Home > Encyclopedia of Nursing & Allied Health > Laser Surgery

Definition

Laser is an acronym that stands for Light Amplification by Stimulated Emission of Radiation. Laser surgery uses an intensely hot, precisely focused beam of light to remove or vaporize tissue and control bleeding in a wide variety of noninvasive and minimally invasive procedures.

Purpose

Laser surgery may be used to:

• cut or destroy tissue that is abnormal or diseased without harming healthy, normal tissue
• shrink or destroy tumors and lesions
• cauterize (seal) blood vessels to prevent excessive bleeding

Precautions

Although many laser surgeries can be performed in the physician's office rather than in a hospital, practitioners must be at least as thoroughly trained and highly skilled their counterparts in a hospital setting. The American Society for Laser Medicine and Surgery, Inc. recommends that:

• All operative areas be equipped with oxygen and other drugs and equipment required for cardiopulmonary resuscitation (CPR).
• Nonphysicians performing laser procedures be properly trained, licensed, and insured.
• A qualified and experienced supervising physician be able to respond to and manage unanticipated events or other emergencies within five minutes of the time they occur.
• Emergency transportation to a hospital or other acutecare facility be available whenever laser surgery is performed in a nonhospital setting.

All patients who are considering laser surgery should be fully informed about the procedure's relative risks and benefits, as well as any alternatives that may exist. Some types of laser surgery, for example, should not be performed on pregnant women or on patients with severe cardiopulmonary disease or other serious health problems. The patient should understand why laser surgery a better choice than traditional surgery (in this instance), and how much experience the physician has in performing the laser procedure the patient is considering. Generally, surgical nurses will inform patients about the planned procedure and, if hospital policy permits nurses to do so, obtain their informed consent to proceed; some hospitals require doctors to do this.

Description

The first working lasers were introduced in 1960. They were initially used to treat diseases and disorders of the eye, where transparent tissues gave ophthalmic surgeons a clear view of how the narrow, concentrated beam was being directed. Dermatologic surgeons helped further pioneer laser surgery, developing and improving many early techniques and refining surgical procedures.

Lasers are medically useful because they can be directed with pinpoint accuracy to cut, vaporize, or weld tissue while cauterizing blood vessels and nerves to reduce or eliminate surgical bleeding and postoperative pain. This reduces postoperative swelling and scarring as well as the length of the recovery period. A laser's heat often destroys bacteria and viruses in the surgical field, creating a more sterile environment that is less prone to infection. Because a smaller incision is required, laser procedures often take less time than traditional surgery. Lasers can also be tailored to particular applications.

All lasers operate on the principle of selective photothermolysis, meaning that the laser's wavelength, energy density, power, and exposure time determine what types of tissue will be affected and the effects that will be produced. Lasers can be further adapted to different medical procedures with special delivery (such as fiberoptic cables) that help apply the laser beam.

Laser applications

Sometimes described as "scalpels of light," lasers are used alone or with conventional surgical instruments and can be tailored with seemingly infinite precision for a vast number of surgical procedures. For these reasons laser surgery is often standard operating procedure for specialists in cardiology, dentistry, dermatology, gastroenterology, gynecology, neurosurgery, oncology, ophthalmology, orthopedics, otolaryngology, pulmonology, and urology.

Lasers are used to erase birthmarks, skin discolorations, and skin changes due to aging; to remove benign, precancerous, or cancerous tissues or tumors; to stop snoring; remove tonsils; remove or transplant hair; and relieve pain and restore function in patients too weak to undergo more invasive surgery. Lasers are also used to treat angina; cancerous or noncancerous tumors that cannot be removed or destroyed; cold and canker sores, gum disease and tooth sensitivity or decay; ectopic pregnancy, endometriosis, and fibroid tumors; gallstones; glaucoma, mild-to-moderate nearsightedness, astigmatism, and other conditions that impair vision; migraine headaches; noncancerous enlargement of the prostate gland; nosebleeds; ovarian cysts; ulcers; varicose veins; warts; and numerous other conditions, diseases, and disorders.

Types of lasers

CARBON DIOXIDE LASER. Carbon dioxide (CO₂) lasers were the first to find surgical applications, and they remain the most used of all medical lasers. CO₂ laser light is absorbed readily by water in the cells, allowing tissue to be cut precisely with minimal bleeding. The laser beams can be concentrated into a fine beam that slices like a scalpel, or diffused to shave or vaporize tissue. This versatility makes them valuable in many types of procedures from wart removal to brain surgery.

NEODYMIUM:YTTRIUM-ALUMINUM-GARNET LASER. Neodymium:yttrium-aluminum-garnet laser (Nd:YAG) lasers can penetrate tissue more deeply than other lasers, allowing surgeons to operate on parts of the body that could previously be reached only through invasive surgery. Nd:YAG lasers are the most frequently used laser in dental procedures, and are also well suited for respiratory surgery because they cauterize and seal the tiny vessels of the lung. They are also used to excise tumors with minimal damage to healthy tissue, and may even eliminate micrometastases before they can spread to another region.

Other types of YAG lasers are:

• The KTP laser, produced when Nd:YAG laser light is passed through a potassium-titanyl-phosphate (KTP) crystal. This green laser is used frequently for vascular lesions (such as leg veins) and to remove certain tattoo colors.
• The erbium (Er:YAG) laser, which penetrates less deeply into tissue; it is used in dental and hair removal procedures.
• The holmium (Ho:YAG) laser, used in orthopedic surgery to eliminate extraneous bone and cartilage, to destroy kidney stones, in endoscopic sinus procedures, and for prostate removal.

ARGON LASER. Another laser to find early medical application, the argon laser produces a blue-green light that is selectively absorbed by hemoglobin and melanin. This means that argon laser light is drawn to areas that are heavily pigmented or rich in blood vessels. Argon lasers are most often used for opthalmic surgery and surface skin blemishes (birthmarks, enlarged blood vessels) because they vaporize and seal blood vessels on contact. In a special procedure known as photodynamic therapy (PDT), this laser is also used in conjunction with lightsensitive dyes to shrink or dissolve tumors.

Preparation

Because laser surgery is used to treat such a wide variety of conditions, patients should be given specific, detailed instructions about how to prepare for their procedure. Diet, activities, and medications may or may not have to be limited prior to surgery, so it's important that nurses offer written and/or verbal preoperative patient education and instructions. Many procedures require a preoperative physical examination to determine the patient's general health and current medical status, especially if general anesthesia will be used. Patients should also be given a realistic expectation of the procedure's outcome and the duration of recovery.

Aftercare

Many laser surgeries are be performed on an outpatient basis, and patients are usually permitted to leave the

hospital, medical office, or surgical center once their vital signs have stabilized. Patients who have been sedated should not be discharged until they have completely recovered from the anesthesia and they are oriented and alert. Most practitioners require discharged patients to be accompanied by a responsible adult. Patients should not drive themselves to or from the facility.

The physician may prescribe analgesic medication for postoperative pain, and should provide easy-to-understand written instructions that describe how the patient's recovery should progress, the actions to take in the event of complications, and how to recognize complications requiring emergency medical treatment.

Complications

The risks and complications associated with laser surgery are comparable to those for other surgical procedures. Treated areas can become infected following laser surgery; this should be suspected if burning, crusting of the skin, itching, pain, scarring, severe redness, and swelling appear at the treatment site. Other risks are associated with anesthesia and complications such as hemorrhage, perforation, or infection. Fortunately, errors of this sort tend to occur when a physician is poorly supervised while learning a new skill. Serious complications are rare with experienced doctors.

Some complications may be cosmetic: lighter or darker skin may appear when a laser is used to remove sun damage or age spots from an olive-or dark-skinned individual. This abnormal pigmentation may or may not disappear in time. Black, Asian, Hispanic, or dark-skinned patients should make sure that their surgeon has performed laser procedures successfully on people of color.

Laser surgery also involves unique risks: Imprecisely aimed lasers can burn or destroy healthy tissue, cause injuries that are painful and sometimes permanent, and even compound the problems they are supposed to solve. Errors or inaccuracies in laser eye surgery can damage or worsen a patient's vision, for example. Scarring or rupturing of the cornea is uncommon, but laser surgery on one or both eyes can increase sensitivity to light or glare, reduce night vision, permanently cloud vision, or cause sharpness of vision to decline throughout

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KEY TERMS

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Argon—A colorless, odorless gas, which, when used in a laser, emits a blue-green beam.

Astigmatism—A condition in which one or both eyes cannot filter light properly because the corneal surface is irregular. This results in blurred, indistinct images unless corrected by glasses, contact lenses, or laser surgery.

Carbon dioxide—A heavy, colorless gas that dissolves in water.

Cauterize—The use of heat or chemicals to stop bleeding, prevent the spread of infection, or destroy tissue.

Cornea—The outer, transparent lens that covers the pupil of the eye and admits light.

Endometriosis—An often painful gynecologic condition in which endometrial tissue migrates from the inside of the uterus to other organs inside and beyond the abdominal cavity.

Glaucoma—A disease of the eye in which increased pressure within the eyeball can cause gradual loss of vision. Iridectomy is the laser surgical procedure that helps relieve the pressure.

Invasive surgery—Surgery that involves making an incision in the patient's body and inserting instruments or other medical devices into it.

Nearsightedness—A condition in which one or both eyes cannot focus normally, causing objects at a distance to appear blurred and indistinct. Also called myopia.

Ovarian cyst—A benign or malignant growth on an ovary. An ovarian cyst can disappear without treatment or become extremely painful and have to be surgically removed.

Papillomavirus—A group of viruses that cause several types of warts, some of which can cause cancer.

Vaporize—To dissolve solid material or convert it into smoke or gas with a laser.

Varicose veins—Peripheral veins, usually in the legs, that have valvular insufficiency. This allows blood to pool in the vessels of the lower extremities, permanently dilating the veins.

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the day. To guard against some of these risks, patients must wear protective eye shields while undergoing laser surgery on any part of the face near the eyes or eyelids, and a United States Food and Drug Administration (FDA) mandate requires both health care personnel and patients to use special protective eyewear whenever a CO₂ laser is used.

An unexpected risk associated with laser surgery is the "plume" or smoke that is emitted when lasers vaporize tissue. Studies have shown that although the particles in the smoke are very small (0.5–5.0[.mu]m), they are small enough to pass through a surgical mask. This is a concern for both patient and health care personnel because viral DNA has been shown to survive in the smoke produced when warts are removed by a laser, and some forms of papillomavirus are infectious. To guard against any possible contagion, a vacuum system with a multistage filter is recommend to suction the smoke produced during laser procedures; it must be held very close (about 1 cm) from the target to be effective.

Results

The nature and severity of the problem addressed by the laser procedure, the skill of the surgeon performing the procedure, as well as the patient's general health and realistic expectations about the result of the procedure are among the factors that influence the outcome of laser surgery.

Patients considering any type of laser surgery should be fully apprised of the risks, benefits and potential complications of the procedure as well as any alternative treatment that might be feasible in place of laser surgery. It is especially important for patients undergoing cosmetic procedures to have realistic expectations about the outcomes of these procedures.

Health care team roles

Laser surgery may be performed by a general surgeon, cardiologist, dentist, oral surgeon, dermatologist, gynecologist, ophthalmologist, otolaryngologist, plastic surgeon, urologist or other physician specialist, assisted by specially trained surgical nurses. Preoperative blood work is performed by laboratory technologists, and when necessary, imaging studies may be performed by radiologic technicians.

Patient education

Nurses have a vital role in delivering pre-and postoperative patient education. There is considerable evidence that well-informed patients achieve better clinical outcomes and experience higher levels of satisfaction with treatment. Patients considering laser surgery should be provided with detailed information about the anticipated outcomes of the surgery and the duration of recovery process.

Barbara Wexler