Lasers

LASERS IN GYNAECOLOGY
BY- DR. RIDHI KATHURIA

L LIGHT
A AMPLIFICATION by
S STIMULATED
E EMISSION of
R RADIATION

Lasers are unique and useful tools in the hands of trained surgeons.
They are not a magic wand that can be used to accomplish all surgical tasks.
The introduction of lasers to gynecologic surgery occurred at a time when laser
use in the military, aerospace, and everyday life was highly publicized. This focus
of attention was responsible, in part, for laser's introduction to gynecology.
The initial popularity of laser surgery in turn stimulated the development of more
sophisticated electrosurgical instruments.
This has resulted in the improvement of the tools using electrosurgical energy.
The long-term benefits and future use of lasers in gynecology will require carefully
designed and randomized studies.

BASIC CHARACTERS OF
LASER
1. Monochromicity ( narrow wave length )
2. Directionality / Collimated ( spreads little
with distance )
3. Convergence / Coherent
4. Quantum nature of light
5. Stimulated emission

ᴥ 1917, ALBERT EINSTEIN predicted & described process
of stimulated emission of radiation.
ᴥ 1953, CHARLES TOWNER & COLLG. produced device c/d
‘’MASER’’, which could amplify microwaves by stimulated
emission of radiation.
ᴥ 1960, MAIMAN constructed first working laser, with a ruby
crystal with wavelength of 690 nm. It was stimulated to emit
laser energy by pumping with light from xenon flash lamp.
ᴥ 1964, PATEL developed CO2 laser generating energy at
wavelength 10,600 nm.
Page 5

ᴥ KAPLAN & COLLG, first used laser in gyn surgery, by
doing CO2 laser vaporization of infected cervical tissue.
ᴥ During late 1970’s laser was coupled with
laproscope, performing the 1st successful surgery of its
kind.
Page 6

LASER COMPONENTS
OPTICAL
RESONATOR
• TOTALLY
REFLECTIVE
• PARTIALLY
REFLECTIVE
GAIN MEDIUIM
• SOLID
• LIQUID
• SEMICONDUCTOR
PUMPING
PROCESS
• LIGHT FLASH
• ELECTRICAL
ENERGY

Laser light is extremely bright, of similar color and direction, and is
most often described in terms of its wave characteristics or
WAVELENGTH.
Wavelength is the distance between two successive crests or
troughs, and wavelength determines the color of the light.
Wavelengths are usually measured in Microns or Nanometers
(nm)
Page 8
One micron = 1/1,000 mm.
1 nm =1/1,000,000 mm.
Electromagnetic waves are often referred to as light, although
visible light occupies only a small portion of the electromagnetic
spectrum.

An atom is composed of a positively charged nucleus
surrounded by electrons that orbit this nucleus.
Each electron orbit can be described in terms of energy levels.
As orbital distance from the nucleus increases, energy level
increases.
As per the laws of quantum mechanics,
When an electron moves from a higher-energy orbit to a lower-energy
orbit, the atom loses a specific amount of energy in the
form of a PHOTON, which also has a specific wavelength.

Lasers contain what is referred to as an Active Lasing
Medium: a collection of atoms or molecules that are housed in
an optically resonant cavity.
This cavity, often cylindrical, is designed so that light of a
specific wavelength will resonate between the closed ends of
the cavity.
The active medium is stimulated, by an external energy
source, viz electricity or light, which stimulates the active lasing
medium to higher energy levels.
As decay back to resting energy levels occurs, photons of
energy are released into the optical cavity.
Electrons that are still in excited higher orbital energy levels
can also be stimulated by bombardment with these newly
released photons so that they undergo identical decay and emit
an identical photon.
Page 10
This is called STIMULATED EMISSION, because one
photon has stimulated the production of another photon.

Optical cavity of the laser tube is closed at each end by a mirror.
One of these mirrors is Totally Reflective, but the other is Semitransparent.
Although photon direction in the tube is random, a certain number of photons will
be emitted in the axis of the optical cavity.
The others are focused by the mirrors so that most are resonating or bouncing back
and forth along the axis of the cavity.
Some of these photons emerge through the semitransparent mirror and are
emitted from the laser as the monochromatic parallel coherent laser beam.
Coherent means that the waves are all in phase or perfectly aligned.
The laser thus creates a light that travels in a tight beam over long distances.

•LASER POWER is measured in terms of WATTS, and
LASER ENERGY is expressed in terms of JOULES.
•One Joule Equals 1 W Of Power Applied For 1 Second.
•Lasers are named for the active medium contained in their optical
cavities. Many different lasers have been constructed for diverse uses.
•In gynecologic surgery, the CO2 and YAG lasers are the most commonly
used.
•Despite many efforts, fiber-optic delivery systems have never been
satisfactorily adapted to CO2 laser energy.
However, other lasers produce wavelengths that are conducted along
quartz fibers.
•The use of the fiber is of great advantage in endoscopic surgery
because it can be passed down the channel of an operative telescope,
suction irrigator probe, or other hollow channel within the instrument.

For any given power setting of the laser, the concentration
or density of the power is greater as the spot size becomes
smaller, and conversely, as the spot size (tissue impact
area) is enlarged, the power density decreases.
By focusing or defocusing the laser energy, it is used as a
cutting or coagulating tool.
THE CONCENTRATION OF LASER ENERGY AT ITS
FOCAL POINT IS REFERRED TO AS ITS POWER
DENSITY (PD) AND IS EXPRESSED AS WATTS PER
SQUARE CENTIMETER.
Page 14

►Although the photons of laser light are parallel, laser
energy is not completely uniform throughout the cross-sectional
diameter of the beam .
►The term TRANSVERSE ELECTROMAGNETIC MODE
(TEM) refers to the energy distribution of the cross-sectional
diameter.
For example, in most CO2 surgical lasers, the energy
distribution is greatest at the center of the beam and
decreases toward the periphery.
►If one graphs the energy distribution of the cross-sectional
beam diameter of the CO2 laser, the resultant
curve is bell-shaped.
►This Gaussian distribution does not hold true in fiber-optic
lasers, YAG, Potassium-titanyl-phosphate (KTP), and
Argon, in which energy distribution tends to be more
uniform.

 Effect of lasers on tissue is dependent on the duration that the tissue is
exposed to laser energy.
Page 16
In CONTINUOUS WAVE (CW) mode delivery, the laser oscillates
constantly and delivers non varying power to the tissue.
A PULSED LASER can deliver energy in the form of a single pulse or a
train of pulses. The duration of a pulse is typically less than 0.25 second.
Pulsing the laser to the tissue for a short duration is useful to control the
delivery and power of the beam. Significantly higher power density can cut
tissue with minimal coagulation necrosis at the margins.

Q-SWITCHING LASER is a laser that reduces its pulse time and
significantly increases its peak power.
In this mode, laser radiation is released in a short burst of laser
light with high peak power.
When the shutter of the optical cavity is rapidly opened, the laser
energy is discharged in an extremely short period of time (10-6 to10-9
seconds).
Page 17
Laser energy of 107 watts can be obtained using this mode.
Q-switched laser pulse is used when it is critical to minimize
adjacent tissue effects.
Pulsing lasers at extremely high peak power (e.g., 500 to 2500
pulses/second) permit cutting tissue with lower water content.

AIM- SELECTIVE PHOTO-THERMOLYSIS
a. Getting the right amount
b. Of the right wavelength
c. To the right tissue
d. To damage/destroy/target only that tissue and nothing
else.
 Appropriate EXPOSURE TIME is essential to be
maintained… it is supposed to be lesser than the
Thermal Relaxation Time of the target tissue.
 Optimum energy density or FLUENCE is to be applied
so as to achieve desired effect viz, Vapourization,
Coagulation, Photodisruption.

Three zones of laser tissue damage that may be defined:
(i) the area vaporized,
(ii) the area of tissue death that results from the heated tissue short
of vaporization,
(iii) the area of tissue damage caused by conduction of the heat away
from the lased site
1. Normal tissue
2. Heat affected tissue
3. Coagulated tissue showing vacuolisation
4. Carbonised tissue

 Laser energy interacts with tissue causing biologic, photochemical, or thermal
reactions.
 Laser energy is absorbed, scattered, or affected by the thermal conductivity
and local circulation of the tissue.
 Primary tissue effect of the surgical lasers used in gynecology is thermal.
The beam profile for any given power setting can be altered by changing the
spot size diameter.
Soft tissue is about 80% water by volume. CO2 laser is highly absorbed by
water, limiting its penetration to the surface of the tissue, where it can be
monitored visually.
Page 24

 Deep penetration of this laser energy into tissue is minimal as long as
intracellular and extracellular water remains to be vaporized.
 When heat is delivered by the laser beam, the tissue's temperature is
elevated.
 When tissue temperature is elevated to 57°C, irreversible damage to the
cell's proteins occurs, and the cell dies.
 Between 57°C and 100°C, there will be tissue death without vaporization.
 Above 100°C, vaporization occurs, with conversion of the fluid content of
tissue to vapor and the other cellular components being converted to smoke.
This product is referred to as the LASER PLUME.
When the plume is evacuated, it debrides the area and effectively removes
the tissue. Additional tissue damage results from lateral conduction of heat away
from the laser impact site. The amount of damage caused by heat conduction is
directly proportional to the amount of time spent in lasing.

 Several advantages of CO2 laser over a knife and electrosurgical instruments
are obvious.
Page 27
Laser surgery is performed with no contact to the tissue. No bacteria is
transferred from the surgical instrument to the tissue.
 The laser beam sterilizes the operative field as it vaporizes it.
 Because it removes tissue with vaporization and evacuation, the suctioned
plume allows the tissue base to heal without a devitalized tissue covering.
 Postoperative pain is reduced because nerve endings are sealed by the
beam.
 Coagulating lasers can be used in patients with bleeding disorders. The laser
can be delivered for easy access to confined areas with a clear field of view.

The Helium Neon laser (HeNe) is a gas laser with a wavelength of 633 nm in the
red portion of the visible spectrum.
Page 28
It is a low-powered laser with output ranging from 1 to 100 mW.
The most popular HeNe lasers produces red light. Other colored helium neon
lasers include green with a wavelength of 543 nm, yellow at 594 nm, and orange
at 612 nm.
Helium neon laser is used as an aiming beam for lasers that have non visible
wavelengths, such as carbon dioxide.
When aligned with the non visible laser, it defines the laser's impact site for the
surgeon. This alignment of these two laser beams is checked before treatment
begins.

• The typical helium-neon laser consists
of three components: the laser tube, a
high-voltage power supply, and structural
packaging.
• The laser tube consists of a sealed glass
tube which contains the laser gas,
electrodes, and mirrors.
Page 29
• Depending on the power output of the
laser, the tube may vary in size.
• The laser gas is a mixture of helium and
neon in proportions of between 5:1 and
14:1, respectively.
• Electrodes, situated near each end of the
tube, discharge electricity through the gas.
• Mirrors, located at each end of the tube,
increase efficiency.

• IN HELIUM-NEON LASERS, THE NEON ATOMS ARE THE SOURCE
OF LASER LIGHT.
• Because stimulated emission only takes place when there are excited
neon atoms available, the process will quickly come to an end unless the
neon atoms are replenished with energy.
• The helium atoms in the laser gas carry out the process of re-energizing
the neon. Helium is perfect for this task because it has a meta-stable state
(does not decay as quickly) corresponding to the energy required to re-energize
the neon
• Therefore, not only do the helium atoms have the proper energy to re-energize
the neon, they can hold onto that energy long enough to transfer
it.

o Nd:YAG (Neodymium-doped Yttrium Aluminum Garnet; Nd:Y3Al5O12) is
a crystal that is used as a lasing medium for solid state lasers.
o YAG laser energy is able to penetrate tissue to a much greater depth.
oUnlike CO2 laser, Nd:YAG laser is poorly absorbed by water. The YAG is often
used in a liquid medium.
o Because it penetrates water so well, the YAG is not a good laser for
vaporization. It is an effective coagulator, however, as it passes deeper into
tissue before absorption occurs.
oYAG energy scatters in tissue, so thermal damage is greater than with CO2
laser.
o It is absorbed with a power density that is maximum below the tissue surface.
This limits the ability to visually monitor the YAG laser's depth of penetration and
stresses the importance of the surgeon to understand the physics of each laser.

o YAG laser can be transmitted through quartz fibers and fluids.
Page 32
o The depth of penetration provides excellent hemostasis.
oGoldrath and colleagues in 1981 recognized this and used
Nd:YAG laser for the first hysteroscopic endometrial ablations.
oThis laser is also used for removal of hair and vascular lesions
in a Q-switched delivery.

 Produces a blue-green light that has two distinct bands at 488 nm and
515 nm.
 Referred to as colored lasers because they are in the visible spectrum.
 Can be transmitted through water or quartz fibers of 200 to 600 micron
diameter.
Page 33
 Hemoglobin and other deeply
colored pigments absorb their
wavelengths and are responsible
for their use in vascular and
pigmented lesions.

 Penetration into skin, typically 1 to 2 mm, is affected by the
concentration of skin pigments.
 It produce a moderate scatter 100 times that of CO2 laser.
This results in an excellent hemostasis.
Because of the scatter, they have minimal cutting ability.
The depth of tissue injury is roughly correlated with the laser
power settings.
Page 34

ᴥ KTP-532 laser derives its name from the potassium (K), titanyl (T), and
phosphate (P) crystal used to double the frequency and halve the
wavelength of the YAG laser.
Page 35
ᴥ 532-nm wavelength is emerald green.
ᴥ Tissue effects are very similar to those produced by the argon laser.
ᴥThe KTP-532 is used to vaporize or to coagulate, and energy emerging
from the end of the fiber can be used to cut tissue.
ᴥTheir greatest application has been in endoscopic surgery, because the
delivery systems for their energy can be passed down the operative
channel of an endoscope.

 This laser's wavelength is 2,100 nm.
 It is pulsed at 350 to 700 microseconds at repeating intervals of 5 to 20
Hz .
 The Ho-YAG laser's depth of penetration in tissue is 0.4 mm.
 Like CO2 laser, this laser is absorbed at the superficial layers of tissue.
 Vaporization speed, coagulation depth, and hemostasis can be precisely
controlled.
 These properties can be particularly useful in gynecologic endoscopy.

 Laser treatment can be delivered through small channels to
areas of difficult access.
 Of equal interest is its ability to limit the lateral spread of the
thermal energy.
 The risk of injury to bowel, ureters, blood vessels, and nerves
because of any lateral thermal spread is reduced.
Page 37

ARGON-PUMPED RHODAMINE-B-DYE
LASERS are tuned to produce a specific
wavelength of light.
They are delivered to cells that have been
sensitized with HEMATOPORPHYRIN
derivatives (HPDs).
Certain HPD drugs concentrate in
malignant tissue and are activated by
specific laser wavelengths.
This results in a cytotoxic effect on the
tumor.
The release of singlet oxygen results in the
death of the cancer cells.

o The laser beam must be delivered
from its source to the tissue.
o Carbon dioxide laser, the first laser
used in gynecology, is delivered to
tissue through air in an articulated
arm composed of hollow tubes and a
series of internal mirrors.
o The mirrors are precisely aligned to
keep the laser beam directed along
the path of the arm.
o At the distal end a lens made of a
special compound focuses the laser
beam.

 Delivery unit used to aim and control the laser beam is called
a micromanipulator.
 This system allows the surgeon to precisely deliver the laser
to the tissue.
Page 40
 It is attached to the microscope for easy access by the
surgeon. The beam is reflected to the tissue by a mirror
controlled by a joystick.
 A Colposcope is used for the operating microscope and used
to treat the cervix and vulva.
Micromanipulators can be fitted with focusing lenses similar to
a zoom lens of a camera. This allows the spot to be varied in
size without changing the optical focus for the surgeon.

 This system is composed of a focusing lens contained within a
metal tube that is held in the hand.
 The lens typically has a short focal length, capable of producing
a very small 0.2-mm spot size.
Page 41
 With this narrow beam, the laser is used as a cutting
instrument.
By pulling the hand piece away from the tissue, the surgeon
creates a larger spot size used for vaporizing tissue.
 Cutting and coagulating external genital surgery became its
principal application

 Next advancement was the use of lasers in laparoscopy.
 CO2 laser was delivered through large channels in a single
puncture operative laparoscope.
 The large channels were necessary to transmit the beam and
avoid reflections from the channel walls.
 Rigid wave guides were introduced that could also be used
through ancillary 3 mm or larger channels.

 Fibre delivery is less cumbersome and produces less plume and more
hemostasis.
Page 43
 It requires smaller channels.
 The aiming beam is easily seen.
 This mode of delivery is especially useful in hysteroscopy because
fiber lasers could be used through fluid distending media.
 Neodymium and holmium YAG are delivered through optical quartz
fibers 100 to 600 microns in diameter.
 At the tip of the fiber, the beam diverges, so power density is greatest
just off the tip of the fiber.
The beam also can also be defocused by moving the tip of the fiber
farther away from the target tissue.

‡ First use of lasers in gynecology was to treat CERVICAL
INTRAEPITHELIAL NEOPLASIA (CIN) and VISIBLE CONDYLOMATA of
the lower reproductive tract.
Page 45
‡ The precise cutting and ablative properties of CO2 laser prompted an
interest in this surgery.
‡ It was successfully used in the 1980s, and CO2 laser was enthusiastically
received by many gynecologists.
‡ Colposcopy provided an accurate means of identifying the location and
size of the lesions, and CO2 laser provided unparalleled precision to treat
these conditions.
‡ Micromanipulator delivery is most popular, although another alternative is
using the laser hand piece while visualizing the surgical field through a
colposcope.

 CIN / Squamous Intraepithelial Lesions (SILs), has been treated
successfully by either in situ destruction or excision.
 In 1968, Palucek and Townsend reported a series in which cryosurgery was
used to destroy CIN.
 From the beginning, however, the use of destructive procedures that did not
produce a pathologic specimen evoked strong criticism, fearing that lack of a
complete pathologic examination of the target tissue could result in a missed
diagnosis of invasion.
 In the late 1960s, Cartier (Paris) developed a cutting loop electrode with a
wire diameter of 200 micron that, when properly used, produced only a very
small amount of thermal damage in the excised specimen.
 A larger wire loop was designed for excisional cervical surgery in the United
States. Its use, known as a Loop Electrode Excision Procedure (LEEP) or a
Large Loop Excision Of Transformation Zone (LLETZ) procedure, provided a
tissue specimen as an alternative to ablation procedures.

 Although CIN has been described as a noninvasive surface phenomenon,
it is well known that the process involves the endocervical crypts.
 The work of Te Linde and others pointed out that the endocervical crypts
were involved in CIN, but it
was Anderson and Hartley in 1980 who really
emphasized the therapeutic implications;
namely, adequate depth of destruction or
excision is required to achieve satisfactory
results.
 Anderson and Hartley measured the depth of
crypt involvement and found that 99% of CIN
extends no further than 4 mm from the surface
into the cervical crypt.
Page 47

 If an area of intraepithelial neoplasia on the cervix was either excised or
vaporized to a depth greater than 4 mm, virtually all of the neoplastic process
would be treated.
 This concept of depth-of-crypt involvement is extremely important as it
dictates a measurable depth of destruction to be achieved by vaporization of
the transformation zone if a surgical specimen is not to be removed by
conization
 It follows that if the lesion of intraepithelial neoplasia is visualized in its
entirety (i.e., if the borders of the lesion are clearly seen on the cervix, and the
lesion does not extend up into the canal), then it can be biopsied and correctly
diagnosed as intraepithelial neoplasia.
Page 48
 This assumption provides the justification for all nonexcisional, ablative
procedures used to destroy cervical intraepithelial disease.
 Laser ablation by virtue of its ability to be delivered under colposcopic
magnification and applied according to a patient's specific, unique anatomy is a
valuable tool.

Cervical conization has been defined as an
operation that removes a volume of tissue from
the central longitudinal axis of the cervix
including the external os & certain length of
endocervical canal.
Actual shape of the volume of tissue removed
should be determined by the distribution of the
lesion and not by some preconceived
geometric shape.
Conization, then, is a generic term, and does not necessarily imply that
a perfect cone-shaped defect has been produced in the cervix.
Cones can be asymmetric- short, long, thin, cylindrical, or any other
shape that accomplishes the intended goal of complete removal of the
lesion and the tissue at risk.

A number of techniques have been used to perform conization operations.
In laser surgery, the end result is the same. If the CIN lesion cannot be entirely
visualized or a neoplasm cannot be properly diagnosed for any reason, the CIN
should not be treated by an ablative procedure.
PRE REQUISITES
a. Lesion must be completely visualized.
b. Transformation zone must be completely seen.
c. No doubt as to the intraepithelial nature of the disease.
d. Adenocarcinoma of the endocervical canal must be ruled
out.

It has the advantage of being able to vaporize intraepithelial disease occurring
on unusually shaped cervices eg. in fetal diethylstilbestrol (DES)-exposed
patients (patients with cervical-vaginal anomalies or very narrow vaginas).
Page 51
General anesthesia is usually not required.
Preoperative medication may include antiprostaglandins; this reduces the
cramping that accompanies the laser ablation.
Local anesthesia is most preferred by colposcopists.
Intracervical Lidocaine 1%, injection directly into the cervix at 12, 4, and 7
o'clock.

No special prep is necessary.
The cervix is cleaned with a 4% acetic acid solution, and the lesion to be treated
is identified.
Margin of the transformation zone is outlined by a series of vaporization craters,
using short bursts of laser energy .
The entire transformation zone is included in the area to be vaporized.
The dots are connected so that the area to be treated is completely outlined.
Spot size of 2 mm is used for the vaporization operation.
Vaporization is carried to 7 mm.
Depth can be measured with a calibrated measuring device.

It is more accurate to divide the cervix into sections and then destroy the tissue
section by section.
In this way, part of the normal cervical anatomy is preserved throughout the
operation, and even though the topography of the cervix may change, the exact
depth of destruction can always be measured for each section.
The margin peripheral to the transformation zone is treated for a distance of 2 to
5 mm.
Page 53

The endocervical canal is exposed with a
cotton applicator for examination.
A wet applicator is used within the canal to
limit the laser beam from vaporizing the
upper canal.
POST OP INSTRUCTIONS
Patients undergoing laser surgery to the cervix usually require very little
postoperative care.
Postoperative follow-up in 2 to 4 weeks.
Coitus is avoided for at least 4 weeks.
Temperature elevations above 38°C and bleeding heavier than her normal
menses are reported. About 15% of these patients will have some small amount
of vaginal bleeding. Excessive bleeding is encountered in only about 2% of the
patients.
The patient is allowed to return to work within 48 hours.

1. There is less bleeding than with a scalpel.
2. There is less tissue damage than with the electric cautery.
3. The procedure has advantages over cryosurgery in that it can be
done with much more precision, and the results are better for
lesions of all sizes.
4. Morbidity is low.
5. All types and extents of intraepithelial neoplasia can be treated.
6. The most conservative procedures can be performed by using
combinations of vaporization and excision.

• Unlike the cervix, the vulva is often the site of multifocal disease.
• Vulvar laser surgery should be done with the aid of the colposcope.
• It is also imperative that the surgeon performing laser surgery on the vulva or
the vagina has a working knowledge of vulvovaginal histology and of the
variations in thickness of normal and abnormal neoplastic vulvovaginal
epithelium.

ANATOMY OF THE
VUVLAR SKIN
 Vulvar skin is composed of two layers, EPIDERMIS and DERMIS.
 Margin between epidermis and dermis is an irregular one because of the RETE
RIDGES.
Between the rete ridges are projections of dermis known as DERMAL PAPILLAE.
The dermis can be divided into two layers: the Superficial Papillary Layer and the
Deep Reticular Layer.
There are also skin appendages, such as
Pilosebaceous follicles;
Eccrine Sweat glands;
Apocrine glands;
which project deep into the dermis.

VIN, & Human Papillomavirus (HPV), may involve skin appendages
and epidermis.
Although the thickness of the epidermis may be a fraction of a
millimeter, the dermis may measure 7 to 8 mm in thickness, and skin
appendages may penetrate the full thickness.
It is the goal of the laser surgeon to remove the involved epidermis
and a portion of the skin appendage that may also be involved in the
disease process
Page 58

 Unlike cervical vaporization, the depth of vaporization on the vulva
cannot be measured.
Page 59
 REID 1991 suggested 4 Surgical Planes as follows:-
a. Epidermis down to the basement membrane.
b. Extending into the papillary layer of the dermis so that the laser
surgeon removes both the epidermis and the papillary dermis.
c. Extends upto the reticular dermis and uncovers the coarse
collagen bundles that can be seen through the colposcope as
grayish white fibers.
d. Complete removal of the skin right down to the underlying
subdermal fat.
If this level is reached, healing must take place from the periphery, or
a graft must be supplied.

Genital warts are soft growths on the skin and mucus membranes of the
genitals.
Page 60
Most commonly caused by HPV.
They may be found on the penis, vulva, urethra, vagina, cervix and
in & around the anus.
Genital warts are a sexually transmitted infection (STI).
Certain types of HPV can lead to pre cancerous changes- cervical cancer, or
anal cancer.

• It involves the epidermis and may also involve the
superficial portions of skin appendages.
• Only the warty lesion itself plus the surrounding
epidermal margin need to be destroyed
• Each condylomata should be identified and the laser beam directed this
target.
•Laser vaporizes the condylomata rapidly with the beam. The char and debris
are wiped away, and the proper surgical level is colposcopically identified.
Page 61
• Vaporization is done upto the papillary dermis (second surgical
plane).
•Cold normal saline is used to cool the vulvar skin, because cooling helps
reduce the heat diffusion and, therefore, the resultant tissue injury lateral to
the laser impact site.

It is impossible to colposcopically differentiate
between some forms of HPV lesions that occur on the
vulva and significant VIN.
Therefore, it is extremely important to obtain a biopsy
specimen of the vulva in as many areas as necessary
to correctly identify the pathology before laser surgery.
When laser surgery is used, the vulva is recolposcoped, and 4% acetic acid is applied
to demonstrate areas and borders of neoplastic or viral involvement.
Page 62
The larger areas are outlined in the manner described for CIN.
If a lesion is large, it may be divided into smaller areas for lasing, because this
provides a more accurate approach.

As soon as the laser beam is passed over the surface of the tissue, all landmarks
disappear.
Proper identification and marking of the limits of the disease by the laser is a highly
necessary step in treatment.
Although destruction must be carried to the third surgical plane (i.e., the reticular
dermis), the first step in vulvar laser surgery always involves identifying the papillary
dermis.
When the tiny micropapules of this layer are seen, the laser surgeon again ablates
through this most superficial dermis, wiping away char and identifying the underlying
reticular dermis.
Page 63
A. Pt after 4 wks of therapy.
B. Pt after 6 wks of therapy

Often intermittent pulses of laser energy can improve surgical control of the laser
beam.
Instead of reducing the power of the beam, it is possible to use the mechanical timer
on the laser console to reduce exposure by delivering one-tenth-second to one-twentieth-
Page 64
second bursts of laser energy.
This technique allows the surgeon time to react to the microsurgical review of the
tissue and more easily control the rate of energy delivery, thus too-deep penetration,
char, and residual thermal damage are also reduced to a minimum.

POST - OP CARE
1. Foley catheter may be required to avoid the immediate discomfort caused by
urinary salts on the denuded vulvar surface.
Catheters can be placed either through the urethra or suprapubically.
2. An antibacterial cream or ointment, such as Sulfadine Cream or Bacitracin
Ointment, is applied to the lased tissue to protect the raw surface from
agglutination and to help prevent superficial infection.
3. The patient must be given instructions to keep the vulvar folds separated, and
the application of this medication helps in this respect.
4. An ice pack is placed on the vulva when the patient leaves the operating room.
5. Sitz baths begin the first day after laser surgery and are continued two times a
day until the patient is no longer uncomfortable and the vulvar area is well on the
way to reepithelialization.
6. The patient is seen in a week to ensure there is no agglutination of vulvar folds.

Vaginal Intraepithelial Neoplasia (VAIN) and associated HPV infections
are among the most difficult lower reproductive tract intraepithelial
neoplasias to treat for a number of reasons:
i. The vagina has a large surface area, which is difficult to visualize
Page 67
colposcopically.
ii. There are many rugae and folds in the vagina.
iii. The angle of the vaginal axis makes it difficult to treat by
perpendicular beam impact.
iv. The vaginal fornices are difficult to stabilize because they are quite
distensible, and the cervix may hide portions of the fornix.
v. The colposcopic appearance of VAIN varies greatly and often goes
unrecognized even by the expert colposcopist.

VAIN does not demonstrate mosaic patterns except in areas of
Adenosis.
Often one sees coarse punctation, but the lesion may vary in color
from a pale grayish white to the intense whiteness produced by
hyperkeratosis.
Page 68
The lesions are multifocal and the borders are usually distinct,
although the lesions may be serpiginous.
VAIN May Appear As An Iodine-free Zone.
In the postmenopausal patient, it is helpful to treat the patient with
topical estrogen for 2 weeks before examination for optimal accuracy
of the iodine test.

When the vaginal epithelium is destroyed, there
must be visual identification of the underlying
lamina propria because, as it is impossible to
accurately measure the depth of destruction in this
very irregular area.
Because the vaginal squamous epithelium is only a
fraction of a millimeter thick and there are no skin
appendages in the vagina, ablation is a superficial
operation.
Surgeon often uses the speculum to one side and shoots through the open sides to
manipulate the target into a position that is perpendicular to the laser beam.
The vaginal rugae must also be ironed out to ensure even laser energy application.
All of this is & thus most patients with VAIN require general anesthesia on an
outpatient basis.
Page 69

Laser beam is rapidly passed over the area, and the epidermis is lifted
away from the underlying lamina propria.
A wet sponge or cotton swab is used to wipe away char and coagulated
epithelium.
Often the tops of rugae are removed, but the troughs or valleys in
between still contain viable dysplastic epithelium.
With proper use of the speculum and other instruments, this problem is
easily overcome.
Page 70
Adequate margins of 5 mm or more are used.

POST - OP CARE
 Much of the discomfort encountered in postoperative vaginal laser surgery
stems from laser wounds in the vaginal introitus.
 Sitz baths .
 Protective vulvar creams.
 Daily vaginal applications of either Estrogen or Sulfa Cream or of some
other bacteriostatic preparation.
With extensive laser treatment, vaginal walls can touch each other. The
patient should also be examined at intervals to make sure that vaginal
coaptation is not occurring.
Vaginal healing usually takes place from the periphery of the wound
because of the lack of skin appendages in vaginal mucosa.
If the laser has been thorough and the denuded area is large, healing is
often delayed, and granulation tissue may result. This granulation tissue can
be removed and the wound then treated with Silver Nitrate.

procedure percentage
1. Fulguration / Excision of endometriosis 68 %
2. Lysis of adhesions 62 %
3. Ovarian Cystectomy 31 %
4. Division of Uterosacral Ligaments 30 %
5. Presacral Neurectomy 10 %
6. salpingo-oophorectomy 22 %
7. Removal of Ectopic Pregnancy 10 %
8. Myomectomy 4 %
9. Neo salpingostomy 4 %
10. LAVH 18 %
11. Retropubic Urethropexy 10 %
12. Sacral Colpopexy 3 %

Advantages of laser surgery in the abdomen include precision,
limited adjacent tissue damage, rapid healing, minimal scarring,
and the ability to treat areas of difficult access from a remote site.
An example of the minimal trauma of laser on tissue is the research
work of Bern, who demonstrated the ability to remove intracellular
chromosomal material with the carbon dioxide laser without
destroying the cell.
Page 74

THE DELIVERY OF LASER UNDER MICROSCOPIC CONTROL WAS
USED FIRST IN OPEN ABDOMINAL INFERTILITY SURGERY
Page 75
1) Adhesiolysis
2) Fenestration of paraovarian and polycystic cysts
3) Vaporization of endometriosis
4) Fimbrioplasty
5) Neosalpingostomy
6) Resection of ectopic pregnancy
7) Tubal anastomosis
8) Tubal implant
9) Myomectomy
10)Metroplasty

ADVANTAGES
Greatest magnification
Spot-size control
Ease of deep pelvic surgery
Instrument-free field
Constant focus
Remote control
DISADVANTAGES
Delivery angle restricted
Difficult to change spot
Larger spot size with a greater margin of injury

ADVANTAGES
Can be used without magnification
Develops smallest spot size possible
Multiple angle of delivery possible
Focus and defocus is easy
Highest power density for minimal tissue injury
DISADVANTAGES
Cumbersome equipment
Shallow depth of focus
Difficult to maintain precise focus
Handpiece must be in field

 Unipolar electrocoagulation
 Bipolar electrocoagulation
 Laser coagulation
 Extracorporeal ligatures
 Extracorporeal sutures
 Intracorporeal sutures
 Endocoagulation (Semm)
 Hemoclip

It is important that surgeons, nurses, and all those associated with
laser surgery have an understanding of the potential health and safety
hazards associated with the use of medical laser systems and the
precautions needed to use them safely.
Laser injury and potential hazards can be considered related to the
organ systems at risk.
Page 79

EYE is considered to be the organ most vulnerable to damage by
laser.
The eye collects and concentrates light energy on the retina.
It has a natural protective mechanism in the lid and tearing reflexes.
However, many lasers are extremely intense and are delivered so
rapidly that injury can occur.
Lasers in the visible and near infrared bands will be transmitted
through the eye to the retina.
With sufficient intensity, they can cause visual loss.
Page 80

Protective measures for eye protection include spectacles, goggles, or coverall
goggles to filter out the specific laser wavelength while transmitting visible light.
Colposcopes and operative lenses of laparoscopes shield the laser surgeon's
eyes from CO2 laser injury when delivered through these systems.
The fiber-optic lasers that penetrate water and clear glass also penetrate the
eye.
In endoscopic surgery, special glasses or filters specific for the laser are used for
protection.
The optical filter is coupled to the eyepiece of the telescope and can be activated
when the surgeon steps on the foot switch.
Page 81
As a general rule, eye protectors are required for work with lasers.

SKIN is considerably less vulnerable to laser injury than the
eye.
Skin injury can also occur from ignition of flammable material
by the laser beam.
Laser hazards to operating room personnel and patient
includes accidental exposure from misdirection of the laser
beam.
The risk of this happening can be reduced by using the
Standby Mode when not actually operating.

Electrical hazards of laser equipment are similar to other
types of electrical or electronic equipment.
There is no unique electrical safety problem associated with
laser use.
Vaporization of tissue produces smoke with potential health
hazards.
Careful evacuation and filtration of the laser plume will reduce
any hazard of laser smoke inhalation.
The evacuation of the plume is most effective if the tip of the
tube is within 2 cm of the tissue being treated.
It is important to remove smoke from the closed abdominal
cavity during laparoscopic surgery. This allows the surgeon to
see clearly as well as removing it from inhalation by the
operating room personnel.
Special high-efficiency masks provide additional respiratory
protection.
Page 83

 Understand the physics and tissue effects of the laser one is
using.
Page 84
Implement precautions needed for laser safety.
 Set the time the laser is exposed to tissue for the optimum
effect.
 Biopsy tissue before coagulation or vaporization if
intraepithelial stage is in doubt.
 Select appropriate backstops if laser beam can continue
through the tissue being treated.

Lasers

More Related Content

What's hot

Viewers also liked

Similar to Lasers

More from drmcbansal

Recently uploaded

Lasers