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The advent in the 1960s of the unique and exciting new form of energy called laser brought to medicine a marvelous tool that could accomplish new treatments of previously untreatable disorders as well as improved treat­ ment of mundane problems. This brilliant form of light energy is many times more powerful than the energy of the sun yet can be focused microscopically to spot sizes as small as 30 microns. Lasers can be directed into seemingly inaccessible areas by mirrors or fiberoptic cables or can be directly applied into sensitive areas such as the retina without damage to intervening structures. There has been a rapid proliferation in the use of lasers in all surgical specialties. Starting with bold ideas and experiments of "thought leaders" in each specialty, the application of lasers has evolved into commonplace usage. Beginning with the era when laser presentations and publications were an oddity, now nearly all specialty areas have whole sections of meetings or journals devoted exclusively to laser usage. Laser specialty societies within a specialty have developed and residency training programs routinely instruct trainees in laser techniques. Basic science and clinical experimentation has supported laser knowledge. Laser usage has also become international. Newer wavelengths and accessories have added to the armamentarium of laser usage. Despite the rapid growth in laser interest, no single source exists to instruct the many new laser users in proper, safe, and effective use of this new modality.



Chapter 1. Biophysics, Advantages, and Installation of Laser Systems

Lasers were first conceived by Einstein in 19171 when he wrote his “Zur Quantum Theorie der Strahlung” (the quantum theory of radiation) which enumerated concepts of stimulated and spontaneous emission and absorption. Drs. Arthur Schawlow and Charles Townes, in 1958,2 extended lasers into the optical frequency range and Maiman, in 1960,3 operated the first laser using ruby as the active medium (ruby laser). C.K.N. Patel, in 1964,4 working in the Bell Laboratories, first developed the CO2 laser. Jako and Polanyi studied the absorption of human cadaver vocal cords when exposed to a pulsed neodymium laser, and later a CO2 laser, thus providing one of the first purely medical applications.5,6 These investigations eventually led to the development of an endoscopic delivery system in 1968. Jako first described the precision of the laser beam and noted the subsequent good wound healing.7 Hall,8 in 1971, accurately described tissue reactions to laser. Ketcham9 in general surgery, Goldman and Blaney10 in dermatology, Zweng11 in ophthalmology, Kaplan et al.12 in plastic surgery were all early contributors to their specialties. Currently, many medical and surgical specialties are finding innovative uses for multiple laser systems in both the diagnostic and therapeutic arenas.
David B. Apfelberg

Chapter 2. Administrative Responsibilities of Laser Surgery: Financial and Legal Aspects

The decision to purchase a laser and implement a laser program in your office or hospital requires sound thinking, decision making, and planning. Providing laser treatments to patients carries with it a commitment to quality care as well as concern for safety of both patients and personnel. This chapter will outline the decisions administrators or managers must make prior to purchasing a laser; legal issues and malpractice implications associated with use of the laser; policies and procedures needed to guide the use of lasers; and education and training of physicians and personnel who use or work with the laser.
Julia A. Kneedler, Judith I. Pfister

Chapter 3. Administrative Responsibility for Laser Surgery: Nursing and Administration Roles

Nurses are becoming more involved in the care of patients receiving treatments from various technological sources, ranging from invasive forms of diagnostic examinations such as arteriography and pneumoencephalograms to noninvasive procedures such as computerized axial tomography. With the proliferation of technology in the medical field a natural progression will involve nurses in a variety of disciplines.
Carolyn J. Mackety

Chapter 4. Implementation and Management of a Laser Program

This chapter is intended to provide general guidelines, suggestions, and resource information for consideration in evaluating, planning, implementing, and maintaining an effective Laser Program. It is hoped by the authors that the information, in whole or in part, will be relevant for facilities considering the feasibility of a Laser Program, those in the process of initiating a Program, as well as for facilities seeking to revise or expand their present approach.
Frances Gray, Harry Mittelman

Chapter 5. A Summary of Safety Considerations for the Medical and Surgical Practitioner

The use of lasers in medical and surgical applications is rapidly expanding and impinges upon many disciplines from the clinical laboratory to the office practice to the operating room. It is essential that users of these powerful tools be knowledgeable of their potential hazards and the means to protect patients and personnel against injuries or undesired effects. Below, we have included information about how lasers are classified; the development of protective standards; the regulatory process that governs laser production and application; the current status of protection standards that apply to lasers, especially those used in medicine/surgery; the specific kinds of hazards associated with medical/surgical applications; and the means whereby such hazards have been controlled. In the discussion of hazards control we have tried to present various alternatives, stressing those that we feel have worked well. Since laser technology is still a young field, it is likely the problems at present unenvisioned will occur and methodologies for controlling hazards will evolve.
John A. Holmes

Chapter 6. Past, Present, and Future Usage of Lasers in Ophthalmology

Of all the medical specialties, ophthalmology has been one of the earliest and most enthusiastic users of lasers. A variety of ophthalmic lasers are now widely and successfully used, and several promising new laser types are under investigation.
Edwin E. Boldrey

Chapter 7. Past, Present, and Future Usage of Lasers in Otolaryngology-Head and Neck Surgery

Four types of lasers are currently in use in otolaryngology-head and neck surgery and many more are in various stages of development. These include the carbon dioxide (CO2) laser, argon laser, argon-pumped tunable dye laser, and neodymium:yttrium aluminum garnet (Nd:YAG) laser. The potential clinical applications of each of these surgical lasers are determined by their wavelength and specific tissue absorptive characteristics. Therefore, the surgeon should consider the properties of each wavelength at the time that he or she chooses to utilize a particular laser. This will facilitate the achievement of his or her surgical objective with minimal morbidity and maximal efficiency.
Robert H. Ossoff, James A. Duncavage

Chapter 8. Past, Present, and Future Usage of Lasers in Gynecology

In gynecology, the carbon dioxide (CO2) laser—with its well-discussed capacities for greater precision, cleaner incisions, and faster healing than are possible with conventional methods—has become the treatment method of choice in the management of neoplastic disease of the cervix, vagina, and vulva. The CO2 laser has also been adapted to the operating microscope for reconstructive surgery of the female reproductive tract, a crucial factor in cases where preserving reproductive anatomy is desired. In April 1983 the Diagnostic and Therapeutic Technology Assessment (DATTA) project of the American Association rated the CO2 laser as
a safe and established procedure in treating selected cervical, vulvar and vaginal neoplasia and condyloma acuminatum … (especially) where the preservation of normal anatomic function is considered to be of paramount importance … because of reduced scar formation and maintenance of the normal architecture of the reproductive tract.1
Joseph H. Bellina, Ana C. Fick, Jeff D. Jackson

Chapter 9. Past, Present, and Future Usage of Lasers in Clinical Neurosurgery

Technological innovations have had significant impact on the delivery of neurosurgical care. The introduction of lasers into the armamentarium of surgical instruments has provided neurosurgeons with a method of tissue removal that is more delicate than those previously available. At present, the primary application for lasers in neurological surgery is in the ablation of critically placed neoplastic tissues. Because the interaction of laser energy with tissue is inherently hemostatic, this relatively nontouch technique of removing neoplasms decreases blood loss. Tissue coagulation or removal can be accomplished without mechanical manipulation; therefore damage to surrounding normal tissues is less. In addition, evoked responses and EEG can be monitored continuously during laser surgery so that aspects of the surgical procedure that compromise neural function can be immediately recognized and remedied. Competent use of surgical lasers results in precise and hemostatic ablation of target tissue with decreased likelihood of damage to adjacent normal structures. Although these assets are particularly valuable in neurosurgery, the percentage of cases in which laser use is “a must” is probably less than 10%.1
James E. Boggan, Michael S. B. Edwards

Chapter 10. Past, Present, and Future Usage of Lasers in General Surgery

A paradox exists when considering general surgical applications of lasers. There is probably no surgical specialty that has found less clinical application for this new surgical instrument. This is probably due to the fact that most general surgical procedures are well standardized, have good exposure and visualization of surgical areas to be treated, and excellent available instrumentation.
John A. Dixon

Chapter 11. Past, Present, and Future Usage of Lasers in Plastic Surgery, Dermatology, and Podiatry

Lasers have assumed a very important role in the treatment of cutaneous or superficial lesions in plastic surgery, dermatology, and podiatry. They have provided beneficial improvement for multiple disorders for which no reliable and effective treatment has been previously available. In addition, the laser treatment of several very ordinary, mundane disorders has resulted in a marked diminution in posttreatment edema and pain, thus improving postoperative comfort and establishing the laser as the preferred modality for such disorders. Advances in laser treatment have been particularly dramatic in plastic surgery, dermatology, and podiatry because of the readily accessible superficial location of most of the disorders, which can be treated often on an out-patient basis under local anesthesia without the necessity for special instrumentation as in other laser specialties.
David B. Apfelberg, Morton R. Maser, Harvey Lash, David N. White, Teruko Smith

Chapter 12. Past, Present, and Future Usage of the Laser in Urology

Investigations into the use of the laser in urology were reported as early as 1968 when Mulvaney and Beck reviewed their attempts to fragment urinary calculi.1 In 1973, attempts were made to utilize the CO2 laser as an adjunct to partial nephrectomy.2 The endoscopic applications of first the argon and later the neodymium:yttrium aluminum garnet (Nd:YAG) laser were reported by Staehler and Associates in 1976.3 Later Staehler and Hofstetter both reported on the clinical results using the Nd:YAG laser to treat superficial bladder tumors.
Barry B. Stein

Chapter 13. Past, Present, and Future Usage of Lasers in Gastrointestinal Endoscopic Hemostasis

In 1971, a surgeon named Goodale at the University of Minnesota described the first application of a laser to the gastrointestinal tract.1 He performed open surgery and using a CO2 laser to coagulate diffuse bleeding from the stomach in an attempt to avoid gastric resection. This article inspired other people in the world to look to the possibility of the endoscopic delivery of laser energy for coagulation.
Richard M. Dwyer, Richard G. Block

Chapter 14. Hematoporphyrin Photomedicine of Cancer

The concentration of porphyrins by malignant tissue has been known for decades and has been thoroughly reviewed in several recent symposium volumes.1–3 From these symposia as well as the many articles published in refereed journals, a picture emerges that is both positive and negative. On the positive side it has been demonstrated that (1) some porphyrins are concentrated selectively in malignant tumors in animals and man; (2) the concentrated porphyrins can be detected by fluorescence emission, thus facilitating identification of malignancy; (3) the concentrated porphyrins will absorb light of particular wavelengths, leading to a photochemical destruction of the tumor; and (4) in some human cases, localized tumors have been eradicated by this method with no regrowth detected for up to 2 years.
Michael W. Berns


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