sonable, with excellent secretarial skills, tele- The unique feature of marketing health care
phone personality, and ability to use the services is created by the role of the physician
computer and word processor. Her organiza- as the key actor in the purchase decision. Con-
tional skills should be equal to an office man- sumers can purchase medical and surgical ser-
ager. vices provided by the Laser Center only through
the physician.
Today the masses can be easily reached by
the media and therefore the customer can be the
Marketing Strategies consumer. The physician can decide who will
A percentage of the marketing position should purchase these services, the amount of services
be allocated to the ALC. Marketing of the ALC that may be purchased, and in some instances
will have a two-pronged attack: physicians and when they will be purchased.
352 Carolyn J. Mackety

Elements of Patient Satisfaction feasibility of laser usage, assessment of specific

laser needs, evaluation, selection, and acquisi-
The elements that are needed for patient satis- tion of equipment, establishing laser safety rules,
faction of the laser center may include the fol- policies and procedures, training and creden-
lowing factors: tialing of personnel, and determination of laser
usage charge structure. For a majority of insti-
Friendliness of the nursing staff tutions, these issues provide a challenge, pre-
Quality of care senting difficulties and opportunities for admin-
Attention to patient needs istration and staff.
Waiting time A decision as to whether or not the "ideal"
Physical environment program or center is feasible for the facility must
Confidence in physician take several factors into consideration. After
Cost of procedure these factors have been weighed, a determina-
Ambiance of the facility tion of the feasible program or center for the
There has been significant increase in aware- hospital can be made.
ness both in the consumer and customer market With the proliferation of lasers in all aspects
of the advantages of lasers in medicine and sur- of medicine and surgery, eventually to enter the
gery; however, the laser market is still under- diagnostic departments, lasers will be every-
developed as a service in the hospital market where. What does the future hold? Oncology
place. centers will implement photodynamic therapy
This demand is created by as an alternative treatment for various types of
cancer. Vascular laboratories will begin using
1. A growing awareness among consumers of laser diagnostic tools, such as laser dopplers.
the most cost-effective health care services Cardiac catheter laboratories will expand their
2. The prospective payment system services to include laser angioplasty. The in-
3. The concern of corporations to use modalities vasive radiologists are exploring various types
of health care that are less costly oflasers to add to their armamentarium. Lasers
The Laser Center must provide quality ser- already are in the laboratory, separating blood
vices (high tech) that are consumer-centered cells and products.
(high touch) at a reasonable cost with a high Technology is impacting our practice as phy-
convenience factor for the consumer. sicians and nurses, expanding our horizons with
new, exciting practice techniques. Cost-effective
delivery of health care is a prime concern, and
Summary technology assists in this process. It is predicted
that the growth for lasers in medicine and sur-
Ambulatory Laser Centers, whatever the geo- gery will be 26% per year until the end of this
graphic location, present a challenge for the fa- century. Are we as health care professionals
cility. Most health care facilities will face a va- ready to meet this growth potential in the de-
riety of issues that include determining the livery of quality patient care?
45
The Laser Industry: Present and Future
Arthur A. Bertolero

The laser industry, is more than 15 years old. pediently. Argon, CO 2 , Nd:YAG, and other
While the first medical lasers were developed wavelengths are all capable of performing many
and used in the mid-1960s, it was not until the of today's laser procedures. This fact is sub-
mid-1970s that published reports established the stantiated by clinicians every day, as they
laser as a useful surgical tool. The argon laser choose laser wavelengths in much the same w.ay
has been used clinically in ophthalmology and as they choose scalpel blades or electrosurgical
in plastic surgery since 1976. The CO 2 laser has devices. These decisions are based on training,
been used in ENT surgery since 1972, in gyne- experience, ease of use, availablity, and per-
cology since 1973, and in neurosurgery since sonal preference as much as they are based on
1976. The surgical Nd:YAG laser was first used wavelength. 4 .5
in gastroenterology and urology in 1977, and the The ability for a laser to be used in more than
ophthalmic pulsed N d: YAG laser in 1980. 1- 3 one specialty gives the laser the potential to be
By 1986, the equipment segment of the a more highly utilized, more cost-effective in-
worldwide medical laser business represented a strument. Unfortunately, this potential has yet
$200 million market. The method of marketing to be fully realized. However, in the area of
medical lasers has changed little over the last prospective reimbursement, the laser has
ten years. Lasers continue to be sold by spe- emerged as the most often-mentioned factor in
cialty-directed marketing, with lasers being sold converting inpatients to outpatients and in re-
for primary use by a single specialty. It is this ducing the length of stay in hospital. In this way
type of marketing and utilization that gives laser alone, many lasers are justifying their expense.
critics their case against lasers. With the ex- Today the laser industry is at its most critical
ception of ophthalmology, lasers used by a single phase since the introduction of lasers to the
specialty are often underutilized, and therefore medical community. Of the dozens of laser
are not cost-effective. With a few qualifications, companies, less than a handful are profitable.
the critics are correct. However, in the lasHen At the same time, fierce competition is driving
years, there have been hundreds of papers pre- laser prices down, and customers are demanding
sented and published that prove, well enough more services. The confusion in the marketplace
for most physicians, that lasers can do many about the specific therapeutic applications of
procedures significantly better than conventional each laser, and about how to choose a laser
methods. Thus we can conclude that the surgical manufacturer most advantageously, has length-
benefits and better quality of care provided by ened the decision-making process and increased
the laser, rather than its cost-effectiveness, are the cost of selling lasers. The only certain fact
responsible for the esteem this technique cur- is, that the financial numbers do not add up for
rently enjoys. most laser companies, and, as a result, there will
Ten years of laser research and applications be a major shakeout in the laser industry in the
development have led to considerable overlap next few years similar to that which has occurred
in regard to matching lasers to applications ex- in the computer industry.
354 Arthur A. Bertolerc

The worldwide medical laser equipment mar- The various types of lasers are at different
ket is forecasted to grow to more than $400 mil- stages in their adoption. Figures 45.1 to 45.7
lion by 1990. Several factors indicate that even show the hospital and office market penetration
a market that is twice the size oftoday's market in the United States, with estimates for the total
will have a difficult time providing a return to size of each segment worldwide.
investors in medical laser equipment compa- The CO 2 laser hospital market is entering the
nies. 6 "late majority" phase, characterized by ac-
There is, however, a bright side. Medical las- ceptance by nearly 50% of the market (Figure
ers are no longer the "concept sell" they once 45.1). This market is now mature. The number
were. Effective marketeers will be able to of applications has increased, prices have come
shorten the buying cycle substantially and down, and the size of this market segment has
thereby increase profits. An emerging dispos- grown. Now, smaller hospitals are entering the
ables segment offers the promise of a higher market, and larger hospitals are buying their
profit aftermarket. Finally, the inevitable shake- second and third CO 2 lasers, so that by 1990 this
out will leave a few major companies with market segment should represent over 8000 las-
enough volume to gain profitability. ers worldwide.
The office CO 2 market is in the "early adop-
ter" phase, with the market still under devel-
The Present-Day Laser Industry opment (Figure 45.2). The office applications
and CO 2 lasers designed and priced for this mar-
The laser industry today is in one of its most ket will increase the size of this market. This
dynamic stages. Rapid growth and fierce com- market represents at least 4000 lasers worldwide
petition in a confused marketplace have made by 1990.
difficult financial times for a large number of The Nd:YAG laser hospital market segment
laser companies. Before we discuss this issue, is in the "early adopter" phase (Figure 45.3).
we will analyze the relatively small market for This market is still in development, and several
which too many are competing (Table 45.1). potential applications could substantially in-
There are at least five major companies selling crease its size. This market will represent 6000
surgical Nd:YAG lasers and five times as many lasers worldwide by 1990. Some market analysts
selling ophthalmic Nd:YAG lasers. There are feel this segment will be the fastest-growing
more than ten companies selling CO2 lasers. In segment in the next two to three years.
all, there are more than 30 companies competing The Nd:YAG laser office market segment is
for a market that is big enough for no more than in the "innovator" phase (Figure 45.4), char-
12 companies at the most. The shakeout and acterized by purchases by a small group of in-
consolidation that will take place over the next novative physicians who will prove the profit
few years will leave no more than six to seven potential for "office Y AG" lasers. If the office
major companies. In addition, there will be four Nd:YAG laser is viable, then smaller, less ex-
or five minor companies selling specialty or low- pensive, Nd:YAG lasers could expand the po-
price "generic" lasers. 6 tential of this market. With the products cur-
rently available, and with the limited number of
applications, the office N d: Y AG market will
TABLE 45.1. The medical laser equipment market represent 2000 lasers worldwide by 1990.
(in million $, worldwide) The argon and KTP-532 (potassium titanyl
Type of laser 1986 1987 1988 1989 1990 phosphate) lasers are in the "early adopter"
39.0 50.7 65.9 85.7 121.4
phase, with some well-proven applications that,
Nd:YAG
CO, 62.6 78.3 97.90 122.4 135.0 unfortunately, offer only limited market poten-
Argon II.5 13.2 15.2 17.5 20.1 tial (Figure 45.5). However, the development of
Ophthalmic 82.0 92.5 105.2 119.5 135.5 new applications could expand the market for
Other 2.0 4.3 7.0 12.5 16.0 these products. Currently, the market for these
products represents 2000 lasers worldwide.
Total 197.1 239.0 291.2 357.6 428.0
The ophthalmic laser market includes argon,
Source: Surgical Laser Technologies and industry estimates. krypton, and short-pulsed Nd:YAG lasers (Fig-
45. Laser Industry: Present and Future 355

1986

La .. La,.
Mojorily Mojorily

FIGURE 45.1. The CO 2 laser hospital market. FIGURE 45.2. The CO 2 laser office market.

1986

FIGURE 45.3 . The surgical Nd:Y AG laser hospital FIGURE 45.4. The surgical Nd:YAG laser office
market. market.

19So

1976
Time of
Adoption

Late
Mojorily Laggords jorily Laggards

FIGURE 45.5. The argon and KTP-532 (potassium FIGURE 45.6. The ophthalmic laser hospital and of-
titanyl phosphate) lasers hospital and office mar- fice markets.
kets.

ure 45.6). This market is in the "late majority" Present-Day Laser Users
stage and is the most mature of all of the seg-
ments. This market may provide a model for all Figure 45.7 exhibits the current mix of laser
the other segments. One example of this is that users. Table 45.2 shows the varying degrees of
the price of ophthalmic lasers has decreased and usage by the major medical specialties in 1986.
the market size has increased. This seems to be
holding true for the CO 2 office market, also.
However, making too many comparisons to the
ophthalmic market may not be wise. No other Laser Applications
segment has yet to produce an application that
is near the frequency of posterior capsulotomy Table 45.3 shows the various types of lasers and
or retinal coagulation procedure. This market is their applications . It is reassuring to see the
estimated to represent 8000 lasers worldwide. multitude of applications that certain lasers
356 Arthur A. Bertolero

The Profitability Problem

Many people find it beyond belief that laser
companies have a hard time making a profit.
Yet, the fact remains, there are only a few prof-
Optha lmology
itable laser companies. A closer examination of
60% the typical laser sale explains the dilemma most
GeMrat Surgery.
Pulmonary . Plastic,
laser companies face.
Pod iatry

A verage laser selling price $ 75,000

Typical cost of selling and -16,000
marketing
FIGURE 45.7. Laser user mix: Percent oftotallaser pro- Typical cost of first-year 3,000
cedures performed . (Estimates from the industry a nd warranty
Surgical Laser Technologies , Inc.)
Typical cost of installation 1,000
Typical cost of inservice 3,000
Typical cost of physician training 2,000
have. However, the overlap in applications has Typical cost of manufacturing/ - 45,000
caused a great deal of confusion for the potential overhead
laser buyer. It is not as simple as a CO 2 for this Typical cost of inventory and 1,000
procedure and a Y AG for that operation. For debt
certain procedures, it is possible to have one Typical cost of research and 4 ,000
physician who prefers CO 2 , one physician who development
prefers Y AG and one physician who prefers Ar-
Total cost $ 75,000
gon. However, the challenge for the hospital
Profit 0
administrator is almost always the same: Choose
a laser that will provide the highest utilization. 4.7
Utilization can be adequate to justify purchase
with one or two procedures being performed Laser prices are being forced down by com-
frequently. However, as smaller hospitals or petition , and confused buyers are demanding
outpatient clinics justify laser purchases, they costly on-site demonstrations, causing selling
may make determinations based not only on the costs to increase. It is easy to see why laser
primary uses but on the range of applications companies are struggling to make a profit. The
anyone laser offers their physician mix . revenue that most companies generate from
service contracts rarely produces profit. It is this
dilemma that makes a shakeout in the laser in-
TABLE 45.2. Access to lasers by laser type dustry inevitable.
Percent of specialists with
access to laser
Clinical Specialty Argon CO, Nd:YAG The Future of the Laser Industry
Neurosurgery <3 70 10
Ophthalmology 40 N/A 65* There will be fewer laser companies to deal with
ENT surgery 5 60 <5 in the next few years. Those that weather the
Gynecologic surgery 15 40 10 storm will be left with a market that is big enough
Gastroenterologic surgery <2 N/A 25
to produce profits for well-positioned compa-
Plastic surgery 10 15 <5
Urology N/A 5 10 nies. Several laser companies may try to ride
Pulmonary surgery N/A <5 10 out the storm under the umbrella provided by a
General surgery N/A 10 <3 large parent corporation. While a few companies
The Marketplace for Medical Laser Meeting, Boston; May,
may survive with help from a parent company,
1986. Roger Guidi. sponsored by Laser Focus Magazine. they will do no more than survive unless they
*Pulsed Nd:Y AG. establish a viable position in the market.
45. Laser Industry: Present and Future 357

TABLE 45.3. Current applications for laser surgery* (September 30, 1986)
Type of laser
Argon/ Contact
Clinical Specialty Application ICD-9 Argon Krypton CO, Dye Nd:YAG Nd:YAG**
Dermatology and Excision/destruction of X X
Plastic surgery lesion of skin and
subcutaneous tissue
Port-wine nevi 86.3 X X
(birthmarks)
Tattoos 86.3 X X X X
Warts 86.3 X X X
Keloids (acne) 86.3 X
Excision of eyelid wart 08.22 X
Excision of lesion or 27.43 X X
tissue of lip
Excision of soft tissue 83.49 X X
Photodynamic therapy X
ENT Excision/destruction of
(Otolaryngology) lesionsltissue of
surgery External ear 18.29 X X
Nose 21.30- X X
21.32
Lips 27.43 X X
Oral cavity 27.49 X X
Tongue 25.1 X X
Pharynx 29.3 X X
Larynx (vocal cord) 30.09 X
Stapedectomy 19.1 X
Myringotomy 20.1, X
20.09
Gastroenterologic Excision/destruction of
surgery lesion/tissue of
Esophagus 42.39 X X
Stomach 43.41- X X
43.49
Duodenum 45.31, X X
45.32
Small intestine 45.33, X X
45.34
Large intestine 45.4 X X
Rectum 48.33, X X
48.35
Hemorrhoids 49.46 X X X

General and Excision/destruction of

Oncologic surgery lesion of
Pancreas 52.2 X X X
Liver 50.21, X X X
50.29
Abdominal wall 54.3 X X
Pancreatectomy, partial 52.59 X X X
Hepatectomy, partial 50.22 X X X
Gynecologic surgery Excision/destruction of
lesions of
Cervix 67.3 X X
Vulva 71.3 X X
Uterus/intrauterine 69.19 X X X
Vagina 70.33 X X
Urethra 58.3 X X
Perirectal tissue 48.82 X X X
(warts)
 358 Arthur A. Bertolero

TABLE 45.3. Continued

Type of laser
Argon/ Contact
Clinical Specialty Application ICD-9 Argon Krypton CO 2 Dye Nd:YAG Nd:YAG**
Surgical procedures,
including
Celiotomy 54.11 X
Conization, cervix 67.2 X X
Endometrial ablation X X
Intrauterine septae/ X X
adhesiolysis
Myomectomy 68.29 X X
Oophororrhaphy 65.71 X X
Oophorcystectomy 65.29 X X
Oophorotomy 65.0 X X
Salpingolysis 68.29 X X
Salpingoplasty 66.79 X X
Salpingostomy ·66.73 X X
Treatment of X X X X
endometriosis
Tubal ligation 66.2, X X
66.3
Vaginectomy 70.4 X X
Vulvectomy 71.5, X X
71.61,
71.62
Neurosurgery Excision/destruction of
Brain tissue & lesions 01.51, X X X
01.59
skull lesions 01.6 X
Spinal cord lesions 03.4 X X
Cranial and peripheral 04.07 X X
nerves
Division of intraspinal 03.1 X
nerve root
Partial excision of 07.62 X X
pituitary gland
Endarterectomy, 38.11 X X X
intracranial vessels
Ophthalmology Excision/destruction of
Eyelid lesion 08.20, X
08.25
Retina & choroid 14.24, X
lesion 14.25
Iridotomy 12.12 X X
Iridoplasty 12.39 X X
Trabeculoplasty 12.79 X
Discission and excision 13.64, X
of secondary 13.65,
cataract 13.69
Repair of retinal tear 14.34, X
14.35
Endophotoincision 14.79 X
(removal of
vitreous strands)
Orthopedic surgery Osteotomy (division of 77.3 X
bone)
Excision of lesion or 77.6 X
tissue of bone
Arthroscopy 80.2 X X
 45. Laser Industry: Present and Future 359

TABLE 45.3. Continued

Type of laser
Argon/ Contact
Clinical Specialty Application ICD-9 Argon Krypton CO, Dye Nd:YAG Nd:YAG**
Soft tissue, ganglion X X
neurolysis
Thoracic surgery Thoracotomy 34.09 X X
Excision or destruction 32.29 X X
of lesion of lung
Bronchial dilation 33.91 X X X
Dilation of larynx 31.98 X
Dilation of trachea 31.99 X X X
Urology Partial nephrectomy 55.4 X X X
Excision of bladder 57.59 X X X
lesion
(transurethral)
Excision or destruction 58.3 X X X
of urethral tissue
Exxcision of lesion of 56.41 X
ureter
Excision of perirectal 48.82 X X X
tissue (condylomas,
warts)
Excision/destruction of 64.2 X X
lesion of penis
Source: Hospital Technical Series, Vol. 5, No.9, Guideline Report. Implementing Laser Technology in the Community
Hospital. 1986 American Hospital Association, Division of Technology Management and Policy, 840 North Lake Shore Drive,
Chicago, IL 60611
*This table lists several ofthe major clinical applications that can be enhanced through the use of surgical lasers. While every
attempt has been made to include the most common laser applications, the table is not meant to be comprehensive or exhaustive.
Its purpose is to illustrate the diversity of various surgical lasers.
**Based on data supplied to Surgical Laser Technologies, Inc. in conjunction with clinical investigations. These data were
not included in the original work. Also, this material is intended to describe clinical applications, not FDA market clearances.
Current market clearance status should be obtained directly from the regulatory affairs department of the laser manufacturer.

See references 8--\0 for further discussion.

There will only be room for one or two full- $5 million market. With the introduction of dis-
line manufacturers who offer all the currently posable Nd: YAG fibers, CO 2 waveguides, Con-
used wavelengths. The rest of the market will tact Laser Probes and Laser Scalpels, and other
be made up of well-positioned specialty com- consumables, the size of the accessory market
panies. There will likely be companies special- could grow to more than $100 million in 1990.
izing in CO2 office products, laser lithotripsy, Numerous market observers have felt that the
laser angioplasty, and laser hyperthermia. There single factor most relentlessly holding back the
will be successful specialty companies due to development of lasers has been the lack of ad-
technology advances aided by the ability to gain equate delivery systems. The further develop-
FDA market clearance well in advance of other ment of delivery systems could make the ac-
competitors, thus enabling the specialty com- cessory segment of the market one of the
pany to establish a position in a market niche industry's most important market segments. 6
before the full-line manufacturer can enter. In any discussion of the future, photodynamic
The most exciting prospect for the future is therapy (PDT) and new wavelengths must be
the potential size of the accessory market. In discussed. The current restrictions imposed by
1986, the accessory market, comprised of pro- the FDA, requiring lengthy clinical trials and
tective eyewear, smoke evacuators, microman- extended follow-up, have helped to protect the
ipulators and handpieces, was no larger than a laser industry from itself-like it or not. How-
360 Arthur A. Bertolero

ever, this process means that any new drug-en- References

hanced therapy or any new wavelength will take
l. Dixon JA: Surgical Application of Lasers. Year
two to three years before it is cleared for mar-
Book Medical Publishers, Chicago, 1983.
keting by the FDA. Therefore, new wavelengths
2. Joffe SN: Neodymium-Y AG Laser in Medicine
will play only a minor role in the next five years. and Surgery. Elsevier, New York, 1983.
3. March WF: Ophthalmic Lasers: Current Clinical
Uses. Slack Inc., Thorofare, NJ, 1984.
The Future is Now 4. Surgical Practice News. Lasers in surgery come
of age. May 1986.
In the last few years, the laser has moved from 5. Alder HC: 1986 Guideline Report. Implementing
a device that still had many detractors to a de- laser technology in the community hospital. Hosp
vice that is widely accepted as a tool that enables Tech Ser 5(9), 1986.
physicians to do better, more cost-effective sur- 6. In Vivo: The Business and Medicine Report, July!
gery and endoscopy. Aug, No 17, 1986.
Today, the future is being shaped by clinicians 7. Lasers in Surgery and Medicine, Vol 6, No 4,
using lasers to do more and more of their surgery 1986.
8. Goldman L: Current and future development in
and therapeutic endoscopy. The techniques they
laser surgery. Surg Clin North Am 61(5), 1984.
are developing today will not be published for 9. Lobraico R, Bellina JH, et al: Guide to Laser
some time. The products they want today will Surgery. 1982.
not be ready soon enough. The laser industry is 10. Mackety C: Beyond your first laser. Paper pre-
struggling to keep up. When industry listens to sented at the First National Conference on Clin-
those who use the lasers, they realize-the fu- ical Lasers-Practical Management and Utiliza-
ture is happening right now. tion Strategies, Aug. 15, 1984.
Index

Absorption, wavelength-dependent, 10 Antrostomy, laser, 166-169

Absorption coefficient, 336 Aphakia, 282
Accessory market, 360 Arachidonic acid metabolites, 174, 176
Acoustic neuromas, 121-123 Argo~laser, 79,110,119,354,356
Adenoid enlargement, 171 in neurosurgery, 131-137
Air embolization, 194-195 Arteriovenous malformations (AVMs), 124-128
Airway lesions, 104-109 Asherman's syndrome, 200-201
Airway maintenance, 106 AVMs (arteriovenous malformations), 124-128
ALC, see Ambulatory laser centers
Alveolar osteitis, chronic, 242
Alveolar pyorrhea; 242-243 Backscattering, 146
Ambulatory laser centers (ALC), 345-352 "Balloon system," 203
case-mix analysis, 345-346 Basal cell carcinoma, 220-224
construction parameters, 347-349 Basal tumors, 119
evaluation, 346 Beam control, invisible, 328
feasibility study for, 345-347 Beam divergence of endoprobes, 303
financial considerations, 346-347 Beam path
job descriptions in, 350-351 limited open, 321
marketing strategies for, 351 totally enclosed, 320-321
medical staff commitment, 345 totally unenclosed, 321-322
operating budget, 347 Beam-path controls, 320-322
policies and procedures, 349 Biliary tract calculi, 91
reimbursement factors, 346-347 Biolaser technician, 351
staffing, 349-351 Biologic effects, 5
Anal canal, 247 Biostimulation, 2
Anal incontinence, 254 Bladder cancer, 99-103
Analgesia on tooth, laser, 238-239 Bladder cells, 275
Anesthesia, 288-292 Bladder tumors, 96-98, 154
for bronchoscopy, 288-289 "Blanching technique," 201-202
for endoscopy, 288 Bleeding, see also Hemorrhage
for gastroenterology, 289 esophageal varices, 38
for general surgery, 291-292 gastrointestinal, 30-40
for neurosurgery, 290 lower gastrointestinal, 39
for open surgery, 290 Mallory-Weiss tear, 38-39
for otorhinolaryngology, 290-291 uterine, 195
for urology, 289-290 Blood loss, 20, 22
Anesthesia techniques, 113-114 Bone repair activation effect, 240-244
Angiokeratoma, 221, 225, 226 Bougienage, 54
Angiomas, cavernous, 209-211 Brain tumors, 123-124
ANSI Z-136 standards, 314 Bronchial tumor resection, 14
362 Index

Bronchoscope,Shapshaylaser, 151 Charge-coupled device (CCD), 46

Bronchoscopic resection, 110-117 image sensor, 236
Bronchoscopy, anesthesia for, 288--289 Cheek cancer, 244, 245
ChemoJadiotherapy, 174-178
Cholangioscopic surgery, 91-95
Caldwell-Luc operation, 166, 168, 169 Choledocholithotripsy, 4
Cancer CIS (carcinoma in situ), 183, 190
bladder, 99-103 Cis-dichlorodiamine platinum (CDDP), 175
cervical, 183, 190 Clinical nurse specialist/laser, 350
cheek, 244,245 CME (cystoid macular edema), 276, 277, 284-285
esophagogastric, 80-83 CO laser, see Carbon monoxide laser
of esophagus, 53-59 CO 2 laser, see Carbon dioxide laser
of gastric cardia, 53-59 Coagulation probe, 210
gastrointestinal, see Gastrointestinal cancer Coagulation volume, 11
lung, 104-109 Coaptation, 37
nasopharyngeal, 173 Colonic hemorrhage, 35-36
rectosigmoid,80-83 Computer-controlled contact Nd:YAG laser system,
skin, 220-224 305-310
tongue, 156-158, 177 Computerized tomographic (CT) scans, 55
tracheal, 105 Conchotomy,163-165
Cancer residue, 45 Conization of uterine cervix, 183-191
Capsular opacity, 276 Contact endoprobes, 303
Capsular tags, 286 SLT, 65-72, 99-103
Capsular wrinkling, 275-276 Contact lasers, 19-29
Capsulotomy, posterior, 275-281 Contact photocoagulation, 37-39
Carbon dioxide laser, 104, 110, 150 Contact vaporization, 209
beam, 170 Contained laser units, 344
clinical applications of, 120-123 Cooper 8000 laser, 102-103
development of, 118--119 Copper-vapor laser, III
hemorrhoidectomy and, 250-251 Cost of gynecological laser surgery, 348
hospital market, 354, 355 Cryotonsillectomy, 160, 165
noncontact, 263-264 CT (computerized tomographic) scans, 55
office market, 354, 355 CUSA (ultrasonic dissector), 268-269
tissue interactions of, 332-335 Cutting-off effect, 143
Carbon monoxide laser, 2-3 Cystoid mascular edema (CME), 276, 277, 284-285
performance of, 297 Cystoscope, 15
room-temperature, 297
tissue interactions of, 332-335
variable-function apparatus, 294-300 Dental caries, 227-228
Carbonization, 337 prevention with lasers, 227-233
Carcinoma Dental restorative materials, 231
basal cell, 220-224 Dental surgery, 235-245
in situ (CIS), 183, 190 Dentin, carious, 235
Cardiovascular stability, 291 Dentin canal, 239
Caries, dental, see Dental caries Dentin formation, secondary, 239-240
Carious dentin, 235 Depo-Provera, 196-197
Carotid laser angioplasty, 141 Dermatology, 154,208-212
Cavenous angiomas, 209-211 current applications in, 358
Cavitation, 339 Diffuse reflection nominal hazard zone range, 318
CCD, see Charge-coupled device Diffuse reflections, 316-317
CDDP (cis-dichlorodiamine platinum), 175 extended source, 318-319
Center for Devices and Radiological Health (CDRH), hazards from, 312-313
315 Diode laser, low-energy, 4
Cerebellopontine angle tumor, 124 Dorsal root entry zone (DREZ) lesions, 119
Cerebral tissue, thermal diffusion in, 132-133 "Dragging technique," 201-202
Cervical cancer, 183, 190 DREZ (Dorsal root entry zone) lesions, 119
Chalcogenide glass fiber, 297-298 Dumon-Harrel bronchoscope, 112
Index 363

Duodenal ulcers, 38 Gastric cardia, cancer of, 53-59

Dyes, tissue light absorption by, 332 Gastric ulcers, 38
Dysphagia, 53 intractable, 85-90
Gastroenterology, 14, 152-153
anesthesia for, 289
Edema current applications in, 358
cystoid macular (CME), 276, 277, 284-285 Gastrointestinal bleeding, 30-40
depth of, 143-144 Gastrointestinal cancer
Electrocoagulation, 30 advanced or recurrent, 42-45
Elschnig's pearls, 275, 281 contact endoprobe in, 74-78
ELT (endoscopic laser therapy), 53-59 early, 44-45
Encephaloscope, 15 in Japan, 61-64
Endodontic quartz laser probe, 237-238 Gastrointestinal lesions, nonbleeding, 79-83
Endodontic therapy, 241 Genital tract lesions, lower, 205-206
Endometrial ablation, 192-199 Glaucoma, 274, 279
Endometriosis, ablation of early pelvic, 203-205 aphakic malignant, 282
Endometrium, photocoagulation of, in chronic men- Glomus jugulare tumors, 124
orrhagia, 200-203 Granuloma faciale, 220,221
Endoprobes Gynecology, 154, 200-207
beam divergence of, 303 cost of laser surgery in, 348
contact, see Contact endoprobes current application in, 358-359
Endorod (SLT contact endoprobe), 65-72, 99-103
Endoscopic hemostatic techniques, 39
Endoscopic instrumentation, 13-15 Head malignancies, 174-178
Endoscopic laser therapy (ELT), 53-59 Head tumors, 156-159
Endoscopic laserthermia, 68-72 reconstructive surgery for, 179-182
Endoscopy, 46 Heat generation, 332
anesthesia for, 288 Hemangioblastomas, 123-124
Nd:YAG laser, 139-142 Hemangiomas
Endoscopy suite, 32 capillary/cavernous, 215, 217-220
Engineering controls, 328 port-wine, 221, 225, 226
Entryway controls, 323 treatment of, 152
Ependymomas, 139 Hematologic parameters, 260-261
Epistaxis, 217, 220 Hematometria, 198
Esophageal varices, 38 Hemorrhage, see also Bleeding
Esophagogastric cancer, 80-83 colonic, 35-36
Esophagus, cancer of, 53-59 control of, 152-153
Excimer laser, 5 delayed, requiring hysterectomy,
Exposure limits, maximum permissible (MPE), 313, 195-196
314, 315 immediate, 195
Extended source diffuse reflections, 318-319 upper gastrointestinal, 31-39
Eye Hemorrhoidectomy, 247-254
exposure to infrared wavelengths, 313 carbon dioxide laser and, 250-251
laser hazards to, 311-313 evaluation of contact laser, 254
Eyeshields, patient, 325 Nd:YAG laser for, 251-254
Eyewear, laser protective, 327 review of procedures, 249
technique of contact laser, 252-253
Hemorrhoids, 247
Federal Laser Product Performance Standard classification of, 247
(FLPPS), 314 conservative treatment, 248
Fiberoptic delivery systems, 32 first-degree, 247
Fiberoptic-on-Iaser nominal hazard zone range, 320 injection treatment, 248
FLPPS (Federal Laser Product Performance Stand- internal, 247
ard),314 clinical features, of, 248
Fluid overload, 195 treatment of, 248-250
Focused intrabeam condition, 312 interoexternal, 247
Free-standing laser centers, 345, 350 operative treatment, 248
364 Index

Hemorrhoids (cant.) Laser centers

recurrence of, 254 ambulatory, see Ambulatory laser centers
second-degree, 247 contained unit, 344
Hemostasis, 27, 209-210 free-standing center, 345, 350
Hemostatic techniques, endoscopic, 39 integrated unit, 344-345, 350
Hepatolithiasis, 91 types of, 344-345
Hyaloid vitreolysis, 283 Laser classifications, 314-315
Hyaloidectomy, anterior, 282 Laser-controlled area, 322-323
Hydrocephalus, 142 Laser danger warning sign, 322
Hyperthermia Laser Hospital, 5-6
endoscopic laser, 68-72 Laser industry, 353-361
energy resources for, 302 future of, 357, 360-361
interstitial localized, 174-178,302-310 present-day, 354-356
Hypertrophied tubal tonsil, l71-172 Laser plume, 33
Hypoxia, 112 Laser prices, 357
Hysterectomy, 183,200 Laser protective eyewear, 327
after ablation, 187-198 Laser range equation, 315
delayed hemorrhage requiring, 195-196 Laser resection, dangers of, 111
Hysteroscope, 195 Laser safety committee, 324
Laser Safety Officer (LSO), 314, 315
Laser safety technician, 350
IDE (Investigational Device Exemption), 315 Laser specialists, medical, 325
Infrared glass fibers, 296-297 Laser surgery
Infrared lasers, 332-333 advances in Japan, 1-6
Infrared wavelengths, eye exposure to, 313 current applications for, 356, 358-360
Ingrown nail, 211 gynecological, cost of, 348
Integrated laser units, 344-345, 350 maturity of, 1
International Congress of Laser Surgery and Medi- safety controls for, 314
cine, 6th, 4 safety in, 198, 288
International Society of Laser Medicine and Surgery, training in, 198
1, 2 Laser task force, 345
Interstitial contact probes, 302-304 Laser therapeutics, 4-5
Interstitial irradiation, 28-29 Laser treatment, preoperative, 108
Interstitial localized hyperthermia, 174-178,302-310 Laser users, present-day, 356, 357
Intervertebral disk disease, 140-141 Lasers used in medicine, 99, 248, 250; see a/so specific
Intrabeam nominal hazard zone, 315-316 lasers
Intrabeam viewing, 312 access to, by laser type, 357
Intraocular lens (IOL) markings, 278-281 accessory market, 360
Intrauterine excisional procedures, 206-207 classification of, 2, 3
Investigational Device Exemption (IDE), 315 clinical applications of, 119-128
Invisible beam control, 328 education and training for, 324
IOL (intraocular lens) markings, 278-281 equipment market for, 354
Iridectomy, 283 frequency of use, by medical specialty, 3
Irradiance, retinal, 312, 313 future of, 6
hazards to eye, 311-313
in hemorrhoidectomy, 247-254
Japanese Society of Laser Medicine and Surgery, I high-intensity irradiation by, 333-334
Job descriptions, 350-351 infrared, 332-333
in service and trial run for, 325
low-energy, 4-5
Keloid/hypertrophic scars, 214-215, 216 low-intensity irradiation by, 334-335
Keratosis, skin cancer, 220-224 multichannel fiber system, 212
KTP (potassium titanyl phosphate) twin crystal laser, nominal hazard zone (NHZ), 315-320
200, 354, 356 service and maintenance for, 324
videoendoscopes with, 51-52
Laserthermia, 302
Lambert's Cosine Law, 317 endoscopic, 68-72
Laparoscopic application, 15 Multiple, system, 310
Index 365

thermogram during, 305 in ophthalmology, 271-274

Lens-on-laser nominal hazard zone range, 319-320 contact delivery systems and accessories for, 19-
Light absorption by tissues, 330-332 29
Light guides, 13 convergent system, 156
Light intensity, average, 333 in dental surgery, 235-245
Lithotomy, 91 in dermatology, 208-212
Liver surgery, 268-269 development of, 119
Lower gastrointestinal bleeding, 39 in early pelvic endometriosis, 204-205
Lower gastrointestinal tract, 153 effect on tissue, 11-12
LSO (Laser Safety Officer), 314, 315 for endometrial ablation, 192-199
Lung cancer, 104-109 endoscopy in neurosurgery, 139-142
Lymph node metastasis, 62 in gynecology, 200-207
handpiece with variable beam direction, 237
in head tumors, 156-159
Macular burns, 312 healing of lesions induced by, 341, 343
Mallory-Weiss tear, bleeding, 38-39 for hemorroidectomy, 251-254
Masers, 7 high-energy, 42
Mastectomy, 291-292 high-power applications of, 150-151
MC (myocutaneous) island flap, 179-180 interstitial localized hyperthermia, 174-178
Medical laser specialists, 325 for intractable gastric ulcer, 85-90
Membranectomy, pupillary, 281 in liver sUligery, 268-269
Meningiomas, 119, 139, 146-148 low-power applications of, 151
Menorrhagia, 192 in nasopharyngeal diseases, 170-174
chronic, 200-203 in neck tumors, 156-159
continued, 196-197 in neurosurgery, 131-137
MMB laser, 102-103 non contact (air-fibre) technique, 33-35
MPE (maximum permissible exposure limits), 313, noncontact delivery systems and accessories for,
314,315 10-17
Mucosa flap, laser welding for, 245 in oral surgery, 235-245
Multichannel fiber system, 212 in otorhinolaryngology, 156-178
Multiple Laserthermia system, 310 overview of applications, 150-155
Myocutaneous (MC) island flap, 179-180 in pancreatic surgery, 266-268, 269
physiology, 213
in plastic surgery, 208-212, 213-226
Nasopharyngeal cancer, 173 in posterior capsulotomy, 276-281
Nasopharyngeal diseases, 170-174 Q-switched, 227-233
Nasopharyngeal neoplasms, 172-173 in reconstructive surgery for head and neck tumors,
Nd:YAG laser 179-182
in airway lesions, 104-109 safety procedures for surgery, 311-329
analgesia on tooth, 238-239 short-pulsed, in ophthalmology, 275-286
anesthesia for surgery, 288-292 in superficial lesions, 224
angular distribution of light, 133, 134 surgical hospital market, 354, 355
arteriovenous malformations and, 124-128 surgical office market, 354, 355
beam, 170 tissue interactions of, 336-343
in bladder tumors, 96-98 in tonsillectomy, 160-163
bone repair activation effect, 240-244 variable-function apparatus, 294-300
in brain tumors, 123-124 Neck malignancies, 174-178
brief history of, 7-8 Neck tumors, 156-159
in bronchoscopic resection, 110-117 reconstructive surgery for, 179-182
in cholangioscopic surgery, 91-95 Neodymium:yttrium aluminum garnet laser, see
in chronic sinusitis, 166-169 Nd:YAG laser
clinical applications of, 123-128 Neoplastic disease, 152-153
commercial continuous wave, 12-13 Neurofibromas, 208-209
in conchotomy, 163-165 Neuromas, acoustic, 121-123
in conization of uterine cervix, 183-191 Neurosurgery, 131-137
contact anesthesia for, 290
computer-controlled, 305-310 contact Nd:YAG laser in , 143-149
in neurosurgery, 143-149 current applications in, 359
366 Index

Neurosurgery (cont.) Photocoagulation, 30

fiberoptic laser endoscopy in, 139-142 contact, 37-39
Nevi, pigmented, 211, 212 of endometrium in menorrhagia, 200-203
Nominal hazard zone (NHZ), 315-320 transcleral, 271
diffuse reflection range, 318 Photodynamic therapy (PDT), 104-109
distance values for typical surgical lasers, 320 Pigmented nevi, 211, 212
fiberoptic-on-laser range, 320 Piles, see Hemorrhoids
intrabeam,315-316 Pituitary tumors, 119-120
laser criteria used for distance calculations, 321 Plastic surgery, 154, 208-212, 213-226
lens-on-laser range, 319-320 current applications in, 358
Noncontact lasers, 10-17 Popcorn effect, III
Port-wine hemangioma, 221, 225, 226
Potassium titanyl phosphate (KTP) twin crystal laser,
OD (optical density), 326--328 200, 354, 356
Olfactory groove meningioma, 147 Power attenuator, 77
Ophthalmic laser hospital and office markets, 354, Power delivery, 295-296
356 Power densities, 20, 22
Ophthalmology Power ranges, 309-310
contact laser applications in, 217-274 Power ratio control, 299, 300
current applications in, 359 Preoperative laser treatment, 108
short-pulsed Nd:YAG laser in, 275-286 Proctoscopy, 248
Optical density (OD), 326--328 Prosthetic tubes, 54-55
Optical fibers, quartz, 13 Protective equipment, personal, 326
Oral mucosa, welding of incised, 245 Protective eyewear, laser, 327
Oral surgery, 235-245 Proteins, tissue light absorption by, 331
Orthopedic surgery, current applications in, Pseudophakia, 280, 282
359-360 PTCCD (percutaneous transhepatic cholecyst drain-
Osteitis, chronic alveolar, 242 age),94
Otolaryngology, 152 PTCD (percutaneous transhepatic choledoco drain-
current applications in, 358 age), 91-93
Otorhinolaryngology, 156--178 Pulmonary medicine, 151-152
anesthesia for, 290-291 Pulp, secondary dentin formation in, 239-240
Oxyhemoglobin, 332 Pupillary membranectomy, 281
Pyorrhea, alveolar, 242-243

Pachydermatocele of Recklinghausen's disease,

209 Q-switched Nd: YAG laser, 227-233
Pancreatectomy, 266 Quartz crystals, 20, 304
Pancreatic disease, 267-268 Quartz fiber probe, 237-238
Pancreatic surgery, 266--268, 269 Quartz optical fibers, 13
Papilloma virus, 205
Patients
concerns of, 325 Radiance, 318
eyeshields for, 325 Radiation therapy, 53-54
safety of, 325 Radical neck dissection (RND), 179-181
satisfaction of, elements of, 352 Recklinghausen's disease, pachydermatocele of, 209
PDT (photodynamic therapy), 104-109 Reconstructive surgery for head and neck tumors,
Pelvic endometriosis, 203-205 179-182
Percutaneous transhepatic cholecyst drainage Rectal polyposis, 80, 82
(PTCCD),94 Rectosigmoid cancer, 80-83
Percutaneous transhepatic choledoco drainage Rectosigmoid villous adenoma, 80-82
(PTCD), 91-93 Reflections, diffuse, see Diffuse reflections
Perforation, uterine, 196 Retinal effects, laser, 311
Periapical operation, 241 Retinal irradiance, 312, 313
Periodontal operation, 242 Retinal pigment epithelium (RPE), 271-274
Personal protective equipment, 326 Retinotomies, 273
Index 367

RND (radical neck dissection), 179-191 Thermal energy, 332

RPE (retinal pigment epithelium), 271-274 Thermal increase, l32
Ruby laser, 7, 118 Thermocouples, 304
Thermogram during laserthermia, 305
Thermotherapy, 174
Safety Thoracic surgery, 152
controls for laser surgery, 314 current applications in, 360
laser committee, 324 Thoracic sympathectomy, 141
of patients, 325 Tissue coagulation, 245
procedures for Nd:YAG laser surgery, 311-329 Tissue cutting mechanism, 332
Sapphire contact scalpel excision, 217, 219, 220 Tissue damage, 312
Sapphire contact tips and scalpels, 2l3-214 temperature rise and, 337
excisional procedures with, 205, 206 Tissue interactions, 330-332
Sapphire crystals, 20, l31, 304 of carbon monoxide and carbon dioxide lasers, 332-
Sapphire probes, 194-195 335
Scattering, 10 of Nd:YAG lasers, 336-343
Scattering coefficient, 336 Tissue necrosis, 20, 23
Schott KG-3 and KG-5 glass, 328 Tissue temperature, l32
Sclerotomy, 273 Tissues
Shapshay laser bronchoscope, 151 distribution of laser intensity in, 236-237
Sinus inflammation, 167 laser effect on, 235-236
Sinusitis, chronic, 166-169 light absorption by, 330-332
Skin cancer, 220-224 spectral analysis of, 235
Skin tumors, 208 Tongue cancer, 156-158, 177
SLT Chisel Probe, 66-67 Tonsil, hypertrophied tubal, 171-172
SLT Conical Probe, 27 Tonsillectomy, 160-163
SLT contact endoprobe (Endorod), 65-72, 99-103 Trachaelcancer,105
SLT Contact Laser, 306, 307 Tracheal mucosa, 342
SLT Contact Laser Probes, 19-29 Tracheal stenosis, 112-1l3, 151
flat, 37-38 Tracheobronchial tumors, 114-117
rounded, 74-78 Training programs, 329
splenic resection with, 256-264 Transcleral photocoagulation, 271
SLT Laser Scalpels, 24-29, l37, 303 Transurethral laser destruction of bladder cancer
Smoke, 20, 22 (TULD),99
SOP (Standard Operating Procedure), 323-324 Transurethral resection techniques (TUR), 96-98
Spinal cord tumors, 119 Tubal tonsil, hypertrophied, 171-172
Spleen, 256 TULD (transurethral laser destruction of bladder
Splenic parenchyma, 259 cancer), 99
Splenic resection, 256-264 TUR (transurethral resection techniques), 96-98
SSRL (Suggested State Regulation for Laser), 314
Standard Operating Procedure (SOP), 323-324
"Strapper," 269 Ulcers
"Suction knife," 269 duodenal, 38
Suggested State Regulation for Lasers (SSRL), 314 gastric, see Gastric ulcers
Surface cooling, 11 Ultrasonic dissector (CUSA), 268-269
Surgical Laser Technologies Inc., see SLT entries Upper gastrointestinal hemorrhage, 31-39
Synechialysis, 283 Upper gastrointestinal tract, 152-153
Ureterorenoscope, 15
Urinary bladder tumors, 96-98
Task force, laser, 345 Urinary tract infections, 198
Telangiectasia, superficial, 221-222, 226 Urology, 153-154
Temperature control method, 306, 307-309 anesthesia for, 289-290
Temperature rise, tissue damage and, 337 current applications in, 360
Tentorial meningioma, 147 Uterine bleeding, 195
Thermal diffusion in cerebral tissue, l32-l33 Uterine cavity, visualization in, 202-203
Thermal effect, 10-11,236,239-240 Uterine cervix, conization of, 183-191
368 Index

Uterine perforation, 196 Videoendoscope, 46-47

Uterine template, 193 Videoendoscopy, 46-52
Visualization in uterine cavity, 202-203
Vitrectomy, 273
Vaporization Vitreolysis
contact, 209 anterior, 284-286
depth of, 143-144 hyaloid, 283
Variable-function fiberoptic laser apparatus, procedure for, 285-286
294-300
Varicose veins, 214
Varicosities, superficial, 221-222, 226 Warning sign, laser danger, 322
Vascular anastomosis, 245 Water, tissue light absorption by, 330-331
Vascular tumors, 119 Wavelength-dependent absorption, 10