By Noel A. Berger, DVM, MS For The Education Series
Originally published in Veterinary Practice News, December 2012
When I need a surgical instrument that is safe, effective, versatile, easy to use and affordable to own, I reach for my CO2 laser.
It has been over 16 years since my first Luxar laser was brought into the operatory, and I have always been well pleased with the results. Currently I am using a 30-watt AescuLight laser that delivers the intense coherent monochromatic collimated beam of photons through a hollow flexible waveguide delivery system to the handpiece, and ultimately the patient.
I also use a diode laser (980nm), a low energy laser (905nm) for physical therapy and a cluster of LEDs to activate adipose-derived stem cells in platelet rich plasma, but my overall favorite unit is the CO2 laser (10,600nm).
Soft Tissue Laser Surgery
The unique physical characteristics of the laser-tissue interaction between CO2 laser light and well-hydrated tissue are not at all dependent on intracellular pigments1-3. This gives me excellent precision, depth control and predictable surgical results when I use a CO2 laser to cut or ablate tissue.
Because this wavelength of laser light is highly absorbed in water, it does not transmit deeply into the tissue bed, giving the nickname “WYSIWYG”—what you see it what you get. This phenomenon ensures that the laser light will travel only as deep as the surgeon can see, and not damage underlying or surrounding tissue.
Learning Curve and ROI
The best part of using this technology is knowing how simple it is to acquire the skills to operate the equipment safely.
Any doctor with any level of surgical skill should quickly become proficient at making a single pass, full thickness skin incision. A CO2 surgical laser certainly does not need to be reserved for special procedures, and may be used exclusively in lieu of scalpel or scissors.
I routinely use my laser for spay and neuter procedures, removing cutaneous masses, ablating granulation tissue beds or tumor beds, and many other purposes that involve dividing tissue. Every clinical veterinarian who performs surgery can use a laser to perform these tasks, and perform them with less pain, less bleeding, less swelling and enhanced cosmesis.
The learning curve to acquire laser surgery skills is not as steep as learning other skills such as ultrasonography, laparoscopy or orthopedics. Although I am comfortable with performing more advanced diagnostics and surgical procedures, clearly the return on investment of time and money was the most rapid when I learned how to use the CO2 laser.
I have seen other veterinarians attempt to perform surgeries with a diode laser, or with an articulated arm CO2 laser, and without a laser altogether. There is no question as to the superior ease and facilitated excellence of using a CO2 laser with a flexible hollow waveguide delivery system to make this procedure successful every time. I strongly recommend practicing with someone well experienced in this technique.
Laser Assisted Uvular Palatoplasty (LAUP)
Many brachycephalic feline breeds (Himalayan, Persian) may have some compromise to upper airway flow, but this condition is primarily a health concern for dogs (Old English bulldog, pug, Lhasa apso, Boston terrier).
Generally the uvula is examined under sedation, and if it is thickened and overlaps the epiglottis, it may be excised back to a level that approximates the caudal pole of the tonsils—see Figure 4 (shown is Aesculight back-stop laser handpiece in position immediately preoperative) and Figure 5 (immediately post-operative)].
Many patients also have profound tonsillar hyperplasia, and the CO2 laser (see Figure 6) is ideal for removing the glands as well as the redundant uvular tissue. This is achieved at high power and in a single pass to remove the tissue without post operative pain, swelling or bleeding. All of my patients are usually eating and drinking normally that evening.
The ear is generally considered a very highly vascular and innervated tissue; thus any injury, disease or surgery to the ear is expected to be painful and hemorrhagic. Using a CO2 laser obviates those concerns.
Myringotomy is a controlled single pulse, low power ablation of a precise area of the tympanum, useful for relieving pressure or fluid buildup in the middle ear; see Figure 7.
A video otoendoscope is generally used in conjunction with a laser to perform the procedure. Lacroix- Zepp otoplasty, vertical ear canal ablation, and total ear canal ablation and pinnectomy (Figure 8) are all simplified using a CO2 laser due to its non-contact mode. These surgical procedures are easier to perform due to the enhanced visualization of the surgical field available when a laser is used.
In my community I participate in several trap-neuterrelease programs for feral cats. I use a laser to create a circular notch in the lateral ear margin to identify a cat as being sexually sterilized: females with right ear notch (see Figure 9), and males with left ear notch.
The tipless AescuLight handpiece facilitates this procedure; I can use a 0.25mm diameter beam for the skin incision, then switch to a 0.4mm diameter beam to divide the linea alba, then finally switch again to a 0.8mm diameter beam to create the ear notch, all without having to change tips on the handpiece.
The handpiece is autoclavable, and the surgeon can easily change the spot size during a surgical procedure without having to exchange sterile tips. The procedure is quick and does not require suturing upon completion. It is painless to the cat, and the laser beam sterilizes the skin defect.
Stem Cell Surgery
As part of my practice’s comprehensive and integrative approach to pain management, we employ adipose- derived stem cell therapy to treat osteoarthritis of dogs and cats. In dogs and cats, the stromal vascular fraction of adipose tissue works best for treating degenerative joint disease. Using a CO2 laser to create the incision—see Figures 10 and 11—is a natural requirement for us to perform the procedure well.
There are three general approaches to collect the fat for the procedure.
Falciform fat is the most common area used to harvest adipose tissue. Even in small dogs or cachectic patients, a good amount of fat is easily harvested from a cranial abdominal incision. Using a CO2 laser for this approach causes the skin to be numb post-surgically, and if laser is used to divide the linea alba for the laparotomy, that is even better for the patient’s comfort.
Many stem cell practitioners will choose to obtain fat from a reservoir caudal to the scapula deep to the latissimus dorsi muscle. This is important if an older patient cannot be placed in dorsal recumbency, or if a previous abdominal surgery resulted in the falciform fat being discarded. I have found that using a CO2 laser in this area greatly reduces the likelihood of seroma formation.
And finally, if falciform fat is not available and there is a paucity of fat behind the shoulder, a large inguinal fat pad can be used. The benefit of using a CO2 laser to harvest inguinal fat is that the energy is applied in non-contact mode, meaning no instrument touches the tissue.
This results in less trauma to the area and better visualization. Together, these allow for a more comfortable surgical extraction of fat from the groin with fewer iatrogenic complications.
Surgical CO2 lasers have withstood the test of time, and evidence-based medicine shows them to be highly effective for use in all companion animals. Flexible hollow waveguide CO2 laser is an affordable surgical tool that is easy to learn to use and master; it provides the best method to give the surgeon a good approximation of holding a scalpel, without the required traumatic contact of a blade or scissor.
Any surgeon of any experience level with an interest should be able to excel in its use with a minimal investment of time and effort. It gives the surgeon confidence that the end result of her work will be a less painful, less swollen, pleasant appearing incision.
All Images Courtesy of Dr. Berger
Dr. Berger is a graduate of Cornell University (1988) for both his DVM and MS in clinical sciences. He is certified by the American Board of Laser Surgery in veterinary surgery and has written a textbook on the subject. He is the owner of a second animal hospital and his second CO2 laser at the Animal Hospital and Laser Center of South Carolina, Pawleys Island, located between Myrtle Beach and Charleston. He lectures frequently on laser physics and clinical applications for small animal veterinarians, and is available for consultation and training.
This Education Series article was underwritten by Aesculight LLC of Woodinville, Wash., manufacturer of the only American-made CO2 laser.