Gregory T. Absten BSC, MA, Stephen N. Joffe BSC, MB, CHB, MD, FRCS (Edinburgh and Glasgow), FCS (South Africa), FACS (Auth.) - Lasers in Medicine - An Introductory Guide-Springer US (1985

Lasers in Medicine
An introductory guide
Lasers in Medicine
An introductory guide
Gregory T. Absten
BSc, MA
Instructor in Laser Surgery at the
University of Cincinnati Medical College,
Scientific Fellow of the American Society
for Laser Medicine and Surgery and
President of The Laser Forum, Inc.
AND
Stephen N. Joffe
BSc, MB, ChB, MD, FRCS (Edinburgh and Glasgow),
FCS (South Africa), FACS
Professor of Surgery and Director
of Gastrointestinal and Endocrine Surgery at the
University of Cincinnati Medical Center
Springer-Science+Business Media, B.V.

1985 G.T. Absten and S.N. Joffe
Originally published by Chapman and Hall in 1985.
This paperback edition is sold subject to the condition that it

shall not, by way of trade or otherwise, be lent, resold, hired
out, or otherwise circulated without the publisher's prior
consent in any form of binding or cover than that in which it
is published and without a similar condition, including this
condition, being imposed on the subsequent purchaser.
All rights reserved. No part of this book may be reprinted or
reproduced or utilized in any form or by any electronic,
mechanical or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage and retrieval system, without permission in writing
from the publisher.
British Library Cataloguing in Publication Data
Absten, G. T.
Lasers in medicine.
1. Lasers in medicine
I. Title II. Joffe, Stephen N.
610'.28 R857.L37
ISBN 978-0-412-26650-8 ISBN 978-1-4899-3156-6 (eBook)
DOI 10.1007/978-1-4899-3156-6
Color plates appear between pages 34 and 35
Acknowledgements VII
Preface IX
Glossary XI
1 Laser physics for the non-specialist 1

Properties of waves 2
Where does laser light come from? 4
Special properties of laser light 7
The laser medium 8
Laser power 9
Summary 12
2 Tissue interaction 14
3 Properties of individual lasers 18

The carbon dioxide (C0 2 ) laser 18
The argon laser 20
The neodymium: yttrium aluminium garnet (Nd : YAG) laser 20
The dye laser 21
The excimer laser 22
4 Laser beam delivery systems 23

Carbon dioxide lasers 23
Argon and dye lasers 24
Neodymium: YAG lasers 24
VI Lasers in Medicine
Excimer lasers 25
Aiming beams 25
5 Overview of clinical applications 26

Advantages of laser surgery 26
Gynecology 27
Otorhinolaryngology 29
Neurosurgery 31
Dermatology and plastic surgery 33
Gastroenterology 35
Urology 36
General surgery 37
Orthopedics 38
Ophthalmology 38
Vascular surgery 42
Photo radiation therapy 43
6 Laser safety 47
General points 47
Carbon dioxide lasers 50
Neodymium: YAG lasers 52
Argon lasers 53
Selected references for further reading 55

Index 59
Acknowledgements
Grateful thanks are due to the following people for their help with
certain sections of the manuscript:
Dr A.L. McKenzie, Principal Physicist, Department of Medical
Physics, Royal South Hants Hospital, Southampton, England.
Dr. J.K. Haywood, Head of Medical Physics Unit, South Cleveland
Hospital, Middlesbrough, England.
Dr. S.G. Bown, Senior Lecturer in Medicine, Clinical Laser Unit,
University College Hospital, London, England.
Parts of this book previously appeared in an article entitled
'Fundamentals of laser surgery', by G.T. Absten, published by the
Paul Rogers Company, Cincinnati, Ohio, USA.
Preface
Lasers were developed out of Einstein's theories, but the first work-
ing device was not produced until 1960. Since then, they have
found applications in many areas of medicine, and hold promise for
many more. This book has been written to provide a basic found-
ation on lasers - what they are, how they work, and what they can
do for the patient. It assumes only a basic scientific background in
the reader, and has many simple and clear diagrams. It should be of
interest to clinicians, surgeons, nurses, safety officers, patients and
interested laymen.
The book consists of six chapters, and following a glossary of
technical terms, begins with a brief discussion of the physics behind
laser action. This section is illustrated with clear diagrams, and
is written in an easy-to-follow style. It describes how laser light
originates, and how it differs fundamentally from ordinary light.
The remainder of the book is concerned with the use of lasers in
medicine. Chapter 2 deals with the various ways in which a laser
beam can interact with tissue, and shows how this depends on the
particular laser being used. The following chapter describes some
properties of those lasers which are most usually used in current
medical practice, but also discusses new and experimental develop-
ments. There are various methods of getting the laser beam to the
target tissue, and these are described in Chapter 4. This is an area of
intense research and development at present, since the usefulness of
the laser is greatly dependent on how accurately it can be delivered
to its intended target.
The largest chapter of the book, Chapter 5, is devoted to a dis-
cussion of clinical applications. At least a dozen specialities now use
x Lasers in Medicine
laser therapy, and there is no doubt that this will increase. Perhaps
two of the most exciting developments are the use of lasers in
cancer treatment, and in vascular surgery to reopen blocked blood
vessels.
The final chapter is concerned with a most important topic, that
of laser safety. Although laser radiation is not associated with the
hazards common to ionizing radiation, the beams can carry enor-
mous energies and it is of the utmost importance that the safety
aspects are clearly understood. This chapter can give only a brief
outline, and appropriate texts should be consulted before lasers are
used. There are inevitable transatlantic differences in practice, some
of which have been referred to in the text.
The book ends with a list of selected references for further
reading, and an index.
Glossary
Note: American spelling has been used throughout this book
Amplitude the maximum height of a wave above the zero line.

Argon a gas used as a laser medium.
CO2 carbon dioxide gas, used as a laser medium.
<;Oherence waves are 'coherent' when they are in phase with each
other both in space and in time.
Collimation waves are 'collimated' when they are all parallel. In
practice, laser light is almost parallel, and there is only a very small
divergence (spread) of the beam over long distances.
Electron a negatively charged particle present in all atoms. Elec-
trons encircle the positively charged nucleus in defined orbits. They
can be energized to move to higher orbits but they quickly fall back
to their original orbits while emitting a photon of light. This is
known as 'spontaneous emission'.
Endoscope an instrument which can be inserted into the body so
that a doctor can look inside. Flexible endoscopes are made out of
fiberoptic tubes and can be bent round corners (for example, into
the intestines), while rigid endoscopes are straight tubes which
cannot be bent. Laser beams can be fired through fiberoptics in
endoscopes to reach internal areas of the body.
Excimer 'excited dimer'. Substances being used as the basis of lasers
emitting ultraviolet light.
Xll Lasers in Medicine
Fiberoptics a system of flexible tubes with internal reflective sur-
faces through which light can pass even though the tubes may be
bent. Many hundreds or even thousands of individual fibers are
needed to transmit an image, but only single fibers are used to
transmit laser light during treatment.
Hemostasis any procedure that stops bleeding.
HpD Hematoporphyrin derivative. A drug which is used in 'photo-
radiation therapy' and which is activated by laser light.
Joule a unit of energy. Laser powers are sometimes expressed in
Joules per second. A power of 1 Joule per second is known as 1
Watt.
Mode a term used to describe how the power of a laser beam is
distributed within the beam (for example, most power at the center,
or most power at the edge).
Mode-locking a process similar to 'Q-switching' except that tlte
pulses produced are even shorter (about 10-12 second) and emerge
in short bursts of about 10 at a time instead of singularly.
Monochromaticity waves are 'monochromatic' when they are all of
the same wavelength.
Nd:YAG neodymium yttrium aluminium garnet, a mineral crystal
substance used as a laser medium.
om nanometers. One nanometer is equal to 10-9 meter, and is the
unit in which wavelengths are often expressed. Visible light ranges
from about 400 nm in the deep blue and violet to about 750 nm in
the deep red.
Phase waves are 'in phase' with each other when all the troughs and
all the peaks coincide with each other. The result is a reinforced
wave with an increased amplitude, which is part of the reason for
the great brightness of a laser beam.
Photon a particle of light. Light has the properties of both particles
and waves.
Population inversion a state in which a substance has been ener-
gized so that more atoms or molecules are in a given excited state
than in a corresponding state of lower energy. This is a necessary
condition for laser action to occur.
Glossary xiii
Power the amount of energy associated with a laser beam. It can be
expressed in Joules (units of energy) or in Watts (units of Joules per
second).
Power density (irradiance) the amount of energy concentrated into
a spot of a particular size. It is expressed in Watts per square
centimeter.
PRT Photoradiation therapy. An experimental treatment for cancer
in which laser light is used to transform a relatively harmless drug
into a cell-killing agent. Initially the drug is injected into the body
and is selectively retained by the cancer. Laser light of the correct
wavelength then modifies the drug which then destroys the cancer
(see HpD).
Pulse a discontinuous burst (of laser light) as opposed to a con-
tinuous beam.
Q-switching 'quality switching'. A process for creating laser beams
with very high powers (millions of Watts) but for very short periods
of time (10-9 second). See also 'Mode-locking'.
Watt a unit of power, equivalent to 1 Joule per second. Laser
powers are often expressed in Watts, or in Watts per square centi-
meter of spot size.
1
Laser physics
for the
non-specialist
The word 'LASER' is an acronym for Light Amplification by the

Stimulated Emission of Radiation. Visible light is only one small
portion of the electromagnetic spectrum (Fig. 1). Although the
exact nature of light is still not understood, it does show properties
both of discrete particles (photons) and waves. For the purposes of
understanding the electromagnetic spectrum and lasers, we will
primarily look at light in terms of its wave characteristics. A wave is
characterized by four quantities: wavelength, amplitude, frequency
and velocity (Fig. 2).
Fig. 1 The electromagnetic spectrum, showing the wide range of wave-

lengths from the very short cosmic rays to the very long radio waves.
2 Lasers in Medicine
Fig. 2 The basic properties of a wave. The diagram shows a wave of

velocity v, wavelength A and amplitude a.
Properties of waves
Wavelength
The wavelength is the distance between two successive crests, or
any other two points on the same parts of the wave. The color of
visible light is determined by its wavelength, which is measured in
fractions of a meter known as 'nanometers' (nm). One nm is equal
to 10-9 meter. Visible light waves have wavelengths in the range
of about 385-760 nm (see Fig. 1). More energy is associated with
shorter wavelengths than with longer wavelengths.
Amplitude
The amplitude is the height of the wave with maximum displace-
ment from the zero position.
Frequency
The frequency is the number of waves passing a given point
per second, and is expressed in cycles/second, or Hertz (Hz). The
shorter the wavelength, the higher is the frequency, since more
waves will be able to pass a given point in a certain time.
Laser physics 3
Velocity
The velocity of waves is a constant in a given medium, and is equal
to about 186300 miles/second or about 300 000 km/second, in a
vacuum.
Some further properties of waves also need to be considered.
Phase
Waves (of the same wavelength) are 'in phase' when all the troughs
and all the peaks, are opposite each other. If two such waves meet,
the result is a reinforced wave of double the amplitude and of
increased brightness. Conversely, if the waves are 'out of phase'
(troughs opposite peaks), then the result is a disappearance of the
wave (Fig. 3).
(i) f---~--+---~
- f - - - - \ - - ---/------'-
(ii) I'----lt-----+-----.Jt..-
!iii) i<----T-------t'------~
~ r-----------
Cancellation
(iv) k---+--~r----r-
Fig. 3 Phase. Waves (i) and (ii) are 'in phase' since all the troughs and all
the peaks are opposite each other. The result is a reinforced wave of double
the amplitude. Waves (iii) and (iv) are 'out of phase' since troughs are
opposite peaks. The result is a complete cancellation.
Coherence and incoherence

Coherent light consists of unbroken waves that are of constant
wavelength and have no phase differences either in time or in space.
An analogy may be drawn between a pure musical note (coherent)
and noise (incoherent).
Where does laser light come from?

Having considered some of the fundamental properties of light
waves, we are now in a position to understand how a laser works,
where its light comes from, and how this light differs fundamentally
from ordinary light.
In an atom, electrons are found to occupy certain discrete energy
levels or orbits. These electrons are not free to have energies be-
tween levels or to take up positions between orbits, so that when
the energy level of an atom is changed, the electrons must move
up or down to the next orbital level. When an atom or molecule
absorbs energy, electrons move into higher orbits, but fall back to
their own less energetic resting orbits almost immediately. From
each retreating electron there escapes a tiny burst of surplus energy
- a photon, the basic unit of light. The energy of the photon is
simply the difference in energy between two levels involved. When
many atoms in a medium undergo spontaneous orbital decay, the
process is known as 'spontaneous emission'. The decays of different
atoms occur at random so that although all electrons moving be-
tween the same two levels result in photons of equal energy and
wavelength, there are random differences in phase and the light is
therefore incoherent (Fig. 4).
A substance has the potential to become a lasing medium if it can
have more atoms or molecules in a high energy state than in its
resting energy state. This is known as a 'population inversion'.
In most lasers, a medium of gas, liquid, or crystal is energized
(pumped) by a suitable source (light, electric discharge, radio fre-
quency). The input of pumping energy raises electrons to higher
energy levels in more atoms, more quickly than spontaneous decay
can return them to their original level. Once there is a preponder-
ance of these excited atoms (i.e. atoms having an electron in a
higher energy level), a further process becomes probable in addition
to the spontaneous emission just described. A photon from an
initial spontaneous decay stimulates each excited atom in its path to
emit a photon entirely identical to itself in frequency, wavelength,
amplitude, phase and direction. This is known as 'stimulated
emission', each photon stimulating another energized electron to
produce a further photon, until a cascade of growing energy sweeps
through the medium (Fig. 5). The waves of light produced in this
way are reflected back and forth many times by mirrors at each end
(j i)
Fig 4 Spontaneous emission. The diagrams show energized electrons in

three atoms decaying back to their original orbits with the spontaneous
production of a photon of light. The wavelength and amplitude of the
emitted light varies according to the magnitude of the energy change, and is
distributed in random directions. The overall light output is incoherent.
PI
Pz
P3
(i) (ij) (iij)
Fig.5 Stimulated emission. The diagrams show energized electrons in three atoms in a substance which has undergone a
population inversion, so that many of the atoms are in an excited state. The first atom (i) undergoes a spontaneous decay
and emits a photon P l ' This interacts with a second energized atom (ii), and stimulates the emission of a second photon
P2 with precisely the same wave characteristics, and in perfect phase with Pl' Each of these identical photons can then
further stimulate energized atoms to produce additional identical photons, as P3 , etc.
Laser physics 7
of the laser chamber. One of these mirrors will either have a hole at
the center, or be only partially reflective, so that the laser beam can
leave the chamber (Fig. 6).
The laser beam is then usually passed through a manipulative
device to be delivered to the site of action (see Chapter 4). Lenses at
the end of the tube can be used to focus the beam.
(; ---11 -=-=-=::::::~-:-:s:::::::::::-=~-
lrenf=s
\
Totally reflective mirror
\ L Focol length ~
Partially reflective mirror
Fig. 6 Schematic diagram of laser chamber. The growing cascade of light
produced by the stimulated emission is reflected back and forth between
the mirrors at either end of the laser chamber until the beam leaves the
chamber through the partially reflective mirror. It can then be focused by a
lens, and pass into a suitable delivery system (see Chapter 4).
Special properties of laser light

Laser light differs from ordinary light in much the same way that
music differs from noise. Three particular properties are respon-
sible for this difference: coherence, collimation and monochro-
maticity.
Coherence
Ordinary light, from a lamp or a fire, is 'incoherent', and consists of
a mixture of wavelengths radiating in all directions. The waves are
being continually interrupted and restarted out of phase. Laser
light, on the other hand, is 'coherent', and consists almost exclus-
ively of one wavelength, with all its waves travelling in the same
direction and in 'phase' with each other. Waves are in 'phase' with
each other when all the troughs and all the peaks are exactly
opposite one another.
Collimation
A collimated beam is parallel and does not diverge, in contrast to
the light from, say, a flashlight (torch) which will spread out as it
travels further and further away (Fig. 7). Laser light is practically
parallel, so that a laser pulse fired at the moon produces a spot half
a mile wide over a distance of 240 000 miles. For practical everyday
purposes, this amount of spread is insignificant. Collimation also
means that there is minimum loss of power along the laser beam,
and is one reason why the laser beam can be so very powerful. A
laser beam can be a billion times brighter than sunlight.
======~IJ==============
Fig. 7 Collimation. The light from a flashlight (torch) is not collimated
and will spread out along the length of the beam. In contrast, the light from
a laser is highly collimated, and has an insignificant spread along the length
of the beam.
Monochromaticity
Monochromaticity indicates that the emitted photons are all of the
same wavelength (color). Light from a hot object such as a glowing
filament or a lamp consists of a mixture of all possible wavelengths
in a broad range. All the energy of laser light is concentrated at a
few discrete wavelengths (usually one) (Table 1).
The laser medium

A laser is usually named after its active medium, that is, the
Laser physics 9
Table 1 Characteristic wavelengths of light from some lasers
Laser Colour Wavelength (nm)
Argon Blue 488.0

Green 514.5
Krypton Green 530.9
Yellow 568.2
Red 647.1
Ruby Red 694.3
Nd:YAG Infrared 1064
Carbon dioxide Infrared 10600
substance which exhibits the lasing action. This can be a liquid, solid,
or gas. Substances which have been used include the following:
Solids: ruby, neodymium: YAG (yttrium aluminium garnet, a rare
earth crystal).
Gases: carbon dioxide, argon, krypton, helium/neon.
Liquids: dyes, which allow laser light of various wavelengths to be
obtained for specific purposes.
Other substances have also been used, but the lasers which have
found widest applications in medicine at the moment are those
based on carbon dioxide, argon, neodymium YAG, krypton and
various dyes. All these substances need to be energized to excite the
electrons into a population inversion state. Solid and liquid lasers
tend to be energized optically, usually by strobe lamps, and gas
lasers tend to be energized electrically by direct current of 200 to
25 000 volts.
Laser power
The power of a laser is measured in Watts Goules/second), but of
greater importance is the amount of power which can be focused
into a spot. The power density or irradiance of a laser is the number
of Watts/cm 2 of spot size, and it is the most important single factor
in the effective application of a laser. The spot size is dependent on
several variables, including the focal length of the lens, the mode,
and the wavelength of the laser.
The focal length of the lens

The lenses are interchangeable, and the smaller the focal length, the
smaller the spot size and the greater the power density. As an
example, CO 2 lasers can achieve spot sizes in the range 0.025 to
0.05 mm and these will surely find applications in the near future.
However, spot sizes in the 0.1-0.8 mm range are more represent-
ative of present CO 2 surgical lasers.
Mode
This refers to the distribution of power over the spot area, and
determines the precision of the operative spot size. The technical
term is the 'Transverse Electromagnetic Mode' (TEM) of the beam.
The most fundamental mode, known as TEMoo , shows a power
distribution over the spot which has most of the power at the
center. A graph of beam intensity against the spot axis is shown in
Fig. 8. This mode can produce the smallest spots. However, if the
laser beam is passed through an optical fiber, the fundamental
mode structure will be lost.
When the power level is not distributed in this fundamental
manner, it is said to be in a multimode distribution and it is possible
for many modes to be present simultaneously in a multimode dis-
tribution. This can occur in many different patterns, but a common
mode of this type is known as TEM o1 , which exhibits a cold region
in the center of the beam (Fig. 9). The surgical effect would be
analogous to cutting with a dull knife, although there would still be
sufficient power density for some other procedures.
The wavelength of the laser

Each laser will have its characteristic wavelength (Table 1), al-
though in some cases it is possible to change this (e.g. dye lasers, see
Chapter 3). Generally, the shorter the wavelength the smaller the
spot which can be produced. Thus, an argon laser can produce a
much smaller spot than a carbon dioxide laser. However, the type
of laser would be chosen for its specific effects on tissues rather
than for its spot size capabilities.
Table 2 shows some relationships between applied power and
Laser physics 11
Beam
intensity ... . .: ... ,"". .-:'. .
, '
Spot Qxis
Fig. 8 Mode TEMoo, with most of the power at the center of the spot.
different spot sizes generated by lenses of various focal lengths.

The effects of the laser beam can also be usefully manipulated by
time, that is, using a pulsed beam rather than a continuous mode.
For example, the biological effects of 10 Watts for 0.2 second may
be similar to those of 20 Watts for 0.1 second. The relationship
between power and time is given by the term 'Joule' Uoule/second
= 1 Watt). The power outputs of lasers which are generally used in
a pulsed mode may be expressed in Joules.
Q-switching and mode-locking

Q-switching is a term used to describe the 'quality' switching of
Beam
intensity
Spot Qxis
Fig. 9 Mode TEM o1 , with a 'cold' region in the centre of the spot.
the optical resonator in the laser. It creates high peak powers in

millions of Watts but delivers it in only a few nanoseconds (10-9
seconds). Mode-locking creates similar end results but through a
different mechanism. The ultrashort pulse is now actually a train of
even shorter pulses. Thus the laser burst may still last several
nanoseconds but may contain ten individual pulses, each lasting
only a few picoseconds (10- 12 seconds).
Summary
1. Laser light is produced from certain energized substances when
their excited electrons are stimulated by photons of light to
produce further identical photons.
2. Laser light differs from ordinary light in three ways - it is
coherent (all the waves are in phase with each other and travel in
Laser physics 13
Table 2 Average power density values at different spot sizes and power
levels
Focal length of lens

(mm) 50 125 250 340 430
Spot diameter (mm) 0.1 0.22 0.45 0.60 0.80
Power Power density
80 Watts 1020000 210000 50000 16000 3000

60 Watts 760000 160000 38000 12 000 2000
40 Watts 510000 105000 25000 8000 1300
20 Watts 250000 53000 13 000 4000 640
5 Watts 64000 13 000 3000 1000 160
The spot diameter is controlled partly by the focal length of the lens used to focus
the beam. The power densiry values given in this table, in units of Watts/cm 2 spot
size, correspond to a rypical CO 2 laser beam with a diameter of about 7 mm before
being focussed down to a spot by the particular lens.
the same direction), it is highly collimated (beams diverge very

little over long distances), and it is monochromatic (all the
waves are, usually, of the same wavelength).
3. Lasers are named after their active medium. The most common
medical lasers are argon, carbon dioxide, neodymium: YAG,
krypton and dye lasers.
4. Laser power is usually measured in Watts, but for operating
purposes the power density (Watts/cm 2 spot size) is more im-
portant. This is brought into a focal spot of which the size is
determined mainly by the beam divergence angle and the focal
length of the lens. The detailed distribution of power within the
spot is determined by laser mode.
2
Tissue
. .
InteractIon
Each type of laser exhibits differing biological effects and is, there-
fore, useful for different applications. The three primary types of
laser used for surgery are not competitive, but are complementary.
The surgical effect of any of these lasers depends on the manner in
which the beam distributes its heat.
The nature of interaction of all laser light with biological tissue
can be described in terms of:
1. Reflection (Fig. 10)
2. Transmission (Fig. 11)
3. Scattering (Fig. 12)
4. Absorption (Fig. 13)
In order for the light to exert an effect upon tissue it has to be
absorbed. If it is reflected from or transmitted through the tissue,
no effect will occur. If the light is scattered, it will be absorbed over
Fig. 10 Reflection. A laser beam is reflected from the surface of a tissue,

and has no effect.
Tissue interaction 15
Fig. 11 Transmission. A laser beam is transmitted through a tissue, and

has no, or only very minimal, effect.
*
Fig.12 Scattering. A laser beam is scattered by a tissue, and absorbed over
a large area. Its effects are diffuse and weakened.
Fig. 13 Absorption. A laser beam is absorbed by a small volume of tissue,

and exerts its effects within this volume.
a larger volume so that its effects will be more diffuse. A thorough

understanding of these four characteristics of light and their effect
on tissues is necessary before the surgeon may most appropriately
select the correct laser system for a particular application.
Regardless of the laser system used for surgical application, laser
light that has been absorbed by tissue may cause the following
effects:
Coagulation
necrOSIS
hemostasis
Vaporization
cutting
debulking (evaporating or sublimating tissue)
Sonic
membrane disruption.
Whether used to cut or sublimate tissue, the CO 2 laser is actually
vaporizing cells. The mechanism of vaporization relies on rapid
heat transfer from the beam to the cell.
The cellular water is heated to its boiling point. The heat causes
complete destruction both of all cellular proteins and of the cell
itself (Fig. 14).
Fig. 14 A cell has absorbed laser light and is heated to boiling point. The
cell is destroyed.
The rapid rise in intracellular temperature and pressure causes an

explosion of the cell, throwing off steam and cellular debris (Fig.
15).
The steam and debris rising from the impact site is seen as the
laser plume. This plume remains in the path of the laser beam and
the particle fragments flash white hot as they are carbonized (Fig.
16). The laser beam is used for its thermal effect on tissue and the
color of the beam determines only how efficiently this thermal
transfer occurs in different tissue.
Since bone and cartilage contain relatively little water, they
evaporate differently from soft tissue. Bone has a tendency to con-
duct heat away from the impact site to adjacent tissue. To protect
these tissues and limit the thermal damage, a superpulse mode is
preferred. This mode appears as a continuous beam, but is actually
Tissue interaction 17
Fig. 15 The cell explodes, throwing off steam and cellular debris.
Fig. 16 The steam and debris rise from the site of impact and are car-
bonized in the laser beam.
turning on and off about a thousand times per second with high
peak powers (up to 500 Watts) on each spike. This allows a 'cooler'
cutting of the bone or cartilage. Bone may also need to be con-
tinuously irrigated to prevent flaming. The peak superpulse power
of the laser systems may be varied by the power control on all units.
However, it must be said that the cutting of bone with lasers is not
entirely satisfactory.
3
Properties of
individual
lasers
The carbon dioxide (C02 ) laser

The CO 2 laser has been the primary instrument for surgery. The
specific absorption of its middle infrared output of 10 600 nm light
by water in biological tissue is independent of tissue color, unlike
the argon laser. Furthermore, its minimization of tissue damage
with virtually no scattering differentiates it from the Nd:YAG laser.
This high degree of absorption in soft tissue with limited lateral
damage is what makes the CO 2 laser a precise surgical instrument
to use for vaporizing ti"sue with a hands-off technique. The hall-
mark of the CO 2 laser therefore is its surgical precision. It performs
in the following order of suitability: cutting, vaporization, coagu-
lation.
Cutting
When used for cutting, the beam is used with the spot in focus on
the tissue (Fig. 17). This allows the surgeon to work with a precise
beam and to have only localized areas of damage. The ability of the
beam to seal vessels and lymphatics as it cuts creates a dry surgical
field which makes many procedures easier and quicker.
The depth of the cut is determined by the power density and the
time of application. Incisions made with the laser heal in much the
* *
Properties of individual lasers 19
l05~r Loser
(i) (i i!
Fig. 17 Focus and defocus. In (i) the laser beam is focused on the tissue in
a small spot. In (ii) the laser beam is focused in front of the tissue, so that a
defocused spot, of larger area and lower power, impinges on the tissue.
same way as a conventional wound, and histologically, the scars are

identical at 20-30 days, although the order of the healing process is
slightly different. In practice, many surgeons see no clinical dif-
ference between the two wounds after about 7-10 days.
Vaporization
The vaporization of tissue can be performed with focused or de-
focused beams (Fig. 17). Although small areas may be vaporized
with a focused spot, larger areas are better handled with a de-
focused spot, although a higher total power may need to be applied
to compensate for the dilution in power density. Vaporization is
useful for debulking tumors or removing tissues one cell layer at a
time from delicate structures.
Coagulation
Vessels up to about 0.5 mm in diameter can be coagulated instantly
in the cutting (focused) mode, but larger vessels need to be treated
with a defocused spot. The necessary precision to weld arteries for
microsurgery and anastomoses of small vessels and nerves can be
achieved.
The argon laser

The first significant medical use of lasers was the use of argon lasers
in the treatment of diabetic retinopathy in 1965. Since that time,
the extensive experience with argon lasers has resulted in the argon
laser photocoagulator becoming the treatment of choice for this
retinal disorder. Dermatology is the other major application of
argon laser therapy.
Argon lasers produce a visible blue-green light (488 and 515 nm)
which is easily transmitted through dear aqueous tissues. Certain
tissue pigments such as melanin and hemoglobin will absorb argon
laser light very effectively. The interaction of low levels of this
blue-green light with highly pigmented tissues results in sufficient
localized heat generation to be a highly effective coagulator. This
principle of selective absorption is used to photocoagulate pig-
mented lesions such as portwine stains (see cover illustration and
Color Plate II).
The argon laser beam passes through the overlying skin without
significant absorption and reaches the pigmented layer of the lesion
to effect protein coagulation. After treatment, gradual blanching of
the laser coagulated area occurs over several months.
When the argon beam is focused to a very small spot (or its
power increased sufficiently), its power density is high enough to
result in vaporization of the target tissue.
The neodymium: yttrium aluminum garnet (Nd: YAG) laser

The laser that is best suited for primary coagulative properties is the
Nd:YAG. Although not nearly as precise as the COl> it will
coagulate vessels up to about 4 mm in diameter, and larger with
manipulation. The argon laser has also been used to coagulate
tissue, but its effects are primarily on the hemoglobin and not on
the vessel wall (as in gastrointestinal bleeders).
Nd: YAG is a solid crystal which is stimulated to emit laser light
in the near infrared region of 1064 nm. These units produce power
levels of 15 to 100 Watts, transmitted through a fiberoptic system.
The beam is transmitted through dear liquids, which allows its
use in the eye or other water filled cavities such as the bladder. Its
absorption by tissue is not as color dependent as is the argon laser,
so that the Nd: YAG beam is absorbed by almost any tissue that is
Properties of individual lasers 21
not clear, the darker the tissue, the greater being the absorption.
The differentiating physical characteristic of this laser is its high
degree of scattering upon impact with tissue. The zone of damage
thus produced by an impact is not limited as is the CO2 laser. A
homogeneous zone of thermal coagulation and necrosis may extend
4 mm from the impact site and precise control is not possible.
These characteristics make the Nd: YAG laser an excellent tool
for tissue coagulation, but very crude to use for precise control of
cutting and avoidance of tissue damage. Use of contact delivery
systems with sapphires, diamonds or quartz will allow both cutting
and coagulating with precision and avoidance of excessive tissue
destruction.
The dye laser

Ever since the invention of the laser, it has been the dream of
physicists to produce a wavelength-controllable device. The dye
laser is a solution to this problem. In this instrument, a suitable
organic dye, such as is used to color fabrics or other material, is
irradiated with a strong light source, usually the beam of an argon
laser. The dye fluoresces over a broad spectrum of colors, but a
specific wavelength can be made to lase by inserting into the cavity
a tuning element such as birefringent crystal. By turning this crystal
through various angles, only one narrow range of wavelengths can
leak through the crystal to support laser oscillation, so that the
operator can virtually dial up laser light of the required color.
The dye laser is used where the selective absorption character-
istics of the tissue confer a therapeutic advantage upon certain
wavelengths of radiation. For example, hemoglobin has a local
absorption peak at 577 nm, so that vascular lesions, such as port-
wine stains, can absorb the laser radiation, while, in the non-vascu-
larized tissue of the skin, the beam diffuses away relatively harmlessly.
The dye laser is also used in photo radiation therapy as we shall
see in Chapter 5, where a wavelength is selected which corresponds
to a particular absorption peak of a drug such as HpD (hematopor-
phyrin derivative). The optimum wavelength in this case is 630 nm,
but, as other drugs are developed, it is hoped that the absorption
peaks will shift into the near infrared, where radiation penetration
will be deeper. Dye laser technology will easily accommodate such
a move out of the visible spectrum.
The excimer laser

The term 'excimer' is derived from 'excited dimer' and refers to a
molecule which is comparatively stable when excited, but which,
when it loses energy by emitting a photon, splits up into its com-
ponent parts. Conditions are therefore ideal for lasing, since this
removal of molecules in the resting energy state results in a popu-
lation inversion, which we described earlier. Characteristically,
excimer lasers emit in the ultraviolet spectrum, and deliver energies
of about 0.1 Joule in a pulse of duration around 20 nanoseconds
(10-9 second). These lasers are likely to find applications in
several areas of medicine in the near future.
4
Laser beam
delivery systems
Much of the development work in laser systems is in the area of

delivery devices, i.e. how the laser light is delivered to the desired
target. The delivery mechanisms that are used for the various lasers
in different applications can be summarized as follows.
CO2 lasers
A fiberoptic system for the CO 2 laser is not currently available, but
several developments using infrared fibers are taking place. At
present, an articulated arm is required to deliver the beam to the
various treatment sites. The arm is a hollow tube that has several
joints, or articulations, to allow it to be somewhat maneuverable
and flexible. The articulations contain reflective infrared mirrors
that bounce the beam out of the end of the arm regardless of its
position. Care must be taken with the mirrors in these arms to
avoid slight misalignments which would prevent the beam from
coming straight out the end of the arm.
Various devices are attached to the end of the arm. To use the
laser with an operating microscope a micromanipulator is used.
The beam enters the device, passes through lenses and zoom lenses
and onto a mirror which deflects it into the operative field. A
'joystick' is used by the surgeon to wiggle the mirror and manipu-
late the beam to the treatment site.
Handpieces allow the freehand use of the laser in the fashion of a
laser scalpel. A lens is contained in the handpiece to focus the beam.
This is exactly analogous to using a magnifying glass and the sun to
cause a burn.
C02 laser bronchoscopes and laparoscopes allow use of the laser
down the trachea or into the abdomen respectively. Development is
occurring for other types of laser endoscopes.
Computer-laser scanners are used like an electronic microman-
ipulator for the microscope. This allows the surgeon to program in
any irregular area, shape or line and automatically and uniformly
laser that pattern.
Argon and dye lasers

These are delivered primarily through fiberoptics which, in the case
of argon lasers, may terminate into hand pieces or micromanipu-
lators.
The ophthalmic use of the laser is almost exclusively through the
slit lamp. A micromanipulator device is then used to deliver the
beam through a contact lens into the eye. An internal shutter in
argon laser micro manipulators protects the surgeon when the laser
is fired. Handpieces are attached to the ends of fiberoptics for use in
other procedures such as dermatological work.
Optical fibers may also be delivered through laparoscopes and
flexible endoscopes.
Nd: YAG lasers

These are delivered through the same types of fiberoptic device as
the argon laser, and, with the exception of the Q-switched lasers,
are all delivered in this way.
Nd: YAG laser fibers consisting of either glass or quartz are fre-
quently used inside a flexible catheter that allows coaxial flow of
CO 2 gas to cool the tip and to keep off debris. When used in a
liquid environment such as the bladder, the laser fiber is used alone.
The Q-switched pulse (see page 11) cannot be passed into a fiber
because the power density is so high that it would shatter the fibers.
Handpieces and micromanipulators are available. A special
quartz scalpel, called an Auth blade, is used with the Nd:YAG
laser. The fiber is plugged into this transmissive blade. As the blade
cuts mechanically the laser energy is transmitted through its edge,
causing homogeneous coagulation. These have problems and are
Laser beam delivery systems 25
still in developmental stages, and newer artificial ceramic materials
are becoming available for transmission of laser energy, for
example, the laser probe and microendoprobe allow contact photo-
coagulation, tumor vaporization and cutting.
A combination COz/Nd: YAG micromanipulator allows use of
both beams through the same micromanipulator.
Excimer lasers
These lasers are still in the experimental stage for medical appli-
cations, but the beam can be delivered through a fiberoptic system.
Aiming beams
Since some laser beams are invisible to the eye, such as the COz and
Nd: YAG, for example, which emit light in the infrared region of
the spectrum, it is necessary for the equipment to incorporate a low
power laser which emits visible light. A red helium/neon laser
would normally be used. This allows the operator to adjust spot
size and operating distance before the operating beam is switched
on. Lasers emitting visible light, such as argon lasers, would be
adjusted by using a low power setting.
5
Overview of
clincial
applications
Advantages of laser surgery

The potential advantages of laser surgery are:
1. No-touch technique.
2. Dry surgical field.
3. Reduced blood loss.
4. Reduced edema.
5. Limited fibrosis and stenosis.
6. No interference with monitoring equipment.
7. Potential elimination of residual neoplastic cells, reduction in
recurrences and spread.
8. Precision.
9. Elimination of instruments in field.
10. Reduced postoperative pain (selectively).
11. Sterilization of the operative site.
12. In contrast to ionizing radiation such as X-rays, there is no
evidence that medical lasers can cause genetic damage and
cancer.
The CO 2 laser is currently the most commonly used laser in an
operating room setting. It has widespread applications that make
use of its cutting and vaporizing abilities. Its secondary coagulating
ability is also beneficial in most cases.
The argon laser is the most prevalent overall, though not in an
Overview of clinical applications 27
operating room setting. Its primary use has been in ophthalmology
as a retinal photocoagulator. Its use in dermatology for colored
skin lesions has been secondary. Endoscopic applications have been
rather uncommon.
The Nd: YAG laser is still classified for restricted use as an
investigational device by the Food and Drug Administration (FDA)
in the USA, but was recently approved for use in gastrointestinal
bleeding and cancer, whereas the CO2 and argon lasers are
approved for most procedures by the FDA. The Nd: YAG laser will
nevertheless see major use in the next few years in many specialities.
Its use in ophthalmology as a pulsed Q-switched or mode-locked
laser (see page 38) has already seen explosive growth.
An overview of the major specialities that have current laser use
is as follows.
Gynecology
This speciality probably has the largest potential volume of uses for
the CO2 laser. It is used in endometriosis to vaporize endo-
metriomas and dissection of adhesions. It provides a no-touch
method for freeing stuck tubes and ovaries and totally eliminates
abdominal blood loss. When used through a laser laparoscope,
mild to moderate endometriosis may be treated at the time of
laparoscopy.
Other abdominal cysts and tumors may be excised or vaporized
with similar benefits. Its ability to vaporize tissue with minimal
damage even when associated with extensive and dense tissue ad-
hesions has proven of great value for patients with complications of
pelvic inflammatory disease.
The CO 2 laser is used in microtuboplasty to cut the tube prior to
reanastomosis. The benefits of this technique are more contro-
versial but it does eliminate bleeding. Some experimental work is
being done to weld the tube together with the laser. A laser incision
also provides a precise, atraumatic means of opening the end of a
closed tube in a bloodless fashion. The power density of the laser
may be lowered and used to 'paint' a ring around the end of the
fallopian tube. This shrinks tissue and causes a flowering of the
tube for a neosalpingostomy. One of the biggest advantages of the
laser for microtuboplasty is that it can reduce operative time by
one-third to one-half.
The laser has been used to cut and cauterize the fallopian tubes in
sterilization procedures but this is of questionable medical and
economic benefit.
Uterine myomas may be removed by vaporization or excision. A
micro laser myomectomy provides improved hemostasis, precision,
and the ability to remove fibroids from previously inaccessible
areas as well as removing the need for a hysterectomy.
The CO 2 laser has also been used in cornual reimplantation.
Radical procedures, such as radical vulvectomies, and excision of
large vascular tumors may be performed with the laser for im-
proved hemostasis. The benefits are substantial but these appli-
cations require high powers of 60 Watts or more from a CO 2 laser.
One of the most common uses of the CO2 laser is the treatment
of cervical intraepithelial neoplasia (CIN) by using the laser
through the colposcope. Laser vaporization of the cervix provides
advantages over cauterization, knife conization or cryotherapy. It
leaves the cervix in a more viable condition, with no stenosis and
minimal scarring. It also eliminates the heavy discharge associated
with cryosurgery and is significantly more precise. This allows
treatment of the CIN while maintaining fertility for the patient.
Laser colposcopy is also an outpatient or office procedure in con-
trast to a knife conization which is considered a major surgical
procedure. Treatment of CIN with a laser achieves substantially
equivalent cure rates to that of hysterectomy, a major surgical
procedure that involves six weeks of convalescence.
Similar advantages are gained in the laser treatment of vaginal
intraepithelial neoplasia (VIN).
Genital warts such as condyloma accuminata may be treated to
advantage with the CO 2 laser. It is used not only to vaporize
lesions through the colposcope but also to flash sterilize the skin
between lesions. This kills the virus in its dormant stage and can
reduce the frequency and extent of outbreaks.
Herpes lesions have also been treated successfully with the CO 2
laser, although this application is controversial. Good 'cure' rates
might be achieved if the lesions are treated within 48 hours of the
initial outbreak. After the virus has migrated back to the presacral
ganglion it is impossible to stop recurrences.
Laser treatment, in both herpes and condyloma, provides less
discomfort and decreases the extent of outbreaks for the patient.
Both procedures can be carried out on an office or outpatient basis.
The Nd: YAG laser has been used to advantage in the treatment
of menorrhagia, uncontrolled bleeding from the uterus. The only
alternative is a complete hysterectomy. Laser treatment can be
performed on an outpatient basis. Protocols for this procedure
usually require patient consent to undergo sterilization at the time
of treatment if it has not been performed previously. A laser fiber is
passed into the uterus via a hysteroscope. A saline solution is used
to flush and distend the uterus while the laser is used to coagulate
the endometrium.
Nd: YAG and argon lasers have both been used investigationally
in laser laparoscopy for the treatment of endometriosis. The color
seeking properties of the argon, and to a lesser degree the Nd: YAG
laser selectively photocoagulate the pinkish red implants of endo-
metriosis. The CO 2 laser is now the accepted one for this pro-
cedure.
Otorhinolaryngology
This is one of the best uses for the CO 2 laser because of the no-
touch technique, absence of postoperative swelling or stenosis, dry
operative field, and greatly reduced postoperative pain.
Recurrent respiratory papillomatosis occurs throughout the an-
terior nasal cavity, subglottis and mainstem bronchi. These rela-
tively inaccessible locations make the CO 2 laser ideal for removal
of all visible papillomas by vaporization. Complete hemostasis
allows all visible lesions to be destroyed under constant visual
control.
Removal is accompanied by minimal damage to underlying
tissue. The airway can be maintained so that tracheostomy is
usually unnecessary. Recurrences are encountered in every case but
a large percentage of the patients go into a year or more of re-
mission after two or more excisions with the laser.
CO 2 laser destruction is the best method of patient management
at this time. It reduces the need for tracheostomy and provides the
best chance of spontaneous remission.
Application of the CO 2 laser to laryngeal diseases requiring
microlaryngoscopy has provided a degree of precision otherwise
impossible. The precision cutting and excellent healing is an even
greater advantage than the hemostasis. Postoperative pain is mini-
mal and most procedures may be done on a same day surgery basis.
The need for tracheostomy is reduced. Most cases require general
anesthesia and appropriate safety precautions must be taken be-
cause of the endotracheal tube.
Surgical applications of the CO 2 laser in microlaryngoscopy
include vocal cord nodules, polyps, vocal cord hyperkeratosis,
granulomas, arytenoidectomy, Reincke's edema, cysts, webs and
laryngeal stenosis.
All airway lesions are more critical in the child than the adult
because of the small size of the airway. The treatment of congenital
and acquired lesions in pediatric surgery has proven the CO 2 laser
to be a remarkably effective tool. It is ideal for infants. Its prop-
erties of hemostasis, enhanced visibility, lack of postoperative
edema and scarring all contribute to its successful application in
pediatrics.
The CO 2 laser is used to treat choanal atresia and intranasal
telangiectasia, although the latter is also beginning to be treated by
the frequency doubled Nd: YAG laser.
Laser tonsillectomy is most appropriately carried out in patients
with coagulopathies such as hemophilia. It is also helpful in
patients with palatal incompetence because of the lack of scarring.
However, the anterior pillar must be sacrificed in laser tonsillec-
tomy.
The cost-effectiveness of the laser has been proven because most
children may be discharged the morning after surgery. Few recur-
rences of lesions are observed.
The CO 2 laser is used to vaporize or excise lesions of the oral
cavity and tongue such as leukoplakia and other benign lesions. It is
also used for tongue releases.
Nasal and intranasal applications include choanal atresia, rhino-
phyma, polyposis, synechia, papilloma, telangiectasia and granu-
loma.
Tumors of the trachea and bronchi may be treated with the C02
or Nd:YAG laser as a palliative approach to airway maintenance.
The CO2 laser is precise, hemostatic, provides immediate results
and shows rapid healing. A rigid CO 2 laser bronchoscope is
presently required to deliver the beam, but there is speculation that
a CO2 laser optical fiber may soon become available. The endo-
scopic coupler is the instrumentation that allows simultaneous
viewing and laser beam delivery down the tube of the broncho-
scope. Control of the beam is critical to avoid penetration of the
trachea and underlying great vessels. Extraluminal tumors that
compress the airway cannot be treated with either the CO2 or
Nd:YAG lasers via the airway.
The Nd: YAG laser is also used to treat airway obstruction that
differs markedly in its tissue effects. The CO 2 laser vaporizes
tumors immediately. This causes tissue removal and the effect is
limited to what the surgeon sees. The Nd: YAG laser photocoagu-
lates tissue. This cooks tumors throughout, which causes delayed
tissue sloughing and necessitates aggressive postoperative broncho-
scopy to maintain a dear airway. This is also true of photoradiation
therapy in the airway. The Nd:YAG laser has the added advantage
of being able to be delivered via fibers through flexible broncho-
scopes though rigid instruments are frequently preferred. Unlike the
CO2 laser, the Nd:YAG laser usually removes tumors in several
treatments over a few days.
Argon lasers have been used successfully in otology for stapedot-
omy because of their small spot sizes. The laser punches a series of
holes in the footplate of the stapes that allow an area to be tapped
out with minimal mechanical trauma to middle and inner ear struc-
tures. The prosthetic piston will be placed in this hole. This use has
come under question because of the tranmission of the argon light
into the cochlea which has been shown to cause nerve damage in
cats. The footplate may also need to be painted red, with some
blood, to effect absorption of the argon wavelength. The CO2 laser
may see better application here when the spot sizes of commercial
lasers are reduced to submillimeter dimensions.
The argon laser has also been used for tympanoplasty, myrin-
gotomy, treatment of fixed malleus syndrome, and removal of
polyps, nodules and benign growths. None of these argon laser
procedures are well established or generally accepted.
Neurosurgery
The primary laser instrument in neurosurgery has been the CO2
laser and it is considered a standard of practice for this speciality.
The Nd: YAG laser will see growth in the coming years. Use of the
argon laser in neurosurgery is minimal and should be viewed as the
exception.
The CO2 laser provides surgical precision that has been imposs-
ible before. It allows the surgeon to remove a tumor from
previously inoperable areas because of its no-touch technique and
precise tissue destruction. In debulking techniques of large bloody
tumors it also offers an atraumatic, no-touch instrument, reason-
able hemostasis, and enhanced visibility.
With any cranial tumor, the craniotomy may be made smaller
when performing laser surgery. A tumor the size of an orange may
be removed through a quarter size opening by coring the center of
the mass. Excellent hemostasis allows the surgeon better anatom-
ical visualization which provides more control. The no-touch tech-
nique is one of the biggest advantages. The less pulling, tugging and
manipulation of brain tissue that is done the better the patient's
postoperative recovery. Many laser patients are alert, up and
around the day after surgery.
CO 2 lasers are useful for vaporizing meningiomas which have
tough dural attachments that are otherwise difficult to extract.
Their use for acoustic neuroma has become a standard due to their
precision and the preservation of the acoustic nerve. These lasers
are similarly ideal devices for tumors around the optic chiasm and
nerve to preserve function. For work around such delicate struc-
tures, the laser should be used in the pulsed or superpulsed mode
to avoid heat damage. Precise surgery may also be performed in
shaving tumor remnants from arteries one cell layer at a time, with
no damage to the underlying vessel.
In transphenoidal hypophysectomy, the laser offers an atrau-
matic, no-touch technique that eliminates instruments in the
narrow canal of the speculum. Many pituitary tumors are soft and
suckable and do not require use of the laser. Recurrent adenomas,
particularly those that have been treated with radiation therapy, are
hard and rubbery, and very difficult to remove. The laser provides
an ideal instrument for this purpose.
Spinal tumors also benefit from the no-touch technique of a CO 2
laser, particularly intramedullary tumors. Manipulation of the cord
can be kept to a minimum, resulting in less damage to both cord
and nerve roots. The laser has been used in fenestration of syrin-
gomyelia which offers a permanent fluid pathway because of the
sealing effects of the laser. Intractable pain has been treated with
laser lesions of the dorsal root entry zone (DREZ), a more precise
and controlled method than other techniques.
The CO 2 laser has been used to dissect away back muscles for
spinal surgery and laser diskectomy. Both are controversial uses,
although they certainly exhibit no undue risks or complications.
The argument in back surgery for taking down muscle is that the
patient undergoes no muscular spasm, as is frequently encountered
with electrocautery. This results in markedly decreased back pain
postoperatively. The laser is used to remove fractured disks by a
vaporization process while compressing the vertebrae in a con-
tinuous fashion to 'feed' the cartilage into the laser beam. In
conventional disk surgery, the cartilage is pulled from the inter-
vertebral space in different pieces. The laser process may avoid
breaking off pieces of the cartilage and make it easier to remove.
The Nd: YAG laser is an investigational device for neurosurgery.
It is being examined for the coagulation of vascular tumors that
may then be vaporized away with the CO 2 laser. It is also being
used to shrivel up arteriovenous malformations. This one single use
alone would make its application in neurosurgery successful. In the
near future, laser neurosurgery will be performed with combined
C02 INd: YAG lasers. This may be achieved by combining their
outputs in a micromanipulator, or employing a combined CO 2 /
Nd:YAG laser.
The Nd: YAG laser is a fulgarative, coagulating instrument.
While it is excellent for highly vascular tumors, it would be un-
suitable for precise vaporization of tumors adjacent to delicate
structures. The underlying tissue would necrose and die.
Because of the wavelength, it is possible to achieve micron spot
sizes with the argon laser. This provides a very high degree of
precision. However, its power output is inadequate for debulking
procedures and its color selectivity is a general disadvantage.
Its use in the shrinking of arteriovenous malformations may be an
advantage because of the color selectivity. The question to be
answered is whether it works better than the Nd:YAG laser in this
application.
Dermatology and plastic surgery

Dermatologists divide their use of CO2 and argon lasers fairly
equally. The color selectivity of the argon and the precision and
hemostasis of the CO2 are used to their best advantages. The
Nd:YAG laser is finding some applications in dermatology.
Investigationally, a 577 nm dye laser has been used to achieve
precise, selective vascular changes beyond the abilities of the argon
laser. This 577 nm green-yellow wavelength has been shown to
produce very selective microvascular damage with little or no
damage to other structures such as the epidermis.
The argon laser, because of color selectivity, is used to photo-
coagulate pigmented cutaneous lesions such as portwine stains (see
Color Plate II), capillary/cavernous hemangiomas, telangiectasia,
strawberry marks, Campbell DeMorgan senile angiomas and acne
rosacea. It is used to remove tattoos, treat pyrogenic granuloma,
sebaceous nevi and the Peutz-Jegher syndrome. Investigational uses
include keloid scars, subcutaneous varicose veins, road skid burns,
moles, warts and nevi of the Osler-Weber-Rendu syndrome.
Portwine hemangiomas involve an increase in the number of
vessels in the subepidermal zone. The argon laser is transmitted
through the epidermis as if through a window pane and coagulates
vessels in the upper one millimeter of the dermis. This treatment is
performed as a series of applications over several months to pro-
mote healing and re-epithelialization. The darker, deeper purple
colored lesions respond the best to argon laser. Pinker hemangio-
mas that blanch under pressure are reported to respond better to
CO2 laser therapy. A test area is treated first to see if fading will
occur.
Tattoos have been difficult to remove with any form of treatment.
The laser provides a good, but not perfect, modality of treatment.
The argon laser selectively obliterates the dye in a tattoo. Pro-
fessionally done tattoos are easier to remove than amateur ones
because the dye is deposited at a more uniform depth. The argon
light will penetrate the epidermis, leaving no surface scar. Hyper-
trophic scarring is a problem and although a tattoo may be erased,
a scar may be left in its image. Recently tattoos have been success-
fully removed with the Nd:YAG laser, and this method appears to
have overcome some of the previous problems.
The advantage of the CO 2 laser in tattoo removal is that vapor-
ization is unselective to color and edges of the tattoo may be
blanched out into surrounding skin. Although a superficial scar is
left, it is not in the image of the original tattoo.
All types of laser produce a sterile field. This is excellent in
guarding against sepsis. Since the laser seals lymphatics it is of
potential benefit in treatment of cutaneous malignancies.
The CO2 laser has been used in breast surgery to reduce blood
loss. Skin incisions made with the CO 2 laser produce scars that are
Plate I Patient undergoing
photoradiation therapy with a
dye laser for a tumor in his right
cheek. Four fibers are
delivering laser light which can
be seen shining through the skin.
Plate lJ(a) Patient with a Plate lJ(b) The same patient

portwine stain (birthmark) on after treatment with an argon
her cheek. laser, showing the greatly
improved cosmetic appearance
which can be achieved.
(Photographs by courtesy of Mr J,A.S. Carruth, Royal South Hants Hospital,

Southampton).
Plate IIl(a) Tumor of the PlateIII(b) Thetumorhas
esophagus. The tumor is the been removed by treatment
bright red mass in center, and with aNd: YAG laser thereby
has almost completely blocked clearing the blockage.
the esophagus leaving only a
very small opening (the black
area to the leftofthe tumor).
(Photographs by courtesy of Dr S.G. Bown, University College Hospital,

London, and first published in The Proceedings of the Royal Institution of
Great Britain, 55, 177-97, 1983).
Plate IV(a) Proliferative Plate IV(b) Complete

diabetic retinopathy in an regression of the hemorrhage
insulin-dependent diabetic and new vessels has been
patient of 20 years duration. achieved by pan retinal
Several areas of hemorrhage photocoagulation with an
with optic disc argon laser.
neovascularization (new
vessels) can be seen.
{'Photographs by courtesy of Mr R.J. Cooling, Moorfields Eye Hospital,

London).
cosmetically similar to that of a cold knife. If an electrocautery
incision is the alternative, the laser scar will be cosmetically more
acceptable. A recently described ceramic probe for the Nd: YAG
laser is able to perform bloodless mastectomies.
Gastroenterology
Both argon and Nd:YAG lasers have been used endoscopically in
the treatment of gastrointestinal disease. The argon laser received
most attention in the early days, and its limited penetration
was thought to render it safer. However, this limited penetration
reduced its effectiveness for hemostasis, and once experimental
studies had established that the Nd: YAG laser was quite safe when
used at appropriate power and pulse duration settings, the deeper
penetration of the latter was found to be considerably more effect-
ive. The CO 2 laser cannot be used through flexible endoscopes,
since present optical fibers cannot transmit its infrared light.
The most important current application of lasers in gastroenter-
ology is the endoscopic treatment of hemorrhage from peptic
ulcers. The ulcers most at risk from recurrent bleeding are those in
which an artery can be identified in the ulcer crater at emergency
endoscopy. Laser treatment of these considerably reduces the need
for emergency surgery. In cases which are actively bleeding at the
time of endoscopy, a jet of CO 2 gas delivered coaxially through a
thin catheter containing the laser fiber can be used to clear blood
from the field of view. It also removes debris which may otherwise
lead to destruction of the fiber tip.
Angiomata of the gastrointestinal tract also respond well, but
lasers are of no value in the treatment of more diffuse lesions, such
as hemorrhagic esophagitis, gastritis, or duodenitis. Despite anec-
dotal reports to the contrary, there is no convincing evidence that
lasers have any value in the treatment of hemorrhage from eso-
phageal varices.
A new application of lasers in gastroenterology is the recanal-
ization of advanced obstructive tumors (see Color Plate III). This is
entirely palliative, and only appropriate for the ablation of large
nodules of tumors occluding the lumen of the gut. It can however
provide effective relief of symptoms, particularly for the dysphagia
associated with advanced esophageal and other tumors unsuit-
able for other forms of treatment and also for other areas of the
gastrointestinal tract. Some small benign polyps can be destroyed in
their entirety.
Urology
Urologists use the Nd: YAG laser for endoscopic applications and
the CO 2 laser for treatment of superficial lesions or open surgery.
The argon laser is used endoscopically but to a much lesser extent
than the Nd:YAG laser.
The argon laser has been used in the treatment of condyloma and
ablation of external genital lesions. The CO2 laser is much more
common and useful in these applications. The argon laser is used
in transurethral surgery to treat small bladder tumors and open
urethral strictures, in the same way as the Nd: YAG laser is used.
The argon laser is more useful for long urethral strictures than
the Nd: YAG. The CO 2 laser, because of its precision, is better than
both of these, but, because of its limitation in beam delivery, is
practical for only the distal segment of the urethra. CO 2 laser
cystoscopes are in development.
As in gynecologic applications, the CO2 laser can vaporize and
sterilize condylomata and external lesions. Its use in the treatment
of herpes is still controversial. Partial nephrectomy is performed
with the C02 and Nd: YAG lasers as cutting beams to significantly
reduce blood loss and retain maximum function in the remaining
portion of the kidney. One of the developmental uses of low power
density CO 2 laser irradiation is to accomplish tissue welding in a
variety of fields. These include the reanastomosis of the vas de-
ferens using CO 2 laser welding.
The Nd: YAG laser is the primary instrument for bladder work.
Although it has been employed in most of the previously mentioned
applications, its primary use has been the transurethral treatment of
bladder tumors. The laser fiber is passed through a cystoscope with
a fiber deflector on its tip. It is passed into the bladder while
inflating with water. It causes a homogeneous band of necrosis in
the mucous membrane of the bladder down to the serosa without
seriously compromising the mechanical stability of the bladder wall
or causing perforations.
There are many advantages in the use of laser therapy in urology.
Since anesthesia is not required for endoscopic use, sedation may be
administered and the procedure carried out on an out-patient basis.
The ablation of the tumor is contactless, bloodless, and interrupts
lymphatic drainage. Transurethral catheter drainage of the bladder
is eliminated and the procedure itself does not take very long to
perform.
Tumors up to two centimeters or so may be totally eliminated by
the laser while larger ones may be removed via a cutting loop and
the tumor bed then laser coagulated. Second sessions for the laser
coagulation are necessary with these larger tumors.
The Nd: YAG laser has been used clinically to treat bladder
tumors, penile carcinoma, urethral strictures and prostate cancer.
Investigative work is being carried out on the disintegration of renal
caculi via Nd: YAG laser fibers passed through the ureter, as well as
for bladder and ureteral stones.
General surgery
Many surgical procedures performed by general surgeons utilize all
three types of laser and extend into the speciality areas we have
discussed. Otherwise the use of a laser in this field depends on the
surgeon and patient population. General surgical procedures are
performed almost entirely with the CO 2 laser, primarily to control
blood loss in radical procedures or for tumor surgery.
The CO2 laser is used to exploit its hemostatic and lymphostatic
effects. This also decreases the likelihood of seeding malignant cells.
It may be used satisfactorily for skin incisions but offers no advan-
tages except for the two mentioned. If these effects are not needed
the laser should not be used.
High powers and broad spots create excellent hemostasis to
allow use in the excision of metastases of the liver, partial pan-
createctomy and other vascular organ work. As with neurosurgery,
the higher the power ability of the CO 2 laser, the better. Over 60
Watts is preferred. Other specialiaties may adequately work with
40 Watts and under. This 60 Watts plus of power is not used at the
high end all of the time but is necessary as a reserve when heavy
bleeding is encountered.
The CO 2 laser sterilizes as it vaporizes so is a good tool to use for
debridement of external ulcers. It may also be used in burn de-
bridement for both sterile technique and hemostasis. The Nd: YAG
laser is presently being assessed for pancreatic and liver surgery.
Orthopedics
Orthopedic surgeons have very limited uses for the laser at present
but much developmental work is being carried out. The CO 2 laser
is used to vaporize methyl methacrylate when replacing artificial
joints. The beam should be 'hot' enough to vaporize the glue but
not hot enough to cause underlying bone damage. Constant irri-
gation to avoid flaming, and high smoke evacuation, are necessary.
Developmental work is being performed to deliver the CO 2 laser
beam through an arthrosope. This beam can 'melt' and shape
cartilage as if it were ice. The Nd:YAG laser is currently being
investigated in arthroscopic and open work.
An exciting prospect for reconstructive orthopedic microsurgery
is the development of laser welding of tissue. Reconstructive micro-
vascular surgery may be shortened considerably and nerve function
restored to a much greater level. More is discussed on this under
developments in vascular surgery (page 42).
Ophthalmology
Ophthalmologists were the pioneers of lasers in surgery. Lasers
have been used for precise photocoagulation of the retina since the
mid-1960s. (See Color Plates IV a and b.) The argon laser is the
primary surgical instrument for ophthalmic use. Krypton lasers,
with their yellow and red wavelengths, are also used by retinal
specialists. These colors allow more control in the macular area. The
use of Q-switched and mode locked Nd: YAG lasers is now seeing
explosive growth in the USA and the FDA has temporarily put a stop
on the number of lasers that manufacturers are allowed to supply.
CO 2 lasers have seen some investigative work in this field but have
minimal, if any, current practical applications.
Besides surgical uses, lasers are also used in the eye diagnostic-
ally. Lasers can c;lifferentiate between faulty optical or neural
systems during an initial screening test.
To test neural function, the image analysis ability of the retina
may be determined by laser interferometry. The bandlike inter-
ference patterns produced on the retina are independent of the
dioptics of the eye. Patients with a visual disturbance can also have
a chart projected directly onto the retina by laser. This provides
predictive ability when considering operations such as cataract
removal, vitrectomy, corneal transplant, etc.
Changes in the shape of the eye may be easily documented and
tracked by using interferometric techniques. This can be used to
assess increased cup/disk ratio indicative of glaucoma. There are
some problems with these techniques and other methods may prove
supenor.
As a vaporizing instrument, the CO2 laser has been used to
excise scleral and retinal tumors. It has also been used to create
bloodless scleral flaps. It may be used in the interior of the eye only
in open procedures since the wavelength cannot be transmitted into
the eye as can argon and Nd: YAG lasers. The CO 2 laser has been
used through ophthalmic probes containing infrared windows at
the distal tip. These are passed into the eye and the laser is used
to cut vitreal strands, vaporize small tumors and weld detached
retinas. The window of the probe must touch the target since the
CO 2 wavelength will not be transmitted through fluid. Investi-
gative work is being carried out to perform scleral welding. In
conjunction with computer scanners and small spot sizes, work is
being conducted to precisely and automatically make corneal in-
cisions and create corneal buttons.
Argon is the common ophthalmic laser. Photocoagulation with
this laser is the most widely accepted and longest established use of
lasers in medicine. In diabetic retinopathy patients suffer from a
proliferation of blood vessels on the retina. These vessels are fragile,
begin to bleed, and may even cause tearing of the retina because of
retraction of the vitreous. Pan retinal photocoagulation (PRP) with
the argon laser beam may slow or stop progression of the disease
but cannot restore function already lost, in ordinary circumstances.
Numerous lesions are placed in the peripheral retina to stop pro-
liferation of the vessels. The pigment seeking quality of the beam
allows efficient absorption by hemoglobin and red pigment. The
lesion is in the pigment epithelium and the photorecepter area. A
green only option on the argon allows deeper penetration of the
beam with less damage to surface retinal vessels.
The exact mechanisms of the induced changes in the retinal
microcirculation are not clear. The general principle is that oxygen
tension levels in the retina are changed so that new vessels do not
have to constantly proliferate. This also provides better oxygen-
ation of the remaining photoreceptors which can actually improve
vision if they were hypoxic enough initially.
Krypton lasers produce yellow and red light (see Table 1). For
work in the macular area this light will spare the macula lutea and
be absorbed in the pigment epithelium. The yellow xanthophyll
pigment is contained in the macula and will not absorb yellow light
at all and red light very poorly. Red light is used in subretinal
treatment of neovascular membranes. It spares surface retinal
vessels and the macula, and destroys the pathologic subretinal
blood supply.
Some types of senile macular degeneration (SMD) are very re-
sponsive to laser treatment.
Lasers have been used in several different ways to treat glau-
coma. In closed angle glaucoma, iridotomy may be performed with
the laser to open a channel for fluid flow between the anterior and
posterior chambers of the eye. Originally a pulsed ruby laser was
used to develop this approach but argon lasers are now the stand-
ard. Eye color obviously affects how well this technique works
mechanically. For instance, a blue iris does not absorb the light as
readily as a dark one. Laser iridotomy has a problem with long
term patency of the fenestration but is a simple procedure that
can be easily and quickly reperformed. With the coupling of Q-
switched Nd: YAG to argon lasers the procedure may be more
effective mechanically without regard to iris color. The argon laser
may be used to photocoagulate the iris and the Nd: YAG laser to
make a hole in it. This is not current practice. The surgical altern-
ative to laser iridotomy is iridectomy. This is an invasive, surgical
procedure requiring operating room time and facilities. Medication
may still be required to help control pressures even with the laser
procedures.
Argon laser trabeculoplasty is used to treat open angle glaucoma.
The laser is used to create multiple lesions around the periphery of
the iris into the trabecular meshwork. It is used to thermally shrink
the mesh, creating larger spaces for fluid to flow through. The
contact lens that is used for treatment has an angled mirror around
the edges to bounce the argon light into the trabecular meshwork.
Patients can usually maintain acceptable intraocular pressures with
minimal medication.
Pulsed Nd: YAG lasers, of the Q-switched or mode locked
variety, produce nonlinear effects at a small focal point. Tremen-
dous peak powers in the millions of Watts delivered in an ultrashort
burst cause a tiny concussive effect at the 50 micron spot. One can
see the sparklike effect and listen to the crack as it literally snaps
apart a membrane. The intense focus of the laser pulse creates an
ionization effect on the target and works by sonic, or acoustical
means - a little sonic boom. This is a cold cutting effect sometimes
called disruption. The ionized plasma absorbs the laser radiation
and so forms a shield which protects the retina from the beam.
The main use of these lasers currently is in cataract surgery, and
they are also being investigated in vitreoretinal, corneal and glau-
coma surgery. Procedures may be performed in the surgeon's office
or outpatient facility and take only a few minutes. This sharply
contrasts with the open surgery that would otherwise be required.
The laser is not used for the primary cataract surgery to remove
the lens itself. That is still performed by conventional techniques
and the membrane of the posterior capsule left intact. This provides
mechanical support for the intraocular lens implant and decreases
the likelihood of some postoperative complications. Unfortunately
this membrane becomes clouded in a large percentage of these
patients. Without the laser another operation is required, with its
associated risks, to open the membrane. Instead, the laser is used to
perform a posterior caps ulotomy by snapping an opening in the
membrane. This requires only a few laser shots. Targeting is im-
portant since a slightly anterior focus can create pits in the surface
of the implant.
When used for posterior capsulotomy the laser may be safely
used as a stand alone unit on a slit lamp. For other procedures that
may involve blood vessels, such as cutting a vitreous strand, an
argon laser should be available. If the cold cut of the Nd: YAG laser
creates a small hemorrhage in the eye it is important to be able
to photo coagulate it immediately. This argon laser is the logical
choice. Some ophthalmic Nd: YAG lasers have what is termed a
'free running' or thermal mode. This allows continuous wave, low
power operation for purposes of coagulation. The power is insuf-
ficient to use this mode for other surgical procedures requiring a
continuous wave Nd:YAG laser.
Investigators are pursuing other ophthalmic applications of the
Q-switched capability. Internal sutures may be removed by a laser
cut. Vitreous opacifications may be disrupted if they are avascular,
and vitreous strands may be severed. Peripheral iridotomy can
be made in conjunction with the argon laser, and other surgical
fistulas can be created. Adhesions may be dissected, and if an
implant must be removed the laser can cut the loops.
Melanomas in the eye are being successfully treated with photo-
radiation therapy. This avoids enucleation of the eye and retains
vision in the healthy portion of the retina.
Vascular surgery
There are no current established clinical applications for surgical
lasers in vascular surgery. The potentials are so significant, how-
ever, that the investigative work deserves mention. Major laser
vascular procedures can be broadly classified as either laser
anastomosis or laser angioplasty.
Welding of small vessels is now being undertaken in experi-
mental laboratories and has been used clinically in a few cases. Low
power density COz laser energy is pulsed on the seam to create an
immediate and permanent laser weld. Power densities in the broad
range of 5 to 80 Watts/cm z are used. The exact mechanisms have
not been delineated. A proposed theory is that tissue fluids are
heated to 55-58 DC, which causes distortion of the tertiary bonds in
protein. This causes the protein strands to wrap around each other
and lock. The process is taken almost to the point of tissue co-
agulation. Some of the welding appears to be due to coagulation.
This would imply tissue damage without necrosis. If tissue growth
occurs faster in the healing process than the coagulated zone
necrosis, this could explain the 'weld'.
One investigator is using a coagulated protein sheath to rejoin
nerves. An argon laser is used to coagulate heparinized blood
placed around the sheath. This serves as a sealed protein sheath to
stabilize the ends until regeneration occurs. COz lasers are also
used to directly weld the nerve.
Blocked blood vessels are being opened experimentally by pass-
ing laser fibers through endoscopes or catheters into the vessel. The
laser then fires and opens a hole through the blockage in the vessel.
Several cases have been performed clinically in France during
coronary artery bypass surgery. Both argon and Nd:YAG lasers are
being used. COz lasers may prove effective when fibers become
available. Experimentation is being undertaken with ultraviolet
wavelengths from excimer lasers and this may offer good results.
Development in this field is reminiscent of the film Fantastic
Voyage, in which a laser was used from inside a man's brain to
open a blockage.
Photoradiation therapy
Photoradiation therapy (PRT) involves the use of a photosensitizing
agent to treat malignant tumors (see Fig. 18). In this instance the
hematoporphyrin derivative (HpD) is the photosensitizing drug
used and is activated by the 630 nm red light produced from an
argon pumped dye laser. This laser is used because of its ability to
produce intense levels of monochromatic light. Other light sources
may be used, such as filtered slide projectors, but these are not as
effective.
Fluorescence of some tumors upon illumination with a Wood's
lamp was noted as long ago as 1924. This principle was then used
as a localization technique by the systematic injection of hemato-
porphyrin, beginning in 1942. In 1961 Lipson reported the use of
(a) (b) (e)
* (d) (e)
Fig. 18 Diagrammatic and simplified illustration of photoradiation

therapy: (a) patient with tumor in chest; (b) hematoporphyrin derivative
(HpD) injected intravenously and taken up by the whole body; (c) HpD
selectively retained by the tumor after about three days; (d) HpD photo-
activated by 630 nm laser light; (e) toxic products produced in (d) destroy
tumor, leaving normal tissues undamaged.
hematoporphyrin derivative (HpD), which was shown to have a
superior tumor localization to that of hematoporphyrin. The use of
HpD then transitioned from diagnostic to therapeutic use when
Diamond reported in 1972 the destruction of experimental tumors
by white light exposure after HpD injection.
The group at Roswell Park Memorial Institute has been studying
response of a wide variety of malignant tumors in man to PRT and
HpD. Dougherty reported complete or partial response of 111 out
of 113 cutaneous and subcutaneous malignant lesions in 1978.
From the results obtained by various investigators so far, it is
clear that PRT with HpD is a valid treatment. The HpD is initially
distributed through all the cells but begins to clear out of normal
tissue after several hours. An initial dose of 2.5-5 mglkg of body
weight is injected as a single intravenous bolus. A maximum dif-
ference in concentration levels between tumor cells and normal
tissue occurs in about three days. Normal tissue does retain some
HpD and this is complicated by the fact that different tissues retain
various concentrations. Skin, liver, kidney and spleen hold onto the
HpD longer than other tissues. Bronchial mucosa retains one of the
lowest concentrations so endobronchial lung tumors are among the
easiest to treat.
The goal is to calculate dosages of drug and light so that acti-
vation of the higher concentrations of HpD occurs while remaining
below the necessary threshold to activate HpD in normal tissue.
This is controlled by dosage and timing of the HpD administration,
color, intensity and distribution of the light, and its method of
delivery. The technique is illustrated diagramatically in Figure 18,
and a patient undergoing treatment is shown in Color Plate I.
Until recently, most patients treated with this form of therapy
have previously exhausted the full gamut of conventional therapies
of surgery, radiation, immunotherapy and chemotherapy. Results
have been encouraging enough for a few investigators to utilize
PRT for some early lesions as the primary form of treatment.
The absorption spectrum of HpD has peaks which may be util-
ized to activate the drug. Blue light of about 405 nm is absorbed
most strongly but a lesser absorption peak also exists in the range
of red light at 630 nm. The red light, however, will penetrate tissue
much better than the blue. Red light will scatter up to approxim-
ately 2 em through skin. The amount of light energy delivered to an
area is measured with a radiometer and time is calculated to deliver
doses of between 25 Joules/cm2 and 150 Joules/cm 2 , depending
upon the tumor.
The drug is activated by the light through singlet oxygen pro-
duction. The cell's membrane may be involved in this photo toxic
effect although HpD is distributed throughout the cell as follows:
cytoplasm 60-70%, mitochondria 13-15%, microsomes 7-13%,
and nuclei 4-9%. Recent evidence suggests that the abnormal
tumor circulation and the tumor lymphatics are also implicated in
the cytotoxic process. Gross tissue effects proceed from moderate
or severe edema to complete necrosis of the tumor exhibited by a
black eschar.
This form of therapy is investigational and has not proven to be
curative for malignancies. It will in all probability be used as an
adjuvant therapy and, for some neoplasms, the primary form of
treatment. Its mechanism is independent of previous or subsequent
chemotherapy and/or X-ray therapy.
There are side effects and complications to this form of treat-
ment. Patients may undergo an increased photosensitivity of the
skin to sunlight for about one month after treatment. Staying out of
the sunlight for a month, however, seems a small price to pay for
the possible benefits.
Full thickness necrosis of tumors of the intestinal tract may lead
to fistula formation. Endobronchial treatments may cause pro-
duction of gelatinous secretions and edema of the airway causing
obstructions. Post treatment hemorrhage is possible following
necrosis of tumor and any involved vessels.
Current technology with lasers and fiberoptics makes it feasible
to deliver high intensity light to almost any site in the body, at
sugery, or through endoscopes and needles. PRT may then be used
to treat malignancies that are not responsive to current modalities.
It may be used to treat nonresectable lesions of the pancreas or
brain. Combination therapies with systemic treatment, ionizing
radiation or hyperthermia are possible since PRT is a local treat-
ment and requires localized hyperthermia.
Investigators are making progress on a purified form of the HpD
using its active ingredient as the photsensitizer. This should make
tumors responsive while limiting to an even greater degree its effect
on normal tissue. Other light sources are also being examined. A
cheap, intense source of monochromatic light with limited heat
production would be a major breakthrough. Gold vapor lasers are
being considered that would theoretically give twice the output at
half the initial cost of argon pumped dye systems. It may even be
possible to pump certain crystals with aNd: YAG laser to obtain an
inexpensive source of intense red light.
6
Laser safety
General points
Hazards associated with the use of surgical laser systems require
appropriate safety precautions and policies. It is beyond the scope
of this section to delineate fully the potential biological and ocular
hazards associated with the full spectrum of laser wavelengths. A
suggested reading list is included at the end of the book for those
wishing more comprehensive information.
We will discuss practical safety considerations as they relate to
the surgical or outpatient environment with CO 2 , argon and
Nd: YAG laser systems. There is a great deal of overlap in safety
practices with these three laser systems, with eye protection being
the biggest differentiating factor.
Laser manufacturers are required under the ANSI-Z-136.1
standard in the USA and the BSI standard BS 4803 in the UK to
provide certain design and engineering safety measures in their
equipment. In other countries equivalent conditions must be ob-
served. These include requirements such as key interlocks and
visual or audible warning systems. These measures are already in
place on commercially available lasers.
While there is broad international agreement over safety levels
and practices involving the use of laser radiation, differences exist
between national administrative mechanisms for accrediting doc-
tors and surgeons for laser work.
In the UK, a local body such as the Radiological Safety Com-
mittee is concerned with laser safety policy, but does not take upon
itself responsibility for accrediting laser users. However, the British
Medical Laser Association (BMLA) has been asked to consider
accreditation in individual cases.
In general, it is considered good practice for a Laser Safety
Committee to be established with representatives from each of the
interested specialities, anesthesiology, operating room director,
and administration. Such a Committee can adopt credentialling
standards for surgeons and formal laser safety policies and pro-
cedures.
Training is the single most important factor in the safe use of any
laser. This applies to the laser surgeons, laser specialists and oper-
ating room personnel.
Customary credentialling standards for surgeons include a twelve
to sixteen hour hands-on training experience with the laser. This
may be broken down into three primary components:
1. Fundamentals of laser surgery (theory).
2. Hands-on animal work.
3. Clinical orientation to laser procedures.
Additionally, some Committees require an in-house preceptor for
the surgeon's first one or two cases. Once a surgeon is trained on
one type of laser it does not mean that they should be automatically
credentialled on the other types. They should not require another
full twelve or sixteen hour course but they should have some type of
supervised, hands-on orientation to the new unit(s).
One or two nurses or surgical technicians need to be selected to
receive thorough training in the operation and safety practices of
the laser. Normally, a laser manufacturer's instruction on how to
turn on and fire the laser is inadequate. Twelve to sixteen hours of
instruction in the theory of the primary surgical lasers, nursing
considerations, safety practices and operation of the specific unit
are recommended.
The operation of the laser unit will be left to no more than a few
laser nurses. The operating room circulator should not be used for
this function when he or she is required to leave the room periodic-
ally. This position is more important for CO2 and Nd: YAG lasers
in a surgical setting where the surgeon does not have direct control
of the laser. An outpatient ophthalmic argon laser, for instance,
may be adequately operated by the surgeon if desired.
The function of the laser nurse or laser protection supervisor in
surgery is to ensure that hospital personnel follow recommended
Laser safety 49
safety practices, wear protective eyewear and operate the laser unit
correctly. The laser must always be placed in the standby position
when the surgeon is not using it. If applicable the laser nurse will
also check that the surgeon is on the approved lists for laser priv-
ileges from the Safety Committee. The nurse or protection super-
visor will precheck the laser to assure its proper operation and
beam alignment, and maintain a laser log for all cases. This log does
not become part of the patient's chart.
Operating room personnel need to be aware of safety procedures
relevant to the type of laser being used, but need not be instructed
in detail in its operation.
Warning signs should be placed on all entries to the surgical suite
before the laser is operated. These signs should state the type and
class of laser used and its maximum power output (these signs are
available from the suppliers).
The keys to the laser should be controlled by the laser nurse and
the head nurse of surgery or outpatient unit. These keys should not
be left in the lasers and no one else should have a laser key. This will
control unauthorized access to the units.
Electrical hazards are common to all three types of system. Under
no circumstances should anyone other than authorized service per-
sonnel open the protective covers of the laser units. The argon and
Nd: YAG lasers have particularly high amperage power supplies
and have been responsible for deaths of laser technicians. Liquids
must not be placed on the laser units because of the danger of
spillage and internal short circuiting of the laser.
The radiation hazards of the laser, posted on the warning signs,
have nothing to do with X-rays or any type of diffuse ionizing
radiation around the equipment. The laser beam itself is the radi-
ation referred to and in this context radiation simply means light.
Apart from the question of eye safety, this beam is only a hazard
upon direct impact. Women in any stage of pregnancy may work
around conventional laser units with no adverse effects. An X-ray
laser does exist but as it requires a small nuclear explosion for
energizing, it is of main interest to the military. Although it may not
be practical for quite some time, it should produce interesting off-
shoots for medicine, such as holographic X-rays, and holographic
diffraction studies.
CO 2 lasers
This is the most common laser used in an operating room. Its
wavelength is outside the retinal hazard region because diffuse
reflections are not transmitted through the fluid of the eye. It does
present the potential for corneal or scleral burns when the beam is
sufficiently focused on the eye. The effect is both immediate and
painful. For this reason safety glasses are required. Either glass or
plastic will absorb a diffuse CO 2 laser beam. Common practice in a
surgery setting in the USA is to wear one's own corrective glasses,
although for additional protection safety glasses with side shields
are available. In the UK, ordinary corrective glasses would be con-
sidered inadequate, as they do not conform to the requirements of
the Protection of Eye Regulations 1974. Contact lenses of any type
are inadequate.
The patient's eyes must also be protected if they are in a position
that exposes them to the laser. Wet sponges taped in place over the
eyes if the patient is asleep, or safety glasses if they are awake, will
provide protection.
The surgeon working through an operating microscope is pro-
tected by its glass lens systems and needs no other protection.
Sponges and drapes are also kept wet for fire protection. These
materials are soaked only in the immediate surgical field. Dry
sponges will flame immediately upon impact with the CO 2 laser. A
container of water or saline should always be kept available to
douse a flame if one should start. The normal pan of irrigating fluid
will serve this purpose.
Most paper drapes available in the USA are fire resistant and may
be safely used with the laser. When in doubt, test any material
for flammability beforehand. Cloth drapes should be moistened
around the perimeter of the surgical field.
Do not use this laser in the presence of flammable preparative
solutions or drying agents. This is most important with the CO 2
laser but would apply to both argon and Nd: YAG if lasing is being
performed through these solutions. These alcoholic solutions may
be used, but the area should be dry before lasing.
During oral, nasopharyngeal or laryngotracheal surgery, special
precautions must be taken to avoid an airway explosion and blow-
torch type fire. A polyvinylchloride endotracheal tube must never be
used. Alternatives include the Norton flexible metal tubes, red
Laser safety 51
rubber or laser resistant tubes.
When Norton metal tubes are used, no distal cuff is placed, so
that no flammable materials rest in the airway. This provides
complete protection against fire but is an open ventilation system
to which the anesthesiologist must be agreeable.
Red rubber tubes are wrapped in an overlapping spiral fashion
from the cuff up, with reflective foil tape. After intubation the
inflated cuff and length of the wrapped tube are padded well with
moist cottonoids. For further protection the cuff may be inflated
with saline and methylene blue dye. If the cuff were inadvertently
ruptured by the laser the blue saline would soak through to the
cottonoids and the surgeon would be aware of the deflation.
Manufacturers' recommendations should be followed in using
laser resistant type tubes. These do not afford total protection
against a fire and additional precautions are recommended.
None of the tubes should be taped in place during these pro-
cedures so that they may be pulled quickly if a fire starts. The tube
must be marked with a distance marker for correct placement and
checked frequently.
The laser must never be used in the presence of explosive
anesthetics for obvious reasons.
Methane gas is also flammable. Whenever lasing is being carried
out around the rectum, it must be packed or covered with a moist
towel or sponge. Failure to do so could cause serious internal injury
to the patient and/or facial burns to the surgeon.
During micro laryngoscopies or when otherwise exposing the
patient's face to the laser beam, the entire face should be draped
with wet towels. The only exposed area should be the oral cavity.
Care should also be taken to protect the teeth with bite blocks or
soaked towels. A CO 2 laser impact on tooth enamel will create a
small, permanent, black hole in the tooth.
Laser units should always be placed in the standby position by
the laser nurse when they are not being used.
Special instrumentation is available that has been blackened or
anodized to reduce the danger of the CO 2 beam reflecting off the
instrument and striking other objects. These instruments are an
important safety precaution in ear, nose and throat laser surgery.
They are of benefit, but not critical, in other types of CO 2 laser
surgery. It is the diffuse matt finish of the instrument that causes the
reflected beam to scatter diffusely, not the black color. When
regular instruments and retractors are being used, they may be
covered with moistened sponges for protection.
Teflon coated instruments must never be used in the lasing area.
These produce extremely toxic fumes when lased.
Pyrex or quartz rods are used routinely in gynecologic laser
surgery as fine dissecting rods that act as backstops for the CO2
laser beam. Glass rods should not be used because they will shatter,
leaving tiny glass fragments in the field.
Nd:YAG lasers
The surgical, continuous wave, Nd: YAG laser is used primarily
through an endoscope. In addition to the electrical hazards already
discussed, safety precautions center around eye safety and care of
the endoscopes. Although the type of fire hazard associated with
CO 2 lasers is not present, precautions must still be taken.
It is critically important that all personnel be wearing the appro-
priate safety glasses before they enter the room when the laser
is being fired. This applies to those nonendoscopic uses that are
considered open applications. The patient's eyes should also be
protected. Regular glass or plastic glasses will not suffice. A special
safety glass of the correct optical density for the Nd: YAG laser
must be used.
The Nd: YAG laser presents the most serious visual hazards of
the three types of laser, and it may be prudent to consider the
installation of door interlocks that will automatically stop lasing
action while the door is open.
Windows must be covered with light tight shades or panels so
that observers are protected from unintentional viewing. Glass
windows will not stop the beam.
When the laser is used in closed applications, such as through an
endoscope while it is in the patient, room personnel need not wear
protective eyewear. For the surgeon's protection a near-infrared
filter is placed over the eyepiece of the scope. If a teaching head is
attached it will also require the filter. These may either be per-
manently glued to the eyepiece or attached as a removable cap. If
the cap is used it is imperative that the surgeon assure that each cap
is in place before the procedure begins.
When filters are being used on the endoscopes and personnel are
not wearing eye protection, a hazard exists if the laser fiber or
Laser safety 53
entire endoscope is pulled out of the patient and fired into the open
room. In this situation it is critically important that the laser be
disabled before and immediately after the closed procedure so that
it cannot be fired in the open configuration.
Operating microscopes do not provide eye protection for the
surgeon with this laser and a filter must be incorporated into the
micromanipulator device. Room personnel must all wear protective
eyewear.
It is possible to cause extensive damage to flexible endoscopes by
firing the laser with the fiber not fully extended from the channel.
This is possible because one can still see the red guide light on the
target while the fiber is withdrawn into the 'scope'. As a matter of
policy, it is important for the surgeon to have had the tip of the
fiber in his field of view before firing the laser.
Because of the high degree of back-scatter with the Nd: YAG
lasers, and the black color of the plastic tip of most endoscopes, it is
possible to melt this tip and even cause a small fire if high concen-
trations of oxygen are being used. The further away from this tip
the fiber may be placed the better. Additionally, some endoscope
manufacturers can attach a white replacement tip on some 'scopes
that will reduce its absorption of the laser.
A fire hazard also exists when lasing an airway tumor while
ventilating with high concentrations of oxygen. Fat in a tumor may
flare from the laser and, in the presence of oxygen, cause a small
flash. This is of very short duration and does not pose the types of
problem posed by an endotracheal tube fire with the CO 2 laser.
The beams of Q-switched or mode-locked Nd: YAG lasers used
for ophthalmology are generally focused at a large angle of con-
vergence, so that, beyond the focus, the beam irradiance drops
quickly. However, reflections from the surface of the cornea or the
contact lens can still be hazardous up to a meter away, depending
upon the curvature of the reflecting surface. It is therefore im-
portant that attendant staff wear safety glasses whenever this type
of laser is being used.
Argon lasers
Argon lasers are used through either a handpiece or microscope, or
through a slit lamp for ophthalmology. In some ophthalmic equip-
ment they may be used in conjunction with a krypton laser.
These lasers present almost no fire hazard, and eye protection is
the central safety requirement. Special glasses for the argon laser
wavelength must be worn by all personnel in the room. Light-tight
shades should cover windows that might allow inadvertent view
and the patient should wear eye protection for other than oph-
thalmic procedures.
The argon laser attachments for microscopes and slit lamps have
an internal shutter that protects the surgeon from the flash of light.
Although its use in ophthalmology through the slit lamp and con-
tact lens is almost a closed procedure, it is still important for the
assistant to wear eye protection. Specular reflections at certain
angles from the contact lens held by the ophthalmologist and from
the slit lamp might be picked up in certain situations.
Filters or protective ~yewear should be used in endoscopic pro-
cedures with the argon laser. The same definitions of closed and
open procedures, and precautions, apply to Nd: YAG lasers.
Selected references
for further reading
(a) General
Bennett, C. (ed.) (1982), Technos-Lasers, Vol. 1 Humana, Clifton, N.J.
Boraiko, A. (1984), The Laser. Nat. Giwgr., 165 (3),335-63.
Caulfield, J. (1984), The wonder of holography. Nat. Geogr., 165 (3),
365-77.
Einstein, A. (1954), Ideas and Opinions, Bonanza Books, New York.
Gore, R. (1983), The once and future universe. Nat. Geogr., 163 (6),
704-49.
Naisbitt, J. (1984), From an industrial society to an information society; in
Megatrends, Warner Books, New York.
(b) Laser physics

Fisher, J. (1983), The power density of a surgical laser beam: its meaning
and measurement. Lasers in Surgery and Medicine, 2 (4), 301-15.
Fuller, T.A. (1980), The physics of surgical lasers. Lasers in Surgery and
Medicine, 1, (1),5-14.
Hallmark, C. (1979), Quantum mechanics; in Lasers, the Light Fantastic,
Tab Books, Blue Ridge Summit, Pa.
Luxon, J. (1983), Applied Laser Optics, Laser Institute of America, Toledo.
Maiman, T. (1960), Stimulated optical radiation in ruby. Nature, 187, 493.
Polyani, T. (1982), Physics of surgery with the CO 2 laser; in Microscopic
and Endoscopic Surgery with the CO 2 laser (eds A. Andrews and T.
Polyani), John Wright, Boston.
Tilley, D. and Thumm, W. (1974), Physics, Cummings, Philippines.
(c) Medical applications of lasers

Abela, G.S., Norman, S., Cohen, D., Feldman, R.L., Geiser, E.A. and Couti,
C.R. (1982), Effects of carbon dioxide, Nd:YAG and argon laser
radiation on coronary atheromatous plaques. Am. J. Cardiol., 50,
1199-205.
Anderson, R., Jaenicke, K. and Parrish, J. (1983), Mechanisms of selective
vascular changes caused by dye lasers. Lasers in Surgery and Medicine,
3 (3),211-15.
Andrews, A. and Polyani, T. (eds) (1982), Microscopic and endoscopic
surgery with the CO 2 laser, John Wright, Boston.
Apfelberg, D., Kosek, J., Maser, M.R. and Lash, H. (1979), Histology of
port wine stains following argon laser therapy. Br. J. Plast. Surg., 32,
232-7.
Auler, H. and Banzer, G. (1942), Untersuchungen uber die rolle der por-
phine bei geschwulstkranken menschen une tieren. 2. Krebsforsch, 53,
64-8.
Ben-Bassat, M, Ben-Bassat, M. and Kaplan, I. (1976), A study of the ultra-
structural features of the cut margin of skin and mucous membrane
specimens excised by CO 2 laser. J. Surg. Res., 21, 77-84.
Bischko, J. (1980), Use of the laser beam in acupuncture. Int. J. Acu-
puncture and Electro-Therapeutic Research,S, 29-40 ..
Bown, S. (1983), The Internal Surgeons without a knife - the Laser and the
Endoscope. Proc. Roy. Inst. Great Britain, 55, 177-97.
Carruth, J.A.S. (1983), Lasers in Medicine. The Practitioner, 227, 1565-
74.
Dew, D., and Lo, H. C02 laser microsurgical repair of soft tissue: pre-
liminary observations. Presented at the 3rd annual meeting of the
American Society for Laser Medicine and Surgery, January 1983, New
Orleans, Louisianna.
Diamond, I. et al. (1972), Photodynamic therapy of malignant tumors.
Lancet, 2, 1175-7.
Dougherty, T.]., Kaufman,J.., Goldfarb, A., Weishaupt, K.R., Boyle, D.G.
and Mittleman, A. (1978), Photoradiation therapy for the treatment of
malignant tumors. Cancer Res., 38, 2628-35.
Dougherty, T.J., Weishaupt, K.R. and Boyle, D.G. (1981), Photoradiation
therapy of malignant tumors; in Principles and Practice of Oncology
(eds V. DeVita et a/.), Lippincott, Pa.
L'Esperance, F. Jr (1968), An ophthalmic argon laser photocoagulator
system: design, construction, and laboratory investigation. Trans. Am.
Ophthalmol. Soc., 66, 827-994.
Goldrath, M., Fuller, T. and Segel, S. (1981), Laser photovaporization
of endometrium for the treatment of menorrhagia. Am. J. Obstet.
Gynecol., 140, 14.
Selected references for further reading 57
Gomer, e.J. (1978), Evaluation of in vivo tissue localization and in-vitro
photosensitization reactions of hematoporphyrin derivative. PhD
thesis, State University of New York at Buffalo.
Green, D. and Cohen, M. (1971), Laser interferometry in the evaluation of
potential macular function in the presence of opacities in the ocular
media. Trans. Am. A cad. Ophthalmol. Otolaryngol., 75, 629-737.
Hall, R.R. (1971), The healing of tissues incised by a C02 laser. Br.] Surg.,
58,222.
Jain, K. (1980), Sutureless microvascular anastomosis using a Nd:YAG
laser.]. Microsurgery, 1,436-9.
Joffe, S.N., Muckerheide, M.e. and Goldman, L. (1983), Nd: YAG Lasers in
Medicine and Surgery. Elsevier, New York.
Kroetiinger, M. (1980), On the use of the laser in acupuncture. Int. J.
Acupuncture and Electro-Therapeutic Research, 5, 297-311.
Lipson, R.L. (1960), The photodynamic and flourescent properties of a
particular hematoporphyrin derivative and its use in tumor detection.
Master's thesis, University of Minnesota.
Lipson, R.L., Blades, E.]. and Olsen, A.M. (1961), The use of a derivative
of hematoporphyrin in tumor detection. J. Nat. Cancer Inst., 26, 1-8.
Marchesini, R. Thermal eHects of the Nd:YAG laser irradiation: thermo-
graphic results. Presented at the 3rd annual meeting of the American
Society for Laser Medicine and Surgery, January 1983, New Orleans,
Louisianna.
McCaughan, J.S., Guy, J.T., Howley, P., Hicks, W., Inglis, W., Laufman,
L., May, E., Nims, T.A. and Sherman, R. (1983), Hematoporphyrin
derivative and photo-radiation therapy of malignant tumors. Lasers in
Surgery and Medicine, 3 (3), 199-209.
Moritz, A. (1947), Studies of thermal energy: III. The pathology and
pathogenesis of cutaneous burns: an experimental study. Am. ].
Pathol., 23, 915-37.
Policard, A. (1924), Etudes sur les aspects oHerts par des tumeurs experi-
mentales examinees a la lumiere de Woods. Compt. Rend. Soc. BioI.,
91, 1423-4.
Verschueren, R. (1982), Tissue reaction to the CO 2 laser in general. In
Microscopic and Endoscopic Surgery with the CO 2 laser (eds A.
Andrews and T. Polyani), John Wright, Boston.
(d) Laser safety

Laser Safety in Surgery and Medicine, Lase Inc., Suite 222, 8150 Corporate
Park Drive, Cincinnati, Ohio 45242.
Biological Bases for and Other Aspects of a Performance Standard for
Laser Products, H.E.W. Publication (FDA) 80-8092, US Department
of Health, Education and Welfare, Public Health Service, Food and
Drug Administration, Bureau of Radiolotical Health, Rockville, Mary-
land 20857.
Safety with Lasers and Other Optical Sources, Sliney and Wolbarsht,
Plenum Press, 1980, ISBN 0--306--40434-6.
Index
Abdominal cysts, 27 Artificial joints, 38

Absorption, 15 Atomic processes, 4
Acne, 34 Auth blade, 24
Advantages, laser surgery, 26, 36
Aiming, laser beam, 25 Backscatter, 15,53
Airway explosion risk, 50 Back surgery, 32-3
Airway lesions, 30 Benign polyps, 36
Airway tumors, fire hazards with, Bladder surgery, 36-7
53 Bone cutting, 16-17
American National Standards Brain surgery, 32
Institute (ANSI), standard for Breast surgery, 34-5
laser manufacture, 47 British Medical Laser Association
Amplitude, xi, 2 (BMLA),47-8
Anastomosis, 42 British Standards Institution (BSI),
Anesthesia, not required, 36 standard for laser manufacture,
Anesthetics, explosion risk from, 51 47
Angioplasty,42 Bronchoscopes, 24, 30
Animal work, training by, 48
Argon lasers, xi, 9, 20 Capillary/cavernous hemangiomas,
delivery systems, 24 34
gastroenterological applications, Carbon dioxide (C02) lasers, xi, 9,
35 18-19
ophthalmic applications, 38, 39 delivery systems, 23--4
otological applications, 31 general surgery applications, 37
safety of,S 3--4 gynecological applications, 27-8
special safety glasses for, 54 light absorbed by glass/plastic,S 0
urological applications, 36 neurosurgical applications, 31-3
Argon pumped dye lasers, 43 ophthalmic applications, 38, 39
Arteriovenous malformations, 33 otorhinolaryngological
Arthroscopes, 38 applications, 29-30
safety of, 50-2 Diabetic retinopathy, 20, 39
urological applications, 36 Diskectomy,32-3
vascular applications, 42 Disruption effects, 16,41
Cartilage cutting, 16-17,38 Dye lasers, 9, 21
Cataract surgery, 38-9, 41 argon pumped, 43
Cervical intraepithelial neoplasia delivery systems, 24
(CIN),28 dermatological applications, 33-4
Cervix surgery, 28
Clinical applications, 26-46, 56-7 Einstein's theories, ix
dermatology, 33-5 Electrical hazards, 49
gastroenterology, 35-6 Electrically energized lasers, 9
general surgery, 37 Electromagnetic spectrum, 1
gynecology, 27-9 Electrons, xi, 4
neurosurgery, 31-3 Endobronchial lung tumors, 44
ophthalmology, 38-42 Endometriosis, 27,29
orthopedics, 38 Endoscopes, xi, 24
otorhinolaryngology, 29-31 Endotracheal tubes, 50-1
photo radiation therapy, 43-6 Esophageal varices, 35
plastic surgery, 33-5 Excimer lasers, xi, 22, 25
urology, 36-7 Explosion risks, 50, 51
vascular surgery, 42 Eye protection, 50, 52, 54
Coagulation, 15, 19 Eye surgery, 38-42
Coaxial gas delivery, 24, 35
Coherence, xi, 3, 7,12-13 Fallopian tube procedures, 27
Collimation, xi, 7-8, 13 Fiberoptic systems, xii, 23, 24
Colposcope procedures, 28 Filters, endoscope, 52, 54
Combination COzlNd: YAG Fire hazards, 50-52, 53, 54
micromanipulators,25 Fire protection, 50-1
Computer-laser scanners, 24, 39 First lasers, ix, 38
Condyloma, 28, 36 Fistula formation, 45
Contact lenses, 50 Flammable agents, 50
Corneal burns, danger of, 50 Flash fires, 53
Corneal incisions, 39 Flexible endoscopes, xi, 24, 53
Corneal transplants, 39 Focallengths, 10, 13
Cornual reimplantation, 28 Focused beams, 18-19
Coronary artery bypass surgery, 42 Food and Drug Administration
Cranial tumors, 32 (FDA-USA), 27, 38
Craniotomy, 32 Frequency, 2
Cutting, 16, 18-19 Fundamentals, laser surgery, 1-25,
Cystoscopes,36 48
Debulkingprocedures, 16,32,33 Gas lasers, 9

Defocused beams, 19 Gastroenterology, 35-6
Delivery systems, 23-5 Gastrointestinal bleeding, 20, 27, 35
Dermatology, 33-5 General surgery, 37
Index 61
Genital lesions, 28, 36 Laparoscopes,24
Glass rods, 52 Laryngeal diseases, 29
Glasses, safety, 50 Laryngeal stenosis, 30
Glaucoma treatment, 40 LASER acronym, 1
Gold vapor lasers, 45-6 Laser light
Granuloma, 30 effects of, 15-17
Gynecology, 27-9, 52 properties of, 7-8, 12-13
Laser medium, 8-9, 13
Handpieces, 23, 24 Laser physics, 1-13,55
Hazards, 47, 49, 53 Laser plume, 16, 17
Helium-neon lasers, 9,25 Laser safety, 47-54, 57-8
Hematoporphyrin derivative Laser Safety Committees, 48, 49
(HpD), xii, 21, 43-5 Light, nature of, 1
distribution in body, 45 Liquid lasers, 9
purified form, 45 Lymphostatic effects, 34, 37
Hemoglobin, absorption by, 20, 21
Hemophilic patients, 30 Malignancies, 45
Hemostatic effects, xii, 15,37 Manufacturers, safety requirements
Herpes lesions, 28,36 for, 47
Hertz (Hz) units, 2 Mastectomy, 35
Hyperthermia, combined therapy, Matt black instrumentation, 51
45 Melanin, absorption by, 20
Hypertrophic scarring, 34 Melanomas, eye, 42
Hypophysectomy, 32 Meningiomas, vaporizing of, 32
Hysterectomies, alternative to, 29 Menorrhagia, 29
Hysteroscope procedure, 29 Metal endotracheal tubes, 50, 51
Methyl methacrylate glue, 38
Incoherence, 3, 7 Microlaryngoscopy, 29-30, 51
Infrared lasers, 18,20; see also Micromanipulators, 23, 24
Carbon dioxide, Neodymium: Microscopes, operating, 50, 53, 54
YAG Microsurgery, orthopedic, 38
Interlocks, door/key, 47, 52 Microtuboplasty,27
Intractable pain, 32 Mode-locked lasers, ophthalmic
Ionizing radiation, combined applications, 38, 40, 53
therapy, 45 Mode-locking, xii, 12
Iridotomy, 40, 41 Modes, xii, to, 11, 12, 13, 16-17
Irradiance, xiii, 9 Moles, 34
Monochromatic light sources, 46
Joules, xii, 9,11 Monochromaticity, xii, 8, 13
Myringotomy, 31
Keloid scars, 34
Keys, laser safety, 47, 49 Nanometers (nm), xii, 2
Kidney procedures, 36 Neodymium:yttrium aluminium
Krypton lasers, 9 garnet (Nd:YAG) lasers, xii, 9,
ophthalmic applications, 38, 40 20-1
delivery systems, 24--5 Population inversion, xii, 4
gastroenterological applications, Portwine hemangiomas, 34
35 Portwine stains, 20, 34
general surgery applications, 37 Posterior caps ulotomy, 41
gynecological applications, 29 Power
light not absorbed by glass/ factors affecting, 9-12, 13
plastic, 52 units of, xii, xiii, 9, 13
neurosurgical applications, 31, 33 values quoted, 13,20,28,37
otorhinolaryngological Power density, xiii, 9, 13
applications, 31 measurement of, 44--5
pumping with, 46 values quoted, 42
safety of, 52-3 Procedures, 48
urological applications, 36 Properties, individual laser , 18-22
Nerves, rejoining of, 42 Prostate cancer, 37
Neurosurgery, 31-3 Protection of Eye Regulations 1974,
Nurses, training of, 48 50
Protection supervisors, 48-9
Office procedures, 28, 41 Protective eyewear, 50, 52, 54
Operating microscopes, safety of, Pulsed lasers, xiii, 12, 16-17, 22
50,53,54 Pulsed ruby lasers, 40
Operating room personnel, 48-9 pumping, result of, 4
Ophthalmic applications, 24, 38-42
Ophthalmology, 38-42, 53 Q-switched lasers, ophthalmic
Orthopedics, 38 applications, 38, 40, 53
Otorhinolaryngology, 29-31 Q-switching,xiii,l1-12
Outpatient procedures, 28, 41
Oxygen levels, retinal, 39 Radiation hazards, 49
Radical vulvectomies, 28
Pan-retinal photocoagulation Radiological Safety Committee, 47
(PRP),39 Rectum lasing, fire risk, 51
Paper drapes, 50 References, 55-8
Papillomas, 29, 30 Reflecting surfaces, 53
Pelvic inflammatory disease, 27 Reflection, 14
Penile carcinoma, 36 Respiratory papillomatosis, 29
Peptic ulcers, 35 Retinas
Phase, xii, 3, 7 photocoagulation of, 38
Photons, xii, 1,4, 12 testing of, 38
Photoradiation therapy (PRT), xiii, Retractors, 52
21,43-6 Rubber endotracheal tubes, 50, 51
Photosensitivity, 45 Ruby lasers, 9,40
Phototoxic effects, 45
Physics, laser, 1-13,55 Safety factors, 47-54
Pigmented tissues, 20 Scattering, 15
Plastic surgery, 33-5 Scleral burns, danger of, 50
Polyps, 30, 36 Scleral welding, 39
Index 63
Senile macular degeneration (SMD), photoradiation therapy for, 43-6
40 vascular, 28
Singlet oxygen production, 45 Tympanoplasty, 31
Slit lamps, 24, 41, 53, 54
Solid lasers, 9 UK, safety practice, 47-8
Sonic effects, 16,41 Ulcers, 35, 37
Spinal tumors, 32 Ultraviolet lasers, 22
Sponges, flammability of, 50 Urethral strictures, 36, 37
Spontaneous emission, 4, 5 Urology, 36-7
Spot sizes, 10, 13 USA, safety practice, 47
Standby position, 49, 51 Uterine myomas, 28
Stapedotomy,31
Sterile field production, 26, 34 Vaginal intraepithelial neoplasia
Sterilization procedures, 28 (VIN),28
Stimulated emission, 4,6 Vaporization, 16, 19
Sunlight, sensitivity to, 45 Varicose veins, 34
Superpulse mode, 16-17 Vas deferens, 36
Surgical technicians, training of, 48 Vascular surgery, 42
Vascular tumors, 28
Tattoos, 34. Velocity of light, 3
Technicians Visual hazards, 52, 54
death by electrocution, 49 Visually disturbed patients, 38
training, 48 Vitrectomy,39
Teflon-coated instruments, 52 Vocal cord applications, 30
Telangiectasia, 30, 34 Vulvectomy, 28
Tissue interaction, 14-17
Tonsillectomy, 30 Warning signs, 49
Tooth enamel, possible damage to, Watts, xiii, 9
51 Wave properties, 2-3
Trabeculoplasty,40 Wavelength,2
Training, 48 Wavelengths
Transmission, 15 characteristic absorption, 21,44
Transverse electromagnetic modes characteristic of various lasers, 9,
(TEMs), 10, 11, 12 10,18,20,21
Tumors Welding, 36, 39, 42
bladder, 36, 37 Windows, covering of, 52, 54
cranial,32 Wood's lamp illumination, 43
eye, 39 Wound healing, 18-19
gastrointestinal, 35-6
lung, 44 X-ray lasers, 49

Gregory T. Absten BSC, MA, Stephen N. Joffe BSC, MB, CHB, MD, FRCS (Edinburgh and Glasgow), FCS (South Africa), FACS (Auth.) - Lasers in Medicine - An Introductory Guide-Springer US (1985

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Gregory T. Absten BSC, MA, Stephen N. Joffe BSC, MB, CHB, MD, FRCS (Edinburgh and Glasgow), FCS (South Africa), FACS (Auth.) - Lasers in Medicine - An Introductory Guide-Springer US (1985

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Lasers in Medicine

Springer-Science+Business Media, B.V.

This paperback edition is sold subject to the condition that it

British Library Cataloguing in Publication Data

1 Laser physics for the non-specialist 1

3 Properties of individual lasers 18

4 Laser beam delivery systems 23

5 Overview of clinical applications 26

Selected references for further reading 55

Note: American spelling has been used throughout this book

Amplitude the maximum height of a wave above the zero line.

The word 'LASER' is an acronym for Light Amplification by the

Fig. 1 The electromagnetic spectrum, showing the wide range of wave-

Fig. 2 The basic properties of a wave. The diagram shows a wave of

Coherence and incoherence

Where does laser light come from?

Fig 4 Spontaneous emission. The diagrams show energized electrons in

(i) (ij) (iij)

Special properties of laser light

The laser medium

Laser Colour Wavelength (nm)

Argon Blue 488.0

The focal length of the lens

The wavelength of the laser

different spot sizes generated by lenses of various focal lengths.

Q-switching and mode-locking

the optical resonator in the laser. It creates high peak powers in

Focal length of lens

Power Power density

80 Watts 1020000 210000 50000 16000 3000

the same direction), it is highly collimated (beams diverge very

Fig. 10 Reflection. A laser beam is reflected from the surface of a tissue,

Fig. 11 Transmission. A laser beam is transmitted through a tissue, and

Fig. 13 Absorption. A laser beam is absorbed by a small volume of tissue,

a larger volume so that its effects will be more diffuse. A thorough

The rapid rise in intracellular temperature and pressure causes an

The carbon dioxide (C02 ) laser

same way as a conventional wound, and histologically, the scars are

The argon laser

The neodymium: yttrium aluminum garnet (Nd: YAG) laser

The dye laser

The excimer laser

Much of the development work in laser systems is in the area of

Argon and dye lasers

Nd: YAG lasers

Advantages of laser surgery

Dermatology and plastic surgery

Plate lJ(a) Patient with a Plate lJ(b) The same patient

(Photographs by courtesy of Mr J,A.S. Carruth, Royal South Hants Hospital,

(Photographs by courtesy of Dr S.G. Bown, University College Hospital,

Plate IV(a) Proliferative Plate IV(b) Complete

{'Photographs by courtesy of Mr R.J. Cooling, Moorfields Eye Hospital,

(a) (b) (e)

Fig. 18 Diagrammatic and simplified illustration of photoradiation

(b) Laser physics

(c) Medical applications of lasers

(d) Laser safety

Abdominal cysts, 27 Artificial joints, 38

Debulkingprocedures, 16,32,33 Gas lasers, 9

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