Laser tissue welding

Albumin-PEG-Based Biomaterial for Laser-Tissue Soldering and Its Real-Time Monitoring With Swept-Source Optical Coherence Tomography

BACKGROUND AND OBJECTIVES

The study presents a noninvasive, real-time monitoring technique for the cross-sectional imaging of the laser-tissue soldering process with a swept-source optical coherence tomography (SSOCT) system. The study also aims at performing a comparative study of the laser-tissue soldering (LTS) process using optimized compositions of albumin as solder biomaterials.

STUDY DESIGN/MATERIALS AND METHODS

The experimental study was conducted both ex vivo and in vivo to assess the superiority of the LTS process over conventional methods using a noninvasive imaging tool. In our attempt to combine the two techniques into one diagnostic tool, we have used the SSOCT system for a thoroughgoing investigation of the process in real-time. Laser-assisted tissue soldering was performed using a pulsed near-infrared (NIR) laser with a central wavelength of 980 nm, an output power of 5 W, and beam diameter (1/e ² ) of 6 mm. Here, the SSOCT system has been utilized to observe and analyze the transitions taking place in real-time without disrupting the process. For the comparative study, we have used serum albumin in a 70% w/v concentration and albumin-PEG conjugate in a 6:1 ratio as soldering materials. Different stages of the laser interaction process were monitored with OCT B-scans of the incision area. Also, the basis of biomaterial-tissue interaction was studied with the help of Fourier-transform infrared spectroscopy (FTIR) analysis of the soldering materials.

RESULTS

FTIR spectrum alludes to the fact that the intertwining of the soldering biomaterial with tissue collagen creates adhesion. Biomaterial serum albumin with 70% w/v concentration as soldering material demonstrates complete sealing of tissue at the incision with 3 minutes of laser irradiation. SSOCT B-scans have been useful in imaging the incision noninvasively at different stages.

CONCLUSION

Both ex vivo and in vivo demonstration of the LTS process were presented with a clinical resemblance. OCT can be of great value to determine the wound contraction in case of incisional wounds or sealed wounds produced by the LTS procedure. Also, volumetric measurements of percentage reduction in wound area can be done with OCT. SSOCT system can be a potential imaging modality for real-time noninvasive imaging of surgical procedures like LTS. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

In Vitro Feasibility Analysis of a New Sutureless Wound-Closure System Based on a Temperature-Regulated Laser and a Transparent Collagen Membrane for Laser Tissue Soldering (LTS)

For the post-surgical treatment of oral wounds and mucosal defects beyond a certain size, the gold standard is still an autologous skin or mucosal graft in combination with complex suturing techniques. A variety of techniques and biomaterials has been developed for sutureless wound closure including different tissue glues or collagen patches. However, no wound covering that enables for sutureless fixation has yet been introduced. Thus, a new system was developed that allows for sutureless wound covering including a transparent collagen membrane, which can be attached to the mucosa using a specially modified 2λ laser beam with integrated temperature sensors and serum albumin as bio-adhesive. The sutureless wound closure system was tested for its applicability and its cytocompatibility by an established in vitro model in the present study. The feasibility of the laser system was tested ex vivo on a porcine palate. The in vitro cytocompatibility tests excluded the potential release of toxic substances from the laser-irradiated collagen membrane and the bio-adhesive. The results of the ex vivo feasibility study using a porcine palate revealed satisfactory mean tensile strength of 1.2–1.5 N for the bonding of the membrane to the tissue fixed with laser of 980 nm. The results suggest that our newly developed laser-assisted wound closure system is a feasible approach and could be a first step on the way towards a laser based sutureless clinical application in tissue repair and oral surgery.

Micromotors for drug delivery in vivo: The road ahead

Autonomously propelled/externally guided micromotors overcome current drug delivery challenges by providing (a) higher drug loading capacity, (b) localized delivery (less toxicity), (c) enhanced tissue penetration and (d) active maneuvering in vivo. These microscale drug delivery systems can exploit biological fluids, as well as exogenous stimuli, like light-NIR, ultrasound and magnetic fields (or a combination of these), towards propulsion/drug release. Ability of these wireless drug carriers towards localized targeting and controlled drug release, makes them a lucrative candidate for drug administration in complex microenvironments (like solid tumors or gastrointestinal tract). In this report, we discuss these microscale drug delivery systems for their therapeutic benefits under in vivo setting and provide a design-application rationale towards greater clinical significance. Also, a proof-of-concept depicting 'microbots-in-a-capsule' towards oral drug delivery has been discussed.

Closure of skin incision by dual wavelength (980 and 1064 nm) laser application

Thermal effect of dual wavelength (980 and 1064 nm) laser application in skin incision closure was assessed on 18 male and female Wister rats. 1-cm-long incisions were made on the shaved dorsal region of 220-250 g animals. The incisions were closed by laser irradiation at 1 W and exposure time, 5 seconds in continuous-wave mode (CW) and 1 W and exposure time, 10 seconds in pulsed mode to deliver total energies of 5 J and 10 J per spot onto the incisions, respectively. Animals from each group were sacrificed at 0th, 4th, and 7th days and the skin samples of the weld area were excised for histological analysis using Hematoxylin and Eosin (H & E) stain. Mean thermally altered area (TAA) of CW-mode laser-treated groups was found to increase significantly (p < 0.05) compared with pulsed mode laser treated group at 0th and 4th days post-irradiation while no significant difference (p > 0.05) was statistically found at 7th day post-irradiation. Moreover, tighter closure was observed with CW group at 7th day post-irradiation. We thus conclude that 1 W, 5 J for 5 seconds CW mode laser application of 980 and 1064 nm combined beam form in skin incision closure was found to have absolute wound healing capability with minimal thermal alteration.

In vivo studies of ultrafast near-infrared laser tissue bonding and wound healing

Femtosecond (fs) pulse lasers in the near-infrared (NIR) range exhibit very distinct properties upon their interaction with biomolecules compared to the corresponding continuous wave (CW) lasers. Ultrafast NIR laser tissue bonding (LTB) was used to fuse edges of two opposing animal tissue segments in vivo using fs laser photoexcitation of the native vibrations of chomophores. The fusion of the incised tissues was achieved in vivo at the molecular level as the result of the energy–matter interactions of NIR laser radiation with water and the structural proteins like collagen in the target tissues. Nonthermal vibrational excitation from the fs laser absorption by water and collagen induced the formation of cross-links between tissue proteins on either sides of the weld line resulting in tissue bonding. No extrinsic agents were used to facilitate tissue bonding in the fs LTB. These studies were pursued for the understanding and evaluation of the role of ultrafast NIR fs laser radiation in the LTB and consequent wound healing. The fs LTB can be used for difficult to suture structures such as blood vessels, nerves, gallbladder, liver, intestines, and other viscera. Ultrafast NIR LTB yields promising outcomes and benefits in terms of wound closure and wound healing under optimal conditions.

Thermal welding of biological tissues derived from porcine aorta for manufacturing bioprosthetic cardiac valves

Sutures in cardiac valve bioprostheses have several disadvantages as they have to be manually processed and the suturing region is always a mechanically weak spot. Thermal welding of biological tissues has been evaluated as a means of replacing sutures by the direct application of heat to tissues. The mechanical strength of the welds increased up to 50°C and with lower degrees of humidity and longer times of welding. Chemical fixation was essential for the stability of the weld during re-hydration. The average mechanical strength of the welds (0.87 MPa) was lower than the strength of sutures (1.36 MPa) but some results showed strengths that were similar to sutures. Raman and electron micrographs showed that weld formation is primarily associated with chemical bonds between collagen fibers rather than chain flow and interpenetration.

Closure of skin incisions by laser-welding with a combination of two near-infrared diode lasers: preliminary study for determination of optimal parameters

Laser welding has the potential to become an effective method for wound closure and healing without sutures. Closure of skin incisions by laser welding with a combination of two near-infrared lasers (980 and 1064 nm), was performed for the first time in this study. One centimeter long, full-thickness incisions were made on the Wistar rat's dorsal skin. The efficiencies of laser-welding with different parameters were investigated. Incision-healing, histology examination, and a tensile strength test of incisions were recorded. Laser welding with the irradiance level of 15.9 W∕cm(2) for both 980 and 1064-nm lasers and exposure time of 5 s per spot in continuous wave mode yielded a more effective closure and healing with minimal thermal damage, faster recovery, and stronger apposition in comparison with a suturing technique. The conclusion is that skin welding with a combination of two near-infrared diode lasers can be a good candidate for incision closure, and further investigations are in progress for clinical use.

Temporal heating profile influence on the immediate bond strength following laser tissue soldering

BACKGROUND

Bonding of tissues by laser heating is considered as a future alternative to sutures and staples. Increasing the post-operative bond strength remains a challenging issue for laser tissue bonding, especially in organs that have to sustain considerable tension or pressure. In this study, we investigated the influence of different temporal heating profiles on the strength of soldered incisions. The thermal damage following each heating procedure was quantified, in order to assess the effect of each heating profile on the thermal damage.

MATERIALS AND METHODS

Incisions in porcine bowel tissue strips (1 cmx4 cm) were soldered, using a 44% liquid albumin mixed with indocyanine green and a temperature controlled laser (830 nm) tissue bonding system. Heating was done either with a linear or a step temporal heating profile. The incisions were bonded by soldering at three points, separated by 2 mm. Set-point temperatures of T(set) = 60, 70, 80, 90, 100, 110, 150 degrees C and dwell times of t(d) = 10, 20, 30, 40 seconds were investigated. The bond strength was measured immediately following each soldering by applying a gradually increased tension on the tissue edges until the bond break.

RESULTS

Bonds formed by linear heating were stronger than the ones formed by step heating: at T(set) = 80 degrees C the bonds were 40% stronger and at T(set) = 90 degrees C the bonds strength was nearly doubled. The bond strength difference between the heating methods was larger as T(set) increased.

CONCLUSION

Linear heating produced stronger bonds than step heating. The difference in the bond strength was more pronounced at high set-point temperatures and short dwell times. The bond strength could be increased with either higher set-point temperature or a longer dwell time.

Laser-assisted end-to-end BioWeld anastomosis in an ovine model

The BioWeld tube, an albumin-based exovascular stent, has been used for microsurgical anastomoses and compared to conventional sutures. The study presented investigated the potential of the BioWeld tube for vascular anastomosis in larger vessels. Laser-assisted BioWeld anastomoses were compared to conventional-sutured anatomoses of the carotid artery of Merino-x ewes. The BioWeld procedure resulted in 100% survival and 100% patency at 1 and 6 week post-operative periods, with no noticeable foreign body response. Sutured animals showed 100% survival and patency. The ischemic time for BioWeld anastomosis averaged 15 minutes compared with 10 minutes for sutures. This study indicates that the BioWeld tube is an easy to use anastomotic technique with equivalent success rates and comparable anastomotic times.

NIR laser tissue welding of in vitro porcine cornea and sclera tissue

BACKGROUND AND OBJECTIVE

The objective of this study was to test the hypothesis that an near infrared (NIR) laser system (1,455 nm) in combination with a motorized translational stage to control the position and speed of the laser beam and a shutter to control the laser exposure to the tissue being welded could be used to successfully weld ocular tissues.

STUDY DESIGN/MATERIALS AND METHODS

Seventy-five porcine corneas and 23 porcine scleral tissues were welded in vitro in this study. The welded tissues were examined using histopathology and tensile strength analysis. Eight different welding conditions were analyzed for porcine cornea and one for sclera tissues. The tensile strength of the welded groups was compared to a sutured cornea control group.

RESULTS

The NIR laser welding system provides strong, full thickness welds and does not require the use of extrinsic dyes, chromophores, or solders. Mean weld strengths of 0.15-0.45 kg/cm(2) were obtained for the cornea and 1.01 kg/cm(2) for sclera welds. The native H(2)O in the ocular tissue serves as an absorber of the 1,455 nm radiation and helps to induce the welds.

CONCLUSIONS

We conclude that an NIR laser system using an optimal laser radiation wavelength of 1,455 nm can effectively weld cornea and sclera tissue and that this laser tissue welding (LTW) methodology typically causes minimal disruption of tissue, and thus, avoids opacities and irregularities in the tissue which may result in decreased visual acuity. The optimization of a laser welding system that leads to a strong full thickness tissue bond without tissue destruction, an instant seal that promotes wound healing, and the absence of a continued presence of a foreign substance like a suture, is of considerable importance to the ophthalmology medical community. This need is especially apparent with respect to corneal transplantation and fixing the position of corneal flaps in Laser-Assisted In Situ Keratomileusis (LASIK), a laser procedure used to permanently change the shape of the cornea.

Aorta and Skin Tissues Welded by Near-Infrared Cr4+:YAG Laser

OBJECTIVE

The aim of our study was to explore the wavelength dependence of welding efficacy. Ex vivo samples of human and porcine aorta and skin tissues were investigated using a tunable Cr(4+):yttrium aluminum garnet (YAG) laser.

BACKGROUND DATA

Tissue welding is possible using laser light in the NIR spectral range. Collagen bonding in the tissue induced by thermal, photothermal, and photochemical reactions-or a combination of all of these-is thought to be responsible for tissue welding. Laser tissue welding (LTW) has gained success in the laboratory using animal models. Transition from laboratory to clinical application requires the optimization of welding parameters.

MATERIALS AND METHODS

A near-infrared (NIR) Cr(4+):YAG laser was used to weld ex vivo samples of human and porcine aorta and skin at wavelengths from 1430 to 1470 nm. Welding efficacy was monitored by measuring the tensile strength of the welded tissue and the extent of collateral tissue damage. Tensile strengths were measured using a digital force gauge. Changes in tissue morphology were evaluated using optical and scanning electron microscope (SEM). Fluorescence imaging of the welded areas was also used to evaluate molecular changes following tissue welding.

RESULTS

Full-thickness tissue bonding was observed with porcine aorta samples. No collateral damage of the aorta samples was observed. Tissue denaturation was observed with human aorta, human skin, and porcine skin samples. The optimum tensile strength for porcine and human aorta was 1.33 +/- 0.15 and 1.13 +/- 0.27 kg/cm2, respectively, at 1460 nm, while that for porcine and human skin was 0.94 +/- 0.15 and 1.05 +/- 0.19 kg/cm2, respectively, achieved at 1455 nm. The weld strength as a function of wavelength demonstrated a correlation with the absorption spectrum of water. Fluorescence imaging of welded aorta and skin demonstrated no significant changes in collagen and elastin emission at the weld site.

CONCLUSION

The observation that welding strength as a function of wavelength follows the absorption bands of water suggests that absorption of light by water plays a significant role in laser tissue welding.

Preliminary biocompatibility experiment of polymer films for laser-assisted tissue welding

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the impact of a polymer film for liquid solder strength reinforcement on the short term healing of a wound closed by laser-tissue soldering.

MATERIALS AND METHODS

Full thickness incisions created on the dorsum of Sprague-Dawley rats were closed by laser-tissue soldering: albumin solder with Indocyanine Green (ICG) dye was inserted between the incision edges and photothermally coagulated with a diode laser. A poly(DL-lactic-co-glycolic acid) (PLGA) polymer film was implanted subcutaneously in the bottom of the incision (controls had no film). Specimens were harvested at 0, 3, 7, and 14 days for breaking strength testing and histological analysis.

RESULTS

Breaking strengths of the controls at 0 and 14 days were statistically stronger than the specimens with the implanted films (t-test, P < 0.05). A slight difficulty in apposing the wound edges due to the film presence may have contributed to the low acute strengths. Interference with the wound contraction process by the films possibly contributed to the lower breaking strength at 14 days. Wound histology indicated a mild foreign body reaction to the polymer film material.

CONCLUSIONS

The polymer film was well tolerated by the tissue, and the tissue response to the material was consistent with that seen in the literature. The breaking strength differences between control and film-implanted specimens at 0 and 14 days were probably the result of mechanical complications (tissue apposition and wound contraction) due to the presence of the film, and not due to the film material itself. The use of polymer film patches for liquid solder reinforcement and breaking strength enhancement may have certain application specific issues that need to be addressed. Strategies to account for these issues require further research.

Laser tissue soldering: applications in the genitourinary system

Within the past 25 years, lasers have transitioned from merely destructive or ablative tools to those with reconstructive uses. It has been shown that the application of laser thermal energy to tissue will result in welding of the approximated areas. Furthermore, the addition of protein solder and chromophores (tissue soldering) has increased wound tensile strength while decreasing peripheral tissue damage. Laboratory studies have demonstrated application of laser tissue soldering to virtually all components of the genitourinary system. Increasing human experience in recent years has reinforced the success of this technique.

Intraluminal albumin stent assisted laser welding for ureteral anastomosis

BACKGROUND AND OBJECTIVES

The success of laser tissue welding or soldering depends on optimal laser settings, solder material, and tissue type and geometry. To develop a practical laser welding technique for ureteral repair, an intraluminal albumin stent was designed to enhance the welding effects on ureteral end to end anastomosis.

STUDY DESIGN/MATERIALS AND METHODS

In vitro porcine ureters were anastomosed using an albumin stent alone, the albumin stent plus a solder, and the solder alone. All welding was performed with an 810-nm diode laser with either a continuous wave (1 W, CW) or two pulse modes (2 W, 3.3 Hz; 1 W, 5 Hz). Laser parameters, tensile strength (TS) and burst pressure (BP) of the ureteral anastomosis, and tissue thermal injury were measured.

RESULTS

In the 2-W pulse mode, BP in the albumin stent plus solder group (mean 185 mmHg) and the stent only group (mean 133 mmHg) were significantly higher than the solder only group (mean 77 mmHg, P < 0.05). Laser ureteral anastomosis with the stent plus solder group at 1-W CW and 2-W pulse laser modes yielded the highest TS (mean 97, 82 g) and BP (mean 183, 185 mmHg). Among the three modes, the 1 W pulse delivered the lowest energy and yielded the lowest TS and BP in ureteral anastomosis. There was no significant difference in the thermal damage to the tissue among the modes and groups.

CONCLUSIONS

Using the albumin stent increased the reliability of ureter end-to-end laser anastomosis. Further studies will be warranted in vivo and other tubular organs as well.

Newer techniques in intracorporeal tissue approximation: suturing, tissue adhesives, and microclips

Great strides have been made in the discovery of alternative tissue approximation techniques for use in laparoscopy. Although none of the techniques have eliminated the need for suturing laparoscopically, their potential in achieving this end is promising. When an ideal approximation technique is discovered that is easy to use, safe, and reliably able to hold tissue together laparoscopically, laparoscopic reconstructive surgery should become less formidable and more appealing to urologists.

Renal surgery in the new millennium

In the not too distant future, the minimally invasive renal surgeon will be able to practice an operation on a difficult case on a three-dimensional virtual reality simulator, providing all attributes of the real procedure. The patient's imaging studies will be imported into the simulator to better mimic particular anatomy. When confident enough of his or her skills, the surgeon will start operating on the patient using the same virtual reality simulator/telepresence surgery console system, which will permit the live surgery to be conducted by robots hundreds of miles away. The robots will manipulate miniature endoscopes or control minimally or noninvasive ablative technologies. Endoscopic/laparoscopic footage of the surgical procedure will be stored digitally in optical disks to be used later in telementoring of a surgery resident. All this and more will be possible in the not so distant third millennium.

Novel solid protein solder designs for laser-assisted tissue repair

BACKGROUND AND OBJECTIVES

Previous studies have shown that the application of chromophore-enhanced albumin protein solders to augment laser tissue repairs significantly improves repair strength, enhances edge co-optation, and reduces thermal tissue injury. These investigations are furthered with this in vitro study conducted to assess a new range of specially designed chromophore-enhanced solid protein solders manufactured and tested for application during laser-assisted tissue repair.

STUDY DESIGN/MATERIALS AND METHODS

The experimental study was divided into three parts. In the first part of the study, the creation of a chromophore concentration gradient across the thickness of the solid protein solder was investigated as a means to improve control of the heat source gradient through the solder during laser irradiation. In the second part of the study, predenaturation of the solid protein solder was investigated as a means for enhancing the stability of the solder in physiological fluids before irradiation. Finally, in the third part of the study, the feasibility of using synthetic polymers as a scaffold for traditional albumin protein solder mixes was investigated as a means of improving the flexibility of the solder.

RESULTS

Uniform denaturation across the thickness of the solder was achieved by controlling the chromophore concentration gradient, thus ensuring stable solder-tissue fusion when the specimen was submerged in a hydrated environment. Predenaturation of the solid protein solder significantly reduced the solubility of the solder, and consequently, improved the handling characteristics of the solder. The solder-doped polymer membranes were flexible enough to be wrapped around tissue, whereas their solid nature avoided problems associated with "runaway" of the less viscous liquid solders currently used by researchers. In addition, the solder-doped polymer membranes could be easily tailored to a wide range of geometries suitable to many clinical applications.

CONCLUSION

The novel solid protein solder designs presented here add a new dimension to tissue repair as their flexible, moldable, and absorption controllable nature, greatly improves the clinical applicability of laser-assisted tissue repair.

Biodegradable polymer film reinforcement of an indocyanine green-doped liquid albumin solder for laser-assisted incision closure

BACKGROUND AND OBJECTIVE

The purpose of this study was to determine whether solid material reinforcement of a liquid albumin solder coagulum could improve the cohesive strength of the solder and, thus, the ultimate breaking strength of the incision repair in vitro.

STUDY DESIGN/MATERIALS AND METHODS

A 50%(w/v) bovine serum albumin solder with 0.5 or 2.5 mg/ml indocyanine green (ICG) dye was used to repair an incision in bovine aorta. The solder was coagulated with an 806-nm continuous wave diode laser. A 50-micrometer-thick poly(DL-lactic-co-glycolic acid) film was used to reinforce the solder (the controls had solder but no reinforcement). Acute breaking strengths were measured, and the data were analyzed by Student's t-test.

RESULTS

Observations of the failure modes indicate cohesive strength reinforcement of the test specimens vs. the controls. The 2.5 mg/ml ICG reinforced solder was stronger than the controls without reinforcement (P < 0.05) for all laser powers tested. There was no difference between the test specimens and the controls with 0.5 mg/ml ICG solder for low laser powers, but at higher laser powers, the reinforced solder was stronger than the controls (P < 0.05).

CONCLUSION

Reinforcement of liquid albumin solders in laser-assisted incision repair seems to have advantages in terms of acute breaking strength over conventional methods that do not reinforce the cohesive strength of the solder.

Temperature controlled CO(2) laser welding of soft tissues: urinary bladder welding in different animal models (rats, rabbits, and cats)

BACKGROUND AND OBJECTIVE

Laser welding of tissues is a method of closure of surgical incisions that, in principle, may have advantages over conventional closure methods. It is a noncontact technique that introduces no foreign body, the closure is continuous and watertight, and the procedure is faster and requires less skill to master. However, in practice, there have been difficulties in obtaining strong and reliable welding. We assumed that the quality of the weld depends on the ability to monitor and control the surface temperature of the welded zone during the procedure. Our objective was to develop a "smart" fiberoptic laser system for controlled temperature welding.

STUDY DESIGN/MATERIALS AND METHODS

We have developed a welding system based on a CO(2) laser and on infrared transmitting AgClBr fibers. This fiberoptic system plays a double role: transmitting laser power for tissue heating and noncontact (radiometric) temperature monitoring and control. The "true" temperature of the heated tissue was determined by using an improved calibration method. We carried out long-studies of CO(2) laser welding of urinary bladders in various animal models. Cystotomies were performed on the animals, and complete closure of the bladder was obtained with a surface temperature of 55 +/- 5 degrees C at the welding site.

RESULTS

In early experiments on 31 rats, the success rate was 73%. In later experiments with 10 rabbits and 3 cats, there was an 80% and a 100% success rate, respectively.

CONCLUSION

The success rate in these preliminary experiments and the quality of the weld, as determined histologically, demonstrate that temperature controlled CO(2) laser welding can produce effective welding of tissues. The fiberoptic system can be adapted for endoscopic laser welding.

Current trends in hypospadias repair

There is no single, universally applicable technique for hypospadias repair. Command of a technically straightforward repair with few complications and proven success and versatility in a reasonable range of hypospadias defects are desired goals. Several well-established techniques exist for the repair of all hypospadias defects. The Snodgrass tubularized incised plate urethroplasty, a recent contribution with exemplary early results, has become a popular technique for primary and preoperative repair of middle and anterior hypospadias. Other innovative modifications, and technical advances, such as the use of laser and tissue solder, continue to emerge. With time, these may herald improvements to even the most basic of sound principles involved in all hypospadias repair.