A neurosurgeon`s view: Laser interstitial thermal therapy of mesial temporal lobe structures

Stereotactic laser ablation of mesial temporal structures is a promising new surgical intervention for patients with mesial temporal lobe epilepsy (MTLE). Since this procedure was first used to treat MTLE in 2010, the literature contains reports of 37 patients that underwent MR-guided stereotactic laser amygdalohippocampotomy (SLAH) using Laser Interstitial Thermal Therapy (LITT) with at least 1year of follow-up. This early body of data suggests that SLAH is a safe and effective treatment for MTLE in properly selected patients. Moreover, SLAH is substantially less invasive when compared with open surgical procedures including standard anterior temporal lobectomy and its more selective variants, results in immediate destruction of tissue in contrast to radiosurgical treatments for MTLE, and can more readily ablate larger volumes of tissue than is possible with techniques employing radiofrequency ablation. Finally, evidence is accruing that SLAH is associated with lower overall risk of neuropsychological deficits compared to open surgery. Thus, LITT constitutes a novel minimally invasive tool in the neurosurgeon's armamentarium for managing medically refractory seizures that may draw eligible patients to consider surgical interventions to manage their seizures.

Surgeons and their tools: a history of surgical instruments and their innovators--Part II: The surgeon's wand-evolution from knife to scalpel to electrocautery

This is the second of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

The new age of noninvasive facial rejuvenation

The techniques of noninvasive facial rejuvenation are forever being redefined and improved. This article will review historical as well as present approaches to resurfacing, discussing the nonablative tools that can complement resurfacing procedures. Current thoughts on the pre- and postoperative care of resurfacing patients are also considered.

Laser removal of tattoos

In Western countries the phenomenon of "tattooing" is expanding and tattoos are considered a new fashion among young people. In this paper we briefly trace the history of tattooing, the techniques used, the analysis of pigments used, and their possible adverse reactions. We also carried out a review of the international literature on the use of Q-switched laser in tattoo removal and its complications, and we describe our experience in the use of this technique.

Lasers in refractive surgery: history, present, and future

The history of laser refractive surgery is reviewed, followed by an overview of the current state of the field as well as a look at promising future developments.

Masers to magic bullets: an updated history of lasers in dermatology

Laser therapy is one of the fastest expanding and most exciting fields in dermatology. From its theoretical beginnings in Einstein's imagination, lasers have come to be used in treatments for conditions ranging from skin malignancy and acne to hirsutism and photoaging. We will briefly review the evolution of laser treatment, with a focus on the recent developments surrounding the new millennium.

History of lasers

The developments of laser technology from the cradle of modern physics in 1900 by Planck to its latest medical boundaries is an exciting example of how basic physics finds its way into clinical practice. This article merits the protagonists and their contribution to the steps in this development. The competition between the different research groups finally led to the award of the Nobel Prize to Townes, Basov and Prokhorov in 1964 for the scientific basis on quantum electronics, which led to the construction of oscillators and amplifiers based on the laser-maser principle. Forty-three years after Einstein's first theories Maiman introduced the first ruby laser for commercial use. This marked the key step for the laser application and pioneered fruitful cooperations between basic and clinical science. The pioneers of lasers in clinical urology were Parsons in 1966 with studies in canine bladders and Mulvany 1968 with experiments in calculi fragmentation. The central technological component for the triumphal procession of lasers in urology is the endoscope. Therefore lasers are currently widely used, being the tool of choice in some areas, such as endoscopical lithotriptic stone treatment or endoluminal organ-preserving tumor ablation. Furthermore they show promising treatment alternatives for the treatment of benign prostate hyperplasia.

Verifiable CPD paper: introduction, history of lasers and laser light production

The word laser conjures in the mind's eye many aspects of what might be described as 'modern' life. The words 'powerful', 'precise' and 'innovative' complement our conception of the world in terms of technology, whereas patients often associate the words 'magical' and 'lightening quick' with the use of lasers in medical practice. The purpose of this series of articles is to explore the history and development of lasers, the integration of lasers into clinical dentistry and the safeguards as to their regulated use.

Tonsillectomy: haemorrhaging ideas

Tonsil surgery has been described for over 3000 years. Haemorrhage following tonsillectomy remains the most serious complication of surgery. Over recent years several audits have been gathering data on current trends in tonsil surgery and clinical outcomes throughout England, Scotland and Northern Ireland. The results support a return to traditional dissection with ties to reduce the risk of post-operative haemorrhage. We describe the changes that have occurred to improve efficacy and safety during the evolution of the modern tonsillectomy.

[Microsurgery: History of instrumental vascular anastomoses, our experience with eversion-stapling using VCS forceps]

One century, after Carrel in 1906, technics of vascular surgery are the same. After two world wars, peace surgery has been improved by war surgery. Microscopy surgery gave a new way for vascular surgery which became microsurgery with specific instrumentation. We have move from the developing period of microsurgery in the 1970s, to the fully matured period of microsurgery in the 1980s and the the development of clinical free flaps. The 1990s must be the turning point from autogenous tissue transplantation to allogenic transplantation. Ethic comity keeps keys of future! About microvascular anastomoses, many instrumental technics are explored but no-one is better than the classic manual suture. For us, the best instrumental technic is the anastomose with titanium clips VCS((R)) but we only use it in good situation without difficulties.

Minimally invasive spinal surgery: a historical perspective

The concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based. Minimally invasive treatments have been undertaken in all areas of the spinal axis since the 20th century. Lumbar disc disease has been treated using chemonucleolysis, percutaneous discectomy, laser discectomy, intradiscal thermoablation, and minimally invasive microdiscectomy techniques. The initial use of thoracoscopy for thoracic discs and tumor biopsies has expanded to include deformity correction, sympathectomy, vertebrectomy with reconstruction and instrumentation, and resection of paraspinal neurogenic tumors. Laparoscopic techniques, such as those used for appendectomy or cholecystectomy by general surgeons, have evolved into procedures performed by spinal surgeons for anterior lumbar discectomy and fusion. Image-guided systems have been adapted to facilitate pedicle screw placement with increased accuracy. Over the past decade, minimally invasive treatment of cervical spinal disorders has become feasible by applying technologies similar to those developed for the thoracic and lumbar spine. Endoscope-assisted transoral surgery, cervical laminectomy, discectomy, and foraminotomy all represent the continual evolution of minimally invasive spinal surgery. Further improvement in optics and imaging resources, development of biological agents, and introduction of instrumentation systems designed for minimally invasive procedures will inevitably lead to further applications in minimally invasive spine surgery.

Laser Technology-a Surgical Tool of the Past, Present, and Future

EINSTEIN IDENTIFIED the stimulated emission of radiation, a theory that eventually sparked development of the laser. Beginning in 1960, when the first surgical laser was produced, researchers adapted the laser for various surgical needs. They continue to look for new ways to refine and apply this technology. KNOWING THE BASICS of laser science helps OR nurses understand their roles and responsibilities during laser surgery. SURGICAL NURSES must stay current and competent with laser equipment and related safety issues, so health care facilities need to determine the best way to provide ongoing education and training.

Transmyocardial laser revascularisation and other treatment modalities for angina pectoris

Ischaemic heart disease is one of the leading causes of morbidity and mortality in the western world. This paper provides an overview of the different treatments for one of the most common manifestations of ischaemic heart disease: angina pectoris. Besides the currently available conventional methods, several alternative treatments are described, with a special focus on transmyocardial laser revascularisation.

[From Einstein's Quantum Theory to modern laser therapy. The history of lasers in dermatology and aesthetic medicine]

Laser technology has considerably expanded therapeutic modalities in dermatology and aesthetic medicine. In addition, lasers have broadened the spectrum of diagnostic and therapeutic options in many other medical fields. Dermatologists, especially Dr. Leon Goldman, played an important role in the evolution and use of medical lasers. There was a long way from the concept of stimulated emission as the fundamental idea of laser technology by Albert Einstein in 1917 to the practical use of the laser today. We review the development of laser technology from the early days through the latest advances.

Historical survey of laser dentistry

Soon after lasers were invented, investigators began to examine the effects of different wavelengths of laser energy on oral tissues. From soft tissue surgery to restorative dentistry, from reshaping healthy gingiva to treating pathologic conditions, from routine procedures to experimental applications, researchers and clinicians have defined the limitations and shown the advantages of laser use in dentistry.

The role of dermatologists in the evolution of laser surgery

The role dermatologists have played throughout the history of laser development is an extremely vital one. The initial interests of Dr. Leon Goldman stimulated many other individual dermatologists to further his work and develop surgical techniques using newer laser systems to provide more effective treatment for patients with a variety of skin diseases. The long list of current cutaneous laser applications developed by dermatologists makes it virtually certain that members of our specialty will continue to play a significant future role in the refinement of laser instrumentation and operative techniques that are inevitable to occur.

History, Instrumentation, and Techniques of Flexible Endoscopic Laser Surgery in Horses

There are clearly a number of applications for which flexible endoscopic laser surgery has become the state of the art in equine surgery, and the Nd:YAG laser seems to be the most versatile instrument for this type of surgery. Nevertheless, it is critical to understand the advantages and disadvantages of each laser technique. For example, the Nd:YAG laser used in a noncontact fashion seems to be superior when ablation of tissue is required such as treatment of upper airway masses. Conversely, contact Nd:YAG laser techniques have proven themselves to be superior when more precise cutting is advantageous such as treatment of epiglottic entrapment. Ultimately, it seems that a range of lasers is necessary to ensure selection of the most appropriate technique, adding significantly to the expense of equipment but improving the outcome for a range of equine diseases.

Overview of lasers in plastic surgery

The laser used today in plastic surgery has gone through many stages of development. This article examines the history of lasers, including the scientific background and the theory of selective photothermolysis in therapy. In addition, current trends and future developments in laser treatment are discussed.

Laser incisional surgery

Soft tissue surgery is more efficient, and sometimes more effective, using laser incisional surgery as opposed to standard techniques. The modern generation of lasers produces soft tissue incisions with a minimum amount of thermal damage at wound edges. The transition to laser incisional surgery requires a knowledge of methods, maneuvers, and safety information.

Laser tattoo removal

The availability of Q-switched ruby Nd:YAG and alexandrite lasers has revolutionized the treatment of tattoos. These modalities offer significant advantages over all previously available treatments and are currently the standard of care for the cosmetic removal of unwanted tattoos.

History of direct vision internal urethrotomy

Throughout medical history, the treatment of urethral strictures ranged from catheterization, the insertion of bougies, and the application of caustics to different methods of dilation, blind internal urethrotomy, and open surgery. The rise of endoscopy in the 19th century added the possibility of direct vision internal urethrotomy to this therapeutic spectrum. The development of this endourologic method is recapitulated from the first report in 1865 to the gold standard of cold knife urethrotomy in 1971 and later modifications (eg, advanced laser techniques).

[Excimer laser: history, development and comparison of equipment]

We first present the history of the Excimer Laser technological development which began in 1975 with Velazco and Sester's research. We report various studies about lasers conceiving, treatment parameters, laser-tissues interactions, and treatments evolution. In the second part, we compare different Excimer laser systems and their capacities. Three current technologies are used for clinical application: the broad beam lasers, which use a diaphragm or a disc with multiple apertures, the scanning slits and the flying spots. Advantages and disadvantages of the various delivery systems are discussed.

Transmyocardial laser revascularization: historical background and future directions

Transmyocardial laser revascularization (TMLR) was investigated as a possible treatment alternative for patients with refractory coronary artery disease. This paper is a summary of nearly four decades of research by the authors. Beginning in 1969 experimental studies were conducted on the beating heart. A prototype 450 W carbon dioxide laser was used to create channels in the ischemic myocardium. Initial clinical studies began in 1984. A protocol was developed for TMLR as an adjunct to CABG in those patient who had at least one vessel which could be bypassed and areas of ischemia which were not amenable to bypass. In the early 1990's the development of a 850 W CO2 laser for clinical use allowed us to begin investigation of TMLR on the beating heart. Patients with end stage coronary artery disease who were not candidates for other forms of treatment were selected. The early results are encouraging with patient followup of from 3 months to 5 years. There are numerous controversies regarding the effects of TMLR on myocardial function and perfusion. To quantify these effects the authors have performed acute and chronic studies on swine using sophisticated techniques with 3D cine magnetic resonance imaging. We concluded TMLR improved left ventricular function and perfusion in acute and chronic ischemia.

Review of facilitated approaches to vascular anastomosis surgery

BACKGROUND

There is an increasing demand for an easier, quicker, less damaging, but reliable procedure to create a vascular anastomosis. This demand is not new but is revitalized by the movement of vascular procedures in various specialties, including cardiac surgery, toward minimally invasive procedures. This article reviews the most important representatives of devices or methods that have been developed in the last two centuries.

METHODS

A thorough literature search was performed. The outcome is presented and discussed in four parts: (1) stapling and clipping devices, (2) coupling devices, (3) glues, and (4) laser welding.

RESULTS

Stapling devices have not become the standard fashion to create an anastomosis because they are too complicated to use. In selected cases clips have potential in vascular surgery. There is a ring-pin coupling system available that is easy to use and especially suitable for creating an end-to-end anastomosis. The ideal glue is yet to be developed, and the currently available laser welding techniques have to become refined.

CONCLUSIONS

It is anticipated that the future lies in hybrid techniques that combine sutures or clips with glues or laser-welding techniques.

Fundamentals of laser surgery

Laser light has unique properties that enable transmission of high amounts of energy to a narrowly defined site. Biological effects may be thermal, chemical, or mechanical. Medical procedures involve mainly thermal tissue destruction by coagulation (> 60 degrees C) or ablation (> 300 degrees C). The effect is governed by tissue optical and thermal properties and laser variables; contact/non-contact, focus, output power (W), and exposure time (s). The laser medium governs the wavelength emitted. The carbon dioxide (CO2) laser light (10600 nm) requires transmission through articulating arms with mirrors, whereas neodymium:yttrium-aluminum-garnet (Nd:YAG) (1064 nm), and argon (488/515 nm) light can be transmitted through flexible quartz fibres. CO2 lasers are used mainly for high precision tissue ablation; Nd:YAG lasers can coagulate or vaporise larger tissue areas and argon laser applications involve vascular destruction, based on selective absorption by haemoglobin. Research has shifted towards a fundamental understanding of the interactions of light with biological tissue to allow treatment planning and to optimise laser procedures. Applications such as interstitial laser coagulation for local destruction of solid tumours deserve further exploration in general surgery.

Laser applications in the tracheobronchial tree

This article outlines the historical development of the use of lasers in the tracheobronchial tree, the current indications for the use of carbon dioxide and neodymium:yttrium-aluminum-garnet lasers, and the management of complications. The merits of other laser wavelengths are mentioned, including use of the potassium titanyl phosphate laser in the pediatric airway. Photodynamic therapy is discussed, and some future developments are introduced.

Experimental and clinical standards, and evolution of lasers in neurosurgery

From initial experiments of ruby, argon and CO2 lasers on the nervous system so far, dramatic progress was made in delivery systems technology as well as in knowledge of laser-tissue interaction effects and hazards through various animal experiments and clinical experience. Most surgical effects of laser light on neural tissue and the central nervous system (CNS) are thermal lesions. Haemostasis, cutting and vaporization depend on laser emission parameters--wavelength, fluence and mode--and on the exposed tissues optical and thermal properties--water and haemoglobin content, thermal conductivity and specific heat. CO2 and Nd-YAG lasers have today a large place in the neurosurgical armamentarium, while new laser sources such as high power diode lasers will have one in the near future. Current applications of these lasers derive from their respective characteristics, and include CNS tumour and vascular malformation surgery, and stereotactic neurosurgery. Intracranial, spinal cord and intra-orbital meningiomas are the best lesions for laser use for haemostasis, dissection and tissue vaporization. Resection of acoustic neuromas, pituitary tumours, spinal cord neuromas, intracerebral gliomas and metastases may also benefit from lasers as accurate, haemostatic, non-contact instruments which reduce surgical trauma to the brain and eloquent structures such as brain stem and cranial nerves. Coagulative lasers (1.06 microns and 1.32 microns Nd-YAG, argon, or diode laser) will find an application for arteriovenous malformations and cavernomas. Any fiberoptic-guided laser will find a use during stereotactic neurosurgical procedures, including image-guided resection of tumours and vascular malformations and endoscopic tumour resection and cysts or entry into a ventricle. Besides these routine applications of lasers, laser interstitial thermotherapy (LITT) and photodynamic therapy (PDT) of brain tumours are still in the experimental stage. The choice of a laser in a neurosurgical operating room implies an evaluation of the laser use (applications, frequency), of the available budget and costs--including purchase, maintenance and staff training--, and material that will be necessary: unit, peripherals, safety devices and measures, training programme. Future applications of lasers in neurosurgery will come from technological advances and refined experimental applications. The availability of new wavelength, tunable, small sized and "smart" laser units, will enlarge the thermal and non-thermal interactions between laser energy and neural tissue leading to new surgical applications. Tissue photo-ablation, photohynamic therapy using second generation of photosensitizers, updated thermotherapy protocols, are current trends for further use of lasers in neurosurgery.

Laser bronchoscopy

The worldwide epidemic of cancer of the lung has stimulated the development of therapies to relieve endobronchial obstruction. Table 3 lists a number of endobronchial therapies that might be used to treat malignant central airway obstruction. With over 15 years of worldwide experience, the Nd:YAG laser has proven to be the most important of these tools. Laser bronchoscopy can be performed with rigid or flexible instruments and produces a rapid recanalization of the airway with associated relief of symptoms. The treatment is repeatable and has acceptable immediate complications and infrequent delayed complications. To be effective, laser bronchoscopy can only be used for the treatment of intraluminal obstructions. Obstruction by submucosal infiltration and external compression require other endobronchial therapies. The performance of laser bronchoscopy requires an extra commitment by the bronchoscopist. A thorough understanding of airway and mediastinal anatomy is mandatory along with an appreciation of laser physics and tissue interaction. Attendance at specialized training courses may be required to satisfy local credentialing bodies. In the past 15 years, thousands of patients have benefited from the development of laser bronchoscopy techniques. No longer a therapy of last resort, laser bronchoscopy has proven to be an excellent tool to relieve the symptoms of central airway obstruction.

Lasers in neurosurgery: a historical overview

This contribution to the history of laser applications to neurosurgical patients gives the background against which the subsequent developments took place. It covers the important facts regarding the theoretical formulations that led to the invention of the world's first laser in 1960. This was a pulsed ruby laser, which proved lacking in desirable surgical procedures, and at high powers was shown to be damaging to vital organs, such as the brain. It could be lethal to small animals. These very early tests of laser tissue and organ interaction included studies on protein in solution, cultured cells, brain, spinal cord and their surrounding tissues, and transplantable melanomas, as well as ependymoblastomas in mice. Fortunately, the continuous wave CO 2 laser came along in 1967 to replace both the pulsed ruby and neodymium-in-glass lasers. The CO 2 laser was quickly seen to possess surgical properties, namely, vaporization, cutting, hemostasis, and sterilization, without additional damage at a distance or remotely in time. Research studies on normal and pathologic tissues in and around the brain and spinal cord quickly and dramatically showed the potential for benefit to animal and human patients with experimental and naturally occurring neoplasms, burns, and decubitus ulcers. Lasers in neurosurgery are used largely for benign and malignant brain and spinal neoplasms. For benign tumors, debulking of tumor mass, and ablation of unwanted neoplasm without damaging adjacent, vital, functioning neural tissue, the laser adds another therapeutic adjunct and will, at times, aid in complete tumor removal. For malignant vascular growths, the laser will aid greatly in the safest possible excision with maximum hemostasis. Studies around the world, ongoing or planned, will surely extend the uses of lasers for neurosurgery into vascular, infectious, and reconstructive fields, particularly with the proliferation of laser instruments that exploit additional wavelengths into the larger infrared levels and even the shorter ultraviolet region. Experimental and, to some extent, clinical applications are testing the value of Nd:YAG, holmium:YAG, and erbium:YAG lasers in various surgical fields.