Wausau, WI / August 2, 2012

Procedural Skill - General Surgery

Procedural Skills for Using Lasers in General Surgery

Authored by Raymond J. Lanzafame, M.D., MBA, FACS
Approved by The Board of Directors, American Society for Laser Medicine and Surgery

Preamble:

This document is intended to serve as guidance for the safe use of laser technology during general surgical procedures. It is intended as a living document, which will be modified as technologies, and clinical venues change over time.

Introduction:

The general surgeon encounters a wide and varied array of clinical conditions and operative scenarios in daily practice. Many different surgical skills and modalities are required to achieve acceptable outcomes for the patient. Any surgical procedure can be performed using lasers. However, there are no general surgical procedures for which use of laser technology is sine qua non. Few general surgeons use laser technologies today, which is largely due to lack of training and experience with these technologies and the ever-increasing array of alternative technologies and techniques available for clinical use.

General surgeons can use a wide variety of laser wavelengths and laser delivery systems to cut, coagulate, vaporize, or remove tissue. Proper use can reduce blood loss, decrease postoperative discomfort, reduce the chance of wound infection, decrease the spread of some cancers, minimize the extent of surgery in selected circumstances, and result in better wound healing if they are used appropriately by a skilled and properly trained surgeon. They are useful in both open and laparoscopic procedures.

There are some uses for which lasers are indispensable and other uses where their merit is relative. As with any new technique or deviation from the routine, the use of lasers may result in an increase in operative time initially. Surgical “speed” evolves and improves and the “length of the procedure” declines after the “learning curve” and once the surgeon becomes experienced and facile with the technique and the technology used to accomplish a procedure. Several other factors also impact the operative time.

The surgeon should have a complete working understanding of lasers, their delivery systems, and their tissue effects prior to attempting to apply them clinically. The surgeon should attend specific hands-on laser training programs if laser education and the opportunity to use these devices during the course of an approved residency training program were not available or if the surgeon is not familiar with a particular device or delivery system. Clearly, the house officer is in the ideal position to acquire the intellectual and manual skills necessary to use lasers and other technologies properly if this opportunity is provided as a part of the residency training program. Postgraduate continuing medical education programs are useful for those who did not have formal training elsewhere. It is imperative that the surgeon continue to develop these newly acquired skills in an ongoing, graded fashion. This requires the gradual incorporation of the use of laser technology into clinical practice by tackling the simpler procedures and tasks first, followed by more difficult problems later after the surgeon has developed a sense of comfortability with the technology. One should have a working understanding of the limits and advantages of lasers in one’s own hands. The surgeon must be aware that all lasers and delivery systems are not alike and that attention to the selection of the proper wavelength, the proper delivery system, and the proper laser parameters are central to achieving the desired clinical endpoint given the appropriate technical expertise. The selection of a laser device, delivery system, or any other instrument during the course of a procedure is critical to the conduct and outcome of that procedure. The selection of instrumentation for procedures involves a number of variables. However, the preference of the surgeon is a major determinant in this process. Preference depends on availability, skill, judgment, experience, and the sense that a particular tool “feels right” or “works well” for a particular task in the hands of a particular surgeon.

It is helpful to have an assistant who is familiar with the laser(s). The lack of proper assistance might prove disastrous. When possible, the surgeon and surgical assistants should work together frequently and should practice with the equipment prior to attempting a major procedure for the first time. These practice sessions can be accomplished in the laboratory or after hours. Meat, fruit, and vegetables provide sufficient material for the surgical team to familiarize themselves with the technology. Practice, when coupled with an adequate understanding of what a particular laser wavelength and delivery system is capable of accomplishing, enables the surgeon to select the appropriate laser for a given procedure.

Each laser wavelength has a characteristic effect on tissue and it is the combination of the laser tissue interaction, and the selection of the appropriate delivery systems and laser parameters that determine the ultimate effects of laser use during surgery. This presumes that the surgeon has the appropriate skill and technique. The ability to achieve the desired effect on the target tissue is also dependent on the surgeon’s understanding about the relationship between Power Density and the laser tissue interaction. The surgeon generally endeavors to use the highest power density that can be safely controlled, thereby minimizing the duration of the exposure and unwanted tissue injury by conductive heating of the tissue during contact with the laser beam.

Let us begin our discussion of “how” to use lasers optimally with some suggested guidelines for use of CO₂, KTP, and Nd:YAG lasers. The reader should recognize that the tables, which follow, represent a series of parameters that are not intended to be absolute but are intended to be suggestions, which should be tailored for the procedure to be performed. Modification of the suggested parameters should be based on the skill and experience of the surgeon. It should be noted that surgery will proceed more efficiently and with less thermal damage to adjacent tissues when the surgeon uses the maximum power density (fluence) that he/she is able to control comfortably.

Table 1 presents guidelines for the CO₂ laser. Parameters for the KTP laser are presented in Table 2. Table 3 lists suggested guidelines for the use of the Nd:YAG laser.

Preparation of the Operative Site and Surgical Retractors

Wound scrubs and paints should be aqueous or non-flammable. It is a prudent practice to ensure that no surgical prep solution is allowed to puddle on or around the patient. Draping and gown materials should be flame-retardant or non-flammable. Cooling blankets must not contain alcohol or other flammable coolants.

The wound itself should be surrounded with moistened towels or sponges, particularly when one first begins using the laser. This reduces the possibility of fire. Alternatives include the use of gel lubricants, which can be placed in layers around the wound.

Many so-called laser retractors which feature blackened or ebonized surfaces are available. Such specialized instruments may be helpful when working in confined spaces when one is using visible light lasers (e.g. KTP and Argon) and near-infrared lasers (e.g., Nd:YAG). These instruments do not absorb the longer infrared wavelength of the CO₂ laser. To prevent significant reflection or the beam of the CO₂ laser, instruments with a beaded or matte surface, or those with special coatings are required. For the most part, these specialized instruments are unnecessary. Retractors may be wrapped with wet gauze or stockinette material if a significant risk of beam reflection exists. Plastic and acrylic retractors are also useful and inexpensive. However, extreme caution must be exercised to avoid striking them with the laser beam, as they will melt or burn and can cause injury to the patient.

Acrylic blocks are serviceable as inexpensive but effective retractors. Quarter-inch (6 mm) acrylic sheet material can be cut into 8 x 15 x 0.6cm sections, packaged and presterilized for use. They can be resterilized or may be discarded after a single use. These retractors facilitate the application of steady traction on the wound, making incision and dissection more efficient. Wide, malleable retractors may be wrapped with a moistened Miculicz pad or stockinette material as an alternative to the acrylic blocks. These retractors have the advantage of being capable of being formed, which facilitates their use in deeper wounds.

One must maintain constant vigilance when using lasers. The procedure must be conducted with a continuous awareness of the three-dimensional topography and anatomy of the operative site. Adjacent structures should be protected at all times to prevent inadvertent injury. Moistened Miculicz pads or towels are used to pack the wound and adjacent areas. Appropriate optical backstops for the particular laser in use should be employed whenever possible. Examples of these include the Köcher bronchocele sound, glass rods, titanium rods, and saline.

Practical Tips for Laser Use:

All lasers will function most efficiently when appropriate power densities (fluences) are used in conjunction with proper technique. Tissue should be held under constant tension to distract the tissues, thereby exposing the plane of dissection and maintaining good exposure. This requires about twice the amount of “pull” or force, as that is required for conventional surgical techniques.

Cutting should be done in a single pass of the laser, with care being taken to avoid rapid, back-and-forth type motions, which create multiple planes of dissection and undue bleeding. The full thickness of tissue to be cut should be incised by advancing the beam (i.e., your hand) slowly along the proposed line of incision.

Liquefied fat should be aspirated or blotted. This prevents flash flaming of the liquefied fat (in the case of the CO₂ laser), reduces the transmission of thermal energy to the tissues, and permits more efficient incision by enabling more direct interaction between the laser and the tissues to be incised.

The concept that “water is your friend” is important when using a CO₂ laser. Delicate dissection around nerves, tendons, vessels, and other structures can be accomplished safely by infiltrating local anesthetic or saline into the tissue plane below the intended target. This forms a natural barrier to penetration by the laser beam until or unless the surgeon vaporizes this layer. This principle may be coupled with the use of solutions containing epinephrine to enhance the hemostatic effect of the laser by promoting local vasoconstriction. This technique is useful when performing procedures such as hemorrhoidectomy. A similar technique is useful when performing hemorrhoidectomy with the KTP and Nd:YAG lasers. However, these wavelengths are easily transmitted through water or saline. Therefore, an opaque optical backstop should be used. The surgeon should also recognize that absorption of laser energy by the backstop can heat these instruments and result in thermal damage if they are used carelessly or for prolonged periods without stopping to permit them to cool.

Practical Considerations:

A CO₂ laser is useful for the incision, excision, and vaporization (ablation) of tissues. The surgeon should generally select the minimum spot size and the highest fluence that can be managed safely. This increases the efficiency and speed of the procedure and enhances hemostasis. A 125mm handpiece is the most commonly used delivery device for free-hand application. Using the beam in focus will produce optimal results for skin incisions and fine dissection of tissues. Defocusing the beam permits greater transfer of heat to the underlying tissues and improves hemostasis during the division of muscular and parenchymatous organ tissues. Tissues should be maintained under constant traction to facilitate the dissection, and the surgeon should maintain a relatively slow, steady hand speed. It is also important to divide tissues completely in a V-shaped plane in order to achieve the maximum speed and efficiency. Liquefied fat should be aspirated to increase efficiency and present flash fires due to the diesel effect. CO₂ lasers capable of generating outputs greater than 60W can be used for effective and efficient ablation of bulky lesions and expeditious debridements of large areas.

CO₂ laser waveguides are available for both open and laparoscopic use. Rigid waveguides are capable of carrying high fluences, while flexible waveguides are more practical for outputs of 30W or less. These delivery systems are not practical for skin incisions but have been used for numerous other applications.

Laser utilization offers several advantages during operative laparoscopy. Dissection and hemostasis in areas of inflammation and scar can be facilitated, and the potential for stray energy damage, which is a known hazard of electrosurgery, can be minimized. Although virtually all laser wavelengths have found some utility in laparoscopic procedures, the KTP:YAG, holmium, and YAG laser with sculpted fibers or contact tips are the most versatile and are the least intrusive on endoscopic visualization. The argon laser requires the use of camera and/or eye gear filters that alter the color of the image and can decrease the intensity of the image as much as 70%. These systems often employ a shutter mechanism that engages the eye safety filter only when the laser is being fired.

All of the fiber capable lasers can be used under water or saline irrigation and are effective in cases with edema. However, the surgeon must understand the laser tissue interaction for the particular wavelength and delivery system chosen in order to minimize the potential for iatrogenic injury. For example, the Nd:YAG laser is capable of photocoagulating as much as 2cm tissue when applied in a free-beam mode, with much of the photothermal coagulation occurring 4mm beneath the target surface. Using a contact tip or sculpted fiber results in much of the laser energy being absorbed at the tip of the instrument and thereby produces zones of coagulation similar to these seen with electrosurgical devices or the KTP/532 laser.

Generally speaking, the fiber-capable lasers are easier to learn to use initially, since the surgeon is able to maintain tactile feedback as the fibers contact the tissues. These lasers should generally not be used for skin incision and are best used on tissues deep to the dermis. The power densities, and hence speed of action of argon, KTP, and holmium lasers may be increased by using smaller fibers if desired. Contact Nd:YAG tips and sculpted fibers behave most like optically-driven cautery with cutting speed and efficiency reaching a plateau once the tip is heated. The surgeon should remember that these tips can remain quite hot for several seconds after the beam is deactivated. Iatrogenic injury or adherence to the wound can occur at this time if careless tissue contact occurs.

Pulsed dye lasers are also used in general surgical procedures, particularly for the management of common duct stones at the time of cholecystectomy or during perioperative ERCP. These laser systems are also quite helpful in the fragmentation of renal and ureteral calculi.

Lasers have been useful in the palliation of obstructing esophageal, bronchial and colonic lesions both with and without photosensitizing agents such as Photofrin®. Most of these procedures are performed using flexible or rigid endoscopes.

Beginners will achieve better results and improved outcomes by graded use of these devices on simple procedures initially and tackling more complex procedures as operative experience increases.

Practical Tips for Laser Use During Laparoscopic Surgery

It must again be emphasized that the surgeon should have an intimate understanding of the details of the procedure as well as the laser technology and delivery systems selected for use. It is preferable to learn the procedure and become comfortable with it after having successfully accomplishing it using so-called “conventional” devices prior to attempting it with laser technologies. The surgeon should practice with the laser devices as much as possible prior to using them clinically. A thorough understanding of tissue effects and the ability to assemble and troubleshoot the instrumentation is critical. It is helpful to work with the instrumentation in a pelvic trainer and then gradually introduce laser technology into clinical procedures.

Trocar placement should be well-thought and should be based on the needs of the procedure as well as the habitus of the patient. As a general principle, the operative port should be positioned such that the laser fiber (and other instruments) can easily reach the intended surgical site end on. This is particularly important for direct fiber systems such as bare fibers for KTP, holmium or argon lasers, or waveguides for CO₂ lasers. Sculpted fibers and contact tips (sapphire tips) cut and coagulate optimally when they can be dragged obliquely across the tissues rather than using them end-on. Therefore, the trocar placement may need to be modified for the specific laser and delivery system which is to be utilized.

The assistant surgeon should provide steady countertraction in order to distract the line of incision, facilitate exposure, and optimize the efficiency and efficacy of laser use. The tissues should be incised in fluid, complete strokes as this, too, will increase the efficiency of the dissection and enable the dissection to proceed with better hemostasis. Staccato and repetitive passage of the laser fiber over the same area tends to produce a more irregular incision and frequently causes bleeding as vessels become injured at multiple points in the irregular wound.

Typically, the fiber-capable lasers are applied by placing the fiber into a suction-irrigation cannula. The fiber should be positioned such that it is easily visualized and such that the proposed line of incision is not obstructed by the suction irrigator. An optimal distance is often 1-2cm for fiber extension. This permits visualization and maneuverability of the fiber and the surgical site without having the fiber become too floppy as a result of having too much fiber length protruding from the suction irrigator. It is also critical that the fiber be retracted completely within the instrument when the instrument is being removed or inserted into the abdomen (or other site). This maneuver prevents fiber breakage or iatrogenic injury. The foot pedal for the laser and the electrosurgical device should be within easy reach while the monitor is viewed and the instrumentation is manipulated. Ideally, the surgeon should only have access to one pedal at one time in order to prevent inadvertent triggering of the wrong device.

Several devices are available which bend or angulate the bare fiber and thereby permit the surgeon to optimize the position of the fiber relative to the topography of the dissection. Again, the fiber should be permitted to enhance visualization and minimize fiber breakage.

The surgeon should learn to use a light touch when using laser fibers. The rate of movement of the fiber should be deliberately slow enough to allow the tissue to be cut through completely prior to advancing the fiber. The fiber should not be visibly bowed as this indicates undue pressure or too deep a placement of the fiber into the wound. These conditions reduce efficiency and increase the likelihood of fiber breakage.

Sapphire tips and sculpted fibers should be used in a similar fashion to the method suggested for bare fibers. However, the tip or probe should be oriented more obliquely or tangential to the line of incision. This optimizes the coagulative effect of the laser and facilitates the dissection.

Laser Injury Prevention and Recognition During Laparoscopy

The primary risk of injury during laparoscopy is to the patient’s intraabdominal and pelvic structures due to the closed nature of the surgery and the proximity of adjacent structures. Several methods have been developed to minimize the risk of potential injuries due to reflection of energy off of surgical instruments. It should be remembered that the CO₂ laser wavelength is color independent. Therefore, ebonized surfaces are not helpful in this case. Instruments should have brushed beaded or sand-blasted surfaces. Titanium is preferable as a backstop material. The use of ebonized surfaces is helpful in the case of visible light and near-infrared lasers. However, the surgeon must remember that these instruments will become hot as they are absorbing the laser’s energy. Therefore, inadvertent contact with adjacent structures must be carefully avoided to prevent secondary burns.

The surgeon should orient the laser fiber and beam such that the possibility of past-pointing is avoided. This, too, can result in damage to nearby structures, particularly if backstops are not in use during the dissection. The bowel and bladder should always be checked for perforation injuries or potential burns, particularly after extensive dissections or vaporizational procedures. Several strategies have been used, including filling the area with irrigation fluid, insufflating the bowel with air, and/or the instillation of betadine, methylene blue, indigo carmine or other dyes, and observing the tissue for any leaks or staining. Leaks or suspected areas of injury should be oversewn or closed using good surgical technique. Any site of stray burn or contact with a heated instrument should be inspected carefully and should be handled as if it were a frank perforation. This is particularly important when using the Nd: YAG laser since the degree of damage is grossly underestimated by visualization of the surface.

Policy Statement:

This document is intended to serve as guidance for the safe use of laser technology. It is intended as a living document, which will be modified as technologies and clinical venues change over time. As such, it is not intended to be absolute. This guidance shall be used in conjunction with the tenets of the ANSI z136.3 (2012) American National Standards for the Safe Use of Lasers in Health Care Facilities guidelines. It should be periodically reviewed and updated as necessary. The following information is written from the perspective of operative environments as would be found in a hospital or ambulatory surgical setting. The relevant ANSI standards should be consulted for further information concerning the use of lasers and related technologies in other healthcare settings.

Procedure:

1. Laser Utilization: General Requirements and Administrative Controls:

1. Lasers are utilized only by individuals who have been credentialed for the use of specific types of lasers. The individual MAY NOT utilize laser technology for purposes and scenarios for which she/he does not have active privileges and appropriate training and experience.
2. Individuals are not exposed to the useful active laser beam except for healing arts purposes and only when such exposure is authorized by a properly credentialed individual.
3. Registered Nurses, Licensed Practical Nurses, and Technicians operate lasers only after completion of an acceptable program of certification. Personnel are certified to operate specific lasers (e.g. CO₂, KTP, Nd:YAG, etc.).
4. Any utilization or operation of these devices, misappropriation of the laser beam, or harm to the patient or personnel will be reported on an incident report according to facility policy. The Laser Safety Officer and other appropriate personnel shall be notified immediately. Copies of the incident report and supporting documents shall be forwarded to the Laser Safety Officer immediately.
5. Corrective action relating to any incident or quality issue as it pertains to laser use of a laser device shall be determined by the nature and severity of the incident and shall be consistent with local facility, state and federal regulations.

2. Laser Protection for Personnel and Patients

1. Continuing Medical and In-service education should occur on a regular basis.
2. Eye protection is utilized by all personnel and patients in all areas wherein a Class IV laser is in use. The eye protection is specific to the type of laser used and shall be provided to all present within the room as well as being available at all entrances to the area.
3. Flammable prep solutions shall not be used.
4. Warming blankets must not contain flammable coolants.
5. Window blinds are drawn or all windows are blocked as is appropriate to procedure and wavelength.
6. Appropriate eye protection is available outside the OR/treatment room for personnel entering the room.
7. The Laser Safety Checklist, both preoperative and intraoperative sections are verified or the laser is not to be utilized.
8. Employees should be provided with an ophthalmic examination at the time of employment, periodically as determined by existing standards, and at the time of termination of employment.
9. In the event that the laser equipment malfunctions and the laser operator is unable to troubleshoot the problem, laser utilization is discontinued immediately. The Laser Safety Officer shall be notified immediately.
10. Under no circumstances will Operating Room personnel attempt to repair electrical equipment or conduct major repairs of laser optical systems. Appropriately qualified repair personnel should conduct necessary repairs and equipment preventive maintenance.
11. No laser shall be utilized (made ready) unless, water, saline, and/or a fire extinguisher is immediately available and/or open on the surgical field.
12. Flame retardant materials and draping shall be utilized at all times.
13. Laser utilization shall be in compliance with Standards and Policies established by the facility, the current ANSI Standards and other relevant regulations.

3. Patient Surgery as Related to the Use of Lasers

Note: This brief outline is not intended to be all-inclusive, nor should the general principles of sterile technique and the operating room environment be violated.

1. Surgeons using a laser have the responsibility to know how to use the laser properly in order to protect the patient and the Operating Room personnel.
2. The surgeon will assume responsibility for selecting proper power levels and the appropriate lens and/or delivery systems (e.g., fibers, waveguides, microscopes, etc.) for each procedure.
3. To minimize the possibility of a fire hazard, all laser procedures shall have a container of water (saline, fire extinguisher) that is immediately available in the treatment area. All sponges are to be moistened prior to use for packing or placement in the beam path. Specific safety measures for the particular laser in use shall be implemented.
4. To minimize the possibility of a “blow-torch effect”, anesthesia personnel are to use nonflammable endotracheal tubes or specially wrapped tubes during cases involving the oropharynx or airway.
5. During the procedure, the patient’s eyes are to be taped shut, and moist pads applied if the procedure is to be done under a general anesthetic. Patients will wear safety goggles if awake during the procedure. Standard prescription eyeglasses are sufficient for use during CO₂ laser procedures. However, side guards would be ideal and are recommended.
6. A laser log will be kept for each procedure, which includes, but is not limited to:
   1. Patient’s name and facility ID numbers.
   2. Physician performing the laser procedure.
   3. Type of procedure.
   4. Wattage used and mode.
   5. Lens or delivery system used.
   6. Laser Operator and other personnel involved with the procedure.
   7. Listing of fibers or other delivery devices utilized, if any.
   This log will be kept with each laser unit.
7. The laser will be placed on standby in an effort to avoid accidental discharging of the laser when the unit is not in use. The laser shall be turned off when the laser is left unattended for a substantial period of time.
8. The key to the laser is to be accessible only to persons trained in the use of laser and/or to the Laser Nurse Specialist or laser technician. The keys shall be kept in a secure location and are not to be stored in or on the equipment.
9. No alcohol or other flammable solutions will be used as prep solutions or in the presence of operating lasers.
10. The Laser Safety Checklist will be verified by the laser nurse (laser operator) for each case and its completion will be noted in the laser log.

4. Personnel Safety

1. All employees, when working in areas where a potential exposure to direct or reflected laser light greater than 0.005 watts (5 milliwatts) exists, shall be provided with wavelength-specific anti-laser eye protection. All protective goggles shall bear a label identifying the laser for which use is intended.
2. Areas in which lasers are used shall be posted with standard laser warning signs. During the time the laser is “on” or on “standby”, all doors and pass-thru cupboards must be securely closed.
3. Beam shutters or caps shall be utilized, or the laser placed in standby mode when laser transmission is not actually required.
4. The laser beam shall not be directed at anyone other than the patient (operative site).
5. Appropriate eyewear shall be placed at all room entrances.

5. Physician Credentialing:

1. NO ONE should be allowed to use or operate a laser without having attended a wavelength and specialty-specific workshop approved by the Laser Usage Committee or having had appropriate training during residency.
2. Credentialed physicians will be reviewed annually as to continued use of and safe use of the laser.
3. A physician who is newly credentialed must be observed using the laser in the operating room (or other designated laser area) to assure competency.
4. Laser Privileges must be reviewed with each renewal of clinical privileges (Biannual). A physician must document that a minimum of five (5) procedures have been performed over the most recent two (2) year period in order to maintain active privileges for laser use.
5. Physicians who fail to perform a minimum of five (5) procedures during the prior two (2) years will no longer be considered to have privileges for laser use. They will be notified of the same in writing. Said physicians may apply for reinstatement after having provided documentation of proficient and ongoing laser use at another institution or after having attended an approved, specialty and wavelength-specific hands-on laser training program. The Laser Usage Committee will individually review each case.

6. Criteria for Granting Laser Privileges

1. The physician (attending) must be a diplomat of or be admissible to a specialty Board such as the American Board of Surgery; Orthopaedics; Otolaryngology; Ophthalmology; Urology; Dermatology; Plastic Surgery; Cardiovascular Surgery; Neurosurgery; or other medical specialty.
2. The physician must first have been granted appropriate privileges by the facility through the designated certification and facility process. The physician must have privileges to perform requested procedures in the absence of laser use.
3. The physician must have been trained to use laser(s) in a recognized and approved residency program or must have obtained training through an appropriate CME course. The facility’s Laser Usage Committee will review and revise the listing of appropriate training courses and minimum hours of experience necessary for certification for use of the particular laser for which privileges are requested as the need for training and as the providers of programs changes over time. When submitting a request for certification as a user of lasers, the physician must supply a certificate documenting that she/he attended a wavelength and specialty-specific laser course and also present documentation as to the content of that course. The course must include laser physics, safety and principles of laser use, discussion and demonstration of surgical lasers, and hands-on laboratory training with lasers, preferably with laser systems similar to those instruments available at this institution.
4. Physicians using a laser adapted to an operating microscope or other optical device must demonstrate proficiency in the use of the optical equipment in addition to the laser technology. The physician must already have hospital privileges for the use of these instruments in the performance of procedures with conventional techniques.
5. The user of the laser must be cognizant of the safety hazards of lasers. This knowledge must be obtained either through a residency program or an appropriate CME course. Proof of this training must be supplied in writing to the Laser Usage Committee at the time privileges are requested.
6. Initial approval or use of laser will be provisional until the physician has demonstrated the ability to use lasers to a member of the Medical Staff who has been designated by the facility as being qualified and must have achieved the required standards as previously listed. The criteria for recertification shall be set forth and a yearly review of cases and their outcomes shall be performed.
7. If the applicant requests the use of the laser for investigational purposes, the request must receive approval by the facility’s Clinical Investigation Committee (IRB/CIC) as is required for all other research purposes. An appropriate investigational protocol and informed consent process must be in place.
8. Residents involved in the use of lasers may not perform procedures with these instruments until such time as they have attended an in-depth training program or an appropriate CME course recognized to be adequate by the Laser Usage Committee. In addition, residents must be supervised by a laser-certified attending physician during actual utilization of laser technology at all times.

Reference Tables

Table 1: Suggested Parameters for the CO₂ Laser

• Wavelength: 10,600 nm
• Mode: TEMoo
• Handpiece: 124 mm Lens* (0.2 mm spot diameter)

* — The 125 mm lens is the most convenient for use for most applications. The 50 mm lens with a spot diameter of 0.09 mm achieves the same power density with 25% of the wattage. For example, the 10 W with a 50 mm lens in-focus produces the same power density as 40 W with a 125 mm lens in-focus. However, the 50 mm lens is more cumbersome and difficult to use for non-cutaneous applications.

** — This procedure requires the use of an optical backstop such as the Köcher bronchocele sound, which permits precise dissection without damaging adjacent or underlying structures.

*** — Using settings higher than 60W CW increases the likelihood of causing a flash fire due to ignition of aerosolized fat in the plume.

+ — Laser sterilization is accomplished by defocusing the laser and gently heating the wound surface. The tissue should be heated just to the point of desiccation and slight shrinkage of the wound. Blanching and charring of the wound is indicative of excessive irreversible damage to the wound.

++ — Vaporization or ablation of tissues is most efficient when a high power density is used with a large spot diameter. This permits the surgeon to cover a large area expeditiously.

# — Use powers no greater that 40 watts until you become proficient and are comfortable with the higher powers. However, 60 Watts is more efficient and hemostatic.

Table 2: Suggested Parameters for the KTP Laser

* – The KTP/YAG system delivers both the 532 nm (KTP) wavelength and the 1060 nm Nd:YAG wavelength but, at this time, not the two simultaneously. The Nd:YAG can be operated at power settings from one to sixty watts. It is a more efficient photocoagulator than is the 532 nm wavelength at higher powers.

** – The KTP laser is used with the cleaved fiber in direct contact with the tissue for most uses. Near-contact use is analogous to defocusing the laser beam. Skin incisions are usually not made with the KTP laser because of the extent of lateral tissue damage (burn). However, some users do prefer to make incisions in the anoderm with the laser. Blackened instruments and optical backstops are helpful.

*** – Higher energies can be used in aqueous environments, but open and laparoscopic procedures generally do not require settings above 20 W CW. Higher powers will result in frequent damage to the fiber’s tip.

+ – Vaporization is best accomplished by using the fiber in a defocused position. Pulsing the laser or using continuous wave mode for brief intervals reduces the likelihood of flaming and burning of the fiber tip. If fiber burnout does occur, the fiber is easily recleaved and the cladding is stripped, making it again ready for use.

Table 3: Suggested Parameters for Use of the Nd:YAG Laser

• Wavelength: 1060 nm
• Output: 1 – 120 W
• Delivery Systems: Fiberoptic, usually with 0.4 mm or 0.6 mm fibers; varies with type of application and terminal delivery system apparatus. Typical use today generally involves the use of cleaved bare fimbers. The other delivery system information is provided for reference.

* — Not recommended

a — The lens system was one of the first applications of the Nd:YAG laser. The laser energy cuts poorly due to extensive forward and back scattering in tissue. The main applications of the lens system were for coagulation or for tissue vaporization.

b — Polished fiber applications are mainly for endoscopic coagulation or vaporization techniques. It is poor for making incisions.

c — Sapphire tips function as a “laser-assisted” device, with a large portion (up to 80%) of the laser input being converted to heat and only a small percentage (approximately 20%) being transmitted by the distal third of the tip. This explains the lack of increased response with increasing laser power and also explains why the sapphire tip permits the laser to incise tissues with zones of injury which resemble other lasers and electrocautery (i.e., 300–1000μ). Skin incision is not recommended.

d — These recent developments are touted to transmit 81% of laser energy when held in contact with tissue. The fibers, which have recently been placed on the market, are said to transmit 81% of laser energy when held in contact with tissue. There is no published data which verifies this statement. When we tested one fiber, it did not produce coagulation of pigmented meat when held in water in near contact with the meat. They produce effects that are similar to sapphire tips on tissue, but the surgeon can increase incisional speed and effect with increasing power input. Some manufacturers recommend these fibers for skin incision, but many surgeons do not prefer this.

e — Cleaved fibers (bare fibers) can be used for cutting, coagulation, or vaporization. This mode of delivering of YAG energy is extremely dangerous if optical backstops are not used due to the 10° angle of divergence of energy from an optical fiber and due to the extreme forward and backscatter of YAG energy in biological tissues.

Selected References:

1. Laser Institute of America: American National Standard for Safe Use of Lasers in Health Care Facilities (ANSI Z136.3-2012), (131pp), 2012.
2. The Joint Commission on Accreditation of Health Care Organizations; jointcommission.org
3. Apfelberg DB, (ed): Evaluation and Installation of Surgical Laser Systems. New York: Springer-Verlag, (324pp), 1986.
4. Apfelberg DB (ed): Atlas of Cutaneous Laser Surgery. New York, Raven Press, (483 pp), 1992.
5. Daly CJ, Grundfest WS, Johnson DE, Lanzafame RJ, Steiner RW, Tadir Y, Graham MW (Editors): Lasers in Urology, Gynecology, and General Surgery. Progress in Biomedical Optics. S.P.I.E. Vol. 1879, (pp 248), 1993.
6. Joffe SN (ed): Lasers in General Surgery. Baltimore: Williams & Wilkins, (319 pp), 1989.
7. Hinshaw JR, Herrera HR, Lanzafame RJ, Pennino RP: The Use of the Carbon Dioxide Laser Permits Primary Closure of Contaminated and Purulent Lesions and Wounds. Lasers Surg. Med. 6(6):581-583, 1987.
8. Lanzafame RJ, Hinshaw JR, Pennino RP: Cost Effective Retractors for Laser Surgery, AORN 43(6):1218-1219, 1986.
9. Lanzafame RJ, Hinshaw JR (eds): Color Atlas of CO2 Laser Techniques, St. Louis: Ishiyaku EuroAmerica, Inc. (pp 294), 1988.
10. Lanzafame RJ, Qui K, Rogers DW, Naim JO, Hinshaw JR, Caldwell F, Hall D, Perry F: A Comparison of Local Tumor Recurrence Following Excision with the CO2 Laser, Nd:YAG Laser, and Argon Beam Coagulator. Lasers Surg. Med. 8(5):515-520, 1988.
11. Lanzafame RJ, Naim JO, Rogers DW, Hinshaw JR: A Comparison of Continuous Wave, Chop Wave, and Super Pulse Laser Wounds. Lasers Surg Med. 8(2):119-124, 1988.
12. Lanzafame RJ: New Instruments for Laser Surgery. Lasers Surg. Med. 10:595-596, 1990.
13. Lanzafame RJ: Applications of Lasers in Laparoscopic Cholecystectomy. J. Laparoendoscopic Surgery. 1:33-36, 1990.
14. Lanzafame, RJ: Laser safety programs in general surgery. J. Laser Appl. 6:111-114, 1994.
15. Lanzafame RJ: Applications of Laser Technology in Breast Cancer Therapy. Semin Surg Oncol. 11:328-332, 1995.
16. Lanzafame RJ: Prevention And Management Of Complications In Laparoscopic Surgery. New York: Igaku-Shoin Medical Publishers, Inc., (pp 368), 1996.
17. Lanzafame RJ: Ch 50: Laser and Light Treatment for Wound Healing, in Nouri K (ed): Dermatologic Surgery- Step By Step. London, Blackwell Publishing LTD, pp 360-367, 2013.
18. Lanzafame RJ: Lasers in General Surgery, in Simunovic, Z (eds): Lasers In Medicine And Dentistry. European Medical Laser Association. AKD Zagreb Croatia, pp 33-66, 2001. Lanzafame RJ: Laser Energy for Minimally Invasive Surgery, in Wetter PA, Kavic MS, Levinson CJ (eds): Prevention and Management of Laparoendoscopic Surgical Complications 2nd Edition, Society of Laparoendoscopic Surgeons Press. pp 61-72, 2005.
19. Pennino RP, O'Connor T, Lanzafame RJ, Hinshaw JR: Tissue Sculpturing: Potential New Applications and Techniques of CO2 Laser Surgery. Laser Medicine And Surgery News and Advances. 6(5)20-23, 1988.
20. Sliney DH, Trokel SI: Medical Lasers and Their Safe Use. New York: Springer-Verlag, (230 pp), 1992.

Approved by the Board of Directors
American Society for Laser Medicine and Surgery
August 2, 2012

Reviewed by the Safety Awareness Committee in 2020