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869 South Street, Fitchburg, MA 01420-6924
 
 
 
 
 
 
 

Laser Surgery

 
Dear Friends,
As you have asked us frequently to provide the best medical and surgical care for your pets over the years, we have always obliged to answer the calls. A few years ago we added a unique and very effective oriental medical art - acupuncture to our services, that required an extensive training here in America and in Korea. The results of acupuncture have been phenomenal in many clinical cases.
In order to provide better surgical care we have acquired LASER surgical technology and equipment recently, and are offering services throughout the region's pet owners like yourself. This modern surgical technique will be very beneficial to an animal who has a risky surgical condition due to possible blood loss during an operation as well as to any animal operated on because it reduces pain and enhances healing postoperatively.
You can find out more information by calling us at (978) 343-3049, Twin City Animal Hospital or visit our Animal Laser Clinic Website at
http://www.lid.com/yoon.
Thank you for your encouragement over the years.
Samuel S. Yoon, D.V.M., C.V.A.
 
Samuel S. Yoon,
DVMCertified member of
The International Veterinary
Acupuncture Society
 
The Luxar Accuvet CO2 surgical laser is the first CO2 laser to bring proven surgical capabilities to the veterinary surgeon. The benefits of laser surgery can help expand the veterinary practice and improve the standard of care by adding or enhancing successful in-office procedures.
HOW LASER ENERGY WORKS
The AccuVet delivers a concentrated beam of light at 10,600 nm. This particular wavelength is highly absorbed into the intra-cellular water found in soft tissue. The laser energy instantly vaporizes the intra-cellular water, ablating targeted cells quickly and precisely, with little effect on surrounding tissue.
ADVANTAGES OF LASER SURGERY
The special characteristics of the CO2 laser have made it the most widely used type of laser in the world.
Precision - The laser can make fine incision or ablate extremely thin layers of tissue with minimal damage to surrounding areas.
Coagulation - Bleeding is minimized because the laser seals small blood vessels as it cuts.
Non-contact delivery - The laser instrument does not tear or bruise the tissue, so pain and swelling are minimized and recovery may be more rapid.
Sterilization - Laser surgery sterilizes as it cuts so risk of infection is reduced. The laser also may be used to help debride or reduce infected tissue.
Reduced hospitalization time - Less pain, swelling, and bleeding result in faster recoveries, minimizing the time a pet and its owner must be separated.
CLINICAL APPLICATIONS
The AccuVet is ideal for a variety of soft tissue procedures, including treatment of the skin, eyes and mouth. Applications include:
Gingival reduction
Castration and hysterectomy
Declaw procedures
Oral and cutaneous neoplasia removal
Ear Cropping and canal ablations
Wound debridement
Avian and exotic animal procedures
And many more
Bartels, Kenneth E."Laser Use Grows in Veterinary Medicine."Biophotonics International, July/August 1997.
SUMMARY
Although human applications get much more attention and financial consideration, veterinary medicine is another market for biomedical lasers. The cost as well as the debatable returns for this type technology investment have limited the veterinary applications primarily to the academic community, research institutions and specialty practices. As efficacy is proven and equipment costs decrease, however, laser surgical and diagnostic devices will become mainstream in clinical veterinary practice.
The introduction of laser technology in veterinary medicine has been heavily influenced by economic considerations, and by the fact that governmental regulation of innovative technologies is considerably less restrictive when the patients are animals rather than people.Occasionally, the reduction in restrictions has been advantageous in implementing new techniques. For some applications such as "soft" laser therapy for biostimulation (supposedly to improve healing by applying low-power red laser light), protocols and devices that are restricted for human use in the U.S. have been heavily marketed to veterinarians, often on the basis of subjective assessments and anecdotal reports. In any event, the use of lasers in veterinary medicine for photothermal, photomechanical and photochemical applications is expanding rapidly, both in research and clinical practice.Because applications for laser surgery in human medicine are expanding, the desire of physicians and hospitals to purchase state-of-the-art equipment has also increased. As hospitals acquire equipment with advanced designs and options, their used equipment becomes available for veterinarians to purchase. However, even used equipment can be expensive in the long run, since maintenance costs can exceed the initial capital investment.
As with the acquisition of any new technology, it is extremely important that laser applications in veterinary medicine reflect responsible medical and scientific use. Strategies and gimmicks that advertise new and unique equipment can also attract individuals interested in offering treatments that have little or no proven benefit.
REALIZING THE POTENTIAL
An objective approach to surgical laser procedures in veterinary medicine is essential if the potential of this technology is to be realized. "Zap and vaporize" techniques coupled with a "burn and learn" philosophy can do harm to both patient and surgeon and can easily outweigh any benefits. An effort must be made to evaluate the laser's potential benefit to patients, rather than portraying it as a marvel of the 21st century.Although the use of biomedical lasers has generated entirely new treatment concepts, a veterinarian's clinical expertise and knowledge of pathophysiology must be the primary factors for determining whether a laser or scalpel blade is the better choice for a particular procedure.Many of the first reports of biomedical laser use in veterinary medicine involved endoscopy; fiber optics delivered Nd:YAG laser energy to treat laryngeal and upper respiratory conditions in horses, such as entrapment of the epiglottis and laryngeal cysts. Since then, both CO2 and Nd:YAG lasers has been used in general surgery in small animals where precise dissection and control of hemorrhaging are important. These procedures have included liver biopsy and resection of liver lobes, biopsy of the spleen, partial and complete removal of the kidney, and excision and resection of intra-abdominal, intrathoracic, cutaneous and mammary tumors.Recent reports have reviewed clinical uses of laser energy for ablation and coagulation of brain tumors and superficial growths or tumors (Figure 1), treatment of eosinophilic (foamlike) scar growths and ablation of lick granulomas (the buildup of scar tissue from excessive licking) in dogs.Because advantages such as shorter recovery time, less perceived discomfort and availability of potential treatment regimes for conditions not amenable to conventional procedures, biomedical lasers are being used in the realm of exotic animal or zoo practice where hospitalization time must be minimal (Figure 2). Clinical use of the holmium (Ho:YAG) laser for ablation of intervertebral discs in dogs has also recently been instituted and shows tremendous potential (Figure 3).The use of medical lasers for veterinary ophthalmologic applications was established in the early 1980s, although it is not as common as in human practice because of the cost and differences between human and animal conditions. The Q-switched or continous-wave ophthalmic Nd:YAG, argon-ion and diode lasers have been used as photocoagulators in retinopathies, for treatment of lens-induced papillary opacification and for transcleral cyclodestruction of the ciliary body to treat glaucoma, which is very common in dogs. As experience and interest increases and lasers become more available to veterinary ophthalmologists, clinical applications will increase.
Photodynamic therapy has been used clinically in veterinary medicine by several investigators since 1985. A number of initiatives have been reported using the technique to treat dogs and cats with spontaneously occurring tumors, primarily of the skin and mouth. This exciting method of destroying tumors employs interaction of light with a photosensitizer in the presence of oxygen. It will undoubtedly play a much larger role in clinical veterinary medicine as protocols are established and photosensitizing drugs are approved by the U.S. Food and Drug Administration (FDA) for use in animals. Phythalocyanines, theophorbides, 5-aminolevulinic acid and hematoporphyrin derivatives such as Photofrin have shown the most promise.
LARGE ANIMAL SURGERY
Use of biomedical lasers in small-animal orthopedics has been more limited than similar applications in human or equine surgery for two reasons: Expensive arthroscopic equipment is not always applicable or readily available, and it is harder to use on the smaller joints of cats and dogs. Lasers have not been effective thus far for ablation of bone, although various wavelengths from the free electron laser are being evaluated. Ablation with a CO2 laser of the synthetic polymer methylmethacrylate during removal or revision of total hip prostheses from dogs also has been evaluated recently.Surgical laser techniques for equine urogenital and laryngeal procedures were intially reported in 1983.
Clinical and histological evaluation of the CO2 laser's ability to prevent the growth of painful nerve masses in a horse's forefoot after surgery was introduced in 1984. Laparoscopic use of flexible, hoolow fibers with the CO2 laser has been described as a clinical possibility. Developing an economical transendoscopic system to deliver higher powers from currently available CO2 lasers might generate increased interest in their clinical use.The effectiveness of the CO2 laer for cutting horse skin has also been compared with other incisional methods and was found to produce adjacent thermal injury comparable to that from an electrosurgical unit. Other uses of lasers in soft-tissue procedures in large-animal surgery include excision and ablation of tumors and excessive growths of scar tissue, known as proud flesh in horses, with CO2, Nd:YAG, argon-ion, KTP, diode and holmium lasers.
The CO2 and Nd:YAG lasers have proved to be the most effective for rapid excision and vaporization when operated at powers greater than 40 W.In addition, procedures that require meticulous control of hemorrhaging such as excision of penile hematomas, have been performed successfully using an Nd:YAG laser through an optical fiber in contact mode. The CO2 laser's use for preparing a wound bed for skin grafts (called a pinch graft) has found favor among some surgeons since recipient pockets can easily be created in a "no touch" mode that helps control bleeding and can actually sterilize the wound. In addition, precise tissue dissection in the equine abdominal cavity for laparoscopic oophorectomy (removal of the ovary) was found to be safe and effective using CO2 laser energy through a hollow waveguide.
Traditionally, laryngotomy has been used to perform in the pharynx and larynx of horses, but the required use of a general anesthetic often extends recovery time. For the past 12 years, a few equine surgeons have used transendoscopic laser techniques in both contact and noncontact modes. Transendoscopic use of the Nd:YAG laser in the horse has been and continues to be an effective method for treating certain upper airway obstructions.The advantages of approaching minimally accessible lesions, the ability to perform procedures with local rather than general anesthesia and the decrease in recovery time have provided the motivation for continuing this successful effort. Objective protocols have provided effective treatments for nasal pharyngeal obstructions and laryngeal problems such as hyperplasia, enlargement of lymph glands, epiglottic entrapment or dorsal displacement of the soft palate.
Such methods make ventriculectomies possible and have provided adjunctive therapy for diseases of the gutteral pouches connected to the eustachian tubes of horses. Specifically, transendoscopic delivery of Nd:YAG and diode laser energy has provided treatment for endometrial cysts that cause infertility, an otherwise hard-to-approach condition (Figure 4).
LIMITED ORTHOPEDICS
As in small animals, orthopedic applications in large animals have been limited. As delivery methods improve and systems with appropriate wavelengths (Ho:YAG at 2.1 micrometers and Er:YAG at 2.94 micrometers) become more affordable for veterinarians, applications will undoubtedly increase as they have in human medicine, especially in equine surgery. Use of the CO2 laser for intra-articular cartilage vaporization has had favorable results, although delivering this wavelength into a joint is technically difficult.
A report on the use of the Ho:YAG for "low-power" stimulation of healing articular cartilage in the horse has generated interest in possible clinical applications in both human and veterinary medicine. Low-power infrared laser energy, which could accelerate the healing of sutured wounds, has been advocated as an adjunct to postsurgical therapy for equine trauma and for soft-tissue conditions such as teat lacerations in cattle.
A recently described minimally invasive standing method for treating angular limb deformities in foals using the Nd:YAG laser shows excellent potential.As biomedical laser technology merges with military and industrial advances, improvements in existing devices as well as the development of new ideas will continue at astonishing rates. Recent changes in health care philosophy accompanied by more limited funding sources mandate the use of minimally invasive and minimally damaging procedures that should lower overall costs. Veterinary medicine can and should be in the forefront during these exciting times, adding an essential dimension to the development of cutting-edge technology.
Research on basic laser-tissue interaction and selective tissue destruction is increasingly important for achieving the therapeutic goal of minimally invasive procedures for a variety of conditions. Destruction of alimentary tract mucosa is possible using holmium laser energy endoscopically. Intersitial laser hyperthermia to treat malignant tumors will become an effective part of the veterinary oncologist's armamentarium, as will expanded use of photodynamic therapy.
Photothermolysis using appropriate chromophores for selective tissue destruction and sterilization/disinfection is currently being proven an effective treatment for tumors and trauma in clinical and laboratory settings. Minimally invasive urologic techniques for ablation of bladder, urethral and prostatic conditions in small animals will become more common as technology is refined, smaller endoscopes are developed, delivery systems are improved and new laser wavelengths are investigated.
SOFT-TISSUE PROCEDURES
Laser lithotripsy is now possible using both visible and infrared wavelengths. This technology may eventually allow minimally invasive removal of kidney stones and gallstones in animals. Fusion or welding of blood vessels, alimentary tract, ureter or urethra, skin and even bone may be possible. Application of lasers for micromanipulation of gametes and improvement of fertilization and hatching rates during in vitro fertilization are nearly clinical veterinary realities. The use of lasers for soft-tissue dental procedures is already feasible and, with continuing investigations, hard-tissue dental procedures should become so. The Ho:YAG and Er:YAG have already been used for enamel resurfacing and ablation in animals.The existence of diode lasers with wavelengths from the ultraviolet to the far-infrared means that user-friendly, durable, portable, less-expensive laser systems are definitely on the horizon. Currently, FDA-approved high-power diode lasers are available for both clinical and investigational use from manufacturers such as SDL, Diomedics, Cynosure and Applied Optronics.
At this point, diode laser development and technologies that provide smaller but more durable clinical devices for multiple applications seem to hold the greatest promise. In addition, the use of lasers in diagnostic tools and sensors is one of the fastest-growing branches of biomedical laser development. Minimally invasive methods for detecting malignant cells, abnormal tissue and metabolites have tremendous potential. Laser diagnostic technologies could have a significant impact on veterinary medicine if costs for such devices become resonable.
In 1968, the removal of a vocal cord nodule in a dog demonstrated one of the first practical clinical applications of the continuous-wave CO2 laser. Since that time, many other research teams have relied on animal models to determine initial laser parameters and efficacy of new wavelengths, and for final evaluation of new surgical procedures prior to use in human medicine.
THE "RESEARCH TRIANGLE" CONCEPT
"Research triangles" with a veterinary laser laboratory as the base for innovative biomedical laser investigation, have been successful at several institutions including Oklahoma State University (Figure 5). Physicists and laser engineers play the major roles during this initial phase, but veterinarians, physicians and other biomedical scientists also play an active role in any investigation that may result in a clinical application.

The second phase of research and development should logically involve cadaveric or large tissue studies that might lead to live animal investigations. At this stage, veterinarians can be the main catalysts for the advancement of biomedical laser technology and laser-based therapeutic techniques. Their expertise and training with multiple species and practical medical knowlege can often expedite research projects and reduce the number of animals needed for a study.

Objective studies often will prove some applications to be impractical for clinical purposes. However, it is essential to realize that although an idea or new device may be impractical for mainstream veterinary medicine because of high cost and limited availability, veterinay participation on the biomedical research team is essential for both animal care and for an objective understanding of the clinical uses of biomedical lasers.
The third point of the research triangle is the transfer of technology to the human health care provider of commerial venturer who can then market the idea, instrumentation or technique. With this exception in mind, industrial partners and human health care organizations have sought and established collaborations with veterinary biomedical laser programs.
Although a number of manufacturers such as Luxa, Sharplan and Surgimedics have made concerted marketing efforts focused on the veterinary profession, most practitioners find biomedical lasers too expensive and limited in their applicability. However, with trends in veterinary medicine toward minimally invasive diagnosis and therapy, the use of lasers for both direct and transendoscopic tissue ablation should become more popular. Coupled with educational opportunities provided by both manufacturers and academic or organizational outreach programs, veterinary laser surgery and medicine could blossom in the next five years.
YOUR PETS ARE COUNTING ON YOU TO LEARN ABOUT LASER SURGERY.
Why laser surgery?
Less pain -- The laser seals nerve endings as it "cuts," so your pet may require less anesthesia during the operation, reducing the risk of complications. Pain after surgery is also reduced.Less bleeding -- The laser seals small blood vessels during surgery.Less swelling -- Laser energy does not crush, tear or bruise because there is no physical contact with the tissue.
What does this mean for my pet?
Reduced risk of infection -- The laser sterilizes as it removes diseased tissue, killing bacteria that cause infection.Precision -- The laser can remove unhealthy tissue without affecting or removing surrounding healthy tissue.Quick return to normal activities -- Healing is rapid and there is less post-operative discomfort.Laser procedures reduce trauma to your pet, improve healing, and may shorten time spent in the veterinary hospital.
Are lasers new?
No. Laser technology has been proven to work for more than 20 years -- medical doctors have used lasers to help many thousands of people.
We are pleased to be among the first veterinary practices to offer laser surgery specifically for animals.
What types of procedures can lasers perform?
A laser is ideal for a wide variety of surgical procedures for dogs, cats, birds and other animals. Laser surgery can correct many common conditions such as cysts, tumors, warts and infections that may occur around the eyes, ears, in the mouth, and anywhere on the skin. Specialized internal procedures are also possible. Your veterinarian will be able to tell you if your pet's procedure can be performed with a laser.
What is a laser?
A laser is a device that generates an intense beam of light at a specific wavelength.
How does a laser work?
Our patients are treated with a carbon dioxide (CO2) laser, the most widely used type of medical laser in the world. CO2 lasers produce an invisible beam that vaporizes the water normally found in the skin and other soft tissue. Because the laser beam can be precisely controlled, it removes or "cuts" only a thin layer of tissue at one time, leaving the surrounding areas unaffected. This level of control allows your veterinarian to be extremely precise in every laser surgery procedure.