Principles and Practice of Gynecologic Laser Surgery

1 An Introduction to Lasers.- 1.1 General Information.- 1.2 Theoretical Background.- 1.3 Historical Data.- 1.4 Basic Physics of Generating Laser Energy.- 1.4.1 Energy Levels in Atoms.- 1.4.2 Generation of Light.- 1.4.3 Emission and Absorption.- 1.4.3.a. Spontaneous Emission.- 1.4.3.b. Absorption.- 1.4.3.c. Stimulated Emission.- 1.4.3.d. Additional Characteristics.- 1.4.4 The Laser.- 1.4.4.a. Active Medium, Pumping.- 1.4.4.b. Optical Cavity.- 1.4.4.c. Loss and Gain Phenomenon.- 1.4.4.d. Steady State.- 1.4.4.e. Standing Waves.- 1.5 The Molecular Gas Laser (Carbon Dioxide Laser): Energy Levels in Molecules.- 1.5.1. Ground Level at Zero Energy Level.- 1.5.2. Excited Level (V1) or Symmetrical Stretch Mode.- 1.5.3. Excited Level (V2) or Bend Mode.- 1.5.4. Excited Level (V3) or Asymmetrical Stretch Mode.- 1.5.5. Energy Transfer.- 1.6 The Liquid Laser.- 1.7 The Solid-State Laser.- 1.8 The Semiconductor Laser.- 1.9 General Characteristics of Lasers in Medicine.- 1.9.1. The Ruby Laser.- 1.9.2. The Argon Laser.- 1.9.3. The Neodymium-YAG Laser.- 1.9.4. The Carbon Dioxide Laser.- References.- 2 Carbon Dioxide Laser Instrumentation.- 2.1 General Description.- 2.2. Biophysical Data.- 2.2.1. Terminology of Laser Irradiation.- 2.2.2. Absorption and Reflection.- 2.2.3. Significance of Coefficients.- 2.2.4. Power Density.- 2.2.5. Transverse Electromagnetic Mode and Its Significance.- 2.2.6. Laser Modes and Effects of Temperature on Mode Stability.- 2.2.7. Biophysical Parameters of C02 Surgical Lasers and Dosimetry.- 2.2.8. Clinical Conclusions.- 2.3. Current C02 Laser Models.- 2.3.1. Introduction.- 2.3.2. Troubleshooting the System.- 2.3.3. Basic Office System.- 2.3.4. Office Suite Operating Room Supplies.- 2.3.5. Operating Suite System.- 2.3.6. Recording System.- 2.3.7. Ancillary Equipment.- 2.3.7.a. Evacuation System.- 2.3.7.b. Waveguides.- 2.4. Laser Safety.- 2.4.1. General Information.- 2.4.2. Hazards of Medical Lasers.- 2.4.2.a. Injury by Primary Action of the Laser Beam.- 2.4.2.b. Injury by Secondary Effects of the Laser Beam.- 2.4.2.C. Protecting the Patient’s Eyes from Laser Radiation.- 2.4.2.d. Damage to Skin and Underlying Tissues.- 2.4.2.e. Protecting Skin and Underlying Tissues.- 2.4.2.f. Toxic or Pathogenic Effect of Smoke or Vapor from the Intended Target.- 2.4.3. Government Regulations for Laser Safety.- 2.4.3.a. Federal Regulations.- 2.4.3.b. Local Regulations.- References.- 3 Bioeffects.- 3.1 Introduction.- 3.1.1. Experimental Studies.- 3.1.2. Clinical Studies.- 3.1.2.a. Cytologic Analysis.- 3.1.2.b. Histologic Analysis.- 3.1.2.C. Scanning Electron Microscope Analysis.- 3.1.2.d. Clinical Findings.- 3.1.3. Theoretical Analysis and Experimental Verification….- 3.1.3.a. Theoretical Analysis of Heat Transfer— General.- 3.1.3.b. Theoretical Analysis—Closed-Form Solution.- 3.1.3.c. Experimental Verification.- 3.1.3.d. Summary of Theoretical Findings.- 3.1.3.e. Conclusion.- 3.2. Plume Emission Analysis.- 3.3. Photoacoustic Properties.- 3.4. Photon-Tissue Interaction.- 3.4.1. Experimental Design.- 3.4.2. Results.- 3.4.3. Discussion.- References.- 4 Applications in Gynecology with Emphasis on the Cervix.- 4.1. Introduction to Laser Surgery.- 4.2. Clinical Applications in Gynecology.- 4.3. General Considerations of Applications in Cervical Intraepithelial Neoplasia.- 4.4. Cervical Applications.- 4.4.1. Epidemiology.- 4.4.2. Pathology.- 4.4.3. Preoperative Analyses.- 4.4.4. Patient Selection.- 4.5. Technical Approach to CIN Lesions.- 4.5.1. Microsurgical Procedures.- 4.5.2. Instruments, Equipment, and Patient Preparation for Cervical Microsurgery.- 4.5.3. Anesthesia.- 4.6. Vaporization Procedure.- 4.7. Excisional Conization.- 4.7.1. Technical Approach.- 4.7.2. Pathologic Examination.- 4.7.3. Combined Procedures.- 4.8. Postsurgical Care.- 4.9. Evaluation of Healing.- 4.10. Follow-up Examinations.- 4.11. Current Research on CIN.- 4.12. Complications.- 4.13. Laser Technique versus Conventional Methods.- 4.13.1. Laser Vaporization versus Cryosurgery and Diathermy.- 4.13.2. Laser Conization versus Cold Knife Conization and Hysterectomy.- 4.14. Other Indications for Laser Surgery.- 4.14.1. Stenosis.- 4.14.2. Lacerations.- 4.12.3. Bicollis Configuration.- 4.12.4. Adenosis and Cervical Changes Associated with Diethylstilbestrol Exposure in Utero.- 4.12.5. Polyps.- 4.12.6. Leiomyoma.- 4.12.7. Cervicitis.- References.- 5 Laser Surgery of the Vagina, Vulva, and Extragenital Areas.- 5.1. Introduction.- 5.2. Vaginal Applications.- 5.2.1 Adenosis.- 5.2.2. Dystrophy and Neoplasia.- 5.2.3. Postoperative Care and Follow-up.- 5.2.4. Reconstruction.- 5.2.4.a. Longitudinal Vaginal Septum.- 5.2.4.b. Transverse Vaginal Septum.- 5.2.4.c. Gartner’s Duct Cyst and Other Vaginal Inclusion Cysts.- 5.3. Vulvar Applications.- 5.3.1. Introduction.- 5.3.2. Preoperative Analysis.- 5.3.3. Dystrophic and Neoplastic Lesions.- 5.3.4. Premalignant Disease and Degenerative Dystrophia.- 5.3.5. Carcinoma in Situ.- 5.3.6. Primary or Secondary Invasive Neoplastic Lesions.- 5.3.7. Procedure.- 5.3.8. Tissue Reaction.- 5.3.9. Postoperative Management.- 5.3.10. Complications, Results, and Follow-up.- 5.4. Lower Genital Tract Multicentric Viral Lesions.- 5.4.1. Condyloma Acuminatum Lesions.- 5.4.2. Preoperative Analysis.- 5.4.3. Sequence of Therapy.- 5.4.4. Technique of Management.- 5.4.5. Postoperative Management.- 5.4.6. Complications and Results.- 5.4.7. Herpes Simplex Virus Type 2.- 5.5. Other Sites.- 5.5.1. Peritoneal Labial Fusion.- 5.5.2. Hymenotomy.- 5.5.3. Anal Lesions.- 5.5.4. Periurethral Lesions and Skene’s Ducts.- 5.5.5. Bartholin’s Gland Abscess and Cyst Management.- 5.5.6. Other Cutaneous Lesions.- References.- 6 Intra-abdominal Applications.- 6.1. Introduction.- 6.2. Instrumentation.- 6.2.1. Current Laser System for Microsurgery.- 6.2.2. Laser Micromanipulator.- 6.2.3. Omega Modification of Laser Micromanipulator.- 6.2.4. Laser Scalpel.- 6.2.5. Laser Accessory Instruments.- 6.2.6. Laser Laparoscopy.- 6.2.7. Operating Room Modification.- 6.2.8. Recording System: General.- 6.2.9. Recording System: Specialized Video-Cine Modification.- 6.3. Microsurgical Procedures.- 6.3.1. Adhesiolysis.- 6.3.2. Fimbrioplasty and Salpingostomy.- 6.3.3. Tubal Reanastomosis.- 6.3.4. Cornual Reimplantation.- 6.3.5. Ectopic Pregnancy: Linear Salpingostomy.- 6.3.6. Endometriosis.- 6.3.6.a. Endometrial Implants.- 6.3.6.b. Endometrioma: Ovarian Type.- 6.3.6.C. Bowel Endometrioma.- 6.3.7. Uterine Anomalies.- 6.3.7.a. Septal Defects.- 6.3.7.b. Bicornuate Uterus.- 6.3.7.C. Uterine Leiomyomata.- 6.3.8. Tubal Anomalies.- 6.3.8.a. Intraluminal Polyps.- 6.3.8.b. Bifid Fallopian Tubes.- 6.3.8.c. Defective Fimbria Ovarica.- 6.3.9. Ovarian Procedures.- 6.3.9.a. Cystectomy.- 6.3.9.b. Incisional and Excisional Approach.- 6.3.9.c. Wedge Resection.- 6.3.10. Rectovaginal Repair.- 6.4. Conclusion.- References.- Appendixes.- Appendix A. Zeiss Operating Microscope.- I. Optical Principles, Illumination Systems, and Support Systems.- II. Individual Parts, Handling, Assembling, Focusing, and Balancing.- III. Accessories.- IV. Documentation.- V. Maintenance and Cleaning.- Appendix B. Patient Information: Laser Surgery.- Appendix C. Discharge Instructions.- Appendix D. Informed Consent.- Appendix E. Laser Certification.- Appendix F. Societies.- Appendix G. Publications.- Appendix H. Glossary of Laser Terminology.