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The CO2 laser is used in a broad range of clinical applications. The surgical
laser can augment and, in many instances, even replace traditional
instruments and methods. The Aesculight and Luxar CO2 surgical lasers are
useful in procedures where:
The Luxar laser is operated in a non-contact fashion. The tip is held close to,
but does not touch, the target tissue. The tissue effects are different from
contact lasers, where the primary effect is a result of heat conducted from
the tip to the tissue. The primary determinants of laser effect on tissue are:
Wavelength;
Tissue type;
Power density;
Exposure time.
Patients often report less postoperative pain with laser wounds. The laser is
more versatile than conventional surgical instruments because it can:
Incise or excise;
Vaporize or ablate;
Provide hemostasis.
As is the case with any other surgical instrument, no one should use the
Luxar surgical laser, or any other medical laser, without specific training in
both medical laser use and laser safety.
The CO2 laser is not cleared by the FDA for use on bone or in hard tissue
procedures in the United States.
Laser surgery benefits for the clinician
Improved visibility of the surgical field
The laser beam seals capillaries and small blood vessels as it "cuts" the
tissue. This dramatically reduces bleeding, resulting in a much drier and
clearer surgical site. In addition, the Luxar surgical laser does not use the
very distracting aiming beam usually associated with outdated articulated
arm CO2 laser systems.
Reduction of procedure time
The hemostatic effect of the CO2 laser beam and the improved visibility of
the surgical field reduce the time needed to perform the surgery, and may
also reduce the need for sutures, bandaging, and other after-care measures.
Pinpoint accuracy and control
The diameter of the beam may be adjusted down to a small fraction of a
millimeter or expanded to address a much wider swath. The power of the
beam may be set for rapid removal of relatively large tissue amounts, or
adjusted to remove only one or two cell layers at a time.
Increased surgical capabilities
Laser surgery changes the character of many procedures by making them
simpler or by reducing risk. This opens up the possibility of expanding the
clinician's surgical repertoire to include procedures that are not practical
with conventional scalpel-based techniques.
Laser surgery benefits for the patient
Less Pain
The laser seals lymphatics and nerve endings as it cuts, resulting in less
edema and pain that leads to a more comfortable post-operative recovery.
Reduced risk of infection
CO2 laser surgery is a "no touch" technology. The laser beam kills bacteria
in its path, producing a sanitizing effect.
Quicker recovery time
Reduced risk of infection, less bleeding, less swelling, and less pain often
allow the patient a more rapid return to normal activities.
Lasers are more precise and exact than blades (scalpels). For instance,
the tissue near a laser cut (incision) is not affected since there is little
contact with skin or other tissue.
The heat produced by lasers helps clean (sterilize) the edges of the
body tissue that its cutting, reducing the risk of infection.
Since laser heat seals blood vessels, there is less bleeding, swelling,
pain, or scarring.
Operating time may be shorter.
Laser surgery may mean less cutting and damage to healthy tissues (it
can be less invasive). For example, with fiber optics, laser light can be
directed to parts of the body through very small cuts (incisions)
without having to make a large incision.
More procedures may be done in outpatient settings.
Healing time is often shorter.
Though lasers can be used alone, they are most often used along with other
cancer treatments, such as chemotherapy or radiation.
Lasers are also being studied for treating or preventing side effects of
common cancer treatments. For instance, some studies are looking at how
lasers might be used to prevent or treat severe mouth sores caused by
chemotherapy, and how they may be used to treat the swelling
(lymphedema) that can result after breast surgery. More research is needed to
learn about these possible uses for lasers.
Shrinking or destroying tumors directly
The CO2 and Nd:YAG lasers are used to shrink or destroy tumors. They can
be used with thin, flexible tubes called endoscopes that let doctors see inside
certain parts of the body, such as the bladder or stomach. The light from
some lasers can be sent through an endoscope fitted with fiber optics. This
lets doctors see and work in parts of the body that could not otherwise be
reached except by major surgery. It also allows very precise aim of the laser
beam.
Lasers can be used with low-power microscopes, too. This gives the doctor a
larger view of the area being treated. When used with a an instrument that
allows very fine movement (called a micromanipulator), laser systems can
produce a cutting area as small as 200 microns in diameter less than the
width of a very fine thread.
Lasers are used to treat many kinds of cancer. In the intestines or large
bowel, lasers are used to remove polyps, small growths that may become
cancer. The CO2 laser can be used to treat pre-cancerous tissue and very
early cancers of the cervix, vagina, and vulva.
Lasers are also used to remove tumors blocking the swallowing tube
(esophagus) and large intestine (colon). This does not cure the cancer, but it
relieves some symptoms, such as trouble swallowing.
The Nd:YAG laser has also been used to remove cancer that has spread to
the lungs from other areas. This helps patients avoid surgery that would
require removing large sections of lung. This type of laser cannot cure
cancer, but it can improve breathing and other symptoms in many patients.
Cancers of the head, neck, airways, and lungs can be treated (but usually not
cured) with lasers. Small tumors on the vocal cords may be treated with
lasers instead of radiation in some patients. As with tumors blocking the
esophagus, tumors blocking the upper airway can be partly removed to make
breathing easier. Blockages deeper in the airway, such as in the branches of
the breathing tubes (bronchi), can be treated with a flexible, lighted tube
called a bronchoscope and an Nd:YAG laser.
Laser-induced interstitial thermotherapy (LITT) is based on the same idea
as a cancer treatment called hyperthermia. Both methods use heat to help
shrink tumors by damaging cells or depriving them of the things they need
to live (like oxygen and food). In LITT, the laser light is passed through a
fiber optic wire and right into a tumor, where it heats up, damaging or killing
cancer cells. LITT is sometimes used to treat tumors in the liver.
Photodynamic therapy
In photodynamic therapy (PDT), a special drug called a photosensitizing
agent is put into the bloodstream. Over time it is absorbed by body tissues.
The drug stays in or around cancer cells for a longer time than it does in
normal tissue. Shining a certain kind of light on the drug that is in the cancer
cells causes a chemical reaction that then kills the cancer cells.
Key Points
The CO2 laser wavelength is carried via hollow tubes, waveguides, and mirrors.
Conventional fiberoptics are not currently available for clinical use. The
laparoscopic use of this wavelength is possible with the use of a focusing cube
and an operative laparoscope or with a variety of waveguides designed for
multi-puncture laparoscopic applications. The focusing cube permits the use of
the CO2 laser in a free beam mode for cutting, vaporization, and coagulation of
tissue. The focusing cube also is capable of transmitting an aiming beam. This
feature makes it easier for the surgeon to direct the laser energy to the desired
target. A variety of procedures, such as myomectomy, partial oophorectomy,
resection and ablation of endometriomas, adhesiolysis, and even
cholecystectomy have been accomplished successfully with this delivery
system. Cholecystectomy requires a McKernan-type approach. The successful
use of this approach requires knowledge and facility with the operative
laparoscope and the surgeons ability to visualize the desired target and
maneuver a micromanipulator or joystick. The surgeon can alter the tissue
effect by focusing or defocusing the laser beam as well as varying the laser
wattage selected. Laser waveguides are hollow tubes with mirror-like surfaces
that reflect the CO2 wavelength. Waveguides are available in both rigid and
flexible versions and can be used to achieve a spot size (ie, burn or incision)
that is in the range of 0.8mm to 2.2mm. As a general principle, the waveguide
is used in a noncontact fashion, particularly because tissue contact can
obstruct the waveguide and liquid can be drawn into the hollow waveguide by
capillary action. The result of these events is the irreversible destruction of the
waveguide. Recent developments include the Omniguide, which is a smalldiameter solid chalcogenide glass waveguide and which is currently being used
in otolaryngology and neurosurgical applications.
The successful use of this laser for dissection and hemostasis requires that the
surgeon be adept and expert with the laser, as this will affect the ability to
dissect tissues and achieve an adequate degree of hemostasis. Both the
focusing cube and waveguide systems require a direct line of sight or the use of
angled mirrors. This further complicates the maneuverability of these devices
more so than fiber capable lasers and conventional instruments. Both
configurations require flowing gas to cool the system and to prevent vaporized
tissue plume from being thrown into the device. The most frequently used
purge gases are argon and carbon dioxide. High CO2 gas flow rates can actually
absorb the laser energy and reduce its efficiency (ie, the transmission of
energy from the laser to the tissue). Therefore, lower flow rates (ie, 1L/min)
are suggested. Some laser systems are equipped with a nitrogen purge gas
system. The surgeon should NOT use nitrogen during laparoscopy, because its
absorption from the peritoneum can cause the bends.
The optimal use of the CO2 laser for laparoscopic or open use is achieved when
the beam is oriented perpendicular to the desired target. Hemostasis is
enhanced by tissue compression, the use of epinephrine-containing local
anesthetic solutions and the ability of the operator to recognize the presence
of a vessel prior to its division. Under these conditions, the surgeon defocuses
the laser (ie, moves the handpiece, waveguide, or operating laparoscope
farther away from the target) and then applies short bursts of energy to the
vessel in the area to be divided. This maneuver heats and coagulates the
vessel, thereby enabling its division by the focused beam. The surgeon should
use the highest power setting with which he or she is comfortable, because this
will enable more efficient cutting, better hemostasis, and less thermal injury
to the wound edges by minimizing conductive and radiative heat loss into the
wound. Intermittent evacuation of the vaporized tissue plume or the use of a
recirculating filtration system assure a clear field of view and prevent
absorption of toxic products of combustion by the patient. This problem is
identical in magnitude and toxicity to the vaporized tissue plume created
byany electrosurgical, thermal, or laser source. Similarly the smoke should
not be vented into the operating room, because it is considered hazardous for
OR personnel. OSHA/NIOSH has written regulations that require that OR staff
be protected from vaporized tissue plume regardless of its source.
ARGON LASER
The argon laser has been used extensively for gynecologic laparoscopic
procedures in the past.10,33 It has largely been replaced by other technologies
today. This laser produces light in the visible portion of the spectrum. This
laser actually produces 6 lines (wavelengths). However, the majority of the
laser output is in the blue-green spectrum (wavelength = 488 514nm). This
energy is intensely absorbed by hemoglobin and melanin, although other
exogenous chromophores will absorb these wavelengths efficiently. Visible light
wavelengths can be passed through water, enabling the argon laser to be used
in aqueous environments, such as the bladder, during hysteroscopy,
arthroscopy, and in the presence of irrigating fluids. This property enables the
surgeon to photocoagulate a bleeding area while irrigating to locate the source
of the bleeding.
Both free-beam and conventional fiberoptic applications are utilized during
operative laparoscopy. A Microslad unit may be coupled with the operative
laparoscope. A gimbaled mirror and joystick allow the surgeon to maneuver the
beam in the surgical field. The fiber can be used in both a contact and
noncontact mode.
Argon laser light penetrates and scatters in tissues. The resultant damage can
be as much as 6mm. When used in an incisional mode, the speed of incision and
the degree of hemostasis are adequate. Blood vessels on the order of 2mm in
diameter can be divided and coagulated with this wavelength. Although some
authors10,13,16-20,25 have reported successful hemostasis with vessels as large as
3mm to 4mm in diameter, delayed rebleeding may occur. Therefore, the
surgeon would do well to use ligature and hemo-clip methods for hemostasis in
these instances. The etiology of the delayed bleeding is necrosis of
photocoagulated tissue and resultant tissue slough. This condition also occurs
after use of the Nd: YAG laser in a free beam mode on similar tissues.
The contact or fiber-optic method is much more easily mastered than is the
free-beam approach, because the surgeon has direct tactile feedback from the
tissue. The speed of incision and the degree of hemostasis are adequate, and
cleaved bare fibers (ie, urologic fibers), polished GI fibers, sapphire tips (ie,
the delivery device that is marketed as the Contact Laser), sculpted fiber (eg,
Microcontact tip and various other proprietary versions of this technology), as
well as free beam via a micromanipulator or Microslad unit.1,3,5,6,12,16-20,30The
energy of the Nd: YAG laser is intensely absorbed by tissue protein and
chromophores and is highly scattered in tissue. These properties result in deep
penetration of the energy and much greater damage below the tissue than can
be appreciated at the surface. This makes noncontact (ie, GI fiber, free beam)
and bare-fiber applications of the Nd: YAG laser extremely dangerous unless
the surgeon has a thorough understanding of the laser-tissue interaction and
orients the beam in a direction that would reduce the likelihood of damaging
nearby structures. Specialized angled delivery or ADD fibers have been
developed for use in photocoagulation of the prostate. These devices project
the beam at right angles to the long axis of the probe, thereby allowing the
prostatic tissue to be photocoagulated or vaporized. These applications require
knowledge of the anatomy and tissue effects. The surgeon orients the laser
output toward the 10:00 and 12:00 positions and will fire the laser at a preset
energy for a specified length of time based on the volume of tissue to be
photocoagulated.
The Nd: YAG laser is a poor cutting instrument when it is used in a noncontact
mode. The development of sapphire tips and sculpted fiber technologies
facilitate use of this laser in contact with tissue. Free-beam type applications
can result in damage to 1cm to 2cm of liver tissue and the photocoagulation of
vessels up to 4mm in diameter. However, the sapphire tip technology is a
combination of a combined thermal and optical interaction with tissue. Much of
the Nd: YAG energy is absorbed by the sapphire or fiber tip and converted to
heat. The result is to produce optically driven cautery. The temperature of the
tip can be tightly regulated for some applications. These instruments improve
the cutting ability of the laser, but the tissue damage and the extent of
coagulation are reduced dramatically. The histology of these devices is quite
similar to the results produced by electrosurgical devices. Since their main
tissue interaction is thermal cautery, the rate of incision and the degree of
hemostasis can be reduced when these devices are used in the presence of
irrigating fluids or in the aqueous environment of the bladder or joint space.
characteristic wavelength, e.g. a helium-neon laser emits 632.8nm; a ruby laser emits
694.3nm. Laser diodes are nowadays an exciting and compact alternative. Indeed,
holography using laser pointers have also been demonstrated.
High-resolution films are another necessity for holography. With the advent of CCD and
digital image processing, digital holographic interferometry offers tremendous flexibility
and real-time visualization.
Furthermore, image-processing schemes can provide computerised analysis of patterns
for automated defect detection and analysis.
Finally since intricate interferometric patterns have to be recorded, vibration isolation is
also required.
Novel schemes have been proposed, including use of pulsed lasers to record holograms in
factory environments.
Advances and developments in lasers, computers, and recording materials introduce new
techniques such as electronic (or TV) holography, multi-wavelength recording,
thermoplastic medium, timeaveraged holography, dynamic holographic interferometry,
cineholography, and digital holography with each new development. Methods that once
held only academic interest often become practically viable with these developments in
hardware and software.
HNDT is widely applied in aerospace to find impact damage, corrosion, delamination,
debonds, and cracks in high performance composite aircraft parts as well as turbine
blades, solid propellant rocket motor casings, tyres and air foils. But Holography is also
finding new applications in commercial and defense related industries to investigate and
test object ranging from microscopic computer chips and circuits to cultural articles,
paintings and restoration.
Holographic nondestructive testing techniques (HNDT) are used to locate and evaluate
cracks, disbonds, voids, delaminations, inhomogeneity and residual stresses in a test
sample without destruction of the sample. The holographic interferometry techniques are
applied for nondestructive testing of materials.
The HNDT techniques can be used for the testing of laminated structures, turbine blades,
solid propellant rocket motor casings, tyres and air foils. These techniques are also useful
in medical and dental research. In HNDT techniques, the test sample is
interferometrically compared with the sample after it has been stressed (loaded). A flaw
can be detected if by stressing the object it creates an anomalous deformation of the
surface around the flaw. The holographic interferogram will show up the anomalous
deformation by an abrupt change in the shape of the interference pattern.
The object can be stressed by mechanical stressing, pressure or vacuum stressing, thermal
stressing, vibrational stressing and magnetic stressing. The stressing of the object can
create gross deformation and rigid body motion of the object. This will produce fine
interference fringes in the interferogram if the test area is large. In such a situation, the
interference fringes around the flaw will be very fine and it would not be detected by
unaided eye. By using fringe control methods, the effects of gross deformation and rigid
body motion can be compensated.
Field
Applications
Aerospace
Defects
in
honeycomb
plates
Testing
of
construction
materials,
Testing
of
welding
methods
Inspection
of
rocket
bodies
Flow
visualization
in
wind
tunnels
Vibration modes of turbine blades
Automobiles
Testing
of
oil
pressure
sections
Testing
of
welding
methods
Research
in
construction
of
automobile
bodies
Construction of engines
Electrical
industries
and
Civil Engineering
electronic
Analysis
of
Design
of
Research in concrete.
constructions
pipes
Chemical industry
Medicine
Measurement
on
living
bodies
Chest
deformation
due
to
inhalation
Measurement
on
teeth
and
bones
Testing
materials
for
dental
surgery
Testing
of
urinary
track
Measurement on eyes, ears, etc.
Musical instruments