Laser surgery

Definition

The term laser means light amplification by stimulated emission of radiation, and it uses a laser light source (laser beam) to remove tissues that are diseased or to treat blood vessels that are bleeding. Laser beams are strong beams of light produced by electrically stimulating a particular material. A solid, a liquid, or a gas is used. Alternatively, the laser is used cosmetically; it can remove wrinkles, birthmarks, or tattoos.

The special light beam is focused to treat tissues by heating the cells until they burst. There are a number of different laser types. Each has a different use and color. The color, or the light beam, relates to the type of surgery that is being performed and the color of the tissue that is being treated. There are three types of laser: the carbon dioxide (CO ₂ ) laser; the YAG laser (yttrium aluminum garnet); and the pulsed dye laser.

Purpose

Laser surgery is used to:

• cut or destroy tissue that is abnormal or diseased without harming healthy, normal tissue
• shrink or destroy tumors and lesions
• close off nerve endings to reduce postoperative pain
• cauterize (seal) blood vessels to reduce blood loss
• seal lymph vessels to minimize swelling and decrease spread of tumor cells
• remove moles, warts, and tattoos
• decrease the appearance of skin wrinkles

Precautions

Anyone who is thinking about having laser surgery should ask the surgeon to:

• explain why laser surgery is likely to be of greater benefit than traditional surgery
• describe the surgeon's experience in performing the laser procedure the patient is considering

Because some lasers can temporarily or permanently discolor the skin of blacks, Asians, and Hispanics, a dark-skinned patient should make sure that the surgeon has successfully performed laser procedures on people of color. Potential problems include infection, pain, scarring, and changes in skin color.

Some types of laser surgery should not be performed on pregnant women or on patients with severe cardiopulmonary disease or other serious health problems.

Additionally, because some laser surgical procedures are performed under general anesthesia, its risks should be fully discussed with the anesthesiologist. The patient should fully disclose all over-the-counter and prescription medications that are being taken, as well as the foods and beverages that are generally consumed; some can interact with agents used in anesthesia.

Description

Lasers can be used to perform almost any surgical procedure. In fact, general surgeons employ the various laser wavelengths and laser delivery systems to cut, coagulate, vaporize, and remove tissue. In most "laser surgeries," they actually use genuine laser devices in place of conventional surgical tools—scalpels, cryosugery probes, electrosurgical units, or microwave devices—to carry out standard procedures, like mastectomy (breast surgery). With the use of lasers, the skilled and trained surgeon can accomplish tasks that are more complex, all the while reducing blood loss, decreasing postoperative patient discomfort, decreasing the chances of infection to the wound, reducing the spread of some cancers, minimizing the extent of surgery (in some cases), and achieving better outcomes in wound healing. Also, because lasers are more precise, the laser can penetrate tissue by adjusting the intensity of the light.

Lasers are also extremely useful in both open and laparoscopic procedures. Common surgical uses include breast surgery, removal of the gallbladder, hernia repair, bowel resection , hemorrhoidectomy , solid organ surgery, and treatment of pilonidal cyst.

The first working laser was introduced in 1960. Initially used to treat diseases and disorders of the eye, the device was first used to treat diseases and disorders of the eye, whose transparent tissues gave ophthalmic surgeons a clear view of how the narrow, concentrated beam was being directed. Dermatologic surgeons also helped to pioneer laser surgery, and developed and improved upon many early techniques and more refined surgical procedures.

Types of lasers

The three types of lasers most often used in medical treatment are the:

• Carbon dioxide (CO ₂ ) laser. Primarily a surgical tool, this device converts light energy to heat strong enough to minimize bleeding, while cutting through or vaporizes tissue.
• Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Capable of penetrating tissue more deeply than other lasers, the Nd:YAG laser enables blood to clot quickly, allowing surgeons to see and can enable surgeons to see and touch body parts that could otherwise be reached only through open (invasive) surgery.
• Argon laser. This laser provides the limited penetration needed for eye surgery and superficial skin disorders. In a special procedure known as photodynamic therapy (PDT), this laser uses light-sensitive dyes to shrink or dissolve tumors.

Cosmetic laser surgery in progress. The wavelengths of the laser's light can be matched to a specific target, enabling the physician to destroy the capillaries near the skin's surface without damaging the surrounding tissue. (

Photograph by Will & Deni McIntyre, Photo Researchers, Inc. Reproduced by permission

.)

Laser applications

Sometimes described as "scalpels of light," lasers are used alone or with conventional surgical instruments in a array of procedures that:

• improve appearance
• relieve pain
• restore function
• save lives

Laser surgery is often standard operating procedure for specialists in:

• cardiology (branch of medicine which deals with the heart and its diseases)
• dentistry (branch of medicine which deals with the anatomy and development and diseases of the teeth)
• dermatology (science which treats the skin, its structure, functions, and its diseases)
• gastroenterology (science which treats disorders of the stomach and intestines)
• gynecology (science which treats of the structure and diseases of women)
• neurosurgery (surgery of the nervous system)
• oncology (cancer treatment)
• ophthalmology (treatment of disorders of the eye)
• orthopedics (treatment of disorders of bones, joints, muscles, ligaments, and tendons)
• otolaryngology (treatment of disorders of the ears, nose, and throat)
• pulmonology (treatment of disorders of the respiratory system)
• urology (treatment of disorders of the urinary tract and of the male reproductive system)

Routine uses of lasers, include eliminating birth-marks, skin discoloration, and skin changes due to aging, and removing benign, precancerous, or cancerous tissues or tumors. Lasers are used to stop a patient's snoring, remove tonsils, remove or transplant hair, and relieve pain and restore function in patients who are too weak to undergo major surgery. Lasers are also used to treat:

• angina (chest pain)
• cancerous or noncancerous tumors that cannot be removed or destroyed
• cold and canker sores, gum disease, and tooth sensitivity or decay
• ectopic pregnancy (development of a fertilized egg outside the uterus)
• endometriosis
• fibroid tumors
• gallstones
• glaucoma, mild-to-moderate nearsightedness and astigmatism, and other conditions that impair sight
• migraine headaches
• noncancerous enlargement of the prostate gland
• nosebleeds
• ovarian cysts
• ulcers
• varicose veins
• warts
• numerous other conditions, diseases, and disorders

Advantages of laser surgery

Often referred to as "bloodless surgery," laser procedures usually involve less bleeding than conventional surgery. The heat generated by the laser keeps the surgical site free of germs and reduces the risk of infection. Because a smaller incision is required, laser procedures often take less time (and cost less money) than traditional surgery. Sealing off blood vessels and nerves reduces bleeding, swelling, scarring, pain, and the length of the recovery period.

Disadvantages of laser surgery

Although many laser surgeries can be performed in a doctor's office, rather than in a hospital, the person guiding the laser must be at least as thoroughly trained and highly skilled as someone performing the same procedure in a hospital setting. The American Society for Laser Medicine and Surgery urges that:

• All operative areas be equipped with oxygen and other drugs and equipment required for cardiopulmonary resuscitation (CPR).
• Non-physicians performing laser procedures be properly trained, licensed, and insured.
• A qualified and experienced supervising physician be able to respond to and manage unanticipated events or other emergencies within five minutes of the time they occur.
• Emergency transportation to a hospital or other acute care facility (ACF) be available whenever laser surgery is performed in a non-hospital setting.

Diagnosis/Preparation

Because laser surgery is used to treat so many diverse conditions, the patient should ask the physician for detailed instructions about how to prepare for a specific procedure. Diet, activities, and medications may not have to be limited prior to surgery, but some procedures require a physical examination , a medical history, and conversation with the patient that:

• enables the doctor to evaluate the patient's general health and current medical status
• provides the doctor with information about how the patient has responded to other illnesses, hospital stays, and diagnostic or therapeutic procedures
• clarifies what the patient expects the outcome of the procedure to be

Aftercare

Most laser surgeries can be performed on an outpatient basis, and patients are usually permitted to leave the hospital or medical office when their vital signs have stabilized. A patient who has been sedated should not be discharged until recovery from the anesthesia is complete, unless a responsible adult is available to accompany the patient home.

The doctor may prescribe analgesic (pain-relieving) medication, and should provide easy-to-understand, written instructions on how to take the medication. The doctor should also be able to give the patient a good estimate of how the patient's recovery should progress, the recovery time, and what to do in case complications or emergency arise. The amount of time it takes for the patient to recover from surgery depends on the surgery and on the individual. Recovery time for laser surgery is, for the most part, faster than for traditional surgery.

Risks

Like traditional surgery, laser surgery can be complicated by:

• hemorrhage
• infection
• perforation (piercing) of an organ or tissue

Laser surgery can also involve risks that are not associated with traditional surgical procedures. Being careless or not practicing safe surgical techniques can severely burn the patient's lungs or even cause them to explode. Patients must wear protective eye shields while undergoing laser surgery on any part of the face near the eyes or eyelids, and the United States Food and Drug Administration has said that both doctors and patients must use special wavelength-specific, protective eyewear whenever a CO ₂ laser is used.

There are other kinds of dangers that laser surgery can impose of which the patient should be aware. Laser beams have the capacity to do a great deal of damage when coupled with high enough energy and absorption. They can ignite clothing, paper, and hair. Further, the risk of fire from lasers increases in the presence of oxygen. Hair should be protected and clothing should be tied back, or removed, within the treatment areas. It is important to guard against electric shock, as lasers require the use of high voltage. Critically, installation must ensure proper wiring.

Laser beams can burn or destroy healthy tissue, cause injuries that are painful and sometimes permanent, and actually compound problems they are supposed to solve. Errors or inaccuracies in laser surgery can worsen a patient's vision, for example, and lasers can scar and even change the skin color of some patients.

All of the above risks, precautions, and potential complications should be discussed by the doctor with the patient.

Normal results

The nature and severity of the problem, the skill of the surgeon performing the procedure, and the patient's general health and realistic expectations are among the factors that influence the outcome of laser surgery. Successful procedures can enable patients to feel better, look younger, and enjoy longer, fuller, more active lives.

A patient who is considering any kind of laser surgery should ask the doctor to provide detailed information about what the outcome of the surgery is expected to be, what the recovery process will involve, and how long it will probably be before a normal appearance is regained and the patient can resume normal activities.

A person who is considering any type of laser surgery should ask the doctor to provide specific and detailed information about what could go wrong during the procedure and what the negative impact on the patient's health or appearance might be.

Lighter or darker skin may appear, for example, when a laser is used to remove sun damage or age spots from an olive- or dark-skinned individual. This abnormal pigmentation may or may not disappear over time.

Scarring or rupturing of the cornea is uncommon, but laser surgery on one or both eyes can:

• increase sensitivity to light or glare
• reduce night vision
• permanently cloud vision, or cause sharpness of vision to decline throughout the day

Signs of infection following laser surgery include:

• burning
• crusting of the skin
• itching
• pain
• scarring
• severe redness
• swelling

Resources

books

Carlson, Karen J., et. al. The Harvard Guide to Women's Health. Cambridge, MA: Harvard University Press, 1996.

periodicals

"Laser Procedures for Nearsightedness." FDA Consumer (Jan./Feb. 1996): 2.

"Laser Resurfacing Slows the Hands of Time." Harvard Health Letter (Aug. 1996): 4-5.

"Lasers." Mayo Clinic Health Letter (July 1994): 1-3.

"Lasers: Bright Lights of the Medical World." Cosmopolitan (May 1995): 262-265.

"Lasers for Skin Surgery." Harvard Women's Health Watch (Mar. 1997): 2-3.

"Lasers–Hope or Hype?" American Health (June 1994): 68-72, 103.

"New Cancer Therapies That Ease Pain, Extend Life." Cancer Smart (June 1997): 8-10.

"New Laser Surgery for Angina." HealthNews (6 May 1997): 3-4.

"Saving Face." Essence (Aug. 1997), 24, 26, 28.

organizations

American Society for Dermatologic Surgery. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. http://www.asds-net.org .

American Society for Laser Medicine and Surgery. 2404 Stewart Square, Wausau, WI 54401.(715) 845-9283. http://www.aslms.org .

Cancer Information Service. 9000 Rockville Pike, Building 31, Suite 10A18, Bethesda, MD 20892. 1-800-4-CANCER. http://wwwicic.nci.nih.gov .

Mayo Clinic. Division of Colon and Rectal Surgery. 200 First Street. SW, Rochester, MN 55905. (507) 284-2511. http://www.mayoclinic.org/colorectalsurgery-rst/laparoscopicsurgery.html .

Mayo Clinic. Mayo Foundation for Medical Education and Research, 200 First Street. SW, Rochester, MN 55905. (507) 284-2511. http://http://www.mayoclinic.com .

National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. http://www.nci.nih.gov .

other

"Complications of Dermatologic Laser Surgery." 2 Nov. 2001 http://www.emedicine.com/derm/topic525.htm .

"Facts About Laser Surgery." Glaucoma Research Foundation Page. 12 Mar. 1998 http://www.glaucoma.org/fs-lasersur.html .

Haggerty, Maureen. "ASLMS Guidelines for Office-Based Laser Procedures." A Healthy Me Page. 19 Mar. 1998 http://www.ahealthyme.com/topic/topic100587070 .

"Refractive Eye Surgery." Mayo Clinic Online. 15 Mar. 1998 http://www.mayohealth.org/mayo/9707/htm/refract.htm .

"What is Laser?" The American Society for Dermatologic Surgery Page. 19 Mar. 1998 http://www.asds-net.org .

Laith Farid Gulli, M.D., M.S.
Randi B. Jenkins, B.A.
Bilal Nasser, M.D., M.S.
Robert Ramirez, B.S.