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Laser Surgery in Veterinary Medicine

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Laser Surgery in Veterinary Medicine

Edited by

Christopher J. Winkler, DVM, DABLS, VMLSO

Suffolk Veterinary Group Animal Wellness and Laser Surgery Center
Selden, New York, USA
 This edition first published 2019
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© 2019 John Wiley & Sons, Inc.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
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The right of Christopher J. Winkler to be identified as the author of this editorial material has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication data has been applied for

ISBN: 9781119486015

Cover Design: Wiley

Cover Images: Photo credit – Gaemia Tracy, Photo credit – Katalin Kovacs, Photo credit – Christopher J. Winkler

10 9 8 7 6 5 4 3 2 1
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Contents

Dedication and Acknowledgments viii

About the Editor ix
Foreword x
Preface xii
List of Contributors xv
Disclaimer xvii
About the Companion Website xviii

Part I The Science of Laser Surgery 1

1 Laser Physics and Equipment 3

Peter Vitruk

2 Understanding and Utilizing Power Density 14

Noel Berger

3 Laser–Tissue Interaction: Selecting a Laser for Surgery 22

Christopher J. Winkler

4 The Ideal Laser Scalpel 32

Peter Vitruk

5 Combining Laser Surgery with Laser Therapy (Photobiomodulation) 42

David S. Bradley

6 Laser Safety in the Operating Theater 52

Christopher J. Winkler

Part II Laser Surgery in Canines and Felines 61

7 Elective Laser Surgery Procedures 63

Paul Sessa and Andrew Brockfield

8 Oral Laser Surgery Procedures 84

Jan Bellows

9 Laser Surgery Procedures of the Nose and Throat 99

Ray A. Arza
 vi Contents

10 Laser Surgery Procedures of the Ear 106

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Louis N. Gotthelf

11 Periorbital and Eyelid Laser Surgery Procedures 116

Daniel M. Core

12 Ophthalmic Lasers for the Treatment of Glaucoma 129

Noelle La Croix and Jay Wayne

13 Dermatologic Laser Surgery Procedures 141

David Duclos

14 Urogenital and Perianal Laser Surgery Procedures 164

William E. Schultz

15 Oncological Laser Surgery Procedures 198

Devin Cunningham and F. A. (Tony) Mann

16 Laser Photodynamic Therapy Procedures 206

Katalin Kovács

17 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures 217
David S. Sobel

18 Laser Neurosurgical Procedures 239

Gaemia Tracy

Part III Laser Surgery in Equines 245

19 Equine Laser Surgery Procedures 247

Lloyd P. Tate and Kathryn B. Tate

Part IV Laser Surgery in Exotics Species 265

20 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians) 267
Eva Hadzima, Maros Pazej, and Katherine Weston

21 Laser Surgery in Aquatic Animals (Sea Turtles) 292

Brooke M. Burkhalter and Terry M. Norton

Part V Integrating Surgical Lasers in Your Veterinary Practice 313

22 Tips and Tricks for Veterinary Laser Surgeons 315

Les “Laser Les” Lattin

23 Pain Management in Laser Surgery Procedures 320

Noel Berger

24 Laser Surgery in the Mobile Practice 324

Janine S. Dismukes
 Contents vii

25 Economic Considerations for Laser Surgery 327

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John C. Godbold, Jr

Part VI The Future of Lasers in Veterinary Medicine and Surgery 335

26 The Future of Lasers in Veterinary Medicine and Surgery 337

Christopher J. Winkler

Appendix A: Glossary 341

Appendix B: Certifying and Academic Laser Organizations 346
Appendix C: Tables of Laser Settings 347
Index 359
 viii
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Dedication and Acknowledgments
This book is dedicated in loving memory to those who
still remain with us in our hearts, particularly to Donna
and Robert Sessa, and to Jack Winkler.
This book would not have been possible without the
efforts of an extraordinary group of contributing veteri-
narians, experts, and their staffs, in the field of laser
medicine and surgery. The past year has been a wonder-
fully illuminating education in each of your fields, and I
am proud to bring your brilliant work to others’ atten-
tion. It has been the greatest of pleasures collaborating
with you. A heartfelt thank you to you all.
To John C. Godbold, Jr., DVM, whose mentorship,
encouragement, patience, time, and input were invaluable
and instrumental in the creation of this book. I am hon-
ored to call you my teacher, my colleague, and my friend.
To Mr. Stephen Fisher, MBA, of the American Board of
Laser Surgery, for his generous correspondence and aid
with reference materials and figures.
To my editors, Erica Judisch, Purvi Patel, Susan
Engelken, and Sandeep Kumar, for all of your advice and
assistance.
To my own staff past and present, for all of your help
and enthusiasm for this project.
To all of our patients who have helped us learn, and
those that these efforts here are intended to help in the
future, this is for you.
To my family and friends for their support, especially
to my parents Nancy and Joseph, whose own dedication
and faith and love are an everlasting source of
inspiration.
To my children John and Kevin, my greatest endeavor,
and to Nicole, my wife and companion in this our
­adventure. I love you very much.
 ix
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­About the Editor

Christopher J. Winkler, DVM graduated from Ross c­ ontinues to advise educating bodies on veterinary laser
University School of Veterinary Medicine in 2001, and curricula, and offers his services as a laser consultant to
worked on Long Island, NY, as an emergency room vet- veterinarians and equipment manufacturers.
erinarian and associate general practitioner before pur-
chasing Suffolk Veterinary Group in 2006. Incorporating
surgical lasers into his practice in 2010, he soon added
laser therapy and began formal training a short time
later, earning certifications in Veterinary Laser Medicine
and Surgery from the American Board of Laser Surgery
(ABLS) in 2015, and Veterinary Medical Laser Safety
Officer from the American Institute of Medical Laser
Applications (AIMLA) in 2016.
Dr. Winkler has spoken on laser surgery and laser ther-
apy and served as an associate laser surgery wet‐lab
instructor for a number of national veterinary confer-
ences including the NAVC, AVMA, and WVC. He has
also conducted webinars on laser therapy for veterinary
technicians and Ross University students, and published
articles on laser surgery for Veterinary Practice News.
He is a member of the American Society for Laser
Medicine and Surgery (ASLMS), and is a faculty member
of both the American Laser Medicine College and Board
(ALMCB) and the American Laser Study Club (ALSC),
for which he also sits on the editorial board of its journal.
He receives referrals from veterinarians locally and
nationally for laser surgery and laser therapy cases,
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­Foreword
My love affair with lasers and other light based medical
technologies began in 1999 with a picture in a veterinary
trade magazine. The picture, accompanying an article
about a simple CO2 laser surgery procedure, was intrigu-
ing, a bit mysterious, and somehow very exciting.
Our first date was a few weeks later when the repre-
sentative for a surgical laser company brought a CO2
laser to my practice for a demonstration. After putting
the laser in my hands for the first time, the representative
talked me through several procedures. Seeing tissue
vaporize was more intriguing, more mysterious, and
exquisitely more exciting than the picture. I was in love,
and my first CO2 surgical laser was delivered within a
month.
For early adopters of lasers, one of the challenges was
an almost complete lack of information about the science
of laser–tissue interaction and no information about its
use in specific veterinary surgery procedures. Progress
was made and new applications became more common
because early adopters were willing to share their clinical
experiences. We sought any potentially helpful publica-
tion, we networked to share case reports, and we cele-
brated when laser surgery texts were published in 2002
and 2006 (Bartels 2002; Berger and Eeg 2006).
For me, sharing case reports led to making presenta-
tions about laser surgery, and leading wet labs and work-
shops in which my co‐faculty and I learned as much as
participants. Eighteen years and over 600 educational
events later, I continue to join participants in a quest for
up‐to‐date information about surgical lasers and their
use in veterinary medicine. Laser Surgery in Veterinary
Medicine now gives us that information.
Teaching wet labs and workshops has given me the
opportunity to work with many talented colleagues
­serving as co‐faculty. One of the most notable is
Dr. Christopher J. Winkler.
Chris joined the teaching team for a CO2 laser wet lab
I was leading several years ago and immediately excelled
in teaching the technology one‐on‐one. Since then he
has continued to be one of my first choices for co‐faculty.
His depth of knowledge, understanding of the science,
and ability to apply that science to clinical applications is
superb. He is one of only six veterinarians in the world
certified by the American Board of Laser Surgery. No
one is more qualified to be the editor and a contributing
author of Laser Surgery in Veterinary Medicine.
Dr. Winkler has gathered together an impressive group
of scientists and veterinarians from academia, industry,
specialty practices, and general practice as chapter con-
tributors. Together with Dr. Winkler, the contributors
give the veterinary community an authoritative source of
information about laser surgery.
The chapters on the science and safety of laser surgery
are detailed and clearly presented. They include excel-
lent illustrations and diagrams that help simplify the
complexities of laser–tissue interaction.
The chapters on clinical applications contain practical
guidelines about species‐specific procedures, and help
make this book a practical and usable clinical reference.
The inclusion of many intraoperative pictures clarifies
the contributing authors’ text descriptions.
The chapters on integration give a road map for suc-
cessful incorporation of laser surgery into a practice.
And, the final chapter gives a glimpse into the future of
laser surgery and what we can look forward to.
A valuable feature of this book is the information about
laser settings for procedures. Current surgical lasers
have higher power, are more efficient, have improved
software, and an increased number of delivery options.
Since laser settings may vary depending on the specific
equipment being used, tables for recommended settings
use a standardized format applicable to multiple equip-
ment options. Practitioners can adapt the recommenda-
tions to a wide range of equipment.
Another valuable feature is that it is noncommercial.
Just as with the tables of settings, the text describes treat-
ment procedures and protocols in generic, noncommer-
cially specific ways.
Contributing authors do not recommend specific laser
manufacturers. Rather, they describe a broad range of
equipment and discuss the differences, benefits, and lim-
itations between them.
Laser Surgery in Veterinary Medicine will be the go‐to
source of knowledge and reference for veterinary
 ­Forewor xi

s­ tudents, veterinary colleges, general practitioners, spe- Berger NA. Eeg PH. (2006). Veterinary Laser Surgery: A
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cialists, and those involved in the continued develop- Practical Guide. Hoboken, NJ: Wiley‐Blackwell.
ment of new laser devices for veterinary medicine. I look
forward to it being a valuable addition to my library. John C. Godbold, Jr.
And, I look forward to our quest for up‐to‐date informa- Stonehaven Veterinary Consulting
tion about surgical lasers and their use in veterinary Jackson, Tennessee, USA
medicine being over for a while.

­References
Bartels KE. (2002). Lasers in medicine and surgery. Vet.
Clin. North Am. Small Anim. Prac. 32(3). pp. 495–745.
 xii
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Preface
Without any external influence, particles of light known
as photons are spontaneously emitted by excited atoms
and molecules as they return to lower levels of energy.
This is the source of all light in nature. While formulat-
ing his Special Theory of Relativity in 1916, Albert
Einstein described how photons might be emitted from
atoms under external influence. He predicted what is
now known as stimulated emission, where photons of a
particular wavelength could stimulate atoms in an
excited state to emit more photons of the same wave-
length without absorption of the stimulating photons
(Hecht and Teresi 1982b).
Charles H. Townes, James P. Gordon, and H.J. Zeiger
began working on a device in the 1950s that would
amplify stimulated emission. Their invention of the
microwave amplification by stimulated emission of
radiation (MASER) would become the groundwork
laid by Townes and Arthur Schawlow for the device
known as the light amplification by stimulated emis-
sion of radiation (LASER), a term first coined by grad-
uate student Gordon Gould, who also recognized that
the temperature of laser light could exceed that of the
operating temperature of its originating device (Hecht
and Teresi 1982b).
However, it was Theodore Maiman who built the first
working laser in 1960 (Wyckoff 2014). Thinking outside
the box with solid instead of gaseous mediums to create
laser light, his solid ruby laser, pumped by a simple flash-
lamp, was a palm‐sized invention compared to Townes’
large design. Maiman predicted at a press conference
highlighting his invention that such a concentrated light
might be applied to medicine and surgery (Hecht 2005).
Doctors did indeed begin experimenting with lasers in
the 1960s to understand their possible use. Dermatologist
Dr. Leon Goldman was a pioneer of laser surgery, trying
one out on his own skin before offering it to his patients.
A strong advocate of their use, he was the first to suggest
that lasers not only can be used for surgical procedures,
but are required for certain procedures such as those on
the larynx, gastrointestinal (GI) tract, and brain (Hecht
and Teresi 1982c).
In 1964 Dr. Kumar C. Patel invented the CO2 laser, a
device of greater power with the subtle difference of
operating in a vibrational rather than electronic transi-
tion of its active media, creating a wavelength of laser
light much longer than those of other lasers. Though
most of the interest in the CO2 laser at the time was in
military and industrial applications, this wavelength
would prove crucial to what would become one of the
most prolific lasers to be used in human and veterinary
surgery (LuxarCare 2004–2018).
The first CO2 surgical lasers used articulated arms for
delivery of light to the patient. Hollow waveguide deliv-
ery systems were also created in the 1960s alongside the
burgeoning development of optical fibers for commu-
nication and image transmission (Harrington 2000).
These two systems made the delivery of laser light to
the patient more flexible and minimally invasive, and
doctors and veterinarians began adapting them to their
patients and procedures. One notable example was the
Nd:YAG laser, delivered through optical fibers to facili-
tate minimally invasive surgery in equine species
(Hecht and Teresi 1982a).
From the 1970s to the 1980s, Dr. Kathy Laakmann‐
Crothall patented both the all‐metal radio frequency
(RF)‐excited CO2 laser resonator (a lighter, more robust
and heat‐efficient system than previous CO2 lasers) and
the development of a flexible waveguide for CO2 surgical
laser systems. This paved the way for laser surgical units
to be utilized easily in general practice settings, and sur-
gical lasers saw wider marketing to veterinary practices
(LuxarCare 2004–2018).
My own first encounter with surgical lasers occurred
in the early winter of 2000. I was completing my small
animal surgery rotation in my clinical year of veterinary
school when I was assigned with two or three other stu-
dents to a workshop conducted by one of our surgical
interns to declaw a cat with a surgical laser. I remember
it was winter because I was wearing a heavy pair of boots,
which did not fit very well at all into the foot pedal of the
laser’s trigger, and my foot got stuck on the trigger while
I was trying to manipulate the laser. No one was hurt

(including the cat), but I do remember the intern exam-
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ining his fingers as I left the room. My first experience
with surgical lasers was thus not a fond one. I had the
unfortunate impression they were merely a toy for
declaws, and I had no particular desire to encounter
them again as I proceeded with my training.
Nearly 10 years later, my veterinary practice was riding
the rapids of the Great Recession, and I was seeking ideas
to make the practice distinctive. Fortuitously, a surgical
laser representative stopped by and asked for a few min-
utes of my time. These few minutes showed me the sur-
gical laser’s true potential, helping me to push past my
previous encounter and decide to give it a try. I quickly
became fascinated by the subject of laser medicine and
surgery, and over the past eight years I have not con-
ducted a surgery without a laser. I find it quite ironic that
following my first encounter with lasers as a student, I’ve
now had the opportunity to use a number of different
laser models to conduct countless varied successful pro-
cedures, many of which I would not have attempted
without a laser, and that I now cannot say enough about
the benefits a surgical laser brings to both patient and
surgeon. Seeing patient after patient leave my own clinic
and those of my colleagues with such an improved recov-
ery, sometimes almost as if nothing has happened, makes
using lasers a very satisfying clinical experience. Clients
are thrilled we offer this service and enjoy talking about
it with others. No less rewarding are the new friends and
colleagues with whom I’ve since met and worked, and
the educational events I’ve learned and shared. I only
wish I’d started using lasers sooner.
In the past two decades, new advances have been made
in laser technologies that are available now to veterinar-
ians in specialty and general practice, as well as new
techniques for working alongside the burgeoning field of
veterinary laser photobiomodulation. Certifying bodies,
such as the American Board of Laser Surgery and the
American Institute of Medical Laser Applications, and
academic laser societies such as the American Society
for Laser Medicine and Surgery and the American Laser
Study Club, have been established and continue to grow.
The number of veterinarians utilizing laser surgery has
dramatically increased, creating an opportunity for a
remarkable collaboration between this small but grow-
ing body of knowledge and experience, which the reader
will see manifest here.
Laser Surgery in Veterinary Medicine details a wide
variety of laser surgical equipment, and includes the
tutelage, work experience and recommendations of a
number of experienced and talented contributors from a
diversity of venues of laser medicine and surgery. Topics
addressed include laser physics, tissue‐interaction,
safety, photobiomodulation, photodynamic therapy,
small and large animal practice, specialty practice,
Preface xiii
mobile practice, exotic animal practice, and practice
integration. Chapters on canines and felines are further
divided by surgical subject.
Some of the most commonly asked questions I receive
when discussing lasers with veterinarians about their
concerns are recommendations for specific laser settings
and techniques for a given procedure. Today’s lasers have
seen improvements in power, efficiency, ergonomics,
software, and options for spot size and power density
which all affect the answer to these questions. To accom-
modate such concerns of practitioners, tables for recom-
mended laser settings for each procedure have been
designed within this text in a standardized format which
reflects current technology and practices, following
which each procedure is described in further detail. The
tables of laser settings have also been compiled into an
appendix for quick reference in a surgical setting.
In researching and collaborating with so many experts,
we have endeavored together to refrain from recom-
mending specific laser manufacturers, preferring instead
to describe a broad range of equipment which should
serve the practitioner well, while discussing the differ-
ences, benefits, and limitations between them. In like
fashion, rather than describing settings in a manner par-
ticular to a single piece of equipment, the previously
mentioned tables of laser settings discuss their particu-
lars in the broadest possible terms to allow the practi-
tioner to adapt them to the wide range of surgical lasers
available today. In this endeavor my coauthors and I have
strived to provide as much information as possible while
avoiding confusion for the reader, who may still find it
worthwhile to consult their laser’s manufacturer for fur-
ther discussion of the adaptation of these tables to their
own laser surgical unit.
The recommended laser settings within come from the
experience behind performing countless procedures
over many years. They remain recommendations, and
we look forward to our readers sharing their own meth-
ods, refinements, and experiences with us and others.
The understanding of basic subjects such as laser phys-
ics, biophysics, laser–tissue interaction, and laser safety
are becoming a necessary and valuable foundation for
students and practitioners as the use of lasers becomes
more ubiquitous in veterinary practice. This book is
therefore intended as a source of knowledge and refer-
ence for the veterinary student, veterinary colleges, gen-
eral practitioners and specialists alike, and experts in
laser industry for the further development of equipment
and applications. As a state‐of‐the‐art method of per-
forming surgery, we believe laser surgery should indeed
be introduced with great enthusiasm to veterinary stu-
dents at the university level, and my colleagues and I
hope to assist here in making such an introduction an
interesting and informative one.
 xiv Preface
­References
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Harrington J. (2000). A review of IR transmitting, hollow
waveguides. Fiber Integr. Opt. 19. pp. 211–217.
Hecht J. (2005). Beam: The Race to Make the Laser,
Chapters 15 and 16. New York, NY: Oxford University
Press. pp. 169–194.
Hecht J, Teresi D. (1982a. A laser bestiary: different kinds
of lasers. In: Laser: Light of a Million Uses, Chapter 3.
Toronto, ON: General Publishing Company, Ltd.
pp. 36–38.
Hecht J, Teresi D. (1982b. The short but tempestuous
history of the laser. In: Laser: Light of a Million Uses,
Chapter 4. Toronto, ON: General Publishing Company,
Ltd. pp. 49–61.
Hecht J, Teresi D. (1982c. Laser medicine: a bright
promise. Laser: Light of a Million Uses, Chapter 5.
Toronto, ON. General Publishing Company, Ltd. 62–80.
LuxarCare. (2004–2018). Brief history of the surgical CO2
laser. http://www.luxarcare.com/main.
php?group=resources&page=laser_history (accessed 7
August 2018).
Wyckoff EB. (2014). The laser light mystery. The Man Who
Invented the Laser: The Genius of Theodore H. Maiman,
Chapter 4. Berkeley Heights, NJ: Enslow Publishers, Inc.
pp. 23–31.
Christopher J. Winkler
Suffolk Veterinary Group Animal Wellness
and Laser Surgery Center
Selden, NY, USA
2018
 xv
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List of Contributors

Ray A. Arza, DVM John C. Godbold, Jr., DVM

RSA Veterinary Technologies Veterinary Laser Consultant
Taylorsville, KY, USA Stonehaven Veterinary Consulting
Jackson, TN, USA
Jan Bellows, DVM, Diplomate AVDC, ABVP (canine
and feline) Louis N. Gotthelf, DVM
All Pets Dental Animal Hospital of Montgomery, LLC
Weston, FL, USA Montgomery Pet Skin and Ear Clinic
Montgomery, AL, USA
Noel Berger, DVM, MS, DABLS
Quail Hollow Animal Hospital
Wesley Chapel, FL, USA Eva Hadzima, DVM, MVDr
Dewinton Pet Hospital
David S. Bradley, DVM, FASLMS Heritage Pointe, AB, Canada
Veterinary Medical Director
K‐Laser Katalin Kovács, DVM, PhD
Oakdale, CA, USA Small Animal Laser Clinic
Budapest, Istvánmezei út 6. Hungary
Andrew Brockfield, BSc.
Salida Veterinary Hospital Noelle La Croix, DVM, Diplomate ACVO
Salida, CA, USA Veterinary Medical Center of Long Island
West Islip, NY, USA
Brooke M. Burkhalter, DVM
Sea Turtle Hospital at UF Whitney Lab
St. Augustine, FL, USA; Les “Laser Les” Lattin
Turtle Hospital Senior Laser Consultant
Marathon, FL, USA LuxarCare/Aesculight Surgical Lasers
Gaithersburg, MD, USA
Daniel M. Core, DVM
Airline Animal Health and Surgery Center F. A. (Tony) Mann, DVM, MS, Diplomate ACVS,
Bossier City, LA, USA Diplomate ACVECC
Professor
Devin Cunningham, DVM Small Animal Soft Tissue Surgeon
University of Missouri College of Veterinary Medicine Director of Small Animal Emergency
Columbia, MO, USA and Critical Care Services
University of Missouri College of Veterinary Medicine
Janine S. Dismukes, DVM Columbia, MO, USA
Mobile Laser Veterinary Services
Garner, NC, USA Terry M. Norton, DVM, Diplomate ACZM
Georgia Sea Turtle Center
David Duclos, DVM, Diplomate ACVD Jekyll Island, GA, USA;
Animal Skin & Allergy Clinic Turtle Hospital
Lynnwood, WA, USA Marathon, FL, USA
 xvi List of Contributors

Maros Pazej, DVM, MVDr Gaemia Tracy, DVM

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Dewinton Pet Hospital Northstar VETS

Heritage Pointe, AB, Canada Veterinary Emergency Trauma and Specialty Center
Robbinsville, NY, USA
William E. Schultz, DVM
Schultz Veterinary Clinic Peter Vitruk, PhD, DABLS
Okemos, MI, USA Special Advisor on Physics and Safety Education
American Board of Laser Surgery
Paul Sessa, DVM Aesculight, LLC
Salida Veterinary Hospital Bothell, WA, USA
Salida, CA, USA
Jay Wayne, PhD
David S. Sobel, DVM, MRCVS Department of Biology
Metropolitan Veterinary Consultants Suffolk County Community College
Hanover, NH, USA; Selden, NY, USA
Elands Veterinary Clinic
Dunton Green, Kent, UK Katherine Weston, BSc
Dewinton Pet Hospital
Kathryn B. Tate, DVM Heritage Pointe, AB, Canada
Southern Pines, NC, USA
Christopher J. Winkler, DVM, DABLS, VMLSO
Lloyd P. Tate, Jr., VMD, Diplomate ACVS, DABLS Suffolk Veterinary Group Animal Wellness and Laser
Professor emeritus NCSU‐CVM Surgery Center
Southern Pines, NC, USA Selden, NY, USA

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­Disclaimer
Please read the statements and the surgical and thera-
peutic protocols within this text carefully before utilizing
any of this information. The information and recom-
mendations are based on previously published scientific
information and years of practice, clinical, and research
experience by the contributing authors.
Knowledge about laser surgery and photobiomodula-
tion is constantly changing through ongoing research,
clinical trials, and day‐to‐day clinical experience. The
information within this text is presented for educational
purposes only and is designed to be a reference to com-
plement formal training about laser surgery and laser
therapy.
This text contains neither complete nor comprehen-
sive information about any of the conditions addressed,
xvii
and each condition should be evaluated on an individual
basis in each patient prior to surgery. This text is not a
substitute for professional advice, care, diagnosis, or
treatment. It is the sole responsibility of the veterinarian,
veterinary surgeon, veterinary technician, veterinary
assistant, and veterinary therapist to gain the knowledge
and comply with all federal, national, provincial, state,
and local laws regarding the use of therapeutic and surgi-
cal lasers for any condition. Dr. Christopher J. Winkler,
all of the contributing authors of this text, and anyone
involved with the publication of this text expressly dis-
claim any and all responsibility and legal liability for any
kind of loss or risk, personal or otherwise, which is the
result of the direct or indirect use or application of any of
the material within this text.
 xviii
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­About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/winkler/laser

The website includes:

Thirty six videos to accompany Chapters 7, 10, 14, 20, and 21.
 1
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Part I

The Science of Laser Surgery

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Laser Physics and Equipment
Peter Vitruk
­Introduction
This chapter covers the principles of laser physics to the
extent and depth required to understand basic structure
and function of a veterinary surgical laser and the pro-
cess of generating laser light, followed by a discussion on
equipment focusing on the practical aspects of CO2
lasers (the most commonly used surgical laser in veteri-
nary surgery) while briefly reviewing other types of more
specialized surgical lasers.
­Creating Laser Light
Photons and Waves
According to the photon theory of light, light is made
of particles called photons. A photon travels at the
speed of light c; it carries a specific electromagnetic
energy (E = hf, where h is Planck’s constant and f is the
photon’s frequency); and it has a momentum, or spin,
that defines its polarization. The photon theory of light
took its origin from the efforts of Max Planck to prop-
erly explain the spectrum of blackbody radiation; it
remains an important part of Quantum Mechanics,
which explains the properties of light and matter on
the microscopic scale.
According to the wave theory of light, light travels in
a wave at the speed of light c, just as in photon theory.
Such a wave is made of both electric and magnetic
waves oscillating at frequency f (also just as in photon
theory). The orientation of the electrical field defines
the wave’s polarization. The wave theory of light is an
important concept in many branches of physics from
optics to electromagnetism. Quantum electrodynamics
(QED) is the theory that combines both photon and
wave ­theories of light together.
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
3
When considering the principles of lasers and pro-
cesses involved in generating laser light, it is useful to
think of light in terms of photons, emitted or absorbed
when atoms or molecules of the active medium inside
the laser change their atomic or molecular energy states.
For instance, if an electron of an atom having its two
energy states separated by hf, is impacted by a photon of
energy hf, and the photon is absorbed by the atom, the
electron will undergo an energy change from a lower
state to a higher state (Figure 1.1a).
At the same time, when considering the optical prop-
erties of the laser apparatus known as the optical resona-
tor, it is most helpful to think of light in terms of waves.
For instance, consider the shape of the resonator mirror
that matches the shape of the laser beam’s wave front
reflected from the mirror surface (Figure 1.2). Such a
light wave with an extended curved wavefront is the
result of a superimposition of many individual synchro-
nized photons of the same frequency.
Absorption, Spontaneous Emission,
and Stimulated Emission
An atom or molecule that has absorbed a photon and
entered a higher energy state (Figure 1.1a), will undergo
an energy transition to a lower energy state while emit-
ting a photon with energy equal to the difference between
the two states (Figure 1.1b). This is known as spontane-
ous emission, the source of natural light.
In addition to light absorption and spontaneous emis-
sion, a third way light interacts with matter is also possi-
ble, and was first described by Albert Einstein (Siegman
1986; Verdeyen 1989; Saleh and Teich 1991; Endo and
Walter 2007). If the energy of a photon matches the dif-
ference between the two states, and the electron is in the
higher of the two states, then the incoming photon will
trigger the electron to jump to a lower energy state while
 4 Laser Physics and Equipment
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(a)
–

reflector mirror

reflector mirror
Curved total

Curved total
hf hf
c
–

+ Absorption +
of light

Wave fronts of light waves

(b) resonating between the mirrors
–
Figure 1.2 Laser resonator mode having its wavefront matching
hf
– the shape of the resonator mirrors.
hf
Spontaneous
of laser light, and for many practical lasers, the loss is
+ emission +
of light designed to match the amplification of light as it takes a
round trip through the active medium (Figure 1.3). The
length of the resonator apparatus is inversely propor-
(c)
tional to how strong the amplification (or gain) is for any
– particular type of laser. Weak gain lasers, such as surgical
hf
hf hf CO2 gas lasers or ophthalmic excimer gas lasers, require
–
an active medium of relatively long length. Strong gain
Stimulated hf lasers, such as solid‐state erbium or semiconductor
emission
+
of light
+ diode lasers, have relatively short‐length active media.
For the simplest types of laser resonators, the strongest
resonator mode has a bell‐shaped intensity spatial distri-
hf + – bution profile (also known as a Gaussian profile, discussed
Photon Nucleus Electron Atomic energy levels in depth in Chapter 2). As the beam propagates away from
the laser, it diverges and its diameter increases (Figure 1.3).
Figure 1.1 Absorption (a), spontaneous emission (b), and Such diverging laser beams can be easily collimated
stimulated emission (c) of light by an atom.
and then focused by appropriate lenses (Figure 1.4) to be
utilized for medical and surgical purposes.
an identical photon will be emitted in the same direction
as the original incoming photon (Figure 1.1c). Such emis-
Inverse Population and Light Amplification
sion of light is referred to as stimulated emission.
A medium will first need to have an inverse population, a
sufficient quantity of atoms or molecules in higher
Active Medium and Excitation (Pumping)
energy states, for stimulated emission to occur.
Mechanism
Stimulated emission within an optical resonator in turn
A working laser requires two critical components: an results in light amplification, where a single photon
active medium (a medium of atoms or molecules in high among atoms or molecules in high‐energy states can
energy states, such as carbon dioxide gas in a CO2 laser) result in an avalanche of many identical photons of the
and an optical resonator. The high‐energy states of an same wavelength traveling parallel and synchronous to
active medium can be created through a variety of mech- each other through the medium (Figure 1.2). When these
anisms, such as energizing atoms or molecules optically conditions are met in an apparatus, laser light is pro-
(optical pumping), or electrically. Figure 1.3 illustrates an duced. The word LASER is thus an acronym for light
active medium placed between two mirrors that form an amplification by stimulated emission of radiation.
optical resonator. A highly important concept of a functioning laser is a
sustained pumping mechanism that is key to a powerful
laser oscillation, especially for surgical, therapeutical,
Optical Resonator
and industrial applications. Such sustained laser
An optical resonator typically consists of two mirrors, ­pumping may be illustrated by how a CO2 laser pumping
one a total reflector (often concave), and the other par- mechanism is optimized through (i) selecting the
tially reflective and partially transmissive. The transmis- ­composition of gases in the active medium and their
sivity of the partial reflector represents the resonator loss respective partial gas pressure; (ii) selecting the diameter
 ­Creating Laser Ligh 5

Mirror
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(total reflector, gold plated metallic surface)

Active medium
(e.g. gas discharge Laser
plasma in a gas mixture beam
of He, N2, CO2, and Xe) Laser beam
diverges as it propagates,
its intensity decreases
Mirror
(partial reflector, AR coated ZnSe crystal)

Lowest order gaussian

laser beam intensity
profile spatial distribution

Figure 1.3 Laser resonator and an active medium producing a monochromatic, coherent, collimated laser beam exiting through the
partially reflective resonator mirror. The lowest‐order resonator mode is bell‐shaped (Gaussian beam intensity profile). As it propagates
away from the resonator, the laser beam diverges.

Lens collects only a added to the gas mixture to optimize the energy of elec-
Light bulb fraction of the light Lens trons in the plasma so that the most efficient excitation
from the light bulb
of N2 molecules can take place. Now having achieved
proper gas composition, the diameter of the active
medium is also optimized per total gas pressure for max-
imum electro‐optical efficiency, which can exceed 20%.
Ordinary light
Finally, the electric current through the active medium
is not focusable plasma is optimized for the desired combination of out-
Lens collects entire put laser power and laser efficiency.
output of laser
Laser light is
focusable
Properties of Laser Light: Monochromaticity,
Laser
Coherence, Collimation
Laser light emanating from the laser’s partial reflector
(Figure 1.3) is monochromatic (of a single wavelength),
Figure 1.4 Unlike the ordinary light, laser light can be efficiently coherent (the photons of the beam oscillate in sync with
focused into a very small spot.
each other), and typically collimated (the photons travel
parallel to each other, if the partial reflector is designed
of the active medium; and (iii) selecting electrical param- as a flat surface mirror).
eters of the plasma that is maintained inside the active The most important practical feature of the laser beam
gas medium (Endo and Walter 2007). One of the most for surgery is its ability to be focused to a very tight focal
important gases in the active medium of a CO2 laser is spot (Figure 1.4) so that beam power and energy densities
nitrogen (N2) that stores up to 80% of the energy, pumped are maximized. Monochromaticity is also extremely
into the plasma, in its first vibrational excited state. CO2 important, as the laser beam wavelength is uniquely
molecules colliding with such excited N2 molecules related to its interaction with the target tissue’s optical
undergo energy transition into upper lasing energy lev- properties such as absorption, scattering, and reflection
els. In order to maintain the lowest population on the from the target’s surface (discussed further in Chapter 3).
lower lasing energy level of the CO2 molecule, helium Determined by the type of active medium within the opti-
(He) gas is added to the mixture for the most efficient cal resonator, it is the laser’s wavelength that best deter-
cooling of the active medium. Finally, xenon (Xe) gas is mines the purpose for which the laser light will be used.
 6 Laser Physics and Equipment
Another often overlooked property of laser light is its
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power. None of the alternative light‐generating technol-
ogies are capable of producing the same efficacy of a
laser if a specific spectral wavelength is required.
Monochromaticity, collimation, and the sheer amount
of energy of a laser beam make laser surgery practical.
Indeed, as will be demonstrated subsequently, high‐
speed soft tissue laser incisions with erbium and CO2
lasers can only happen at fluencies in excess of hundreds
of joules per square centimeter. This translates to a prac-
tical laser device in the desired optical spectrum range
with strong absorption by histological water of soft tis-
sues with laser beam power in the range of 30–60 W.
­Practical Surgical Lasers
Being the most commonly used surgical laser in veteri-
nary surgery, we will examine the CO2 laser for demon-
strating practical aspects of equipment for generating
laser light and delivering it to the patient (Figure 1.5).
Laser Tube Technology
CO2 laser resonator chambers of the 1960s were made of
glass tubes. They proved quite fragile not only for their
material make‐up but also because they could not
4
8 heat exchangers in their design: air‐cooled (and light
6
7,9,10
7 Some laser manufacturers may claim that their laser
5
1 with which to measure laser power. US Food and Drug
2 Administration (FDA) regulations require the presence
3 of a laser power meter in US medical lasers (FDA CDRH
Figure 1.5 Basic building blocks of a surgical CO2 laser: (1) metal
CO2 laser tube resonator; (2) low‐voltage 32 V DC and RF power
supplies; (3) heat exchanger; (4) beam delivery system; (5) laser
power meter; (6) beam attenuator (shutter); (7) devices
monitoring the performance of the above critical components; (8)
user control panel; (9) software program controlling the above
hardware items; and (10) safety “watch‐dog” software program
monitoring the above items. Source: Image courtesy of
Aesculight–LightScalpel LLC, Bothell, WA.
­perate without a flowing liquid coolant needed to
o
­prevent the glass from cracking under the intense heat
generated by electrical plasma discharges within the
laser tube. Voltages exceeding 10 000 V are required to
create and sustain plasma in such glass tubes, creating a
significant electrical hazard concern. They were also not
serviceable in the event of eroded electrodes and metal‐
sputtered glass tube walls, often necessitating laser tube
replacement in the event of failure. Their other limita-
tions, such as laser pulse width, laser power stability, and
laser beam quality, have led to their replacement in the
mid‐1990s by all‐metal laser resonator chambers in
nearly all industrial and most medical applications
(Figure 1.6).
Rugged and reliable in power ranges from 10 to
1000 W, all‐metal radio‐frequency (RF) excited CO2
laser tubes also allow for fast and relatively inexpensive
service. The all‐metal tube is also easily cooled with
forced air, which allows for a smaller, inexpensive,
­reliable and light‐weight integration of heat dissipation
into the practical surgical laser system.
The CO2 laser is only 10–20% efficient; hence 80–90%
of electrical energy is transformed directly into heat
inside the laser tube and system. This waste heat needs
to be removed or the laser will overheat and its power
will deteriorate during operation. Older CO2 lasers con-
structed without heat exchangers could not be operated
for extended periods of time without overheating and
subsequent laser power deterioration during surgeries
(this is difficult to track if such lasers also lack on‐board
laser power meters for accurate laser beam power moni-
toring). Lasers featured in Figure 1.7 include efficient
weight) or cooled by flowing water (and correspondingly
heavier, with minor concern for affecting electronics
during maintenance).
beam power can be “internally calibrated.” This is tech-
nically impossible if their lasers lack a laser power meter
Title 21 Part 1040.11 defines “medical laser” as such
used on humans). Those lasers lacking them are not
considered medical devices as the absence of laser
power control and monitoring may negatively impact
outcomes of laser treatments, laser power being one
of the critical parameters for quality of incisions and
hemostasis.
FDA regulations (CFR Title 21 Part 1040) also require
another very important safety device: the beam attenua-
tor, or shutter, as a part of the laser intended for either
veterinary or medical use. It is recommended that
­practitioners seeking to purchase a surgical laser make

(a) (b)
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All-metal tube CO2 laser
Figure 1.6 All‐metal (a) and glass (b) CO2 laser tube designs. Source: Images courtesy of Aesculight–LightScalpel LLC, Bothell, WA.
certain that the device is compliant with these and other
local and national regulations and standards for con-
struction and operation of a medical device.
Beam Delivery Technology
Laser light and its energy needs to be delivered efficiently
from laser resonator to target tissue, and this is not a
trivial task.
Historically, the first medical delivery systems devel-
oped in the 1960s were based on a sequence of seven
mirrors (approximating the design and flexibility of the
human arm) that guided the laser beam to a desired loca-
tion, culminating in passing the beam through a focusing
lens in order to maximize laser beam fluence on the tar-
get. Such articulated arm delivery systems (Figures 1.7
and 1.8) saw wide use in the 1970s–1980s. The advan-
tages of the articulated arm are mainly applications
where alternative fiber technology cannot handle high‐
peak laser power. It is also highly efficient in its transmis-
sion of energy from resonator to patient. The alignment
and integrity of all seven mirrors is critical, however, and
can only be verified and calibrated at the factory or by
trained field service engineers; an articulated arm of
questionable alignment should be taken out of service
for maintenance. The system is also quite heavy and can
be taxing during a lengthy procedure.
Solid core fibers (e.g. quartz) were developed and
adapted from communication applications for medical
use. Such fibers guide laser light through them by utiliz-
ing a total internal reflection phenomenon. The advan-
tage of solid core fiber technology is application in
flexible endoscopy. A severe limitation of such technol-
ogy is that current solid core fiber materials cannot
­Practical Surgical Laser 7
Glass tube CO2 laser
transmit wavelengths greater than 3000 nm. Solid core
fibers are thus not applicable as a delivery system for
CO2 lasers and even for 2940 nm erbium lasers, and
advantages they provide to endoscopic applications only
extend to those near‐infrared spectral laser wavelength
ranges that are not ideal for efficient incision. Many vet-
erinary applications still continue to see effective use of
solid core fiber delivery technology, however, and will be
examined later in this text. A highly important aspect of
utilizing solid core fibers is proper “cleaving” of its distal
end, without which the fiber’s tip can fracture during
surgery (due to thermally‐induced mechanical stresses)
and harm the patient.
Flexible hollow waveguide fibers (Figures 1.5, 1.7, and
1.8) became the dominant delivery technology for surgi-
cal CO2 lasers since the mid‐1990s. Such technology is
very similar to solid core fiber technology in a sense that
both rely on (i) minimizing optical losses of the core
(glass in the case of solid core fibers, air in the case of
hollow core waveguide fibers) and (ii) maximizing reflec-
tion of laser light from the internal walls of the fiber.
Hollow core fibers utilize highly polished, highly reflec-
tive metal surfaces, which are additionally coated with a
laser‐wavelength‐specific dielectric layer of specific
thickness. Rugged and long‐lasting, modern‐day hollow
waveguide fibers are capable of transmitting hundreds of
watts of CO2 laser power with beam quality that rivals
solid core surgical lasers (e.g. 2780 nm erbium lasers).
The advantages of hollow core waveguide fiber technol-
ogy over articulated arms are significantly lighter weight
and flexibility, with development for endoscopic use (albeit
limited to rigid endoscopes; flexible endoscope usages
are currently limited to hospital OR applications and con-
tinue to be prohibitively expensive for veterinary use).
 8 Laser Physics and Equipment
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CO2 laser with all- CO2 laser with

metal tube glass tube

Flowing water cooled

resonator and resonator and

glass laser tube

flexible hollow articulated arm
waveguide fiber beam delivery
beam delivery

Flexible hollow
waveguide fiber

Articulated arm
Sterilizable
handpiece
Handpiece

All metal
laser
tube
High voltage
20 000 V DC
power supply
Low voltage
32 V DC
power supply

Water tank

Forced air
cooling
Water pump

Water cooler

Figure 1.7 Side‐by‐side comparison of air‐cooled, all‐metal tube, flexible‐waveguide CO2 laser (left) and a liquid‐cooled, glass‐tube,
articulated arm CO2 laser (right). Source: Image courtesy of Aesculight–LightScalpel LLC, Bothell, WA.

The flexible fiber can also be calibrated at any time by
the user. Care should be taken with both solid and
­hollow core fibers as any kink or break in the fiber will
destroy its transmissive properties and necessitate
replacement.
Hollow waveguide fibers enable use of compact and
ergonomic handpieces (Figure 1.9) with scalpel‐like feel,
featuring pinpoint accuracy as well as enhanced ergo-
nomics, flexibility, and accessibility for surgeons. These
laser handpieces are designed for a laser beam’s focal

(a)
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Seven-mirror articulated arm beam delivery.
Handpiece features a single focal spot size.
Long focus lens in the handpiece, along with
the long optical path through seven-
mirror optical train, require an aiming
beam to track the focal spot of the
invisible CO2 laser beam
Figure 1.8 Articulated arm (a) and flexible hollow waveguide fiber (b) CO2 laser beam delivery systems. Source: Images courtesy of
Aesculight–LightScalpel LLC, Bothell, WA.
spot centered at 2 mm from the distal end of the hand
piece tip (or nozzle). Spot sizes (discussed in Chapter 2)
may be facilitated either by fixed tips selected by the
­surgeon prior to the procedure, or selected during the
procedure on a specially designed adjustable hand piece.
Laser handpieces should be designed for ease of cleaning
and sterilization and must withstand thousands of
­cleaning and autoclave sterilization cycles. Lenses should
be cleaned following procedures as per manufacturer
recommendations.
A highly important practical aspect of any CO2 laser
delivery system is a continuous purge of air (or
­nitrogen or helium, etc.) during surgery. The purge’s
purpose is twofold: (i) prevent the surgical laser plume
from back‐streaming into the fiber and (ii) prevent the
surgical laser plume from obstructing the view of the
surgical site.
Laser Power Control Exposures: Continuous
Wave, Single Pulse, and Repeat Pulse
The pattern of time variation of output power from a
laser apparatus is known as a temporal mode, or expo-
sure, and can be controlled by the user through simple
programming of the laser console and use of the trigger
(usually a footswitch). Exposures are usually available in
three preprogrammed forms: continuous wave, repeat
­Practical Surgical Laser 9
(b)
Flexible fiber beam delivery.
Autoclavable handpiece features
three different focal spot
sizes. No aiming beam is needed
due to short focus lens and short
optical path optical train inside
the handpiece
pulse, or single pulse. Pulse frequency is conventionally
defined as a number of pulses per second, and its unit of
measure is hertz (Hz). The percentage of time that the
laser power is ON is conventionally defined as duty cycle,
displayed as a percentage (%). The duty cycle determines
the average power, which defines the depth of laser inci-
sion (further discussed in Chapter 4).
The continuous wave exposure is turned ON and OFF
by the footswitch, and the lasing duration lasts as long as
the footswitch is depressed (Figure 1.10a,b). Long pulse
and continuous wave CO2 lasers are less‐efficient cutters
but provide for greater depth of coagulation for excising
and incising highly vascular and inflamed tissues such as
hemangioma.
The single pulse exposure (Figure 1.10c,d) is turned
ON and OFF electronically with the lasing duration pre-
determined by the preset pulse duration of 5–500 ms at
the control panel. A single timed exposure is delivered
for each depression of the footswitch.
In repeat pulse exposure, the laser beam cycles
between ON and OFF while the footswitch is
depressed. Repeat pulse exposure (Figure 1.10e,f ) is
turned ON and OFF by the footswitch, while the RF
driver is modulated during “footswitch ON” in a pre-
determined fashion at the control panel by the preset
pulse duration (5–200 ms) and preset frequency (e.g.
in 1–50 Hz range).
 10 Laser Physics and Equipment

(a)
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(g) (h) ON Footswitch controlled OFF

(a) (b) (c) (d) (e) (f) “CONTINUOUS” mode

(i) Power (W) Non-SuperPulse mode LASING

(b) 1 2 3 Time (s)

Power (W) SuperPulse mode LASING

0 1 2 3 Time (s)

(c)
“SINGLE PULSE” control signal @ 100 ms

Power (W) Non-SuperPulse mode LASING

0.1 Time (s)

(d)
Power (W) SuperPulse mode LASING

0 0.05 0.1 0.15 Time (s)

Figure 1.9 Autoclavable laser handpieces available for flexible (e)

“REPEAT PULSE” control signal @ 20 Hz and 50% duty cycle
hollow waveguide fiber CO2 lasers. Handpieces are designed to
work as a distal attachment on a flexible hollow waveguide fiber
(these handpieces do not use disposable tips): (a) handpiece with Power (W) Non-SuperPulse mode LASING
a handle and a back‐stop for laser beam, for use in soft palate
(f) 0.05 0.1 0.15 Time (s)
resection; (b) handpiece with adjustable focal spot size diameters
of 0.25, 0.4, and 0.8 mm; (c) contra‐angle dental handpiece with Power (W) SuperPulse mode LASING
0.25 mm spot size; four straight handpieces with fixed spot sizes of
0.25 mm (d), 0.4 mm (e), 0.8 mm (f ), and 1.4 mm (g); straight
handpiece with fixed 3 mm by 0.4 mm wide ablation rectangular
spot (h); and a smoke evacuating attachment to work with any 0 0.05 0.1 0.15 Time (s)
handpiece (i). Source: Image courtesy of Aesculight–LightScalpel
LLC, Bothell, WA. Figure 1.10 A CO2 laser’s gated exposures: continuous (a, b),
single pulse (c, d), and repeat pulse (e, f ).

exposures. Discussions of SuperPulse will continue in

Laser Power Control Modes: SuperPulse vs.
Non‐SuperPulse
Another programmable method of laser light delivery is
the SuperPulse mode, characterized by extremely short
pulses of high‐peak power, in which pulse durations are
shorter than a target soft tissue’s thermal relaxation time
of approximately 1.5 ms, while the spacing between
pulses is greater than the tissue’s thermal relaxation time.
Such intense pulses of high power exceed the power of a
continuous wave exposure and help to facilitate efficient
ablation, while the interval between pulses minimize col-
lateral thermal trauma. SuperPulse may be available in
different forms of exposure and can be achieved at vari-
able frequencies of 50–400 Hz, with peak laser power
being up to 50 times greater than the average power indi-
cated on the control panel. The non‐SuperPulse mode is
simply characterized by a steady laser output from the
laser tube as described in the previous discussion of
Chapters 2 and 4.
Nd:YAG, Ho:YAG, Er:YAG, and Er:YSGG Lasers
Although the principles of the creation of laser light
remain the same as in CO2 lasers, other lasers use different
active media to create lasers of differing wavelengths,
which may have different applications in soft tissue sur-
gery. Cylindrical rods of yttrium aluminum garnet (YAG),
with additions (known as dopants) of neodymium (Nd),
holmium (Ho), or erbium (Er) are used as active mediums
in Nd:YAG, Ho:YAG, and Er:YAG solid‐state lasers. An
yttrium scandium gallium garnet (YSGG) rod, with an
erbium dopant, is used in the Er:YSGG solid‐state laser.
Clinical applications for the Nd:YAG (1064 nm) laser
are based on the wavelength’s low absorption in water
and a relatively higher absorption in hemoglobin and
oxyhemoglobin. It cannot produce photothermal ­ablation

due to extremely high ablation thresholds and is t­ herefore
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utilized as a hot glass tip cautery device rather than an
optical laser in soft tissue cutting applications (further
examined in Chapter 4). However, its ease of transmis-
sion through inexpensive commercial optical fibers, cou-
pled with a wavelength excellent for achieving coagulation
and hemostasis over large volumes of soft tissue, makes it
ideal for minimally invasive procedures and those involv-
ing neoplasia and other difficult‐to‐reach lesions, par-
ticularly in equines (Chapter 19).
A frequency‐doubled Nd:YAG laser is known as a KTP
(potassium‐titanyl‐phosphate) laser, with a wavelength
of 532 nm. A frequency‐tripled Nd:YAG laser operates at
355 nm, the range where excimer pulsed‐gas lasers oper-
ate. Both 532 and 355 nm Nd:YAG lasers have great
applications in human dermatology, but their applica-
tions in veterinary surgery are limited. Nd:YAG lasers
can achieve short pulse durations at high peak energy,
known as Q‐switching.
The Ho:YAG (2100 nm) laser is also easily transmitted
through optical fibers and can operate in a liquid envi-
ronment. Its absorption in water is much stronger than
for Nd:YAG lasers, and it is a far more efficient photo-
thermal laser than its Nd:YAG cousin. Water absorption
at 2100 nm is still much weaker relative to the CO2 laser
wavelength, which is why the Ho:YAG laser is not as effi-
cient a cutter while producing more collateral thermal
damage. Its absorption in water and its delivery through
optical fibers of small diameter make it ideally suited for
lithotripsy (Chapter 17) and neurological applications
such as IVDD treatment and prevention (Chapter 18).
Both Er:YAG (2940 nm) and Er:YSGG (2780 nm) wave-
lengths are close to the water absorption peak near
3000 nm, which makes them excellent choices for cutting
bone and enamel with relatively low water concentra-
tions. Water absorption at 2940 nm is approximately 3
times stronger than for 2780 nm, and approximately 15
times stronger than for the 10 600 nm CO2 laser wave-
length. Both Er:YAG and Er:YSGG wavelengths are thus
also good for cutting soft tissue, but remain poor coagu-
lators (further discussed in Chapter 4).
Near‐infrared Diode Lasers and Hot Fiber Tips
As further explained in Chapter 4, diode near‐IR laser
wavelengths are weakly absorbed by soft tissue (Fisher
1987, 1993; Willems et al. 2001; Vogel and Venugopalan
2003; Vitruk 2014; Vitruk et al. 2014). Instead, the tissue
is cut thermomechanically on contact with a charred
glass “hot tip” (Figure 1.11), with the temperature profile
inside the tissue approximated as T = 37 + 63(1 − 1.5 (x/δ)
+ 0.5(x/δ)3) and illustrated in Figure 1.12, where
δ = (8Kt)½ is the heat propagation distance,
­Practical Surgical Laser 11
Near IR absorber
(char)
Heat
B diffusion Hot glass tip
from hot
tip
HT >> B
Hot tip coagulation depth
Figure 1.11 Hemostasis and coagulation through heat diffusion
from the hot tip into the soft tissue. HT is heat propagation‐driven
depth of coagulation, B is blood vessel diameter. Source: Image
courtesy of LightScalpel LLC, Bothell, WA.
K ≈ 0.155 mm2/s is the soft tissue thermal diffusivity, and
t is the “ON” time of the heat source at the surface of the
tissue (Ozisik 1980; Willems et al. 2001; Rathmore and
Kapuno 2011; Vitruk et al. 2014).
The heat propagation‐driven coagulation depth
HT = 0.45 (8 Kt)½ contains the 60–100°C tissue tempera-
tures as indicated in Figure 1.12.
For soft tissue cutting with such lasers, an optically
dark carbonized material, or “char” (e.g. organic matter,
burnt ink, or burnt corkwood), is first deposited on the
very end of the fiber tip (Romanos et al. 2015). The diode
laser beam is absorbed by the char, which heats the tip of
the fiber from 900 to 1500 °C (Romanos 2013; Romanos
et al. 2015). As a result, soft tissues are heated up through
heat conduction and diffusion from the hot fiber tip to
and through the soft tissue. The hot tip thus acts as a
nonlaser, thermal ablation device with the approximate
temperature profile in soft tissue shown in Figure 1.12. In
other words, the diode laser does not cut tissue with
photons but with a hot fiber (akin to electrocautery
where soft tissue is cut by a heated metal tip). The cut-
ting speed of a heated diode fiber is limited by its dis-
integration at elevated temperatures (up to 1500°C),
thus raising concerns about biocompatibility of the
burnt tip’s cladding chemicals and thermally fractured
fiber (FDA 2005; ISO 2009; Vitruk 2012; Romanos
2013; Romanos et al. 2015). Sapphire tips are not only
more rugged at high‐operating temperatures in excess of
1000°C but also more expensive (Fisher 1987, 1993).
Figure 1.13 illustrates use of a hot fiber laser tip on gin-
gival tissue. Figure 1.13 illustrates the coagulation depths
calculated for constant tip temperature (red line) and
constant tip power (blue line) conditions, that are also
 12 Laser Physics and Equipment

Figure 1.12 Approximate temperature distribution

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100
T = 37 °C + 63 °C* [1 – 1.5 (x/δ) + 0.5 (x/δ)3] in soft tissue; surface temperature is 100 °C,
coagulation temperature is 60–100 °C, body
90
Soft tissue temperature, T (°C)

temperature is 37 °C. Source: Graph courtesy of

LightScalpel LLC, Bothell, WA.
80

70

60

Tcoag = 60 °C
50

40

0.0 0.2 0.4 0.6 0.8 1.0

Dimensionless distance from the soft tissue surface (x/δ)

10

Diode radiant Diode hot tip coagulation depth

measurements from Romanos (2013):
(photo-thermal)
coagulation depths Temperature controlled
“Leaky” diode No temperature control
Coagulation depth, HT (mm)

Diode hot tip hot tip

1 (100% “black” char)
coagulation depths.
Wavelength independent

Temperature Power
0.1 controlled controlled
hot tip hot tip

Blood capillary diameters, B = 20–40 μm

0.01
0.03 0.04 0.06 0.1 0.2 0.3 0.4 Hot tip-to-tissue
Hot tip handspeed (mm/s) contact time (s)

For 0.4 mm diameter glass tip 13 10 8 6 4 3 2 1.3 1

Figure 1.13 Hot tip coagulation depth, HT (mm) as a function of tip‐tissue contact time (or hand speed). Logarithmic scales are in use.
Source: Graph courtesy of LightScalpel LLC, Bothell, WA.

compared to measurements for constant temperature The coagulation process and cutting capabilities of the
(red circles) and under constant power (blue circles) hot tip strongly depend on the properties of the char on the
conditions (Willems et al. 2001; Braga et al. 2005; Faghri diode’s glass tip. Insufficient charring can reduce the tip
et al. 2010). Figure 1.13 illustrates that the hot fiber tip temperature (which brings sterility ­compliance concerns;
noticeably reduces the coagulation depth to less than FDA 2002) and increases risk of near‐IR‐induced sub‐sur-
1 mm vs. multi‐mm Near‐IR photothermal coagulation face thermal necrosis (Willems et al. 2001); it also height-
depths (see Chapter 4). Also seen in Figure 1.13, the hot ens risks of bleeding due to tissue being cut by sharp edges
tip coagulation depth is affected by tip‐to‐tissue con- of the glass tip. While solid‐state lasers certainly have their
tact time (or by the surgeon’s hand speed, through skill veterinary applications, it is important to remember these
and training), but still significantly exceeds blood vessel factors for efficacy of beam delivery and prevention of
diameters. adverse collateral thermal injury to the patient.

­References
VetBooks.ir
Braga WF, Mantelli MBH, Azevedo J. (2005). Analytical
solution for one‐dimensional semi‐infinite heat transfer
problem with convection boundary condition. AIAA.
4686. pp. 1–10.
Endo M, Walter RF. (2007). Gas Lasers. Boca Raton, FL:
CRC Press.
Faghri A, Zhang Y, Howell JR. (2010). Advanced Heat
and Mass Transfer. Columbia, MO: Global Digital
Press. p. 260.
FDA (2002). Updated 510(k) sterility review guidance
K90‐1: final guidance for industry and FDA. U.S.
Department of Health and Human Services, Food and
Drug Administration, Center for Devices and
Radiological Health, Office of Device Evaluation.
August 30.
FDA (2005). Medical devices with sharps injury prevention
features. Guidance for industry and FDA staff. U.S.
Department of Health and Human Services, Food and
Drug Administration, Center for Devices and Radiological
Health, General Hospital Devices Branch, Division of
Anesthesiology, General Hospital, Infection Control, and
Dental Devices, Office of Device Evaluation. August 9.
Fisher JC. (1987). Basic laser physics and interaction of
laser light with soft tissue. In: Shapshay SM, ed.
Endoscopic Laser Surgery Handbook. New York, NY:
Marcel Dekker. pp. 96–125.
Fisher JC. (1993). Qualitative and quantitative tissue effects
of light from important surgical lasers. In: Wright CV,
Fisher JC, ed. Laser Surgery in Gynecology: A Clinical
Guide. Philadelphia, PA: Saunders. pp. 58–81.
ISO 10993‐1:2009 (2009). Biological evaluation of medical
devices – Part 1: Evaluation and testing within a risk
management process, 4th ed. ISO.
­Reference 13
Ozisik NM. (1980). Heat Conduction. New York: Wiley. p. 352.
Rathmore MM, Kapuno RRA. (2011). Engineering Heat
Transfer, 2nd ed. Sudbury, MA: Jones & Bartlett
Learning. p. 406.
Romanos GE. (2013). Diode laser soft‐tissue surgery.
Compend. Contin. Educ. Dent. 34(10). pp. 752–757.
Romanos GE, Belikov AV, Skrypnik, AV, et al. (2015).
Uncovering dental implants using a new thermo‐
optically powered technology with tissue air‐cooling.
Lasers Surg. Med. 47. pp. 411–420.
Saleh BEA, Teich MC. (1991). Fundamentals of Photonics.
New York, NY: John Wiley.
Siegman A. (1986). Lasers. Sausalito, CA: University
Science Books.
Verdeyen JT. (1989). Laser Electronics. Englewood Cliffs,
NJ: Prentice Press.
Vitruk P. (2012). Soft tissue cutting abilities of CO2 and
diode lasers. Vet. Pract. News. 11. p. 24.
Vitruk P. (2014). Oral soft tissue laser ablative and
coagulative efficiencies spectra. Implant Practice US.
7(6). pp. 19–27.
Vitruk P, Convissar R, Romanos G. (2014). Near-IR laser
noncontact and contact tip-tissue thermal interaction
differences. Paper presented at: Academy of Laser
Dentistry 21st Annual Conference and Exhibition,
Scottsdale, Arizona (27 February 2014).
Vogel A, Venugopalan V. (2003). Mechanisms of pulsed
laser ablation of biological tissues. Chem. Rev. 103(2).
pp. 577–644.
Willems PWA, Vandertop WP, Verdaasdonk RM, et al.
(2001). Contact laser‐assisted neuroendoscopy can be
performed safely by using pretreated ‘black’ fiber tips:
experimental data. Lasers Surg. Med. 28(4). pp. 324–9.
 14
VetBooks.ir
Understanding and Utilizing Power Density
Noel Berger
­Introduction
Laser light output is described in terms of energy, power,
and their respective densities. The importance of power
density cannot be understated as the paramount consid-
eration in regard to a surgical laser’s ability to interact
with biologic tissue; a concept referred to as laser–tissue
interaction (LTI), which will be discussed later within
this text. The most applicable features of a surgical laser’s
power density will be demonstrated in this chapter.
­A Power Density Parable
Energy is expressed in joules.
Power = Energy/Time, expressed as J/s or W.
Fluence = Energy/Area energy is applied, expressed as
J/cm2.
Power density = Power/Area power is applied, expressed
as W/cm2.
As an illustration to explain the concepts of energy,
power, energy density, and power density, the example
of a team of people building a wall using bricks will be
used. For the sake of clarity, we can assume that all of the
people are equal in all regards, and all of the bricks are
equal in all regards. The location of the wall is irrele-
vant. The parameters that are at our disposal are the
following:
1) the number of bricks that are being used to build the
wall (energy density);
2) the length, width, and depth of each layer of bricks
that are laid down (energy density);
3) the number of people working at any given time
(power density);
4) the height of the wall being constructed (power
density);
5) the time required to build the wall (power density).
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
In this first example, there is only one person to con-
struct a wall that needs to be 10 ft high and 100 ft long.
The wall is to be constructed using 1000 bricks that are
1 ft3 each. It takes this individual 1 hour to lay 100 bricks,
so in this particular scenario, the wall will be completed
in 10 hours. The energy required to do this task is repre-
sented by the total number of bricks, e.g. 1000 bricks of
energy. The power required to do this work is a function
of the time required to complete the task, e.g. 100 bricks
per hour. The energy density is a function of the area that
the wall takes up on the ground without regard to the
time required to complete the task, e.g. 1 brick per square
foot. Finally, the power density is a function of the energy
density over time, e.g. 1 brick per square foot per hour.
The parameters of this wall building exercise can be
easily adjusted to provide greater illumination and clarity
to define power density. We can change energy density
by manipulating some of the five parameters mentioned
earlier:
By increasing or decreasing the number of bricks used to
build the wall, we effectively change the wall itself, and
within the parameters of the area contacting the
ground, the energy density will be greater or lesser
based on the depth of each layer, or the area of the wall
in contact with the ground.
When we change the depth of each layer of bricks that
are laid down, the energy density of that wall increases or
decreases. From either side of the wall it still looks like a
wall, but it took more or less actual resources to con-
struct each layer.
We can change power density by manipulating any of
the other parameters mentioned previously:
By adding more workers, or using fewer workers, we will
increase or decrease the power density of this project,
assuming each worker produces effort at the same
rate. From the earlier example where a brick layer can
lay 10 bricks per layer per hour: If there are 10 people
 ­Laser Beam Geometr 15

working, then the project will be completed in one (a) (b) (c)
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hour, but if only one person works for five hours, the
wall will only be half‐completed. More profoundly,
though, if we choose workers that have the power to
lay 200 bricks per hour, the wall‐building power of that
team has instantly doubled.
Finally, the height of the wall has the most intense impact
on our simplified understanding of power density. If
the bricks occupy a given length and width (indicating Figure 2.1 Selected transverse electromagnetic modes (TEMs) of
energy density), and we increase or decrease the height a laser beam. (a) The fundamental mode (TEM00) is Gaussian, with
of each of the individual bricks, the power density has the power of the beam highest at the center and diminishing
logarithmically toward the edge. (b) TEM01 has practically no
subsequently increased or decreased, assuming all power at the center of the beam and has high power at the inner
other influences of labor and time being equal. The circumference of the beam that diminishes logarithmically toward
power density required to perform work to build a the edge. (c) TEM30 is comprised of concentric laser beams: the
wall that is made from taller bricks will be far greater center of the beam is Gaussian, the middle beam has lower power,
than the power density required to perform work to and the outer beam has the lowest power. Many other TEMs exist
but are not desirable for use in surgery.
build the standard wall that is 10 bricks high.
It is the same with laser beams. We can change the
Pc
energy level of the beam. We can change the area that the
beam targets. We can manipulate how long the target is
irradiated by the beam. We can change the time domain
that it takes to release the specified energy of that laser
beam. Thus, the concept evolves that energy and energy
density relate to a quantifiable amount of work that can
be performed by raw materials and their physical prop-
erties. Ultimately, power and power density are then
time‐dependent functions of energy and energy density.

­Laser Beam Geometry de = 2w

The distribution of power density across a laser beam is

called the transverse electromagnetic mode (TEM).
Many distributions of power density are physically pos-
sible and are designated as TEMmn, where m and n are
positive integers representing the number of troughs in
the x‐direction and y‐direction of a three‐dimensional
(3‐D) plot of the intensity profile of a beam traveling in
the z‐direction (axis). Thus, a beam designated by TEM01
would appear to be a bell‐shaped dome having a deep
central crater at the apex, appearing much like a typical
volcano, and a beam designated by TEM30 would appear
very similar to a bull’s-eye (Figure 2.1). Complicated
TEMs are rarely desirable in surgery, and the most com-
mon useful mode of any laser beam is TEM00, or the fun-
damental mode.
The geometry of a TEM00 laser beam is commonly
known as Gaussian and is three dimensional. The high-
est power density, Pc, is at the center of the beam. Power
diminishes logarithmically (Gaussian curve) with dis-
tance from the central axis. The effective diameter, de, of
the laser beam is represented by a cross section at radius
r = w, which defines an area equal to 86.5% of the total
Figure 2.2 Above is a 3‐D representation of a Gaussian laser beam
and the relative power within its spatial confines. Below is the cross
section of this laser beam perpendicular to its axis of propagation.
Note that in a Gaussian laser beam, the center of the beam, Pc,
possesses 100% of the power; this power diminishes logarithmically
toward the periphery of the laser beam. At radius r = w = 1/2 de, the
beam contains 86.5% of the total power density of the beam. There
is very low power beyond the effective diameter, de, while within
the effective diameter the power will be much higher.
spot. Here, the power Pr = Pc e−2. It follows then, that at
radius r < w, the fluence will be much higher than at the
edge of the laser beam, and at radius r > w, the fluence
will be very low compared to the center of the laser beam
(Figure 2.2).
 16 Understanding and Utilizing Power Density
­Power Density’s Effect on Tissue
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Power density is the most important element of laser phys-
ics for the veterinary laser surgeon to comprehend.
Understanding this concept fully will substantially increase
the ability of the surgeon to achieve consistent, reproduci-
ble, and reliable therapeutic outcomes for the patient.
There are basic guidelines for laser energy properties
within soft tissue that any laser surgeon must under-
stand. The laser’s effect depends on the power placed
into the system to produce the photons and the power
concentrated within the effective diameter of the laser
beam. Power is usually expressed in watts on equipment
settings. Any time laser energy is applied to a tissue to
produce a desired effect and time is also a factor, the
term “Joule” is used. A joule is defined as a watt‐second;
it is the amount of time power is applied to a target tissue
to produce a cumulative effect. The aperture spot size,
also known as the focal spot, results in the concentration
of energy within an area producing a power density,
expressed as W/cm2. The advantage of a small focal spot
size with adequate power applied over a specific time is
optimal vaporization of the target tissue. This also pro-
duces less secondary collateral thermal damage to tissue.
Fewer cells are affected, damaged, or destroyed at the
margins of an incision when using higher power density.
LTI depends greatly on wavelength. The 10 600 nm
wavelength is strongly absorbed by water, which makes it
an ideal laser for soft tissue surgical applications. The
near‐infrared wavelengths are poorly absorbed by water
and moderately absorbed by tissue pigments such as
oxyhemoglobin and melanin, which make them accept-
able for tissue coagulation or endoscopic applications.
As long as the laser surgeon has a complete working
knowledge of the wavelength applied and its expected
results, consistent outcomes should be attainable within
the limits of any wavelength.
This is especially so with CO2 laser energy. If sufficient
fluence (energy/area) is delivered to the tissue in a short
period of time, vaporization occurs and a crater will be
created at the tissue surface that has a 3‐D Gaussian pro-
file. This is often referred to as the zone of vaporization
and this will be discussed in greater detail in Chapter 3.
When a deep laser crater is required, a small spot size is
advantageous in that it concentrates a high amount of
energy into the tissue due to extremely high amounts of
excess fluence and rapid vaporization in that zone. When
tissue heating or coagulation rather than vaporization
is the desired effect, a larger spot size increases the area of
the beam and thus reduces the total power density to the
tissue. The energy is dispersed over a larger area, thus
reducing fluence deposited to the target tissue. Lower
power density is desirable for coagulation, and higher power
density is desirable for ablation and incision.
If a surgeon desires to coagulate tissue without vapor-
izing it, the power density of the beam must not exceed
the threshold of vaporization at that wavelength. The
wavelength also should be poorly absorbed by histologic
water and be scattered within the tissue, causing the con-
version of laser energy to thermal energy and a slow
increase in the temperature of the tissue. On the other
hand, if a surgeon desires to precisely incise or cut tissue
with minimal heating of surrounding tissues, the power
density of the beam should far exceed the threshold of
vaporization at that wavelength. The wavelength should
be highly absorbed by water so that the light is attenu-
ated rapidly as well. This causes rapid vaporization of tis-
sue with minimal thermal conduction, but the ability to
coagulate tissue is dramatically limited. There are condi-
tions whereby a wavelength that causes coagulation can
be used to cut, and likewise, there are conditions whereby
a wavelength that causes vaporization can be used to
coagulate. In general terms, to the extent that the effect
of a given wavelength can vaporize and cut tissue, it loses
the ability to coagulate tissue because that system dissi-
pates heat efficiently. Likewise, the surgical effect of
wavelengths that produce good coagulation are generally
poorly ablative because they primarily generate heat as
the result of that system’s LTI.
There are power density thresholds that must be
reached before the effects of rising temperature take
place in the tissue. Since other effects may occur at
higher and higher thresholds, the surgeon must apply the
appropriate power density to achieve the desired thresh-
old without exceeding the threshold for the next higher,
undesired level. If a surgeon needs to only coagulate tis-
sue, then the power density of the beam must be high
enough to exceed the threshold for coagulation, but not
so high as to cause vaporization. Equally true, a surgeon
who is vaporizing or ablating tissue must avoid both char
formation and coagulation. In this latter case, a power
density should be selected that simultaneously exceeds
both the thresholds of coagulation and vaporization but
not the threshold of carbonization. These thresholds
depend strongly on wavelength, power density, and tis-
sue composition – specifically the water content.
The boiling point of water, 100 °C, is reached rather
quickly when CO2 laser power densities above 1500 W/
cm2 are applied, and produce the transformation of liq-
uid water to steam vapor. Above 1500 W/cm2, the laser
will consistently cause boiling. Below 10 W/cm2, only
gentle warming of the water will occur. Between 100 and
1500 W/cm2, a mixture of warming and vaporization will
occur. Within the soft tissue, these thresholds are almost
equivalent. The mechanism of vaporization of soft tissue
by a laser beam is the sudden boiling of histologic water
to form steam. This intracellular steam expands rapidly
and ruptures the relatively weak cell membranes that

previously confined it. The solid residue of cells and con-
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nective tissue are dehydrated and ejected from the
impact zone of the laser beam and may actually ignite or
burn, forming a plume of smoke. The temperature of the
area not vaporized will be <100 °C and falls away expo-
nentially with distance.
­Altering Power Density
The power that a laser beam delivers to the tissue can be
controlled by raising or lowering the laser’s power out-
put (W), changing the diameter of the beam, or changing
the amount of time that the energy is delivered. Successful
surgical laser use requires an understanding of the rela-
tionship between power output and spot size of the
beam, distance to the target tissue, the angle of targeting,
and length of delivery time.
Changes in Power
Power density is measured as the radiant power striking
a target per unit area of cross‐section of a laser light
beam. That power, P, is described as the amount of
energy delivered per unit of time. Power density, Po, is
generally stated in units of W/cm2.
P energy / time
Po P / area
Power density is directly proportional to the power (in
W) that a laser can deliver, and inversely proportional to
the tissue surface area (in cm2) that the beam strikes to
do work. The effective diameter of a laser beam, de, is
conveniently described as the diameter of a concentric
circle perpendicular to the axis of beam propagation that
contains 86.5% of the total power of the laser beam. The
effective diameter of a laser beam is a convenient value
to use when discussing spot size or any other parameter
regarding the power density of a laser beam. Simply
increasing or decreasing the power delivered through
any given constant effective diameter can influence
power density, and that change will be strictly linear. For
example, if 8 W (power) are delivered to a circular spot
that is 0.8 mm diameter, the power density is approxi-
mately 1600 W/cm2, from the following calculation:
P focusing tip or handpiece from the target tissue has an
Po
r2
8W 4
(0.08 cm )2
­Altering Power Densit 17
The power density can be increased to 3200 W/cm2 by
increasing the power to 16 W, and decreased to 800 W/
cm2 by decreasing power to 4 W. Thus, altering power by
a constant factor will alter the power density by an equal
constant factor, if the effective diameter of the laser beam
remains constant. With all other parameters being kept
equal, changing the power delivered to tissue is the sim-
plest and most understandable method of altering the
effective power density.
Changes in Spot Size: Distance and Diameter
The measurement of the circular pattern that laser light
produces at its target is referred to as the spot size. This
is the diameter of the beam at its contact point with the
target t. Most lasers produce a circular spot unless the
beam geometry is altered.
The manipulation of laser energy is somewhat depend-
ent on the type of laser delivery system being used. Laser
beams delivered by a cleaved cylindrical solid fiber will
deliver consistent power density at the working tip. The
power density is manipulated by changing the diameter
of the fiber or by adjusting the power setting at the con-
trol panel.
In contrast, the intensity of a collimated laser beam,
such as one delivered by an articulated arm, is only
altered by managing its power. Collimated beams by def-
inition are not focused, and power density is constant in
relation to target tissue distance. For collimated beams,
changing the distance from the target has no influence
on power density at the tissue target; only the beam
diameter is the effective metric.
The average power density, in W/cm2, of an unfocused
collimated beam of light, or light that has passed through
a cylindrical quartz fiber (such as a near‐infrared laser),
is given by the total beam power divided by the cross‐
sectional area of the beam:
P
Po 127.3 P / (de in mm )2
r2
A focused laser beam, such as those delivered by a hol-
low waveguide delivery system, will converge from the
distal end of its aperture to a finite focal point, then diverge
from this focal point to infinite expansion. This divergence
can be used for the surgeon’s benefit if it is understood
that changing the distance from the target will change the
power density of the beam at the point of tissue contact.
With focused laser beams, the distance of the laser
inverse squared relationship to the amount of energy
imparted on the target tissue. This is because a focused
beam has an optimal focal distance of maximal power
density known as the focal area. Power density then
 18 Understanding and Utilizing Power Density
f
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w(d) W(z)
Θ Z
Figure 2.3 A Gaussian laser beam passes through a focusing lens
and is altered by several optics principles. The depth of focus, d, is
the area proximal and distal to the focal length, f, that contains the
effective diameter of the laser beam. The diameter of the focused
laser beam at d is w(d). The diameter of the laser beam at W(z) is
greater at distance Z, because the focusing of the beam occurs
before or after the target compared to the focal zone. When the
tissue receives laser energy at W(z), the resulting greater area that
is targeted receives a proportional reduction in power density
compared to that at w(d). This optical focusing phenomenon does
not occur with collimated beams, and moving a collimated beam
closer to, or farther away from tissue does not at all change its
power density because the target area remains constant. A
collimated beam has an angle of divergence, Θ, equal to 0°, and
focusing systems may create Θ of 3°–15°.
decreases as the beam converges or diverges away from
this area in either direction (Figure 2.3).
The focal distance, f, of a typical CO2 laser focusing tip is
2 mm from its aperture. This means the power density of the
beam will be highest near this point, and lower power densi-
ties will be found either proximal or distal to this focal point.
(In actuality, this system prevents a perfect focal point, but
there is a focal area in the range of 1–3 mm from the open-
ing. For simplicity, we will describe the focal distance as
2 mm.) A circular area at the focal distance having diameter
de will possess power density Po. The spot size on a plane
perpendicular to the beam axis at a focal distance from the
focal area will have a diameter that varies with the angle of
divergence, θ, from the focusing tip. Smaller size focusing
tips will have higher divergent angles, and larger size focus-
ing tips will have smaller angles of divergence. The diameter
of that spot is approximately calculated by the sine law:
de f sin
The power density at this point is similarly approxi-
mated by
4P
Po
f sin 2
2
Note that power density is inversely related to the
square of the focal distance, f, and inversely related to
the square of the sine of the angle of divergence θ, and
directly related to the square of the secant of . For
2 the inverse square of the effective diameter of the beam.
Figure 2.4 Representation of focused Gaussian TEM00 laser beams
passing through three different lenses at three distances from the
target and a fourth collimated beam delivered from a cylindrical
quartz fiber. Note that the target spots are circular, and the beam
geometries have been exaggerated for illustration purposes only.
From left to right and bottom to top, the lenses are 0.25, 0.4, and
0.8 mm diameters; the fiber in this example is 600 μm in diameter.
The smallest lens produces a laser beam that diverges quite
rapidly from the focal area of the beam producing the most
dramatic changes in power density in relation to distance from
the target. Notice that this conical shaped beam is still very close
to the target and much power density is lost due to defocusing
effects. In contrast, the largest lens in this group produces a beam
that does not diverge much with increasing distance from the
target and there are minor changes in power density with
increasing defocusing distance between the focal area and the
target. The lens in between these two sizes will produce moderate
changes in these parameters. Again, note that in a collimated
beam, there will be no significant change in power density in
relation to distance between the target and the laser aperture
from where the beam is emitted.
focusing tips having the same focal length, f, the change
in spot size produced at a given distance from the focal
point will be greater if the divergent angle, θ, is larger
(e.g. smaller diameter focusing tip). Likewise, a larger
focusing tip having a smaller divergent angle will have
smaller changes in spot size at a given distance from the
focal area. Simply moving the focusing tip, or the end of
the fiber, toward or away from the target will produce
significant alterations in power density at the target tis-
sue. Doubling the distance from the focal point will
reduce power density by more than one‐fourth. This
effect is dramatically reduced with small divergent angles
present in larger focusing tips, and nonexistent in colli-
mated beam delivery systems (Figure 2.4).
More dramatic effects in power density changes are
observed by altering the diameter of the delivery of a
focused laser beam than by altering distance to the tar-
get, and those changes obey an inverse square law.
Assuming a circular spot size and constant power
­delivered, the change in power density will change with

The spot size can be changed by using separate focusing
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tips (typically ceramic or metal) or adjustable lensed
focusing handpieces.
For example, if 10 W are applied through effective
diameters of 1.4, 0.8, 0.4, 0.3, and 0.25 mm, the corre-
sponding power densities would be 648, 1984, 7938,
14 111, and 20 320 W/cm2. Note that by doubling the
effective diameter from 0.4 to 0.8 mm, the power density
is diminished by one‐fourth and that power density
quadruples by using an effective diameter that is com-
paratively one‐half as wide. Likewise, the difference in
power density changes by a factor of approximately 25
when comparing the effective diameters of 0.3 and
1.4 mm.
What does this mean to the target tissues, clinically
speaking? If the clinical objective is to rapidly produce a
zone of vaporization, the laser surgeon should use a very
small spot size with high power. This will provide ade-
quate power density to produce vaporization and allow
for rapid formation of a trough deep into the target tis-
sue. It will also allow most of the generated heat to be
removed in the plume and away from the surrounding
tissue. If the intent is to ablate more superficially or to
cause heating, denaturation, or coagulation of protein
and collagen, then a larger spot size that produces a
lower power density should be used. Be aware that an
increase in char and the potential for peripheral thermal
conduction occurs in this scenario.
Changes in Spot Size: Angle of Incidence
To deliver the full benefit of the power to a surgical site,
the laser beam should be focused to its optimal focal
diameter at the target tissue and be kept perpendicular to
it. Any deviation from this optimal distance and position
will cause a loss of power applied to the tissue, potentially
resulting in undesirable effects. For a perfectly normal
beam, the incident power density, Pi, is equal to the power
density delivered to the target, Pd. However, much power
can be lost if the surgeon applies the laser beam at an
angle φ deviated from normal, such that the normal vec-
tor of power density, Po, delivered to tissue is
Po Pi cos .
A focused cylindrical laser beam will produce a circu-
lar spot when directed normally. When the user changes
the directed angle from normal, the target spot will
become more elliptical. Any deviation from normal by
an angle φ will cause lower power densities at the target
due to distortion of the spot geometry (Figure 2.5).
Note that the resulting power density is also nonuni-
form: the proximal area has increased fluence, and the
­Altering Power Densit 19
Pd = Pi
Po < Pi Pi
φ
Figure 2.5 Two identical Gaussian laser beams of incident power
Pi are directed toward tissue. At the left, the power density of the
beam is optimized when it is directed normally to the tissue and Pi
is equal to Pd, the power density at the effective diameter of the
beam. It will create a Gaussian‐shaped zone of interaction within
the tissue according to the characteristics of both the laser
wavelength and the targeted tissue. At right, the laser beam is
deviated away from normal by angle φ. While the power density
of the incident beam is Pi, its normal vector, Po = Pi cos φ, is less
than Pi. Note that the zone of laser–tissue interaction is
nonuniform. The resulting spot is ellipsoid with higher fluence
closest to the beam and a decreasing fluence gradient tapering
distally from that area. The penetration depth of the laser–tissue
interaction zone is also shallower than expected for the power
delivered, making the unpredictable use of angled beams
suboptimal. The normal beam, delivered perpendicular to tissue,
is repeatedly predictable and this technique should be used to
have idealized vaporization or coagulation.
distal area has decreased fluence, summarily losing the
benefit of optimal power density delivered to the tissue.
Should a surgeon find themselves delivering laser energy
to tissue at an angle, it is concluded that the LTI may be
unpredictable. There may be coagulation in areas where
vaporization is desired, or there may be ablation where
coagulation is desired. The handpiece and laser beam
should therefore be directed perpendicular to the tissue
for predictable effects.
Changes in Time: Laser Delivery Exposures
and Modes
In continuous wave (CW) exposure, the laser output is
steady and constant for the entire duration of the time
that it is used. Duration of CW operation may be as short
as a few milliseconds, or indefinitely, and causes the
greatest accumulation of heat within tissues. Using a
laser in repeat pulse (RP) exposure allows for some tissue
cooling between pulses.
 20 Understanding and Utilizing Power Density
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250 μs
pulse duration

Superpulse
5 ms micropulses
200 Hz

Superpulse
25 ms macropulses
30 Hz, 75% duty
8.333 ms rests
Time

Figure 2.6 Magnified representation of the pulsed SuperPulse CO2 laser energy waveform. Each individual SuperPulse micropulse
possesses high power due to its short pulse duration of approximately 250 μs, with a relatively longer rest period of 5 ms when delivered
at 200 Hz. This feature allows enhanced cooling of the surgical site between pulses because tissue thermal relaxation time is much less
than the rest period. Software‐generated pulsing patterns can produce a variety of SuperPulse duty factors; this example demonstrates a
75% duty factor. With these parameters, the laser delivers 25 ms duration macropulses at 30 Hz of the SuperPulse waveform, leaving a rest
period of approximately 8.333 ms between macropulses. Each macropulse is comprised of five individual SuperPulse micropulses. This
feature allows even greater cooling of tissues at the surgical site. Using lower duty factors can produce even greater cooling benefit at the
expense of requiring longer time to complete the surgical incision.

The SuperPulse (SP) mode of laser delivery is created
using an extremely short time of power application with
a correspondingly longer rest period between pulses.
The peak power of SP is also much higher than energy
delivered by CW over the same time period. The total
fluence delivered by SP is thus generally lower than that
of CW or RP. Ideal delivery and rest times allow for the
longest possible thermal conduction within tissues while
maximizing tissue penetration, due to high power densi-
ties achieved during laser activation.
The SP waveform itself can also be pulsed. During
each macropulse of the SP waveform, there are several
micropulses of laser energy output. A single SP micro-
pulse is generally 200–300 μs and repeats at 150–250 Hz
depending on the rest period. A common use of SP in RP
mode is to create 25 ms macropulses at 30 Hz of SP
micropulses at 200 Hz. A duty factor of 75% provides a
rest period between macropulses of about 8.333 ms to
permit a greater degree of tissue cooling and idealized
cutting with minimized coagulative effects (Figure 2.6).
This is the idealized setting for skin incisions to be cre-
ated using optimized power density as programmed by
the surgeon using the laser’s software settings.
Changes in Time: Hand Speed
A tissue kerf is produced by a Gaussian laser beam that
moves in a given direction, x, in tissue. Its depth, z, is
dependent on excess deposited fluence. Its width, y, is
dependent on the effective diameter of the beam. The
kerf length is a result of the time that the beam moves at
velocity, v. Intuitively, slower speeds create greater pene-
tration depth and deposit more fluence over a given area.
Faster speeds will not allow excess fluence to be depos-
ited at depth and will require higher power density to
achieve the ablation threshold. To avoid excess char for-
mation, a surgeon with rapid hand speed may require
high power to make incisions and a surgeon with slow
hand speed should use lower power when creating
­incisions (Figure 2.7). Further discussion of LTI will be
presented in Chapters 3 and 4.
­Summary of the Importance
of Power Density
It is clear then, that the power density of a laser beam can
be affected by three main components under the c­ linician’s
control: power, spot size, and time. Knowing intuitively
how these components interact will maximize the poten-
tial for a positive therapeutic outcome to the patient. The
interplay of spot size, distance from focal area, angle of
incidence, hand speed, power, and time are the critical
variables all competent laser surgeons need to understand.
Focused laser beams are a model of versatility in offering
the surgeon the means to manipulate power density
through the manipulation of spot size. As the spot size

P decreases while the power remains constant, the power
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v V
X tend to produce tissue vaporization and less thermal con-
Y effective tool for incising tissue without leaving irritating
zV
Zv
Figure 2.7 Two identical Gaussian laser beams of incident power,
P, are targeting tissue and moving from left to right at different
velocities. The beam moving at lower velocity, v, has a larger kerf
diameter, Y, and a deeper penetration depth, Zv. The other beam
moving at higher velocity, V, has a smaller kerf diameter, y, and a
shallower penetration depth zV. Slower hand speeds may cause
deeper tissue penetration, and more vaporization and ablative
effects at its periphery due to excess deposited fluence. Faster
hand speeds provide less deposition of fluence, shallower
penetration depth, and more coagulative effects. The surgeon will
need to marry laser power and individual hand speed to the
properties of laser wavelength and tissue composition in order to
achieve the desired surgical effect.
­Summary of the Importance of Power Densit 21
density (power per unit area) must necessarily increase.
Conversely, as spot size grows from small to large, either by
changing aperture openings, altering the distance from the
target tissue, changing the angle of incidence, or by using
rapid hand speed – the power density will correspondingly
diminish. In general terms, higher power densities will
duction at surgical sites. This makes a surgical laser an
char, but will not serve well for coagulation. Conversely,
lower power density will produce more gradual heating of
tissue and cause coagulative changes due to heat accumu-
lation and thermal necrosis in tissue. These properties are
essential for hemostasis and are also undesirable when
producing incisions or ablations. When properly recog-
nized, these dynamic effects can be utilized by the laser
surgeon to create the necessary alteration in tissue without
unnecessary or undesired transformations.
The clinician can control the kind of effect produced in
the target tissue by first choosing the correct wavelength
of laser for the desired procedure, and then by manipu-
lating the distance, spot size, targeting angle, hand speed,
or power settings on the laser. It is very important to rec-
ognize this flexibility, so the clinician may optimize the
use of their surgical laser device and produce the best
clinical results for their patient.
 22
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Laser–Tissue Interaction: Selecting a Laser for Surgery
Christopher J. Winkler
­Introduction
Have you ever imagined what is occurring on the cellular
level while you are operating? Observing surgical proce­
dures from such a relative distance, it can sometimes be
difficult to envision what’s happening to the cells and tis­
sues of our patients when such procedures happen so
rapidly in our daily or weekly routine. But take a moment
to imagine four different lasers trained on the same tis­
sue. Each laser has the exact same power output, the
same fluence, and is turned on for the exact same amount
of time. The first laser vaporizes intracellular water, cre­
ating a precise incision with no bleeding. The second
laser destroys a tumor without harming any surrounding
tissue. The third laser causes a wide zone of thermal
coagulation around its target that might continue for
hours, while the fourth laser has fascinating effects on
electron transport chains. By using different media of
atoms and molecules in today’s lasers, a wide variety of
laser light of different wavelengths can be produced, and
many are utilized in medicine and surgery for different
effects. The interaction of laser light with living tissue
can be incredibly complex and varied, and thus a more
complicated surgical method to skillfully manipulate
than the scalpel blade or electrocautery. Veterinarians
who wish to provide the best possible care for their
patients will find a deeper study of these interactions
worthwhile, as the advantages of laser light are obvious
in the number and variety of procedures to which it can
be applied; its comparably minimized collateral disrup­
tion to surrounding tissue; its reduction in pain, bleed­
ing, anesthetic risk, healing time, and postoperative
complications; and the available minimally invasive
methods by which it can be delivered to the patient.
A firm foundation of laser physics, power density, and
laser–tissue interaction remains essential to selecting the
best laser for your surgical procedure, unlocking the full­
est potential of your selected laser, and utilizing it to
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
achieve the finest surgical results and the most favorable
outcome for your patient. There is no single wavelength
of laser light that is suitable for all surgical applications,
and not many veterinary practices are likely to have more
than one surgical laser. Such a foundation thus will also
allow laser surgeons to adapt to different procedures and
situations, reaping the most benefit out of the laser avail­
able to them while understanding and minimizing its
limitations.
­Basic Principles
Let us first examine the most basic biophysical interac­
tions inherent in all forms of laser light with living tissue:
reflection, transmission, absorption, and scattering.
(While technically a subset of reflection, the importance
of scattering in medical discussions often results in its
class as a fourth tissue interaction.) These interactions
are important because they may occur to different
degrees at different wavelengths, or may be affected by
different tissue types, and thus have a direct impact on
how effective your laser application is to your surgical
target (Figure 3.1).
Laser light is reflected when the path of the ray of light
is altered by a reflective surface (Figure 3.1b). Reflection
is strongly dependent on wavelength and the color of tis­
sue, with wavelengths between 300 and 2000 nm being
those most strongly reflected. The most significant effect
of reflection of laser light from living tissues is the reduc­
tion of the laser’s power density. The laser is reduced in
its ability to do work, and the beam will have to be applied
at higher power and for longer periods in order to achieve
the desired effect.
Transmission is when laser light passes directly through
tissue without any tissue effects such as absorption or
scattering (Figure 3.1f ). This occurs when the target tis­
sue lacks an appropriate absorption medium relative to
 ­Basic Principle 23

of the laser light itself is known as Rayleigh scattering.

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This type of scattering is strongly dependent on wave­

length. It is also omnidirectional, spreading light waves
both forward and back from its point of origin. Scattering
a
by particles greater than or equal to the wavelength of
b the laser light is known as Mie scattering. Mie scattering
b
is less dependent on wavelength than Rayleigh scatter­
ing, and its light is spread predominantly forward
rather than omnidirectional, making this a particularly
c important consideration to the diode laser surgeon
g (Berger and Eeg 2006).
d For surgery, the most important consequence of scat­
i
tering is the spatial redistribution of radiant power den­
sity, from what would otherwise be a narrow beam of
e g i laser light, into a surrounding volume of irradiated tissue
h (ABLS SG 2016a,b). The scattered laser beam is no longer
collimated or coherent. It will travel with equal probabil­
f
ity in all directions and illuminate tissue in the same dif­
fuse manner as light illuminates water vapor within a fog,
making light appear to be coming from every direction.
Figure 3.1 As a laser beam (a) strikes the surface of the target This is known as randomly diffused radiant flux (RDRF)
tissue, part of it may be reflected (b), or absorbed at the surface and is rather the opposite of what is considered a laser
(c), diminishing the beam’s power density. As the beam travels beam. Laser light scattered in different directions to sur­
further into the tissue, attenuation continues (d), until it is
absorbed by the target tissue (e). Some of the beam may continue rounding areas may be reflected and scattered again
to be transmitted past this point without undergoing absorption (Figure 3.1h), or absorbed (Figure 3.1i), creating effects
(f ). The beam may also be scattered throughout surrounding distant from the target area which may be desirable or
tissue (g), leading to additional scattering (h) or absorption (i) adverse. Such a method is useless for precise incision but
within tissues that are distant from the target tissue site, thus can be very effective for coagulation or the destruction of
causing tissue conditions which may be beneficial or adverse.
a relatively increased volume of tissue.
Absorption by tissues occurs when radiant energy (in
the laser’s wavelength to create a desired tissue effect. this case laser light) is converted into other forms of
Light may be refracted during transmission. Refraction energy, such as thermal or chemical (Figure 3.1e).
of light is a change in the laser’s wavelength, direction, Absorption depends on both the tissue on which the
and speed after crossing the interface of two media laser light is trained, and the light’s own wavelength.
having different indices of refraction (from air into
­ Tissue types that absorb laser light are known as
­tissue, for example). Refraction is important because Chromophores. Chromophores of considerable impor­
indices of refraction are higher at shorter wavelengths tance in laser medicine and surgery include water, mela­
and can result in an increased level of scattering of laser nin, hemoglobin, and fat. Virtually all laser light entering
energy in tissues. the body is absorbed (Stephens 2017). The task of the
Occurring primarily at wavelengths between 600 and laser surgeon is to see to it that surgical laser light is
2200 nm, Scattering is the dominant laser–tissue interac­ absorbed by target chromophores as much as possible in
tion (Stephens 2017). Scattering is a change in direction order to achieve surgical goals. The monochromaticity
of a light ray without a change in wavelength (Figure 3.1g). of the laser’s wavelength (discussed in Chapter 1) affects
The photons of a surgeon’s laser may be reflected off the the most efficient absorption by target tissue chromo­
irregular surfaces of tissue or off the particles and phores to achieve the desired tissue interaction for sur­
­cytoplasmic structures (especially mitochondria and cell gery, making wavelength the most important factor in a
nuclei) within tissues. They could be refracted at surgeon’s selection of laser device for a given procedure.
­interfaces of multiples tissues with different indices of
refraction. Finally, they could also be absorbed by atoms
Absorption and Scattering Coefficients
and molecules to be re‐emitted at the same wavelength
but in a different direction. Laser energy not reflected or transmitted is absorbed by
When water contains even a small fraction of particu­ the tissues. Although not the most dominant laser–
late matter, it becomes a scattering medium (ABLS SG tissue interaction, it is the absorption of light that will
2016a,b). Scattering by particles smaller than the wavelength achieve the goals of the surgical procedure. Absorption
 24 Laser–Tissue Interaction: Selecting a Laser for Surgery
by target tissues is thus the desired effect we’d like to achieve
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with the use of the laser. But absorption by other chromo­
phores in front of the target tissue, such as water within cells
and blood vessels, fat, and pigments such as melanin and
hemoglobin, may vary in their absorption of laser energy at
different laser wavelengths and interfere with laser light
being absorbed by target tissue to its full potential.
Tissue in the treatment area will affect absorption and
scattering to the degree that we can assign absorption
coefficients (α) and scattering coefficients (σ) to different
tissue types such as water, fat, and pigments. The absorp­
tion coefficient of a given tissue depends on both the tis­
sue and the laser’s wavelength, while the scattering
coefficient depends primarily on the laser’s wavelength
alone (Berger and Eeg 2006). Therefore, the suitability of
a particular laser for a specified surgical procedure
depends primarily upon the absolute and relative values
of absorption and scattering for the wavelength of that
laser and for the tissue on which the procedure is to be
performed (ABLS SG 2016a,b).
Incident ray
Penetrating ray
Pp0 = pi – pr
Δz
Pp1 = Pp0 ε–A(Δz)
Pp2 = Pp1 ε–A(Δz)
Pp3 = Pp2 ε–A(Δz)
Pp4 = Pp3 ε–A(Δz)
A t t e n u a t i o n
Figure 3.2 Although Figure 3.1 denotes laser–tissue interaction at a basic level, Figure 3.2 demonstrates the incredibly complex
interactions that can take place (often all at the same time) as laser light travels deeper into tissue, and the attenuation of the beam as a
result. Source: Courtesy of The American Board of Laser Surgery Inc., Trumbull, CT, 2018. Used with permission.
Absorption and scattering diminish the intensity of laser
light as it travels deeper into a medium (Figure 3.1d). This is
known as Attenuation. The laser light will exponentially lose a
constant fraction of its intensity in every unit distance of travel
forward into the tissue along the direction of the original beam
(Figure 3.2). The attenuation coefficient (A) is thus defined as
A
Although there is certainly the possibility that they
exist, this author has yet to meet a veterinarian who
enjoys equations such as those in Figure 3.2, which dem­
onstrates the exponential attenuation of a laser beam as
it travels deeper into tissue. It is sufficient to bear in mind
that due to the combined effects that reflection, absorp­
tion, and scattering have on diminishing the intensity of
laser light, selecting a laser possessing sufficient power
to overcome these effects becomes another important
consideration in the laser selection process.
Reflected ray
Scattered rays
Δz
Δz
Δz
Δz
Δz
Δz
Δz
i n t i s s u e
 ­Methods of Laser–Tissue Disruptio 25

Table 3.1 Relative absorption of laser wavelengths by different chromophores and their absorption depth into tissue.
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Weak 0 ≤ a ≤ 10 cm−1 Moderate 10 ≤ a ≤ 100 cm−1

Strong 100 ≤ a ≤ 1000 cm−1 Intense a ≥ 1000 cm−1

Ar–F Diode laser Nd:YAG Ho:YAG Er:YAG CO2

Tissue type 193 nm 810 nm 1 064 nm 2 100 nm 2 940 nm 10 600 nm

Water Weak Weak Weak Moderate Intense Strong

Hemoglobin Strong Weak Weak Moderate Strong Strong
Melanin Strong Strong Moderate Moderate Strong Strong
Fat Strong Weak Weak Moderate Intense Strong
Absorption depth <1 μm >5 mm >5 mm <0.5 mm <0.1 mm <0.1 mm

Source: Adapted with permission from © The American Board of Laser Surgery Study Guide 2016 Edition (Table 3‐1).

Table 3.2 Methods of laser–tissue disruption and their relative power densities and temperatures.

Tissue disruption Power density (W/cm2) Temperature (°C)

Photochemolysis <1 (Non‐thermal)

Photothermolysis (photopyrolysis) 1–100 60–100
Photothermolysis (photovaporolysis) 100–1 000 000 >100
Photoplasmolysis >10 000 000 000 >2 000

Source: Data courtesy of The American Board of Laser Surgery Inc., Trumbull, CT, 2018. Used with permission.

Table 3.1 shows ranges of absorption coefficients of
different chromophores by different laser wavelengths
used in veterinary surgery, along with the depths to
which they are absorbed into tissue. The greater the
absorption coefficient, the more that wavelength will be
absorbed by that tissue type. Tissues in an operating field
may vary greatly in their constituency from patient to
patient; it is sufficient to remember approximately how
well different tissue types in your procedure may absorb
the laser wavelength you have selected. The tissue depth
a laser may reach is also highly dependent on its
wavelength.
the form of controlled tissue disruption. There are three
primary processes by which laser light can achieve this
(Table 3.2), which the surgeon should consider when
deciding the goals for the surgical procedure.
Photochemolysis
Familiar to anyone who has seen pictures fade in direct
sunlight, Photochemolysis occurs when the absorption of
photons results in a biochemical reaction, breaking down
inter‐atomic bonds in complex organic molecules.
Photochemolysis typically occurs at power densities
below 1 W/cm2 and is therefore not considered a thermal
process unless power densities exceed 10 W/cm2.

­Methods of Laser–Tissue Disruption Photoplasmolysis

Depending on its wavelength, power, and method of
delivery, the absorption of laser light can cause different
alterations to tissue. One is Photobiomodulation, collo­
quially known in veterinary medicine as laser therapy,
where the absorption of photons affects cellular pro­
cesses for the benefit of the patient. Laser surgery
achieves a benefit of a different kind for the patient, in
Photoplasmolysis is the utilization of extremely high
radiant intensities, at power densities exceeding 10 bil­
lion W/cm2, to cause the ionization of atoms and mole­
cules. Such ionization causes the formation of a plasma
of several thousand degree celsius, which can in turn
cause the structural disintegration of any material
substance.
 26 Laser–Tissue Interaction: Selecting a Laser for Surgery
Photothermolysis
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Although several different lasers will be described in this
textbook for a variety of procedures, the vast majority of
laser surgical procedures conducted in veterinary prac­
tice today fall under the general category of
Photothermolysis, where radiant energy is converted into
kinetic (thermal) energy for the purpose of incision,
ablation, and coagulation. Photothermolysis may occur
through:
Photopyrolysis: At power densities between 1 and 100 W/
cm2, Photopyrolysis occurs when tissue temperatures
exceed 45 °C (ANSI 2011). Heating tissue above 45 °C
without exceeding 100 °C causes denaturation of pro­
teins, leading to thermal coagulation but not vaporiza­
tion. Below 60 °C some thermal trauma may occur, but
necrosis is not expected (Peavy 2002).
Photovaporolysis: At power densities between 100 and
1 000 000 W/cm2, Photovaporolysis occurs when tissue
temperatures exceed 100 °C, causing intracellular
water to be instantly vaporized, releasing desiccated
intracellular constituents upward in a plume of
“smoke” in the operating theater.
A threshold of power density exists which must be
crossed before intracellular water will boil, the ablation
threshold for vaporization. The amount of energy
required to cross this threshold is known as the latent
heat of vaporization. It should be noted that vaporizing
heated water requires 10 times more energy than what
was already spent to heat the water. Heat dissipation of
tissue is also always occurring during contact with the
laser, which must have adequate power density not only
to overcome the vaporization threshold for the target tis­
sue but also the heat diffusivity of the surrounding
tissue.
If the surgeon intends to coagulate tissue without
vaporizing it, as in hemostasis or slow ablation, then the
power density of the laser beam must not exceed the
threshold of vaporization. If the surgeon intends to
vaporize tissue as with a precise incision, then the power
density of the laser beam must exceed the ablation
Table 3.3 Three categories of surgical lasers based on their absorption coefficients and absorption‐to‐scattering ratios.
Laser type Absorption coefficient (cm−1) Absorption:scattering ratio (a/s)
WYDSCHY a < 1.0 a/s < 0.1
SYCUTE 1.0 < a < 100 0.1 < a/s < 10
WYSIWYG a > 100 a/s > 10
Source: Data courtesy of The American Board of Laser Surgery Inc., Trumbull, CT, 2018. Used with permission.
threshold of vaporization to boil intracellular water. As
discussed here and in Chapters 2 and 4, it is the surgeon’s
selection of laser wavelength, power density and fluence,
and surgical technique which will achieve the desired
photothermolytic effect with greatest efficiency.
­Select Your Laser
There is no single laser wavelength that will perform
every kind of surgery optimally. As mentioned earlier,
the suitability of a particular laser for a specified surgical
procedure depends primarily upon the absolute and rel­
ative values of absorption (α) and scattering (σ) for the
wavelength of that laser and for the tissue on which the
procedure is to be performed (ABLS SG 2016a,b). Other
considerations are also important, such as the method of
delivery of the light to tissue, available power output, and
the exposures and modes available. But these considera­
tions remain secondary compared to the laser’s absorp­
tion and scattering by the target tissues. Such
consideration of absorption and scattering helps us to
break down different lasers into three broad groups,
shown in Table 3.3.
WYSIWYG Lasers
A laser for precise incision and ablation must possess
absorption coefficients that exceed scattering coeffi­
cients. Such lasers are termed “WYSIWYG” (What You
See Is What You Get), because absorption is dominant
over scattering with the effects immediately apparent to
observation (Figure 3.3). These lasers operate at wave­
lengths outside the 300–2000 nm range where reflec­
tance is very high, so reduction in power density through
reflection of laser light is extremely low. Their wave­
lengths also result in very short penetration depths, so
their effects do not extend deeper into tissues than the
immediate observation of the surgeon. Although their
low scattering coefficients makes them comparatively
poorer coagulators than other laser types, these lasers
are excellent for precise surgery.
Wavelength (nm) Examples
625–1 400 Diode, Nd:YAG
400–625 KTP, pulsed dye, Ho:YAG
1 400–2 500
193–351 Excimers (Ar–F), Er:YAG, CO2
2 940–10 600
 ­Select Your Lase 27
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W Y S I W Y G Axis of beam

Pρ = 100 W/cm2
0
ρ
Stationary,
quasi-collimated,
Gaussian beam of
a carbon-dioxide
Pc Coagulated, charred rim
laser

Ultimate surface First tissue surface

of the laser hole

Minimum zone of
Crater contours 2t
thermal necrosis
at instants
t, 2t, and 4t
Steam and solid
residues of cells,
Tr ejected at ~5 m/s

100 °C
4t

dzc/dt Partially reflected

and attenuated rays

pct = 10 W/cm2
r 37 °C
Profiles of temperature Boiling wall of the crater
vs. distance from the
wall of the crater

W hat
Y ou
S ee
Gaussian apex at time 8t if
wall reflections were absent
I s
W hat
Y ou Actual accelerated apex with
G et partial reflection of rays at
the boiling wall of the crater

Figure 3.3 The effects of a WYSIWYG laser on tissue. Source: Courtesy of The American Board of Laser Surgery Inc., Trumbull, CT, 2018.
Used with permission.

Featuring most prominently among the procedures
reviewed in this text, the carbon dioxide (CO2) laser
may be considered the model for precise surgery due to
its operating wavelength causing a precise photother­
mal effect ideal for photovaporization (ABLS SG
2016a,b). The CO2 laser’s wavelength of 10 600 nm is
absorbed with great efficiency by intracellular water.
The absorption coefficient of water at this wavelength
is very high (Table 3.1), while the scattering coeffi­
cient is extremely low. With low reflectance at this
 28 Laser–Tissue Interaction: Selecting a Laser for Surgery

­ avelength, and ­without a high scattering coefficient to

w WYDSCHY Lasers
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attenuate the beam, water will absorb energy at the car­

What about lasers whose scattering effects exceed
bon dioxide laser’s wavelength consistently at 100 °C,
absorption? These lasers have been termed “WYDSCHY”
resulting in vaporization of the cell instead of coagula­
(What You Don’t See Can Hurt You). Surgical lasers of
tion. Surrounding tissues are able to conduct heat away
this type operate in the 625–1400 nm range, where scat­
with great efficiency, and a SuperPulse mode allows the
tering and reflection are predominant over absorption.
surgeon to exploit this thermal relaxation time between
They also possess a deep penetration depth (Table 3.1).
laser pulses. Recent advances in power output and
Because the scattering coefficient for such lasers is
delivery systems have increased this laser’s efficiency as
higher than for WYSIWYG lasers, every point within the
well. The result is a clean precise incision made at the
illuminated volume of tissue acts as a source of heat
same hand speed as a scalpel blade; little to no hemor­
(Figure 3.4).
rhage with blood vessels less than 0.5 mm diameter
The beam’s power density is attenuated due to most of
being automatically sealed; the destruction of patho­
it being scattered and reflected, and it must reach higher
gens in the zone of the beam; sealed nerve endings
temperatures to be absorbed by the target tissue, result­
resulting in reduced pain; sealed lymphatics resulting
ing in greater collateral thermal trauma due to both ther­
in less postoperative inflammation; and a narrower
mal excess and coagulation and the scattering of laser
zone of collateral thermal trauma than that of electro­
energy throughout surrounding tissues. Thermal excess
cautery, all from an instrument that does not require
and scattered laser energy may indeed be desirable for
physical contact with tissue. The narrower zone of col­
procedures to destroy tumors, or when dealing with
lateral thermal damage also results in tissues less likely
highly vascular tissue. Even when this is desirable, how­
to dehisce with closure. In the past, high operating tem­
ever, the increased scattering means that thermal excess
peratures at this wavelength meant incompatibility
and even tissue necrosis does not always cease when the
with minimally invasive quartz optical fibers, limiting
laser beam is discontinued (ABLS SG 2016a,b). The sur­
delivery to the surgical site through articulated arms.
geon thus should bear in mind that what cannot be seen
The advent of the hollow waveguide is changing this:
under direct observation during the procedure may still
later chapters will demonstrate how this laser is being
have lasting effects on the patient long after the applica­
delivered through otoscopes and even through robotic
tion of the laser has been completed. Clinical judgment
devices to make such a precise surgical instrument a
with a particular patient’s tissue pathology and experi­
minimally invasive one as well.
ence with WYDSCHY lasers thus play great roles in sur­
Another notable example of this laser type is the
gical success.
erbium:YAG (or Er:YAG). At 2940 nm this laser
The particular value of WYDSCHY lasers is their
received FDA‐approved dental applications as a
transmission through quartz optical fibers, making their
favored alternative to burrs for drilling teeth. This laser
delivery to many tissues minimally invasive. Their weak
shares the CO2 laser’s primary chromophore of water,
absorption by water also makes them well suited to
in this case the small amounts of water found between
working in immersed operating fields. These lasers lack
bony matrices of teeth. Using the Er:YAG in pulsed
the power needed to cut radiantly or as precisely as
mode prevents excessive thermal trauma to surround­
WYSIWYG lasers, however, and the fiber is specially cut,
ing tissue, as much as four times less than that created
heated by laser light, and placed in direct contact with
by a dental drill, particularly valuable when protecting
the tissue in order to incise. This direct contact with tis­
adjacent dental pulp which is very sensitive to thermal
sue could cause additional unintended trauma and care
changes. One concern to dentists with such a device is
must be taken not to leave broken tips of fiber within the
the lack of a physical presence of the burr to measure
tissue during surgery. Sapphire tips are available to miti­
the depth of the hole drilled into the tooth. This is
gate this risk and the need to cleave the fiber, but remain
­offset by the reduced physical and thermal trauma
costly.
and reduced bacterial contamination obtained through
These lasers are good coagulators; their absorption by
the laser’s use (Parker 2011). The Er:YAG’s precedent
hemoglobin exceeds that of water, providing greater
use in human dentistry may lead to its eventual wide­
hemostasis of larger vessels than WYSIWYG lasers
spread acceptance in veterinary dental and orthopedic
(Peavy 2002). But as scalpels they are inferior to
procedures.
WYSIWYGs due to the high temperatures necessary for
This group also includes the excimer lasers. The preci­
them to incise. Their wider area of collateral thermal
sion of excimers such as the argon–fluoride laser
damage may also make suture dehiscence more likely.
(193 nm) makes them valuable for ophthalmic use, par­
They are therefore considered poor for precision
ticularly in procedures such as laser‐assisted in situ ker­
surgery.
atomileusis (LASIK).
 ­Select Your Lase 29
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W Y D S C H Y
Quartz fiber
40-W
Gaussian
beam of
Nd–YAG laser Reflected and
backscattered
Boundary surface radiation ~- 50%
of illuminated volume
First
60 °C isothermal tissue
surfaces surface

∼6de

∼4de

demm
=1.6 0.2 s

15 s 0.4 s

∼8 mm
W hat 1.2 s
Y ou
D on’t
Region of maximum
S ee histologic power density
C an
H urt
Y ou

Figure 3.4 The effects of a WYDSCHY laser on tissue. Source: Courtesy of The American Board of Laser Surgery Inc., Trumbull, CT, 2018.
Used with permission.

The Neodymium:YAG (Nd:YAG) laser, at 1064 nm, is
the classic example of this type and used in equine endo­
scopic surgery (Chapter 19). Other examples include
diode lasers, used in antimicrobial applications in veteri­
nary dentistry (Chapter 8), veterinary ophthalmic proce­
dures (Chapter 12), photodynamic therapy (Chapter 16),
and in veterinary endoscopic surgery (Chapter 17).
SYCUTE Lasers
Between WYSIWYG and WYDSCHY lasers are those
lasers that are moderately absorbed by water while still
exhibiting significant scattering in soft tissue. Such lasers
have been termed “SYCUTE” (Sometimes You Can Use
Them Effectively) because their operating wavelengths
allow them only a very application‐specific nature. Those
visible lasers between 400 and 625 nm are weakly absorbed
by water and ablate tissue through the presence of high
amounts of pigment. Near‐infrared lasers of this type
(1400–2500 nm) rely on water as the primary chromo­
phore. Scattering is significant within both ranges.
SYCUTE lasers couple moderate tissue ablation with
moderate hemostasis. They provide a combination of
efficient photothermal effects with shallow absorption
(due to their inherent pulse nature at room temperature,
resulting in little collateral thermal damage). While not
ideal for large‐scale surgery, what makes SYCUTE lasers
particularly valuable is their ability to transmit through
quartz optical fibers with great efficiency, allowing for
precision with minimal invasiveness.
 30 Laser–Tissue Interaction: Selecting a Laser for Surgery
The holmium:YAG (or Ho:YAG) laser is a SYCUTE
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laser. At 2100 nm, the Ho:YAG is well absorbed by water
and deliverable through small‐diameter flexible quartz
fibers. As we will see later in this text, the Ho:YAG is well
suited for a number of veterinary procedures, such as for
endoscopic laser lithotripsy (Chapter 17) and reducing
the risk of spinal disc decompression (Chapter 18).
Other notable SYCUTE examples include potassium
titanyl phosphate (KTP), pulsed dye, and ruby lasers.
Laser Selection Process
Based on an understanding of the information studied in
this chapter and those earlier, the veterinary laser sur­
geon may be able to choose the best laser for a given pro­
cedure by using the following selection process:
1) Decide the goal of the surgical procedure and select
the method of controlled tissue disruption by radiant
energy that is best suited to achieve this goal.
2) Select the best wavelength to achieve the desired tis­
sue disruption, considering the absorption and scat­
tering coefficients of the procedure’s target tissues as
well as adjacent tissues which may be collaterally
affected.
3) Select a laser model capable of delivering the desired
wavelength at sufficient power and time to achieve
the desired tissue disruption with minimal collateral
effects, along with the best delivery method suited for
both this laser model’s beam and the location in or on
the patient for the surgical procedure.
Although secondary, the laser model selected should
ideally be ergonomically comfortable enough to use fre­
quently and over extended periods of time. Such comfort
will enhance the surgeon’s confidence and skill with the
instrument. The selection of a laser from reputable and
well‐established manufacturers is also desirable so that
long‐term service, maintenance, and parts replacement
of such specialized equipment are assured. The cost of
the laser should be the least important deciding factor
(although unfortunately it is often the first overriding
concern of the clinician). A less‐expensive laser will still
be woefully inadequate to the task if it does not achieve
desired tissue effects, lacks adequate power to do so, or is
so uncomfortable that the veterinarian ultimately decides
to forgo its use.
­ he Virtue of Selecting High
T laser for all of your procedures, wherever you possibly can.
Power Density
When operating with a laser, it is advised to remember
that hemostasis and the minimization of adjacent ther­
mal trauma are mutually antagonistic aims, as laser
hemostasis requires thermal coagulation of the vessel.
Compromising one to accomplish the other is not usually
critical, as hemostasis may be achieved in multiple ways
during surgery. Therefore, if excision or vaporization is
the desired result, apply the highest power density to the
laser beam that you can safely control within the limits of
your comfort level of hand–eye–mind coordination
(ABLS SG 2016a,b). This allows the tissue to reach the
vaporization threshold as rapidly as possible with mini­
mal collateral thermal injury, achieving the most efficient
removal of unwanted tissue while minimizing damage or
removal of surrounding tissue.
­ urgical Lasers and Proper
S
Technique
Technique and experience can be just as important as
the selection of the laser itself. Figure 3.5 can demon­
strate three different lasers’ effects on tissue due to their
different wavelengths being absorbed to different degrees
by intracellular water, with Figure 3.5a demonstrating
the effects of a WYSIWYG laser, while Figure 3.5c dem­
onstrating the effects of a WYDSCHY laser.
But Figure 3.5 can also represent a laser of a single
wavelength having three different effects on tissue due to
different applications of power density, time, and skill of
application. As discussed in Chapter 2, the aspiring laser
surgeon masters such effects through control of the
laser’s fluence through a combination of three factors:
The spot size of the laser tip at the hand piece, the power
delivered by the laser, and the amount of time the laser is
applied to the site. The amount of time such energy is
delivered is controlled through a combination of your
program selection at the console, your own hand speed,
and how long you depress the trigger (Godbold 2017).
The versatility of possessing equipment enabling the sur­
geon to easily adjust fluence during the procedure can­
not be overstated.
When considering the distribution of power across an
irradiated surface, proper hand technique remains para­
mount to success. Holding the laser handpiece perpen­
dicular to your target tissue will maintain the distribution
of power density across the beam evenly, maximizing the
beam’s efficiency while reducing the chance of beam
reflection. This will maximize both results and safety in
the operating theater.
Finally, a tip from a fellow laser practitioner, especially
for anyone just beginning to use lasers in their practice.
Try to make the conscious decision on your part to use the
Seek additional training with your selected laser, whether
online or at conferences and workshops. The little bit of
extra time it may take to set up your ­equipment, research
its settings, and prepare yourself are well worth the experi­
ence and confidence you will gain for each procedure you
perform, each new laser setting you care to try, and each
patient you will see benefit from your results.
 ­Reference 31
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Zone of vaporization

Char formation

Zone of necrosis

Zone of thermal injury

(a) (b) (c)

Figure 3.5 (a) Demonstrates the tissue effect created by a laser well absorbed by the target chromophore (intracellular water), causing
rapid heating and vaporization and leading to a precise incision with minimal collateral thermal injury. (b) Could denote the same laser
at a reduced power density applied for a longer period of time, or a laser operating at a wavelength less well absorbed in water than
that of (a). (c) Denotes the tissue effect created either by the first laser at a very low power density for an extended period, or a laser
operating at a wavelength very poorly absorbed by water, causing a great deal of scatter and a large zone of thermal injury. Source:
Adapted from Peavy (2002).

­References
ABLS SG. (2016a). Laser biophysics, tissue interaction,
power density, and ablative resurfacing of human skin:
essential foundations for laser surgery, dermatology, and
cosmetic laser procedures. In: The American Board of
Laser Surgery Study Guide (2016 Edition), vol. 3.
Trumball, CT: The American Board of Laser Surgery
Inc. pp. 1–20.
ABLS SG. (2016b). Safe use of lasers in surgery. In: The
American Board of Laser Surgery Study Guide (2016
Edition), vol. 5. Trumball, CT: The American Board of
Laser Surgery Inc. pp. 3–4.
ANSI. (2011). American National Standard for Safe Use of
Lasers in Health Care Facilities, ANSI Z136.3‐2011.
Washington, DC: American National Standards
Institute. pp. 2–113.
Berger NA, Eeg PH. (2006). Fundamentals of laser–tissue
interactions. In: Veterinary Laser Surgery: A Practical
Guide, Chapter 3. Hoboken, NJ: Wiley Blackwell.
pp. 33–36.
Godbold J. (2017). Using the CO2 surgical laser to produce
the best tissue effect. Atlas of CO2 Laser Surgical
Procedures, Stonehaven Park Veterinary Hospital Laser
Surgery Center, Jackson, TN.
Parker S. (2011). Lasers in restorative dentistry. In:
Convissar R, ed. Principles and Practice of Laser
Dentistry, 1st ed., Chapter 11. St. Louis, MO: Mosby. pp.
181–201.
Peavy G. (2002). Lasers and laser‐tissue interaction.
Vet. Clin. North Am. Small Anim. Pract. 32. pp.
517–534.
Stephens B. (2017). Laser physics in veterinary medicine.
In: Riegel R, Godbold J, eds. Laser Therapy in Veterinary
Medicine: Photobiomodulation, 1st ed., Chapter 3. Ames,
IA: Wiley Blackwell. pp. 21–23.
 32
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The Ideal Laser Scalpel
Peter Vitruk
­Introduction
While certain veterinary surgical applications are facili-
tated by different laser wavelengths to achieve a specified
outcome, the vast majority of veterinary laser surgical
procedures involve incising and removing tissue as with
surgical steel. In order to take a steel scalpel’s place with
greater benefits to patient and surgeon alike, a surgical
laser ideal for cutting soft tissue must be able to (i) vapor-
ize tissue, and (ii) cauterize surgical margins at the same
time. Not all laser wavelengths are suitable to comply
with both requirements. The following discussion
focuses on some fundamental processes involved in
laser–tissue interaction, analyzing how deeply a laser
beam cuts and how far coagulation and hemostasis
extend into the surgical margins. In this we examine the
physics and mathematics of laser–tissue interaction, tak-
ing a closer look at a laser wavelength well suited to a
great majority of soft tissue surgical laser procedures.
L­ aser Light Absorption by Biological
Tissues
In order to understand how a surgical laser ablates (i.e.
“cuts”) and coagulates soft tissue, one must consider how
laser light is absorbed and scattered by soft tissue.
Most lasers in ablative soft tissue surgery fit into three
wavelength categories:
Near-infrared 810–1064 nm diodes and 1064 nm
(near-IR) Nd:YAG
Mid‐infrared 2790 and 2940 nm erbium (e.g. Er:YAG)
(mid‐IR)
Infrared (IR) (10 600 nm CO2)
Figure 4.1 examines the known optical absorption
coefficient spectra of soft tissue’s four main chromo-
phores (water, melanin, hemoglobin [Hb], and oxyhemo-
globin [HbO2]) in order to analyze photothermal ablation
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
(photovaporolysis) and coagulation (photopyrolysis),
which together comprise photothermolysis. Both photo-
pyrolysis and photovaporolysis are essential parts of soft
tissue surgery (Fisher 1987) as previously discussed in
Chapter 3.
Besides the absorption coefficient spectra for soft
tissue’s four main chromophores (Figure 4.1), their
respective spatial distributions are considered through
a simple two‐layer optical model (Figure 4.2) (Vitruk
2014a,b).
The 100–300 μm thin epithelial layer with its optical
absorption dominated by melanin and water (Figure 4.2,
top) (Prestin et al. 2012), and the subepithelium medium
(connective tissue, inclusive of lamina propria, and sub-
mucosa) with its optical absorption dominated by water,
hemoglobin, and oxyhemoglobin (Figure 4.2, bottom)
(Squier and Finkelstein 2008; Squier and Brogden 2011).
About 75% of the water content is assumed for both
epithelium and subepithelium for convenience, and
adjusting water content within a 70–100% range does
not significantly alter results and conclusions of this
chapter’s discussion.
Photothermal Laser–Tissue Interaction:
Absorption, Ablation, and Coagulation
During photothermal laser–tissue interaction, laser
beam energy is absorbed by the tissue’s chromophores
and heats tissue inside the irradiated volume, which
leads to elevated tissue temperatures that can result in
tissue ablation and coagulation.
Consider Figure 4.3, a one‐dimensional approximation
of a laser beam irradiating the tissue surface (at x = 0)
from the left (graphically represented as a thin slice of a
laser beam directed at a thin slice of tissue), assuming
pulse duration is essentially shorter than thermal relaxa-
tion time (Vitruk 2014a,b). Incident laser beam intensity
(W/cm2) is IB; laser light intensity immediately below the
tissue’ surface is I0. Accordingly, the reflectivity of the
 ­Laser Light Absorption by Biological Tissue 33
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Absorption coefficient spectra for: 4%, 75% and 100% water (green curves); 10% and 100% blood (whole blood
contains 150 g/l of HbO2 (red curves) or 150 g/l of Hb (blue curves)); 2–100% melanin (black solid and dotted lines).

10 000
75% water 100% water
Melanin
volume fraction of
melanosomes in 2–100% range

1000
0%
10
%
30 %
13
2%
Absorption coefficient (cm–1)

4% water

100

10 HbO2
@ 150 g/l in 100% blood

Hb
NIR absorption by hemo- and
@ 150 g/l in 100% blood
oxyhemoglobin in sub-epithelium
connective tissue is approx.
1 1000–10 000 times weaker
HbO2 than absorption by water at
@ 150 g/l in 10% blood erbium and CO2 laser wavelength
Hb
@ 150 g/l in 10% blood
0.1
0

0
0

0
10

15

Wavelength (nm)

Figure 4.1 Optical absorption coefficient spectra at different histologically relevant concentrations of water, hemoglobin, oxyhemoglobin
and melanin (based on data from Hale and Querry (1973), Fisher (1987), Wieliczka et al. (1989), Fisher (1993), Jacques (1996), Jacques
(2013)). Logarithmic scales are in use. Source: Graph courtesy of LightScalpel LLC, Bothell, WA.

t­issue surface is (IB−I0)/IB, and the transmission is I0/IB.

Inside the tissue (x > 0), laser light intensity is exponen-
tially attenuated: I = I0Exp[−x/A], where 1/A is the
Laser beam absorption coefficient from Figure 4.1 (or attenuation
coefficient if light scattering is considered). Assuming
that laser intensity I0 is greater than intensity Ia required
for a specific pulse duration t to ablate the tissue locally,
tissue ablation takes place in 0 < x < xa referred to as the
100–300

Epithelium
μm

contains water and melanin “Ablation Zone” in Figure 4.3. Immediately below the
ablation zone is the heat affected zone xa < x < xc, with tis-
sue temperature ranging from the very high Ta (ablation
temperature) at xa down to the coagulation threshold
temperature Tc at xc (i.e. Ta = 100 °C and Tc = 60 °C). The
Sub-epithelium coagulation depth (H = xc − xa), is defined by the 60–100 °C
contains water and hemoglobin temperature range inside the heat affected zone (Pfefer
et al. 1999; Barton et al. 2001; Mordon et al. 2005; Pang
et al. 2010).

Light Absorption and Scattering in Epithelium

Since melanin is present in the epithelium layer, while
Figure 4.2 Simplified optical model of soft tissue consisting of a hemoglobin is not, and since there is no melanin in
water‐melanin‐rich epithelial layer, and a water–hemoglobin–
oxyhemoglobin rich subepithelium medium (connective tissue
hemoglobin‐rich connective tissue (subepithelium), the
inclusive of lamina propria and submucosa). Source: Diagram optical properties of epithelium and subepithelium are
courtesy of LightScalpel LLC, Bothell, WA. analyzed separately and independently from each other.
 34 The Ideal Laser Scalpel
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Light intensity (W/cm2)
IB
I0
Ia
Ic
er
t las 0
en m
cid ea
In b
B xa - ablation depth
Figure 4.3 Simplified graphical representation of laser beam intensity attenuated inside the soft tissue. Source: Diagram courtesy of
LightScalpel LLC, Bothell, WA.
Similar to melanin content and pigmentation in human
epidermis (Jacques 1996), the epithelium’s volume frac-
tion of melanin pigmentation (Figure 4.1) is estimated at
approximately 2% (very light pigmentation), 13% (mod-
erate), and 30% (dark). Optical absorption in epithelium
at 800–1100 nm near‐IR wavelengths, though highly
dependent on pigmentation, is relatively low due to very
thin epithelium (100–300 μm) (Prestin et al. 2012).
Unlike near‐IR wavelengths, the mid‐IR wavelengths
(erbium lasers) and IR wavelengths (CO2 laser) exhibit
near‐100% absorption in epithelium, which is of high
value for predictable laser photothermal ablation of epi-
thelium (Esen et al. 2004).
Light Absorption and Scattering
in Subepithelium Connective Tissue
Optical absorption depth spectrum for connective tissue
(subepithelium) with 75% water and estimated 10%
blood in soft tissue (hemoglobin and oxyhemoglobin) is
derived from absorption coefficient spectra (Figure 4.1)
for water, hemoglobin, and oxyhemoglobin and is pre-
sented in Figure 4.4. An estimate of attenuation depth as
an inverse of the sum of absorption and reduced scatter-
ing coefficients for whole blood (estimated through
absorption to reduced scattering ratio), is presented in
the inset in Figure 4.4. Attenuation depth is a more accu-
rate representation of laser energy penetration into tis-
sue for near‐IR wavelengths where light scattering
through tissue dominates light absorption by tissue (Hale
and Querry 1973; Fisher 1987; Wieliczka et al. 1989;
Cheong et al. 1990; Fisher 1993; Jacques 1996; Alberts
et al. 2007; Jacques 2013; Vitruk 2014a,b).
Soft tissue Ablation zone
Coagulation zone
Blood vessels
B
xa xc x (mm)
B - blood vessel diameter
H = xa – xc - coagulation depth
As seen in Figure 4.4, both erbium lasers (approximately
3000 nm) and CO2 lasers (approximately 10 000 nm) are
highly absorbed by soft tissue and thus efficient at cutting
and ablating soft tissue purely radiantly without direct
­tissue contact. Diode lasers (approximately 1000 nm) are
inefficiently absorbed by soft tissue and cannot be used
radiantly (noncontact) for cutting and ablating soft tissue
as erbium and CO2 lasers can. Instead, near‐IR diode
lasers are used as hot‐tip contact thermal devices similar
to electrocautery: laser radiation heats a charred glass tip,
which then conducts heat directly into soft tissue.
Thermal Relaxation Time
Soft tissue ablation and coagulation efficiencies are
influenced not only by absorption and attenuation
spectra (Figures 4.1 and 4.4) but also by laser pulse
duration and tissue thermal conductivity (or thermal
diffusivity). The physics behind thermal diffusivity is
similar to diffusion and Brownian motion first described
by Einstein (1905).
The rate at which irradiated tissue diffuses heat away is
defined through thermal relaxation time (Figure 4.4) as
TR = A2/K, where A is the optical absorption (or near‐IR
attenuation) depth discussed above (Svaasand 2003;
Vogel and Venugopalan 2003). Coefficient K is a tissue’s
thermal diffusivity; K = λ/(ϱ C) = 0.155 (+/−0.007) mm2/s
(derived from heat conductivity λ ≈ 6.2–6.8 mW/cm °C;
specific heat capacity C = 4.2 J/g °C, and density ϱ = 1 g/
cm3 for liquid water for temperatures in 37–100 °C range)
(Weast 1980–81). For practical consideration of the
often‐used 0.4 mm laser beam diameter on tissue, thermal
relaxation time in Figure 4.4 is estimated at approximately
 ­Soft Tissue Ablation and Coagulatio 35
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Absorption depth and thermal relaxation time spectrum for sub-epithelium with 75% water and 10% blood
(HbO2 (red curve); Hb (blue curve); 50% Hb + 50% HbO2 (green curve).

808–1064 nm
10 diodes 70

60
Attenuation depth estimate,
reduced scattering coefficient
≥1s

Absorption depth (mm)

50
for whole blood estimated from
40 [18] for: - Hb; - HbO2
(≈ 0.4 mm
1 30 spot size)
Absorption depth A (mm)

Thermal relaxation time

20
≈1s
10

0
650 700 750 800 850 900 950 1000 1050 1100
0.1 Wavelength (nm) 70 ms

0.01 0.7 ms

2780 nm Er:YSGG 9300 nm CO2

2940 nm Er:YAG 10 600 nm CO2

0.001 7 μs
800 1800 2800 3800 4800 5800 6800 7800 8800 9800 10 800
Wavelength (nm)

Figure 4.4 Absorption (and estimated near‐IR attenuation) depth spectra of subepithelium (connective tissue). Logarithmic scale is in
use. Source: Graph courtesy of LightScalpel LLC, Bothell, WA. Adapted from Duclos and Vitruk (2018).

≥1 s for absorption depths in excess of 0.4 mm (i.e. when heat diffusing from the ablation zone to adjacent healthy
the 2‐D radial heat conduction away from the axis of the tissue. SuperPulse ensures char‐free soft‐tissue ablation,
beam takes place). incision, and excision with the thinnest depth of coagula-
The practical implications of the thermal relaxation tion and hemostasis at the ablation margins.
time concept are simple and yet very powerful for appro-
priate applications of laser energy.
The most efficient heating of irradiated tissue takes
place when laser pulse energy is high and its duration is
­Soft Tissue Ablation and Coagulation
much shorter than TR. The most efficient cooling of tis-
Photovaporolysis (Photothermal Ablation)
sue adjacent to an ablated tissue zone takes place if time
duration between laser pulses is greater than TR. Less‐ The most efficient soft tissue photothermal ablation is
efficient heating of irradiated tissue takes place when the vaporization of intra‐ and extra‐cellular water (pho-
laser pulse energy is low and its duration is longer than tovaporolysis) (Fisher 1987, 1993; Vogel and Venugopalan
TR. Less‐efficient cooling of tissue adjacent to the ablated 2003). For a fixed laser beam diameter (spot size), the
zone occurs if time duration between laser pulses is volume of tissue exposed to the laser beam is propor-
shorter than TR. tional to the optical absorption depth (or near‐IR depth,
Short laser pulses (Figure 4.5), allow for the most effi- as defined above). The shorter the absorption depth, the
cient ablation of irradiated tissue with minimum coagu- less energy is required to ablate tissue. The longer the
lation and hemostasis beneath and around it. The optical penetration depth, the greater the volume of
“SuperPulse” mode for CO2 laser pulsing parameters is ir­radiated tissue, and therefore, greater energy is required
optimized around the thermal relaxation time concept to ablate tissue within the irradiated volume. The abla-
(Fisher 1987, 1993). SuperPulse mode (Figure 4.5) is tion threshold energy density spectrum ETH = ϱ A
bursts of short laser pulses with very high peak power (C(Ta − Tb) + r) is presented in Figure 4.6 (derived for
that are spaced far enough apart for efficient tissue cool- short pulse duration t ≤ TR, low pulse repetition rate
ing between pulses. SuperPulse minimizes the amount of f ≪ 1/TR , body temperature Tb = 37 °C, water boiling
 36 The Ideal Laser Scalpel
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Power density (W/cm2), on the tissue, for 0.25 mm focused beam diameter

100 000
Soft tissue ablation threshold @ 10.6 μm = 3 J/cm2

Pulse fluence on tissue

80 000 >20 J/cm2 >> 3 J/cm2
1.6 ms
Soft tissue
thermal relaxation time
60 000

Laser pulse width

approximately 0.25 ms << thermal relaxation time
40 000

Laser pulse spacing is much greater than thermal

20 000 Relaxation time for efficient tissue cooling between pulses

0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5

Time (ms)

Figure 4.5 SuperPulse explained: high power, short laser‐pulse duration maximizes soft tissue removal rate and keeps adjacent tissue
cool. Source: Graph courtesy of LightScalpel LLC, Bothell, WA.

10 000 Ablation threshold fluence (energy density) spectrum

Lower energy threshold result in (1) higher ablation efficiency

808–1064 nm diodes, sub-epithelium connective

and precision and (2) lower risk of collateral damage

tissue, beam diameter << attenuation depth

1000

808–1064 nm diodes, sub-epithelium connective

tissue, beam diameter > attenuation depth
Ablation threshold (J/cm2)

100

9300 nm CO2
10 600 nm CO2
10

2780 nm erbium
2940 nm erbium

0.1
800 1800 2800 3800 4800 5800 6800 7800 8800 9800 10 800
Wavelength (nm)

Figure 4.6 Soft tissue ablation threshold energy density (fluence) spectrum. Logarithmic scale is in use. Source: Graph courtesy of
LightScalpel LLC, Bothell, WA. Adapted from Duclos and Vitruk (2018).

temperature Ta = 100 °C, specific heat capacity
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C = 4.2 J/g °C, latent heat of water evaporation r = 2260 J/g,
and water density ϱ = 1 g/cm3) (Vitruk 2014a,b).
Near‐IR wavelengths (800–1100 nm) are characterized
by hundreds to thousands of times greater photothermal
ablation threshold energy densities than mid‐IR and IR
wavelengths due to weak near‐IR absorption by soft tis-
sue chromophores. Figure 4.7 illustrates the high degree
of scattering and predicted absence of tissue ablation at
810 and 980 nm. In sharp contrast to near‐IR wave-
lengths, the mid‐IR and IR wavelengths are highly energy
efficient at ablating soft tissue photothermally with very
low ablation threshold intensities (Figure 4.6) due to
extremely small volumes of irradiated tissue because of
extremely short absorption depths (Figure 4.4).
Spatial Accuracy of Photovaporolysis
The near‐IR 800–1100 nm operating wavelengths of
diode lasers are highly scattered (Figure 4.7) and poorly
absorbed by both scarce melanin in epithelium and by
low concentrations of hemoglobin and oxyhemoglobin
in subepithelium connective tissue, which results in a
widespread multimillimeter depth of laser energy pene-
tration into soft tissue. Such multimillimeter ambiguity
in tissue removal spatial accuracy at near‐IR wavelengths
increases these lasers’ collateral damage risk of overheat-
ing both soft and hard structures underneath connective
soft tissue if photothermal ablation is attempted. They
have thus been cited as “poor scalpels” (Fisher 1987) and
“not conducive to precise ablation” (Vogel and
Venugopalan 2003), and such risk is referred to as “vital
structures…may be heavily damaged before tissue ablation
400 μm fiber in contact with porcine soft
tissue. 810 nm light is highly scattered and
weakly absorbed
Figure 4.7 Near‐IR wavelengths 810 and 980 nm from commercially available diode lasers are highly scattered and weakly absorbed by
soft tissue, resulting in slow and wide‐spread photo‐coagulation and no ablation. Source: Courtesy of LightScalpel LLC, Bothell, WA.
­Soft Tissue Ablation and Coagulatio 37
at the surface is initiated” (Willems et al. 2001).
The 810 nm soft tissue absorption coefficient of 0.7 cm−1
in (Willems et al. 2001) makes its observations highly rel-
evant to the present analysis where 10% blood absorbs at
the rate of approximately 0.4 cm−1 at 810 nm (Figure 4.1).
Unlike near‐IR wavelengths, the mid‐IR wavelengths
(erbium lasers) and IR wavelengths (CO2 lasers) exhibit
much shorter absorption depths (Figure 4.4) which
makes mid‐IR and IR lasers far more spatially precise
and safer in soft‐tissue ablative applications.
Laser Power Density and Depth of Incision
For a laser scalpel (e.g. CO2 or erbium lasers), the power
density of the focused laser beam is equivalent to the
mechanical pressure applied to a steel blade. In other
words, greater laser fluence (i.e. greater energy density,
or power density times the duration it is applied to the
target) results in greater depth and rate of soft tissue
removal. For short pulse steady‐state ablation conditions
(Vogel and Venugopalan 2003), the ablation depth is
A(E−Eth)/Eth, where A is the absorption depth from
Figure 4.4, Eth is the ablation threshold fluence
(Figure 4.6), and E is the fluence during the pulse. At the
10 600 nm wavelength of the CO2 laser, the ablation
threshold for soft tissue with an assumed water content
of 75% equals approximately Eth = 3 J/cm2. For repetitive
pulses that are scanned across soft tissue, fluence is
defined by pulse frequency and hand speed. In other
words, the depth of incision depends on laser power set-
tings, spot size, and the surgeon’s hand speed (Figures 4.8
and 4.9) (Fisher 1987, 1993; Vogel and Venugopalan
2003; Vitruk 2014a,b).
980 nm 5 W from 400 μm fiber (no contact
with the porcine tissue) produces photo-
coagulation, does not produce ablation.
 38 The Ideal Laser Scalpel

SuperPulse setting @ 25 W average power Figure 4.8 Laser‐tissue incision with focused
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with (0.25 mm spot size) laser beam. A defocused beam

250 000 W/cm2, (>1–2 mm spot size) with reduced fluence will
250 μm, coagulate tissue. Source: Diagram courtesy of
800 μs LightScalpel LLC, Bothell, WA.
pulses

Incision depth
is proportional to
(1) laser average power, and,
250 Hz is inversely proportional to:
(2) focal spot size, and
(3) handspeed

1.5 mm incision depth for 25 W SuperPulse,

250 μm spot size at 2 cm/s handspeed

Figure 4.9 Calculated (Fisher 1987, 1993; Vogel

and Venugopalan 2003; Vitruk 2014a,b) depth of
incision with 0.25 mm focused CO2 laser beam
(0.05 mm2 focal area) through 75% water‐rich soft
tissue, for different SuperPulse power levels
10–50 W and different hand speeds 10–20 mm/s.
Multimillimeter incision depth at hand speed of
10 mm/s or faster is only feasible with laser power
5 above 35–45 W. Source: Diagram courtesy of
n (mm)

LightScalpel LLC, Bothell, WA. Adapted from

4 45 Duclos and Vitruk (2018).
f incisio

3
40
2
Depth o

)
(W

1.0 35
er
ow
rp

30
se

1.5
La

Hand speed (cm/s)

25
2.0

More precisely, for a laser beam moving over target tis-
sue, ablation depth is
1) proportional to the laser’s average power, and
2) inversely proportional to the laser beam width and
surgeon’s hand speed.
Figure 4.9 presents the calculated depth of incision
with a SuperPulse CO2 laser with 0.25 mm focal diame-
ter of the beam. A requirement for multimillimeter deep
incisions with hand speed faster than 10 mm/s is laser
power above 35–45 W.
Photopyrolysis (Photothermal Coagulation)
Coagulation is the denaturation of soft tissue proteins
that occurs in the 60–100 °C temperature range (Pfefer
et al. 1999; Barton et al. 2001; Mordon et al. 2005; Pang
et al. 2010) leading to a significant reduction in both
bleeding and oozing of lymphatic liquids on the margins
of a tissue’s ablation – coagulation zone (Figure 4.3).
Photothermal coagulation (photopyrolysis) is accompa-
nied by hemostasis due to shrinkage of both blood vessel
and lymphatic vessel walls due to collagen shrinkage at
increased temperatures. Since blood is contained within
and transported through blood vessels, the diameter
of blood vessels B (estimated from 21 to 40 μm from
measurements in human cadaver gingival connective
­
­tissue (Yoshida et al. 2011)) is a highly important spatial
parameter that influences efficiency of photopyrolysis
(Figures 4.3 and 4.10). The heat on the surgical margin
can be created either by laser light penetrating into the
tissue (Figure 4.10b), or by heat slowly propagating from
 ­Soft Tissue Ablation and Coagulatio 39
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(a)
Near IR
ion
Incis Scalpe
l (c) absorber
(char)
B
Bleeding

Heat
Blood capillary diameter B diffusion Hot glass tip
from hot
beam tip
(b) Laser

B HT >>B Hot tip

coagulation depth
H Photo-thermal coagulation depth

Figure 4.10 Hemostasis and coagulation mechanisms: (a) none for scalpel, (b) photothermal inside irradiated soft tissue, (c) heat diffusion
from a hot tip into soft tissue. Source: Diagram courtesy of LightScalpel LLC, Bothell, WA.

Coagulation depth (H)

H (mm)

10
Near-IR 808–1064 nm diodes
Coagulation depth H >> Blood vessel diameter B

Good
1 H for t ≈ TR
bleeding
control H for t << TR

0.1
Blood
capillary
diameters
0.01 9300 nm and 10 600 nm CO2 lasers
Coagulation depth H > B blood vessel diameter

2780 nm and 2940 nm erbium lasers

Coagulation depth H < B blood vessel diameter
Poor
bleeding
control 800 1800 2800 3800 4800 5800 6800 7800 8800 9800 10 800
Wavelength (nm)

Figure 4.11 Coagulation depth spectrum for ablation threshold conditions. Logarithmic scales are in use. Source: Graph courtesy of
LightScalpel LLC, Bothell, WA. Adapted from Duclos and Vitruk (2018).

a heat source such as the tip of a cautery device (electro-
cautery or a hot glass tip of a diode laser in Figure 4.10c).
The coagulation depth value H = xc−xa (for 60–100 °C
range inside the heat affected zone in Figure 4.3) relative
to blood vessel diameter B is an important measure of
coagulation and hemostasis efficiency (Vitruk 2014a,b).
It is presented in Figure 4.11 for short laser pulses
(t ≪ TR) and for longer laser pulses closer to thermal
relaxation time (t = TR; the thermal diffusion spreads
heat over an additional distance A, which accordingly
increases the coagulation depth).
For H ≪ B (erbium laser wavelengths, Figure 4.11),
optical absorption and coagulation depths are signifi-
cantly smaller than blood vessel diameters. Coagulation
thus takes place on a relatively small spatial scale and
cannot prevent bleeding from blood vessels severed dur-
ing tissue ablation. Coagulation depth can be increased
by increasing pulse width and rate.
 40 The Ideal Laser Scalpel

For H ≪ B (diode laser wavelengths, Figure 4.11), opti- time, t ≤ TR) with minimum collateral damage to sur-
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cal absorption and coagulation depths are significantly rounding tissue (pulse repetition rate f ≪ 1/TR).
greater than blood vessel diameters. Coagulation thus Soft tissue absorption in the 800–11 000 nm spectrum
takes place over extended volumes far from the ablation varies greatly: it is approximately 1000 times stronger for
site. Extended thermal damage zones for near‐IR irradi- CO2 lasers relative to diodes, and it is approximately 10
ated soft tissue are documented in Willems et al. 2001; times stronger for erbium lasers relative to CO2 lasers
the documented 810 nm soft tissue absorption coeffi- (i.e. approximately 10 000 times stronger for erbium
cient (0.7 cm−1) makes its observations highly relevant to lasers relative to diodes).
the present analysis with absorption coefficient of Because near‐IR photons are weakly absorbed (1000–
approximately 0.4 cm−1 at 810 nm (Figure 4.1). 10 000 times weaker than CO2 and erbium), diode lasers
For H > B (CO2 laser wavelengths, Figure 4.11), coagu- are not often used to cut soft tissue with photons. Instead,
lation extends just deep enough into a severed blood ves- diode lasers cut soft tissue thermomechanically with hot
sel to stop the bleeding, more efficient then for the above charred glass tips (Figure 4.10c). These wavelengths are
two cases H ≪ B, and H ≫ B. Coagulation depth can be very useful in minimally invasive applications such as
increased by increasing pulse width and rate in non‐ those using endoscopes, but are not efficient scalpels.
SuperPulse settings. Mid‐IR erbium laser wavelengths make these lasers
highly energy efficient and spatially accurate photother-
mal ablation tools with poor coagulation efficiency.
­Summary Coagulation depth can be increased by increasing pulse
width and rate.
Absorption spectra of soft tissue (Figure 4.1) are sum- IR CO2 laser wavelengths are highly efficient and spa-
marized in Figure 4.12 with ablation thresholds and tially accurate photothermal ablation tools with good
coagulation depths of soft tissue lasers for conditions coagulation efficiency due to a close match between
most suited for high efficiency photothermal ablation coagulation depth and soft tissue blood capillary diameters.
(where pulse duration is shorter than thermal relaxation Coagulation depth can be increased by increasing pulse

2780 and 2940 nm

J/cm2
10 000 Erbium lasers 0.007 0.22 0.0033
ms

mm
Soft tissue’ main chromophoroes’ absorption coefficient (cm–1)

α ≈ 3300 and 9900 cm–1

TRT ≈ 60 and 6.7 μs
10 times

Photo-thermal coagulation Eth ≈ 0.6 and 0.2 J/cm2

by CO2 lasers is 5–15 times H ≈ 10 and 3.3 μm
deeper than by Er lasers 0.7 2.2 0.033
1000

Photo-thermal ablation
1000 times

Ablation threshold fluence (Eth)

Thermal relaxation time (TRT)

by CO2 lasers is 1000

times more energy efficient
Coagulation depth (H)

100 than by diode lasers 70 22 0.33

10 600 nm
CO2 lasers
2100 nm α ≈ 660 cm–1
Holmium lasers TRT ≈ 1.5 ms
in 100% water
10 Eth ≈ 3 J/cm2 220 3.3
α ≈ 28 cm–1
1/α ≈ 0.36 mm H ≈ 50 μm

800-1100 nm
diode lasers
1 Blood vessel
α ≈ 0.5 cm–1
TRT > 1 s diameters B = 20–40 μm
Eth > 103 –104 J/cm2 Absorption by H2O
H > 10 mm @ 75% concentration in soft tissue

0.1 Absorption by HbO2

@ 150 g/l; Blood @ 10% in soft tissue
0

00

00

00

00

10 00
0
50

00

Absorption by Hb
10

15

30

50

90

@ 150 g/l; Blood @ 10% in soft tissue

Wavelength (nm)

Figure 4.12 Spectra of (a) absorption coefficient (cm−1), (b) thermal relaxation time (TRT) (ms), (c) short pulse ablation threshold fluence
Eth (J/cm2) and (d) short pulse photothermal coagulation depth, H (mm), at histologically relevant concentrations of water, hemoglobin
(Hb), oxyhemoglobin (HbO2) in subepithelial oral soft tissue. Logarithmic scales are in use. Source: Graph courtesy of LightScalpel LLC,
Bothell, WA. Adapted from Duclos and Vitruk (2018) and Vitruk (2016).

width and rate (non‐SuperPulse settings). The CO2 laser
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therefore fits the two requirements of an ideal soft tissue
surgical laser scalpel, namely efficient vaporization of tissue
and efficient cauterization of surgical margins, and is well
suited to a great majority of soft tissue surgical laser
­procedures. Tissue vaporization is achieved through
­photovaporolysis of histological water. Tissue cauterization
­References
Alberts B, Johnson A, Lewis J, et al. (2007). Molecular
Biology of the Cell. 5th ed. New York, NY: Garland
Science (Table 23‐1).
Barton JK, Rollins A, Yazdanfar S, et al. (2001).
Photothermal coagulation of blood vessels: a
comparison of high‐speed optical coherence
tomography and numerical modelling. Phys. Med. Biol.
46(6). pp. 1665–1678.
Cheong WF, Prahl SA, Welch AJ. (1990). A review of the
optical properties of biological tissues. IEEE J. Quantum
Electron. 26(12). pp. 2166–2185.
Duclos D, Vitruk P. (2018). Using soft tissue surgical lasers.
Vet. Pract. News. 30(7). pp. 1, 38–39 (Figures 1‐2).
Einstein A. (1905). Über die von der molekularkinetischen
Theorie der Wärme geforderte Bewegung von in
ruhenden Flüssigkeiten suspendierten Teilchen. Annalen
der Physik. 322(8). pp. 549–560.
Esen E, Haytac MC, Oz IA, et al. (2004). Gingival melanin
pigmentation and its treatment with the CO2 laser. Oral
Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 98(5).
pp. 522–527.
Fisher JC. (1987). Basic laser physics and interaction of
laser light with soft tissue. In: Shapshay SM, ed.
Endoscopic Laser Surgery Handbook. New York, NY:
Marcel Dekker. pp. 96–125.
Fisher JC. (1993). Qualitative and quantitative tissue effects
of light from important surgical lasers. In: Wright CV,
Fisher JC, eds. Laser Surgery in Gynecology: A Clinical
Guide. Philadelphia, PA: Saunders. pp. 58–81.
Hale GM, Querry MR. (1973). Optical constants of water
in the 200 nm to 200 μm wavelength region. Appl. Opt.
12(3). pp. 555–563.
Jacques SL. (1996). Origins of tissue optical properties in the
UVA, visible, and NIR regions. In: Alfano RR, Fujimoto JG,
eds. OSA TOPS on Advances in Optical Imaging Photon
Migration, Vol. 2. Optical Society of America. pp. 364–369.
Jacques SL. (2013). Optical properties of biological tissues:
a review. Phys. Med. Biol. 58(11). pp. R37–R61.
Mordon S, Rochon P, Dhelin G, et al. (2005). Dynamics of
temperature dependent modifications of blood in the
near‐infrared. Lasers Surg. Med. 37(4). pp. 301–307.
Pang P, Andreana S, Aoki A, et al. (2010). Laser energy
in oral soft tissue applications. J. Laser Dent. 18(3).
pp. 123–131.
­Reference 41
is achieved through photopyrolysis of soft tissue in the
t­ emperature range 60–100 °C. Most significant for high
­fluence SuperPulse CO2 lasers, a coagulation depth of
approximately 50 μm is sufficient for cauterization of
sub‐50 μm diameters of blood vessel capillaries. The depth
of coagulation can be extended upward of 500 μm for low
fluence, long pulse, and continuous wave CO2 lasers.
Pfefer TJ, Choi B, Vargas G, et al. (1999). Mechanisms
of laser‐induced thermal coagulation of whole blood
in vitro. Part of the SPIE Conference on Cutaneous
Applications of Lasers: Dermatology, Plastic Surgery,
and Tissue Welding. Proc SPIE. pp. 20–31.
Prestin S, Rothschild SI, Betz CS, et al. (2012).
Measurement of epithelial thickness within the oral
cavity using optical coherence tomography. Head Neck.
34(12). pp. 1777–1781.
Squier CA, Finkelstein MW. (2008). Oral mucosa. In:
Nanci A, ed. Ten Cate’s Oral Histology: Development,
Structure, and Function. 7th ed. St. Louis, MO: Mosby
Elsevier. pp. 319–357.
Squier CA, Brogden KA, eds. (2011). Human Oral Mucosa:
Development, Structure, and Function. Chichester, West
Sussex, UK: Wiley‐Blackwell. pp. 14–16.
Svaasand LO. (2003). Lasers for biomedical applications.
In: Driggers RG, ed. Encyclopedia of Optical Engineering.
New York, NY: Marcel Dekker. pp. 1035–1041.
Vitruk P. (2014a). Oral soft tissue laser ablative and
coagulative efficiencies spectra. Implant Pract. US. 7(6).
pp. 19–27.
Vitruk P. (2014b). How CO2 lasers cut, coagulate soft
tissue. Vet. Pract. News. 26(12). pp. 36–37 (Figures 1‐3).
Vitruk P. (2016). Why soft‐tissue CO2 laser performs well.
Vet. Pract. News. 28(12). p. 36 (Figure 1).
Vogel A, Venugopalan V. (2003). Mechanisms of pulsed
laser ablation of biological tissues. Chem. Rev. 103(2).
pp. 577–644.
Weast RC, ed. (1980–81). CRC Handbook of Chemistry and
Physics. 61st ed. Boca Raton, FL: CRC Press. p. D‐174.
Wieliczka DM, Weng S, Querry MR. (1989). Wedge
shaped cell for highly absorbent liquids: infrared
optical constants of water. Appl. Opt. 28(9). pp.
1714–1719.
Willems PWA, Vandertop WP, Verdaasdonk RM, et al.
(2001). Contact laser‐assisted neuroendoscopy can be
performed safely by using pretreated ‘black’ fibre tips:
experimental data. Lasers Surg. Med. 28(4). pp.
324–329.
Yoshida S, Noguchi K, Imura K, et al. (2011). A
morphological study of the blood vessels associated with
periodontal probing depth in human gingival tissue.
Okajimas Folia Anat Jpn. 88(3). pp. 103–109.
 42
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Combining Laser Surgery with Laser Therapy (Photobiomodulation)
David S. Bradley
­Introduction
This book is dedicated mainly to surgical aspects of laser
use, particularly photothermal laser‐tissue interactions in
invasive methods to excise, incise, ablate, or otherwise
remove or disrupt tissue. Lasers can also have a noninva-
sive, nonablative, photobiomodulation effect on tissue. This
is a result of a photochemical effect between tissue and cer-
tain wavelengths of light. Laser therapy induces an optimal
healing environment that relieves pain and inflammation,
but more importantly, it directly enhances tissue repair,
regeneration, and remodeling of both soft and hard tissue.
The following pages will discuss these mechanisms briefly
and then illustrate how they can be applied to improve the
outcomes of laser and nonlaser surgical procedures.
­ he Science and Physiology
T ents. This enhanced blood flow and oxygenation to the
of Laser Therapy
Laser therapy enables injured or stressed cells to ­function
at their optimal capacity. It restores the normal biologi-
cal function (Tunér and Hode 2002). Laser photobio-
modulation therapy has a direct photochemical reaction
within the body that stimulates a cascade of secondary
effects and “downstream” physiologic reactions (Hawkins
and Abrahamse 2007).
As opposed to the CO2 laser that is in the far‐infrared
range, the primary responses for photobiomodulation
result from using photons within the visible red and
near‐infrared ranges. They have a direct photochemical
effect that enhances blood flow, improves tissue oxygen-
ation, and results in an improved efficiency of the
r­espiratory chain within the mitochondria of the cell due
to changes in membrane permeability, resulting in
improved signaling between mitochondria, nucleus and
cytosol, nitric oxide formation, and increased oxidative
metabolism to produce more ATP (Karu 1989). Other
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
direct effects include the production of reactive oxygen
species as well as superoxide dismutase. It also causes a
beneficial shift in the redox state.
The “downstream” effect of secondary and tertiary
reactions leads to the amplification of the primary pho-
tochemical reactions. Calcium is released from the mito-
chondria to improve and maintain adequate levels to
improve cell metabolism and the regulation of signaling
pathways responsible for significant events required for
wound and tissue repair. Studies document enhanced cell
migration, RNA and DNA synthesis, cell mitosis, protein
secretion, and cell proliferation (Tunér and Hode 2002).
Because this photochemical reaction works at such a
basic metabolic level within the mitochondria, every cell in
the body can respond favorably. Muscle or nerve cells and
tissue that has been damaged can repair faster and better.
Blood vessels and lymphatics will respond favorably,
enhancing tissue perfusion and providing oxygen and nutri-
treated area will help tissue healing (Larkin et al. 2012). The
improved blood flow affected by laser therapy will extend
well beyond the period of direct exposure. This is due to the
warming effect and thermal gradient produced by some
higher‐powered lasers. But more importantly, it is also due
to the vasodilation elicited by the release of serotonin, hista-
mine, and nitric oxide as well as the increased angiogenesis
promoted by basic fibroblast growth factor and vascular
endothelial growth factor (Kubota 2002). This is an impor-
tant consideration when calculating dosage in the immedi-
ate postop period. We want to achieve the anti‐inflammatory,
biostimulatory, and healing effects without creating too
much vasodilation and blood flow. A lower dosage and
power would be used in these situations.
White blood cells will function efficiently to fight
infection and clean up debris. The cascade of metabolic
effects continues, which stimulates various physiological
changes at the cellular level such as activation of fibro-
blasts, macrophages, and lymphocytes; growth factor
release; neurotransmitter release; collagen synthesis; and
 ­Optimal Parameters for Laser Therap 43

improvement of cell membrane permeability and func- (a)

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tion of the Na+/K+ pump. Laser therapy also has a posi-

tive effect on prostaglandin production. This will mediate
neutrophil activation, lymphocyte accumulation, and
other inflammatory effects. Increased ATP will improve
metabolic activity to increase oxygen and nutrient avail-
ability, which can enhance protein and enzyme produc-
tion. It will stimulate and accelerate cell reproduction
and growth, which leads to faster repair of damaged tis-
sues and moderation of the inflammatory response
(Wray et al. 1988; Karu 1989, 1999; Peavy 2002; Martin
2003; Vladimirof et al. 2004; Karu and Kolyakov 2005;
Hamblin and Demidova 2006). This improved rate and
level of healing and reduction in inflammation will also
reduce pain. But in addition, there is a direct stimulation (b)
of other cellular events that provides analgesia.
Additional benefits of laser therapy for postoperative use
include an enhanced production of collagen and epithelial
cells and an improved alignment and organization of col-
lagen fibers that enhances tensile strength of tendons.
Photobiomodulation also stimulates a more normal distri-
bution of Type I and Type III collagen during the healing
process (Kubota 2002; Wood et al. 2010; Paraguassu et al.
2014). This will have positive effects that relate to musculo-
skeletal injury by improving the healing process and reduc-
ing intramuscular fibrosis (Herickson de Brito Vieira et al.
2014; Paolillo et al. 2014; Ribeiro et al. 2015).
Again, all this leads to normalization of cell function. It
enables the cell to do the job it is supposed to do and do
its job better. Laser therapy does not make normal cells (c)
“super” cells. It does not stimulate an amplification of all
metabolic processes, nor does it suppress them. It ena-
bles the cell to do its job, which sometimes means doing
nothing. In vitro studies demonstrate that part of a cell’s
normal function is to recognize normal cell‐to‐cell con-
tact inhibition once cell cultures approach confluence.
This is analogous, in vivo, to a healthy organism, which
will regenerate healthy tissue, but stop further growth
when healing is complete. This is a critical and unique
feature to laser therapy. It accelerates normal healing and
tissue regeneration without producing overgrowth or
neoplastic transformation. Therefore, it improves the
rate and health of the incision healing process with less
scarring and better tensile strength (Figure 5.1).
Figure 5.1 (a–c) This case illustrates severe plasma cell pododermatitis
(a) treated via CO2 laser excision (b) followed with laser therapy to
­Optimal Parameters for Laser Therapy enhance healing and moderate the immune response. Figure (c) is 14‐
days postoperative. Source: Courtesy of Dr. Boaz Man.
Let us briefly review the parameters of laser therapy that
are important for optimal clinical response. The param-
Wavelength
eters of most concern include wavelength, power, deliv-
ery mode, and time. The two most important parameters Wavelength is what determines the best function for a
that dictate how any laser is going to interact with living particular laser as well as dictating penetration efficiency
tissue are power and wavelength. (Figure 5.2). As mentioned, laser therapy works due to a
 44 Combining Laser Surgery with Laser Therapy (Photobiomodulation)

Therapeutic window vs surgical region

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Mid-IR water absorption

(NOTE: Broken Axes)
Goal:
Maximal penetration 1500 cm–1

with biological absorption

From an external source Water continued
into Mid-IR

Cellular targets in the near infrared (NIR) 1000 cm–1

440 nm 800 nm 995 nm 970 nm

Visible beam Water

Cytochrome c oxidase
Hemoglobin (H2O)
500 cm–1
(HbO2)
Infrared
(invisible beam)
Melanim

Absorbption (A.U.)
0.36 cm–1

0.12 cm–1

300 400 500 600 700 800 900 1000 10 000 10 600 11 000
Wavelength (nm)
Visible (400–700 nm)
CO2
UV (200–400 nm)

Figure 5.2 Absorption spectrum chart for the major chromophores involved in photobiomodulation. Source: Courtesy of David Bradley
and K‐Laser.

wavelength‐specific form of photobiomodulation. Most
therapy lasers now combine more than one wavelength
due to a better understanding of the direct photochemi-
cal effects that are produced when a photon of light is
absorbed by specific chromophores within the body
(Longo et al. 1987; Moriyama et al. 2009; Emanet et al.
2010; Assis et al. 2012; Joensen et al. 2012).
Available wavelengths are selected based on the target
chromophores most important to the basic metabolic
process of ATP production: water, Fe (hemoglobin), Cu
(cytochrome‐c oxidase), and melanin and other superfi-
cial mediators (Figure 5.3). The shorter wavelengths
(630–660 nm) are absorbed more superficially and lack
the ability to penetrate as deeply as the longer wave-
lengths. These are very beneficial in wound healing (Al‐
Watban et al. 2007). Wavelengths within the 970–980 nm
range have a moderately increased absorption by water.
This can produce a mild warming effect in local tissues,
especially if higher powered therapy lasers are used, thus
creating a thermal gradient along which blood tends to
flow. The 904–905 nm wavelength is closest to the peak
of the hemoglobin absorption curve. This wavelength
can enhance oxygen release into the tissue by as much as
30–50% over that which the 970–980 nm wavelengths
are capable. Wavelengths in the 750–830 nm range are at
the peak of absorption for the cytochrome‐c oxidase
enzyme. This enzyme is found in the mitochondria of
nearly every tissue of almost every living eukaryote and
is the rate‐limiting step in the conversion of oxygen to
ATP within the electron transport cycle. When
cytochrome‐c oxidase has absorbed energy from a pho-
ton of light at these wavelengths, it can accelerate the
step to improve ATP production, along with production
of nitric oxide.
This basic photochemical reaction improves blood
flow, improves release of oxygen into the tissue, and
improves the conversion rate of oxygen to ATP.
Simultaneously delivering multiple wavelengths can give
a synergistic effect and a wider range of treatment
options that should result in better clinical outcomes.
Power
The next most important parameter to discuss is power.
Specifically, we need to understand irradiance and flu-
ence and how these principles relate to dosage. There is

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Chromophore Biological target
970 nm Water Blood
915 nm Iron Hemoglobin
810 nm Copper Cytochrome c oxidase
660 nm Melanin Skin
Figure 5.3 Targeted photobiomodulation.
nothing inherently good or bad or better or worse about
a high‐powered vs. a low‐powered laser. It depends on
what you want to treat with laser therapy that will deter-
mine the best therapeutic laser for your facility. Let us
start with a few basics here:
“Power” is the rate of delivery of energy and is measured
in watts which is 1 J/s.
“Energy” is the total number of joules delivered and is
simply calculated by multiplying your power by time
in seconds. Power (W) × time (s) = dosage (J).
“Irradiance” is the amount of power (W) delivered to a
specific area.
“Fluence” is the total amount of energy (J) delivered to a
specific area. In laser therapy, this would be your dos-
age to a given area.
Dosage is calculated in the same manner for all lasers.
It does not matter if it is a Class III or a Class IV Laser or
if it is being delivered in continuous wave (CW), repeat
pulse (RP), or SuperPulse (SP). Put simply, dose is meas-
ured in joules, and one watt delivers one joule per sec-
ond. It is the average power capable of being delivered
by a specific laser therapy device that is critical to proper
dosage administration. The photons of laser light (or
any light) are constantly being scattered, reflected, and
absorbed within tissue. As laser light travels through tis-
sue, the number of photons reaching a specific depth
will decrease at a calculated rate. This attenuation or
“decay” of the incident laser beam has to be considered
when calculating the number of photons needed to elicit
a direct photochemical effect on tissue, especially if the
desired target tissue is not on the surface. This decay
and therefore the actual dosage delivered at any particu-
lar depth from the incident beam is calculated by equa-
tions such as the Boltzmann transport equation,
diffusion equation, the scattering coefficient, and oth-
ers. A full explanation of these interactions is beyond
the scope of this chapter but can be found in the litera-
ture (Anderson and Parrish 1981).
­Optimal Parameters for Laser Therap 45
Biological effect
Stimulates microcirculation
Increases cell oxygenation
Enhances ATP production
Promotes wound healing
Power is a critical component when determining effi-
ciency, efficacy, and safety. It is imperative to success to
have the proper number of photons delivered at a proper
rate to saturate the desired volume of tissue. Even though
we often talk in terms of power and energy, what we are
really interested in is irradiance and fluence of the tissue.
Power is what dictates the rate of delivery to the tissue. If
delivered too rapidly, especially to a very small area (high
irradiance), then superficial tissue heating could occur. If
delivered slowly or over a broader area, then all the posi-
tive effects will be experienced in a large volume of direct
tissue stimulation in a reasonable amount of time. The
total energy (fluence) delivered to a tissue or body part
will be a direct result of the irradiance (power delivered
per unit area) at that depth, times the time of exposure.
Dosages listed and recommended in the literature
range from 1 to 2 J/cm2 for superficial wounds and acute
superficial musculoskeletal conditions, to 10 J/cm2 or
higher depending on the size and depth of the lesion, its
severity, and its chronicity (Tunér and Hode 2002; Al‐
Watban et al. 2007; Hawkins and Abrahamse 2007;
Peplow et al. 2010).
The classification of lasers is dictated by ANSI
Standards and is based on the maximum average
power output of any and all laser devices (ANSI 2014).
Maximum laser output is calculated by the total average
power (J/s), not a single burst or peak power. Therefore,
if you want to administer laser therapy to small patients
and superficial wounds as well as to larger patients and
deep musculoskeletal or neurologic conditions, then
selecting a laser that has a broad range of power adjust-
ability from high to low will give the best results on the
widest range of conditions.
Delivery Methods and Time
Varying how laser light is delivered to the tissue also has
clinical significance. Laser light can be delivered in CW,
RP, or SP. The literature continues to show that by adding
 46 Combining Laser Surgery with Laser Therapy (Photobiomodulation)
pulse frequencies to treatment protocols along with con-
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tinuous wave delivery, we may have an enhanced effect
on overall long‐term results across a broader range of
applications and patient conditions. By modifying the
pulse rate with which the laser is being delivered, we can
have differing physiologic effects on cell–tissue struc-
tures (Cheida et al. 2002). It has also been shown that dif-
ferent tissue cultures and cell types respond differently
to differing pulse rates (Karu 1997).
SuperPulse is another laser delivery mode for some
lasers, including some surgical, therapeutic, and indus-
trial lasers. Using SuperPulse in therapeutic lasers can
mitigate thermal and absorption effects of pigmented
tissue. It may therefore (in theory) improve penetration,
and with proper parameters increase the number of pho-
tons that reach the target tissue (Joensen et al. 2012;
Anders and Wu 2015).
It is very important to keep in mind the average power
and the total joules per minute being delivered by a laser
for effective results. Do not be misled by statements of
peak power, especially if the average power is very low,
thusly producing inadequate dosage and power for effec-
tive photobiomodulation in larger areas or deeper
tissue.
Therapy lasers transmit their energy through some
type of handpiece. Many handpieces available today can
be used in a contact or noncontact technique (Enwemeka
2009; Peplow et al. 2010). Contact delivery is especially
important for most musculoskeletal conditions in our
veterinary patients because most of our patients are cov-
ered in fur. In human treatments, clothing is always
removed. Realize that there is no evidence that any type
of handpiece is superior to any other type in proper laser
energy administration. In some acute musculoskeletal
conditions, and particularly in postoperative treatments
where any hair coat has been shaved, a noncontact deliv-
ery may be used. In all treatments, the handpiece should
be held perpendicular to the surface area, and the line‐
of‐drive should be monitored so the energy is better dis-
tributed over the target tissue. Your line of drive or
directional position of the handpiece should correlate
with the anatomy and the direction of the target tissue
distal to the handpiece.
Understanding the physics of laser–tissue interac-
tions is just as important as the physiology and bio-
chemistry. Although laser therapy may seem a very
complicated proposition, the physiology and dosages
are becoming better understood and documented
every day. Studies continue to improve our knowledge
of the mechanisms and optimal parameters behind
successful laser therapy. There are many patient varia-
bles that affect dose: coat length and color, skin color,
hydration, vascularity, chronicity, severity, and even
individual patient response. As we understand laser–
tissue interactions and as more accurate measurements
and calculations are established, we can better ­quantify
minimum desired dosages. This has led to advance-
ments in laser technology and improved understanding
of the science and physics that allows the incorpora-
tion of preset protocols to deliver proper dosages safely
and accurately as well as simplify treatments for veteri-
nary personnel. Because of the wide margin of safety
and ease of use, it can and should be delegated to the
veterinary staff for the most efficient and economic
benefits. Two principles should be kept in mind,
­however. The first is that the only thing we can say for
sure at this time is that if you administer too little a
dosage, you will produce little to no response. And the
second is that there is a very wide margin of safety for
laser therapy.
Initial comprehensive education and training is essen-
tial, but ongoing review and support are just as critical to
realize the full benefits of laser therapy.
This review of the basic tenets of laser therapy that
moderate the inflammatory response, reduce pain,
and enhance the healing process illuminate why it is
an ideal adjunct for any nearly postoperative situa-
tion. Laser therapy works well in conjunction with
other modalities and medications. It can reduce the
incidence of incision complications and enhance the
overall speed and quality of tissue healing (Dungel
et al. 2014; Figurova et al. 2016). It will also have posi-
tive effects on deeper tissue manipulated during sur-
gery, whether this tissue is exposed with a CO2 laser
or other methods. It will enhance osteogenesis in
postorthopedic surgeries (Barbos et al. 2003; Kasem
et al. 2004; Pinheiro et al. 2006; Fujimoto et al. 2010;
Poosti et al. 2012; Chang et al. 2014). It will also
enhance the ­healing in soft tissue structures including
muscle ­tissue and muscle repair (Assis et al. 2012;
Ribeiro et al. 2015).
In addition to the beneficial healing properties, laser
therapy can further enhance the reduced postoperative
pain that is associated with surgery. Laser therapy has
been shown to be extremely effective in providing
analgesia, both short term and long term. This
enhanced patient comfort will reduce the level and
duration of analgesics needed. The combined benefits
of laser surgery and laser therapy serve to further
reduce inherent healing risks and will shorten the time
to recovery. Consequently, the veterinarian is less likely
to encounter the secondary problems related to post-
operative inactivity such as muscle atrophy, weakness,
and loss of conditioning, as well as the more severe
consequences of prolonged recumbency, pressure
sores, and urine scalding. Thus, laser therapy is a tre-
mendous adjunct to the rehab process that will allow
patients to return to their normal activity and become
an active member of the family more quickly
(Simunovik et al. 2000).
 ­Specific Recommendation 47

­General Guidelines Laser Therapy Is Extremely Safe

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Although the following contraindications are still listed

These guidelines will help you understand proper laser
protocols. They will also help you individualize treat-
ments for patients not responding to the preset pro-
grams, or for those conditions that do not fall under the
typical preset protocols on many laser settings.
Some Injuries May Respond to a Graduated
Treatment from Lower to Higher Frequencies
For example, start with CW, then go to 20 Hz, followed by
500 Hz, followed by 2500–5000 Hz. The protocols pro-
grammed into some lasers will do this for you automatically.
Laser Therapy Has a Wide Margin of Safety
For acute or sensitive conditions, always err on the con-
servative side when calculating. You can start conserva-
tively and get more aggressive if a response is not
observed within three to four treatments.
in the literature, some of these may be removed or modi-
fied as we gain a better understanding of all the physio-
logic mechanisms behind laser therapy:
Direct exposure to the eye.
Direct exposure to any cancer/malignancy. (If a tumor has
been removed with adequate margins, laser therapy may
be cautiously used post‐operatively to improve healing.)
Direct exposure to a gravid uterus.
Direct exposure to a joint within seven days of an intra‐
articular or epidural injection of a steroid or non‐ste-
roidal medication.
Direct exposure to an area of active bleeding (due to the
therapy laser’s vasodilatory effects).
Direct exposure to photosensitive patients, especially those
undergoing or recovering from photodynamic therapy.
­Treatment Techniques

Thermal Effects Vary with Hair Coat Current Dosage Recommendations

and Pigmentation: Darker Absorbs More for Postoperative Incisions and Joints
Superficial Wounds/Incisions.
If you get a withdrawal response, add SuperPulse to the
CW phase, increase the spot‐size on the handpiece, Clean 2–4 J/cm2
increase the distance of the handpiece from the tissue, Contaminated 4–10 J/cm2 or higher
move the handpiece more rapidly, or reduce power.
Deep Wounds/Infected Wounds/Orthopedics.
Noncontact Applications Superficial tendons/ligaments 4–8 J/cm2
Deep joints/fractures 6–10 J/cm2
This may be used for all incisions and other immediate
postoperative conditions. It is also used on open wounds
Power Guidelines.
or any area with discharge or exudates, or on very painful
or sensitive areas. Noncontact treatments are almost Area Power (W)
always done in a scanning mode. Scan 1–2 cm from the Skin and mucosa 1–3
surface over both the affected area and 2–5 cm of sur- Carpus/tarsus 3–6
rounding healthy tissue with slow passage (about 3 cm/s). Shoulder 4–7
Stifle 3–6
Thoracic and lumbar spine, hip 6–10
Laser Therapy Effects Are Cumulative Neck 5–10

Response should improve with each treatment until healed.

Optimum Beam Frequency (the preset protocols should
Again, other than with small and routine surgeries that are incorporate these into the program).
often treated just once during recovery, most should
receive a minimum of three to six treatments (akin to Pain/neuralgia 2–20 Hz or CW
10–14 days of antibiotic therapy) in most cases. These Edema/swelling 1 000 Hz
General stimulation 500 Hz
postoperative surgeries should be treated two to three days Inflammation 5 000 Hz
in a row. Then continue every other day or twice weekly for Infection 10 000 Hz
another three to five treatments. If needed, continue twice
weekly or at least once weekly until the surgical site is
healed. As a general laser therapy principle, if positive ­Specific Recommendations
response is not noticed in two to three treatments, then
increase the dose by 25–50% per treatment until a positive We will now discuss some specific conditions and situa-
response is observed. You can also expand your treatment tions and how to incorporate laser therapy into your
area to include more of the potentially involved tissue. standard postoperative routine. This section will discuss
 48 Combining Laser Surgery with Laser Therapy (Photobiomodulation)
soft‐tissue healing that will include routine incisions and
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excisions as well as more advanced and invasive recon-
structive surgeries. It will also discuss hard‐tissue heal-
ing including all orthopedic conditions.
Elective Surgeries and Simple Incisions
and Excisions
Applying laser therapy as part of your routine postsurgi-
cal “pain package” is a common practice in many veteri-
nary facilities. As mentioned above, this has been shown
to reduce the incidence of suture and incisional complica-
tions. For most simple elective surgeries, this is usually
done only once during recovery (Figure 5.4). Adhering to
the principles discussed above and using a “wound” or
“incision” setting on your device, you would deliver 2–4 J/
cm2 of laser energy to each incision and a surrounding
margin of healthy tissue in a noncontact method. For
declaws the same protocol can be applied, delivering a
total of 60 J per paw. The laser energy is applied to the
toes as well as the metacarpal and metatarsal areas.
Soft Tissue Trauma and Reconstructive
Surgery Including Grafts and Skin Flaps
Laser therapy will greatly reduce the severe inflammatory
response often associated with these surgeries. It can
enhance the success of flap viability by the general princi-
ples of enhanced cellular and vascular stimulation.
In these cases, the laser energy would be delivered over
the entire area of injury, graft, or flap (Figure 5.5a). A
“wound” protocol would normally be used. For grafts
and skin flaps, a starting dosage of 2–4 J/cm2 would be
used. For injuries related to trauma (HBCs, falls, dog/cat
fights, etc.), a larger dose may be applied to account for
some of the damage suffered by deeper tissue structures
(Figure 5.5b) (Pinfildi et al. 2005; Mak et al. 2012; Larkin
et al. 2012).
The same principles will apply to any intraabdominal
incisions and repairs (Figure 5.6). Laser therapy can be
used on any structure that can be targeted directly by
exteriorizing or creating an open path for the laser
beam to penetrate. It can be administered by the
­surgeon by wrapping the handpiece in a sterile sleeve.
A more efficient use would be to adjust aperture size
down to allow administration by the surgical techni-
cian. They can remain above the sterile field while
the surgeon provides access to the desired tissue
(Figure 5.6a). The dosage delivered would be similar
to any other surgical incision, including the margin
of healthy tissue (Figure 5.6b). Use a “wound” or
­“incision” setting and apply 2–4 J/cm2.
Although surgical lasers are used almost exclusively
for soft‐tissue procedures, they can be used for orthope-
dic procedures on approach to gain access to hard tissue.
For postoperative orthopedic surgeries, we want to
enhance both soft‐tissue and hard‐tissue recovery. In
cases such as these, the therapy laser is directed, and the
dose is calculated to target the deep tissue structures
(Figure 5.7). The incision and all other superficial struc-
tures in between will also receive an adequate dose of
laser energy to enhance healing, reduce inflammation,
and provide analgesic benefits. The depth of the struc-
ture and the size of the patient will dictate the appropri-
ate dosage. Treat above and below the joint and as
circumferentially as possible.
Figure 5.4 Images of ovariohysterectomy
incisions postoperatively. The incision on
the left did not receive laser therapy post‐
operatively. This incision on the right did
receive laser therapy immediately post‐
operatively. Source: Courtesy of Dr. Susan
Kelleher.
 ­Specific Recommendation 49

(a) (b)
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Figure 5.5 (a) Laser therapy following aural hematoma surgery. Source: Courtesy of Dr. Christopher Joseph Winkler. (b) Soft‐tissue wound
prior to laser therapy (top), one day after (middle), and two days after (bottom) starting laser therapy. Source: Courtesy of Dr. Boaz Man.

(a) (b)

Figure 5.6 (a, b) Intraoperative laser therapy of a bladder incision postcystotomy for stone removal (a), and an abdominal incision
following exploratory surgery (b). Source: Courtesy of Dr. Christopher Joseph Winkler.
 50 Combining Laser Surgery with Laser Therapy (Photobiomodulation)
(a) (b)
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Figure 5.7 Severe comminuted fracture in a sandhill crane shown preoperative (a) and four weeks postoperative (b) with complete
healing. Source: Courtesy of Dr. Santiago Diaz.
­Conclusion
I want to emphasize again that laser therapy is not just a
“nondrug” pain reliever. One of the most exciting aspects of
laser therapy is its ability to directly stimulate tissue repair,
remodeling, and regeneration, even in chronic conditions.
We are seeing improvement and resolution of things that
­References
Al‐Watban FAH, et al. (2007). Low‐level laser therapy
enhances wound healing in diabetic rats: a comparison
of different lasers. Photmed. Laser Surg. 25(2).
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Anders JJ, Wu X. (2015). Comparison of light penetration
of 810 nm and 904 nm wavelength light in anesthetized
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Anderson RR, Parrish JA. (1981). The optics of human
skin. J. Invest. Dermatol. 77(1). pp. 13–19.
ANSI. (2014). American National Standard for Safe Use of
Lasers ANSI Z136.1 – 2014. Washington, DC: American
National Standards Institute.
Assis L, et al. (2012). Low‐level laser therapy (808 nm)
reduces inflammatory response and oxidative stress in
rat tibialis anterior muscle after cryolesion. Lasers Surg.
Med. 44(9). pp. 726–735.
Barbos PA, et al. (2003). Effect of 830‐nm laser light on the
repair of bone defects grafted with inorganic bovine
bone and decalcified cortical osseous membrane. J. Clin.
Laser Med. Surg. 21(6). pp. 383–388.
were traditionally less responsive, as well as helping proce-
dures we encounter everyday heal faster and better. This is
why there is so much excitement about laser therapy. This is
why laser therapy is becoming an integral part of postop-
erative healing and recovery in main stream medicine. And
this is why over 50% of your colleagues now offer laser
therapy as part of their clinical armamentarium.
Chang W‐D, et al. (2014). Therapeutic outcomes of low‐
level laser therapy for closed bone fracture in the human
wrist and hand. Photomed. Laser Surg. 32(4). pp.
212–218.
Cheida AA, et al. (2002). Resonance response of cell tissue
structures to impulse frequency of infrared laser
radiation of low intensity. Vopr Kurortol Fizioter Lech Fiz
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Dungel P, et al. (2014). Low level light therapy by LED of
different wavelength induces angiogenesis and improves
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773–780.
Emanet SK, et al. (2010). Investigation of the effect of GaAs
laser therapy on lateral epicondylitis. Photomed. Laser
Surg. 28(3). pp. 397–403.
Enwemeka CS. (2009). Intricacies of dose in laser
phototherapy for tissue repair and pain relief. Photomed.
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Figurova M, et al. (2016). Histologic assessment of a
combined low‐level laser/light‐emitting diode therapy

(685 nm/470 nm) for sutured skin incisions in a porcine
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model. Photomed. Laser Surg. 34(2). pp. 53–55.
Fujimoto K, et al. (2010). Low‐intensity laser irradiation
stimulates mineralization via increased BMPs in
MC3T3‐E1 cells. Lasers Med. Surg. 42. pp. 519–526.
Hamblin MR, Demidova TN. (2006). Mechanisms of
low level light therapy. Proc. SPIE 6140(612001).
pp. 1–12.
Hawkins D, Abrahamse H. (2007). Phototherapy – a
treatment modality for wound healing and pain relief.
African J. Biomed. Res. (10). pp. 99–109.
Herickson de Brito Vieira W, et al. (2014). Use of low‐level
laser therapy (808 nm) to muscle fatigue resistance: a
randomized double‐blind crossover trial. Photomed.
Laser Surg. 32(12). pp. 678–685.
Joensen J, et al. (2012). Skin penetration and time‐profiles
for continuous 810 nm and superpulsed 904 nm lasers in
a rat model. Photomed. Laser Surg. 30(12). pp. 688–694.
Karu T, Kolyakov SF. (2005). Exact action spectra for
cellular responses relevant to phototherapy. Photomed.
Laser Surg. 23(4). pp. 355–361.
Karu T. (1989). Photobiology of Low Power Laser Therapy.
London: Harwood Academic Publishers.
Karu T. (1997). Nonmonotomic behavior of the dose
dependence of the radiation effect on cells in vitro
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Med. 21(5). pp. 485–492.
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of action of visible to near‐IR radiation on cells.
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Kasem KM, et al. (2004). Enhancement of bone formation
in rat calvarial bone defects using low‐level laser
therapy. Oral Surg. Oral Med. Oral Pathol. Oral Endod.
97. pp. 693–700.
Kubota J. (2002). Effects of diode laser therapy on blood
flow in axial pattern flaps in the rat model. Lasers Med.
Sci. 17(3). pp. 146–153.
Larkin KA, et al. (2012). Limb blood flow after class 4 laser
therapy. J. Athl. Train. 47(2). pp. 178–183.
Longo L, et al. (1987). Effects of diode‐laser silver arsenide‐
aluminum (Ga‐Al‐As) 904 nm on healing of experimental
wounds. Lasers Surg. Med. 7(5). pp. 444–447.
Mak Michael CH, et al. (2012). Immediate effects of
monochromatic infrared energy on microcirculation
in healthy subjects. Photomed. Laser Surg. 30(4).
pp. 193–199.
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reduction and healing. Pract. Pain Manag. (Nov/Dec).
pp. 20–25.
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Moriyama Y, et al. (2009). In vivo effects of low level laser
therapy on inducible nitric oxide synthase. Lasers Surg.
Med. 41(3). pp. 227–231.
Paolillo FR, et al. (2014). Low‐level laser therapy associated
with high intensity resistance training on cardiac
autonomic control of heart rate in wister rats. Lasers
Surg. Med. 46. pp. 796–803.
Paraguassu G, et al. (2014). Effect of laser phototherapy
(660 nm) on type I and III collagen expression during
wound healing in hypothyroid rats: an
immunohistochemical study in a rodent model.
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Peavy GM. (2002). Lasers and laser‐tissue interaction. Vet.
Clin. Small Anim. 32(3). pp. 517–534.
Peplow PV, et al. (2010). Laser photobiomodulation of
wound healing: a review of experimental studies in
mouse and rat animal models. Photomed. Laser Surg.
28(3). pp. 291–325.
Pinfildi CE, et al. (2005). Helium–neon laser in viability
of random skin flaps in rats. Lasers Med. Surg. 37.
pp. 74–77.
Pinheiro Antonio Luis B, et al. (2006). Photoengineering
of bone repair processes. Photomed. Laser Surg. 24(2).
pp. 169–178.
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condylar growth during mandibular advancement in
rabbits. Head Face Med. 8. p. 4.
Ribeiro BG, et al. (2015). The effect of low‐level laser
therapy (LLLT) applied prior to muscle injury. Lasers
Surg. Med. 47. pp. 571–578.
Simunovik Z, et al. (2000). Wound healing of animal and
human body sport and traffic accident injuries using
low‐level laser therapy treatment: a randomized clinical
study of seventy‐four patients with control group. J. Clin.
Laser Med. Surg. 18(2). pp. 67–73.
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 52
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Laser Safety in the Operating Theater
Christopher J. Winkler
­Introduction
Although the benefits of surgical lasers are plentiful and
rewarding, their potential to do harm, both to veterinary
personnel and patient, should never be overlooked.
Well‐rounded training with surgical lasers is not limited
to the particulars of physics and biophysics, procedures,
settings, and technique. It also includes knowledge of the
potential for accident and injury in using these devices,
coupled with the development of a situational awareness
of both surgeon and staff for their patient and operating
environment. It is not the surgical instrument itself that
causes harm, but the person who uses it inappropriately.
As the use of medical and surgical lasers becomes more
prevalent in today’s veterinary facilities, the inclusion of
laser safety discussions becomes essential to any com-
prehensive laser curricula being considered to prepare
veterinary students and practitioners for the equipment
awaiting them.
Laser practitioners should learn to incorporate a
checklist of laser safety measures into their everyday
procedures. Such laser safety measures should include
both those that apply to all surgical procedures, and
special considerations tailored for a particular surgi-
cal procedure requiring additional forethought for
laser safety.
Though this chapter will review here many of the
most important hazards pertinent to the use of lasers
in a veterinary surgical setting, it should not be
intended as a substitute for the more comprehensive
guidelines laid down by the American National
Standards Institute (ANSI) and for mandated federal
and state regulations regarding the use of lasers in the
workplace, specifically in the veterinary practice; the
reader is strongly advised to become familiar with the
latest versions of such.
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
­ overnment Regulations and ANSI
G
Standards
US Federal and State Regulations
Laser safety is overseen at the federal level by the Center
for Devices and Radiological Health (CDRH) within
the US Food and Drug Administration (FDA). The FDA
clears premarket approval of medical devices and
observes and enforces specific laser safety standards to
be provided by manufacturers. State board regulations
and any necessary state licensing for the safe use of
lasers within the veterinary facility should also be
examined and implemented by practice owners, office
managers, laser surgeons, and laser safety officers
(LSOs) (ANSI 2011).
ANSI Standards and the Laser Classification
System
ANSI created and continues to periodically update the
Z136 series of documents as a guide for the safe use of
lasers in the workplace. ANSI Z136.1 describes general
laser safety use, while ANSI Z136.3 details their safe use
in health care. In 2011, Z136.3 was updated to include
guidelines for the veterinary profession. Federal regula-
tions and the ANSI standards classify lasers according
to the potential damage they may do to the eye and the
skin. Some variations within the classes exist to allow
for risk potential differences in operating power,
whether the laser is viewed through an optical collec-
tion device (such as a magnifier), and some specific
operating wavelengths. Manufacturers are required to
apply warning labels to all laser products rated Class 2
and above (ANSI 2011).
 ­Maximum Permissible Exposure and Safeguarding the Nominal Hazard Zon
Class 1
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Class 1 lasers include lasers that cannot cause eye or skin
injury during normal operations, usually because they
are enclosed and therefore never allowed exposure to
eyes or skin. These devices typically operate at less than
1 mW. Examples include CD and DVD players.
Class 2
Class 2 lasers include visible lasers that only remain safe
from being a potential eye hazard by virtue of the aver-
sion response or “blink reflex” (<0.25 s). Exposure times
to the eye that exceed 0.25 s may result in ocular trauma.
Class 2 lasers are typically limited to 1 mW. Examples
include laser pointers.
Class 3
Class 3 lasers include lasers that are dangerous to the eye
under direct and indirect exposure, but generally do not
present a hazard to skin or a fire hazard. Class 3 lasers
typically operate in a range between 5 and 500 mW
(Berger and Eeg 2006), though pulsed Class 3 lasers in
the 400–700 nm range have a limit of 30 mW. Some ther-
apy lasers fall under this category.
Class 4
Class 4 lasers include any lasers that by definition oper-
ate at or above 500 mW of power, and also by definition
include any lasers that through direct or indirect expo-
sure may burn the skin, ignite materials both flammable
and combustible, and cause permanent and catastrophic
eye injury. Safety concerns dictate that Class 4 surgical
lasers be equipped with both a removable safety inter-
lock and a key switch, a guarded trigger switch, and an
emergency shut‐off switch. Examples include surgical
and therapy lasers, military lasers, industrial and scien-
tific lasers, and lasers for entertainment use such as those
seen at rock concerts (ANSI 2011).
­Laser Safety Officer
Veterinary facilities equipped with laser devices for
medical and surgical applications should designate a
staff member as a LSO. This person should be trained
in federal and state regulations and ANSI guidelines
to oversee compliance by the practice and its person-
nel for the safe and appropriate use of the laser
equipment.
The LSOs responsibilities would include (but are not
limited to) seeing to it that laser protocols and proce-
dures for the facility and its handbook are established;
state licenses and regulations for laser use are obtained
and maintained; nominal hazard zones (NHZs, see
below) are established and protocols followed for the
53
passage of personnel and safety guidelines therein; the
operation of the laser is confined to that laser’s NHZ;
safety eyewear and other equipment (such as masks
and a smoke evacuator) are available and used appro-
priately by all involved personnel; appropriate signage
is posted correctly; the laser equipment is properly
maintained; logs of laser use and maintenance are kept
and updated; all personnel are educated and trained in
the basics of laser safety, the familiarity and operation
of each laser unit in the facility, and the procedures to
be followed in a laser‐related emergency. The LSO will
also even be responsible for determining the safety
classification of a laser if that laser’s classification has
not been previously designated by the manufacturer
and affix the appropriate warning labels to the laser
accordingly.
Both online and hands‐on courses exist for certifica-
tion of the LSO position, through organizations such as
the American Institute of Medical Laser Applications
(AIMLA) and the Laser Institute of America (LIA).
Facility personnel to be considered for the position
include the surgeon, the office manager, or a licensed
veterinary technician (LVT). Multiple and deputy LSOs
may also be designated within the same facility as needed
(ANSI 2011).
In this author’s experience, veterinary technicians are
as interested as veterinarians in learning basic laser sci-
ence, how it affects their patients, and aspects of laser
safety. Since having a LSO is so highly recommended in
a practice carrying any type of laser equipment, delega-
tion of the position to an interested and trained LVT
should be strongly considered (Berger and Eeg 2006).
­ aximum Permissible Exposure
M
and Safeguarding the Nominal
Hazard Zone
The maximum permissible exposure (MPE) of laser radi-
ation is that amount of laser radiation to which a person
may be exposed without adverse effects to eye or skin
(ANSI 2011). Specifically, the MPE is 10% of the dose of
laser light that would have a 50% chance of creating dam-
age in a worst‐case scenario (AIMLA 2013). The MPE of
laser radiation is generally applied to all lasers of Class 2
and above.
The determination of a NHZ is made by any space in
which the MPE is exceeded by laser radiation, be it
direct, scattered, or reflected within that space (ANSI
2011). A veterinary operating theater equipped with a
surgical laser may be considered to be an NHZ, though
the exact space is determined by the facility’s LSO
based on manufacturer information. In establishing
 54 Laser Safety in the Operating Theater

NHZ safety procedures, consideration should be given Eye Safety and Eye Wear
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both to personnel within the NHZ and those who might

A review of documented laser accidents between 1964
be exposed to laser radiation when the NHZ is entered
and 1992 revealed that over 70% involved eye injuries,
or exited. Consideration should also be given to any
22% of which were caused by no use or improper use of
reflective surfaces within the NHZ (such as instru-
protective eyewear (Fry 2002). The nature of eye trauma
ments, overhead lights, and the operating table itself ),
caused by laser light is largely dependent on the laser’s
and to safeguarding windows into the operating theater.
wavelength (Figure 6.2), but the ability of a Class 3 or
Doors to the operating room (OR) should be closed
Class 4 medical or surgical laser to cause eye trauma in
while the laser is in operation, and any windows into
nearly any form makes eye safety and protection the
the OR should be rated for the wavelength of the laser
most paramount laser safety concern.
or screened to prevent passage of reflected beams out-
Eye protection should be worn by the patient, the sur-
side. The keys of a Class IV surgical laser should be kept
geon, and all personnel in the operating area. Eyewear
locked in a separate location from the NHZ between
procedures (ANSI 2011).

Signage
Laser NHZs should be labeled with the correct warning
signage (Figure 6.1). Such signs are typically provided by
the surgical laser’s manufacturer. The sign notifies the
reader of the danger of present laser radiation, notifica-
tion of the class of laser(s) in use, the laser(s) maximum
power output and operating wavelength, and the appro-
priate warnings for proper eye protection.
If other tasks not pertaining to laser use also occur in
the designated laser NHZ, then the signage should be
removable and only posted when the laser is in opera-
tion. Alternatively, the LSO may also choose to include a
warning light alongside the sign outside the closed door
Figure 6.1 A laser safety sign posted on the door of a veterinary
of the NHZ, indicating the laser is in use and the warning operating room. It includes information on multiple lasers (of
sign pertinent when the warning light is lit (ANSI 2011; different wavelengths and power output) being used within the
AIMLA 2013; ABLS 2016). same nominal hazard zone.

Figure 6.2 The effects of different

wavelengths of light on the eye. Far‐
ultraviolet, infrared, and far‐infrared
wavelengths cause corneal burns, while
near‐ultraviolet, near‐infrared, and
infrared wavelengths cause
photochemical cataracts. Visible and
near‐infrared wavelengths traversing the
pupil can cause permanent retinal
photochemical and thermal trauma.
Infrared wavelengths also cause flares in
the aqueous humor.

180–315 nm (far-ultraviolet)
315–380 nm (near-ultraviolet)
380–740 nm (visible light)
740–1400 nm (near-infrared)
1400–3000 nm (infrared)
3000–1 × 106 nm (far-infrared)
 ­Maximum Permissible Exposure and Safeguarding the Nominal Hazard Zon
should be appropriate to the specific wavelength of the
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laser in use and be labeled with the associated optical
density (OD) number on the lens or the frame
(Figure 6.3). The OD number describes the ability of
the lens to attenuate radiation of a particular wave-
length. Prescription eye glasses are typically not wrap‐
around and will therefore not adequately protect from
stray reflected rays, particularly from peripheral angles
(ANSI 2011; ABLS 2016).
Though some laser wavelengths are expertly utilized
by veterinary ophthalmologists in corneal and intraocu-
lar procedures to great effect, the majority of lasers at
surgical and therapy wavelengths are not appropriate for
eye treatment, and the beam should never be stared at or
directed into others’ eyes. That being said, concern for
eye safety extends to surgical laser light being shone
directly onto any part of the globe, particularly onto the
cornea and through the pupil. Directing the laser light
through the side of the head, such as into the ear canal
for a polyp removal, or the eyelids for entropion correc-
tion, should not affect the eye itself if proper precautions
to protect the eye are in place. Should the surgeon lack
specific eye protection for the patient, then covering
their face with a moistened towel should provide ade-
quate protection from indirect rays. Eye shields and
moistened gauze may also be utilized for more detailed
work around the eye such as entropion, distichia, or
cherry eye procedures (ANSI 2011).
Magnification devices are recommended as an inval-
uable means of enhancing the surgeon’s performance
by augmenting the visualization of surgical sites and
Figure 6.3 Safety glasses specific for different laser wavelengths.
Both are wrap‐around to protect the eyes from stray reflections
from the sides as well as the front and designed to fit over
prescription eyewear. The pair on the left are OD‐rated for use
with CO2 laser surgery, while the pair on the right are OD‐rated for
diode laser therapy. Due to their specific OD ratings, neither of
these may be used safely for the other’s laser.
55
structures. Such magnification could increase the risks
of stray reflected laser light at near‐infrared, visible, or
ultraviolet wavelengths to the surgeon’s eyes, however,
and attention should be paid to eye safety when utiliz-
ing such magnification aids in conjunction with these
wavelengths.
A receptacle for appropriate safety masks and eyewear
outside the operating theater should also be considered
for those personnel who might need to enter after sur-
gery has commenced. In the fast‐paced environment of
today’s ORs, it is important to remember to have such
eye protection at hand when beginning procedures. It is
the surgeon’s and the LSOs responsibility to see to it that
all appropriate eye wear is being worn before operations
utilizing a laser commence.
Skin Safety
Class IV lasers will by definition cause burns to skin
through direct or indirect exposure. Indirect exposure
can be prevented by using backstops and covering areas
that require protection prior to using the laser. Drape the
patient with moistened towels to protect surrounding
structures and anesthesia equipment, especially oro‐
pharyngeal structures and endotracheal tubes. Packing
the anus with moist gauze will help prevent methane
explosion during perianal and urogenital procedures
(Figure 6.4). Moistened gauze is used as a backstop to
prevent direct tissue damage to structures and drapes
underlying or adjacent to the surgical field.
Proper technique will also help prevent accidental
injury to tissue during incision. The laser’s trigger should
Figure 6.4 CO2 laser removal of a circumanal gland tumor. Note
the use of moistened gauze as a backstop to protect the patient’s
skin and underlying drape material, while the anus is packed with
additional moistened gauze to prevent methane ignition by the
laser. Source: Winkler (2016). Reprinted with permission of
Veterinary Practice News.
 56 Laser Safety in the Operating Theater
be deactivated prior to removing the laser tip from the
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vicinity of the incision, to prevent inadvertent collateral
thermal damage, trauma to unintended targets, and
unsightly cosmetic scars at the incision’s edges. Thorough
practice with the surgical laser on inanimate objects
(such as tongue depressors and tomatoes) will assist the
surgeon in achieving this level of control.
Ultimately, it is the surgeon’s situational awareness
that will help prevent inadvertent exposure to self, per-
sonnel, and patient. This is achieved through an aware-
ness of which direction the laser handpiece is aimed at
any given time, the presence of instruments in the surgi-
cal field which may reflect the beam to cause inadvertent
trauma, placing the laser in STANDBY mode when not
in immediate use to prevent accidental discharge, and
keeping one’s foot off the trigger until ready to activate
the laser. Large bulky footwear such as outerwear boots
should be avoided to prevent them from becoming
lodged against the trigger and causing accidental firing.
The surgeon should warn OR personnel when the laser is
being activated, preparing them for the evacuation of
smoke and for any adverse events.
Smoke and Smoke Evacuators
The sight of copious smoke resulting from the use of a
CO2 surgical laser on a live patient can be impetus to dis-
suade some veterinarians from adapting the use of this
technology. They should lay to rest any concerns that
this smoke is representative of their patient burning, as it
is actually vaporized water (ejected from the surgical site
as steam) containing the combusted residue of the vapor-
ized cell’s constituents. However, this smoke is malodor-
ous, potentially carcinogenic, and has even been shown
to carry live viral particles. Care should be taken to wear
appropriate surgical masks filtering down to 0.1 μm and
to have the smoke collected via smoke evacuator
(Figure 6.5). The smoke evacuator line can be held by an
assistant or placed on a stand over the patient to deal
with smoke, freeing staff for other tasks. A smoke evacu-
ator is often routinely provided by surgical laser compa-
nies at time of sale and should be used appropriately for
all procedures. If a smoke evacuator system does not
turn on automatically as the laser is activated, the sur-
geon should remember to activate the smoke evacuator
system (or have an assistant do so) prior to activation of
the laser itself (ABLS 2016).
Fire Hazards
Surgical laser fire hazards may be thought of as combusti-
ble (oxygen and anesthetic gases or gastrointestinal [GI]
methane) or flammable (materials such as gauze, drapes,
body hair, and liquids). Ignition may occur through direct
Figure 6.5 A surgical mask rated to filter 0.1 μm, helpful in
preventing inhalation of smoke plumes caused by CO2 surgical
laser use, alongside a CO2 smoke evacuator system.
contact, or indirectly from laser light directed off a reflec-
tive surface such as a metal surgical instrument. Such
instruments should never be considered safe from reflect-
ing laser light even if they have been touted as such by
their manufacturers (Godbold 2017).
Endotracheal tubes represent a particular safety con-
cern: a tube filled with one or more concentrated com-
bustible substances placed in one of the patient’s most
delicate and critical areas. A laser striking an endotra-
cheal tube and igniting the gas within could create a
blowtorch‐like effect in the patient’s airway and cause
critical trauma, as well as a severe fire hazard in the oper-
ating theater. Steps to prevent such an occurrence
include draping the tube with moistened gauze or towels
to prevent damage to the tube from direct and indirect
laser exposure, especially in oropharyngeal procedures.
Metal or rubber endotracheal tubes are more durable
than plastic ones and should be considered for additional
protection. Their manufacturers should be consulted
regarding the surgeon’s choice of laser wavelength, as not
all metal or rubber endotracheal tubes may be ideal for
all laser wavelengths (ANSI 2011; ABLS 2016).
Packing the anus with moistened material to prevent
methane ignition has been discussed earlier. The staff
should also use caution and prepare for adverse events
regarding methane ignition when using a laser in enter-
otomy and colotomy procedures, or simply use alterna-
tives to the laser during the enterotomy portion of the
procedure (Fry 2002).
Flammable preps should be avoided when using the
laser. This author’s facility solely uses chlorhexidine for
surgical scrubs, without utilizing preps such as alcohol in
between, and to date has not experienced complications
associated with this practice. Flammable solutions to
 ­Maximum Permissible Exposure and Safeguarding the Nominal Hazard Zon 57

moisten EKG lead contacts should also be avoided; ster-

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ile saline may be used for this purpose instead (Berger

and Eeg 2006).
An endotracheal tube that has ignited while within a
patient’s airway should be immediately removed from
the patient’s airway to the floor, and the oxygen source
shut off. An endotracheal tube fire should be put out
with a CO2 or dry‐chemical extinguisher instead of water
due to the presence of pure oxygen. In either case, the
patient should be immediately assessed for any thermal
trauma and treated accordingly. Drapes, gauze, and tow-
els that have suffered ignition by the laser should be
immediately removed from proximity with the patient
and extinguished or doused with water set aside in the
OR for this purpose (ABLS 2016).
Accidental Trauma
Several procedures bring lasers in close proximity to organs
and vessels where accidental damage could prove severe
and even fatal. Most notable are those conducted in the oral
cavity and airway. An accidental perforation of the trachea
during a laser bronchoscopy could lead to scar formation or
even catastrophic damage to one of the great vessels.
The use of photodynamic therapy to destroy masses
can be very precise and effective. Such necrosis may per-
sist for some time following the procedure, from hours
to days. Care must thus be taken when the mass resides
in a hollow organ, such as one within the respiratory or
GI tract. The continued death of the tumor could lead to
the formation of a fistula, with secondary complications
to surrounding healthy tissue. The patient should be
monitored for signs of this postoperatively, depending
on where the procedure took place within the patient.
The surgeon should take care in protecting organs, ves-
sels, and other important surrounding or underlying tissue
from accidental laser contact, particularly during abdomi-
nal surgeries, such as the spleen on abdominal approach,
or GI tissue during a spay procedure. Keeping the laser
perpendicular to a tented linea alba will help avoid damag-
ing underlying organs on initial approach, while the use of
an instrument such as a groove director (Figure 6.6) will
serve as a backstop while the incision on the linea is com-
pleted. While the CO2 laser is ideal for neurosurgery due
to its minimal capacity for scatter and collateral thermal
trauma, it is also extremely efficient at severing nerves,
and great care must be taken to avoid such trauma acci-
dentally, such as during mass removals on extremities.
Moistened gauze pads are extremely useful as a backstop
for these scenarios. Care should be taken to check and
remoisten them as needed throughout the procedure.
Optical fibers are a novel method of delivering light
into a patient. They are also fragile, and the surgeon
should bear in mind precautions to prevent leaving any
Figure 6.6 Groove director and plunger. The groove director may
be used as a backstop in a variety of laser procedures; its wings
can even be held underneath the gumline against teeth during
gingival resection. Care should be taken with stray reflections of
laser light from its surface. An autoclaved plunger included in a
surgical pack may be used by the surgeon to program a laser
console during a procedure without breaking sterile conditions or
damaging the console.
portion of this foreign object behind. A thorough inspec-
tion of the tip of the fiber should be made before and
after its insertion into the patient. Careful measurement
of the fiber prior to its insertion will help prevent the
possibility of extending the fiber too far through the
instrument of its introduction, which may cause break-
age of the fiber tip (ANSI 2011; ABLS 2016).
Cancer
With the exception of excimer lasers at shorter wave-
lengths than 319 nm, the vast majority of lasers operate
at wavelengths that offer an extremely low risk of the
ionization of atoms which can lead to cancer. Today’s
surgical lasers offer adequate coagulative effects of blood
and lymph vessels to assist in preventing the spread of
malignant cells during the dissection, ablation, or ther-
mal destruction of cancerous tissue. Presurgical cytology
to identify malignant tissue should always be considered
prior to surgery to assist in the planning of the proce-
dure, particularly where surgical margins should be con-
sidered (ABLS 2016).
Electrical Hazards and Equipment
Malfunction
Class IV surgical lasers are often high‐wattage devices.
Care should be taken to protect the unit and personnel
with additional surge protection whenever possible.
The nature of some operations may lead to the spillage of
 58 Laser Safety in the Operating Theater
fluids that could present a hazard to high‐voltage lasers
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through shorts and associated shocks. Measures should
be in place to protect the laser and its electrical source
from such accidental exposure.
To avoid other accidents associated with electrical haz-
ards, laser units should be operated and maintained in
compliance with the manufacturer’s provided instruction
manuals. Cleaning the laser and its lens following each use
as per manufacturer recommendations, and regular
replacement of the hose and filter on the smoke evacuator,
should become part of facility maintenance routines. Test‐
firing the laser for calibration and evaluating adequate
power output should be routinely conducted before pro-
cedures. Test‐firing also establishes whether the laser’s
aiming beam or the laser beam itself may be misaligned,
particularly in those surgical lasers that employ articu-
lated arms. Lasers that fail such tests should be removed
from use to avoid accidental injury to patient and staff
until they may be serviced. Maintenance should be limited
to that which is in manuals provided by the manufacturer
and those tasks which the designated maintenance
employees and the LSO have been trained to perform for
a given laser unit. Maintenance should otherwise only be
performed on the laser unit by the manufacturer.
When several surgical laser manufacturers were asked
what was one of their greatest maintenance problems
encountered with their surgical laser, the most common
reply was the laser’s console becoming damaged by the
operator, through the operator’s adjusting a console set-
ting with the laser handpiece tip while the laser was in
READY mode and with their foot on the trigger. Such a
careless handling of this delicate and expensive piece of
equipment is not covered under warranty, and easily pre-
vented. Switch the laser to STANDBY mode when not in
use, especially when console adjustments are being
made. Use an alternative tool and method to make con-
sole adjustments rather than the laser itself (Figure 6.6)
or have another member of the OR staff do so for you.
Surgeons should keep off the trigger until they intend to
activate the laser (ANSI 2011; ABLS 2016).
Inappropriate and Unskilled Use
As we have studied in previous chapters, there is no one
single surgical laser suitable for all procedures. Choosing
the wrong laser for the procedure may result in unwar-
ranted trauma for the patient. A CO2 laser should never
be considered appropriate for cutting bone and teeth as
an Er:YAG laser would, for example (Godbold 2017).
­References
ABLS. (2016). Safe use of lasers in surgery. In: The
American Board of Laser Surgery Study Guide (2016
Edition), Chapter 5, pp. 3–5, 8–19.
Unskilled use through lack of training can also cause
considerable harm. Using a laser at inadequate power
density or prolonged exposure could cause excess ther-
mal necrosis, which could lead to suture dehiscence and
postoperative complications. A patient’s sensitivity to
light may preclude the use of laser medicine and surgery,
such as applying laser therapy to a patient recovering
from photodynamic therapy. The efforts the surgical
staff invests in laser education, training, and practice will
go far in reaping benefits to patient and facility, foresee-
ing and preventing accidents and injuries while provid-
ing the best possible care to the patient.
­Record‐keeping
Separate training and maintenance logs should be kept
for each individual laser in the practice, noting the date
and time each staff member was trained in laser safety
procedures and protocols, and the date, time, and main-
tenance performed on each laser unit.
Keeping a laser surgical procedure log is also an
excellent practice. Using a standardized method for
recording your laser settings in both your patient
records and your laser log will help you recall settings
for past procedures as you plan future ones, help you
adapt your protocols to different patients, and commu-
nicate your laser technique succinctly with other vet-
erinarians. Important details to include are date,
patient, surgeon, spot size or fiber diameter, power out-
put, exposure, mode, that safety protocols were fol-
lowed, and whether any equipment malfunctions or
difficulties were encountered (Godbold 2017).
­Conclusion
Being aware of laser classifications, surgical laser regu-
lations and standards, the inherent hazards associated
with surgical lasers and how to deal with them, and the
designation of a LSO are all integral to developing and
implementing a veterinary facility’s effective and effi-
cient laser safety program. When undertaken conscien-
tiously and responsibly, the implementation of such a
program need not be particularly difficult or time‐­
consuming, or detract in any way from the benefits and
positive experiences the laser brings to both surgeon
and patient.
AIMLA. (2013). Veterinary Medical Laser Safety Officer
Training course. In: American Institute of Medical Laser
Applications (Ronald J. Riegel, DVM, VMLSO, Presenter).

https://aimla.org/veterinary‐medical‐laser‐safety‐officer
VetBooks.ir
(accessed 16 September 2016).
ANSI. (2011). American National Standard for Safe Use of
Lasers in Health Care Facilities, ANSI Z136.3‐2011.
Washington, DC: American National Standards
Institute. pp. 2–113.
Berger NA, Eeg PH. (2006). Safety considerations. In:
Veterinary Laser Surgery: A Practical Guide, Chapter 6.
Hoboken, NJ: Wiley Blackwell. pp. 79–90.
­Reference 59
Fry T. (2002). Laser safety. Vet. Clin. North Am. Small
Anim. Pract. 32(3). pp. 535–547.
Godbold J. (2017) Introduction to CO2 surgical lasers and
laser safety, and standardized recording system for
hollow waveguide CO2 surgical laser settings. Atlas of
CO2 Laser Surgical Procedures. Stonehaven Park
Veterinary Hospital Laser Surgery Center, Jackson, TN.
Winkler C. (2016). CO2 laser can excise ear, perianal
growths. Vet. Pract. News. 28(1). pp. 50–51, (Figure 9).
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Part II

Laser Surgery in Canines and Felines

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 63
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Elective Laser Surgery Procedures

Paul Sessa and Andrew Brockfield

­ anine and Feline Laser

C provided by the laser allows the surgeon to also
Orchiectomy, Ovariohysterectomy, ­consider a scrotal incision that might have otherwise
been too messy or difficult using a steel scalpel. The
and Ovariectomy scrotal technique has several key benefits: the amount
of tension needed to move the testicle is circumvented,
The canine and feline orchiectomy (neuter) and ovario-
exteriorization of the testicle is much easier, and the
hysterectomy and ovariectomy (spay) are mainstays of
technique will be familiar to most surgeons that per-
domestic animal population control. Utilization of a car-
form feline neuters. Another benefit of the scrotal
bon dioxide (CO2) laser surgery system greatly benefits
technique is that the incision is often undetectable to
both surgeon and patient by improving precision and
the untrained eye, which pet owners appreciate. The
wound healing. Laser incisions are made without direct
decision on whether to perform a scrotal or prescrotal
tissue contact (a 2 mm focal distance is standard for the
technique should be based on surgeon comfort and the
hollow waveguide delivery systems, while a focal dis-
size and anatomy of the individual patient. Skin thick-
tance of 1–3 cm should be maintained for articulated
ness is critically important. Variation in skin thickness
arm systems).
is based on age, breed, and whether the surgeon elects
When correctly incised with the laser the skin is not
to use a pre‐scrotal or scrotal technique. Extremely
expected to bleed, allowing the surgeon to easily visual-
young or small dogs will have very thin scrotal skin and
ize the surgical field. Traction of incision margins is criti-
lower power density will be needed. Postsurgery, care
cal for rapid smooth laser incisions. These techniques
should be taken that the incisions are not on the most
are not significantly different from using a scalpel except
ventral aspect of scrotum where the patient is sitting
for the added hemostasis the laser provides. With a flex-
on the incision. This will lessen the incision trauma.
ible waveguide and adjustable handpiece, power settings
The thinner skin is more mobile and the tension is less,
will vary based on equipment available, surgeon’s prefer-
so healing is usually excellent.
ence, surgeon’s skill level, and on thickness of the patient’s
skin. Higher laser settings (using SuperPulse, if available)
Preoperative
will make char formation much less likely. If formed,
The patient should be prepared in dorsal recumbence
char should be wiped away with moist gauze to minimize
for surgery to the clinician’s standard for a routine
effect on efficiency and healing. Moist gauze should be
sterile neuter, whether prescrotal (Figure 7.1) or
used as a safety feature to prevent accidental contact
­scrotal (Figure 7.2). An intravenous (IV) catheter is
with the surgeon’s hand, surrounding tissues, and drapes,
recommended for this procedure, and standard
as illustrated by the author in some of the provided fig-
presurgical pain control, sedation, induction, and
­
ures (depicted in Figure 7.9).
maintenance of anesthesia may be employed. The sur-
geon and anesthesiologist should select drugs and
Canine Orchiectomy
methods with which they have experience and com-
The neuter in the dog is often taught as a pre‐scrotal fort for this surgery.
incision, with the testicle pushed cranially by the
­surgeon and the two testicles removed from a single Canine Prescrotal Orchiectomy Procedure
midline ­prescrotal incision. The prescrotal technique A closed or open castration can be the surgeon’s choice.
can be used with the laser, but the added hemostasis The laser will allow layer‐by‐layer incisions, making an

Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.

© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
 64 Elective Laser Surgery Procedures
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Figure 7.1 Canine patient prepped for prescrotal laser
orchiectomy.
Figure 7.2 Canine patient prepped for scrotal laser orchiectomy.
open or closed technique an easy adjustment. Use higher
power density and small spot size for open castration,
and lower power density and larger spot size for closed
castration (Table 7.1). The skin should be cut in one con-
tinuous motion just cranial to the scrotum (Figure 7.3
and Video 7.1a). A larger spot size or lower power setting
will allow layer‐by‐layer dissection until just the tunic of
the testicle is exposed (Figure 7.4). Char should be
removed with moistened gauze between such passes.
Constant pressure should then be applied to the testicle
to force the head of the testicle through the incision,
Table 7.1 Canine orchiectomy.
Procedure Canine orchiectomy
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25–0.4
Power (W) 8–15
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100
Figure 7.3 Initial incision for canine prescrotal orchiectomy.
using the laser to gently cut the remaining connective
tissue layers that prevent the testicle from being freed
(Figure 7.5). The exposed testicle will pop completely out
of the incision and is retracted cranially (Figure 7.6).
Fanning the remaining connective tissue will assist in
removing it from the testicular pedicle (Figure 7.7). For a
closed castration, instead of bluntly removing connec-
tive tissue with gauze at this stage, connective tissue can
be easily severed with the laser, making the neuter a dry
procedure with less bruising postoperatively (Figures 7.8
and 7.9, Video 7.1b–e). This incision is made first on one
side of the testicle and then the other. The closed castra-
tion is then double‐ligated and transfixed using absorb-
able suture of the surgeon’s preference (Figures 7.10–7.12).
If the surgeon prefers an open castration, the tunic is
entered by extending the incision into the tunic with the
laser. Absorbable ligatures are used to ligate the testicu-
lar vessels individually. The suture size and method
­chosen will vary depending on the size of the canine and
the surgeon preference. The laser is then used to sever
the testicle (Figure 7.13).
To close the castration (Figure 7.14), a few simple
interrupted absorbable monofilament subcuticular
sutures will suffice with tissue adhesive in the skin
 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 65

(a) (b)
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Figure 7.4 (a, b) The laser offers improved visualization and hemostasis for layer‐by‐layer dissection.

Figure 7.5 The head of the testicle is forced through the initial Figure 7.6 The testicle exposed.
incision.
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Figure 7.7 Remaining connective tissue is fanned out. Figure 7.10 Double clamp for a closed castration.

Figure 7.8 The laser allows the surgeon to easily remove

remaining connective tissue.

Figure 7.11 First transfixion ligature placed.

Figure 7.9 As the surgeon excises connective tissue, he uses

moist gauze as a safety backstop to prevent injury.
 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 67

layer (Figure 7.15). For smaller patients, most can be

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closed using only a few drops of tissue adhesive at the

skin layer. This author never introduces subcuticular
sutures in patients under 20 pounds. (Refer to Video
7.1 for this procedure.)

Figure 7.14 The incision ready for closure. Note lack of

hemorrhage.

Figure 7.12 Double ligation and transfixion in a closed castration. Figure 7.15 Tissue replaced within the incision.

(a) (b)

Figure 7.13 (a, b) The laser is used to separate the testicle distal to the ligatures.
 68 Elective Laser Surgery Procedures

Video 7.1 (a) (This video includes audio commentary). Initial laser, making the neuter a dry procedure with less
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incision for Laser‐assisted Elective Canine Orchiectomy bruising postoperatively. This incision is made first on
(pre‐scrotal technique).
one side of the testicle and then the other (Figure 7.19).
Video 7.1 (b–e) (This video includes audio commentary). By The closed castration is then double‐ligated and
severing testicular connective tissue with a surgery laser, the
surgeon helps reduce postoperative bruising.

Canine Scrotal Orchiectomy Procedure

A closed or open castration can be the surgeon’s choice.
The laser will allow layer‐by‐layer incisions, making an
open or closed technique an easy adjustment. Use
higher power density and small spot size for open cas-
tration, and lower power density and larger spot size for
closed castration. The skin should be cut in one con-
tinuous motion over the scrotal testicle (Figure 7.16). A
larger spot size or lower power setting will allow layer‐
by‐layer dissection until just the tunic of the testicle is
exposed. Char should be removed with moistened
gauze between such passes. Constant pressure should
then be applied to the testicle to force the head of the
testicle through the incision, using the laser to gently
cut remaining ­connective tissue layers that prevent the
testicle from being freed (Figure 7.17). The exposed tes-
ticle will pop completely out of the incision and is
retracted cranially (Figure 7.18). Fanning remaining
connective tissue will assist in removing it from the tes-
ticular pedicle. For a closed castration, instead of
bluntly removing connective tissue with gauze at this Figure 7.17 The head of the testicle is forced through the initial
stage, connective tissue can be easily severed with the incision.

Figure 7.16 Initial incision for canine scrotal orchiectomy. Figure 7.18 The testicle exposed.
 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 69

transfixed using absorbable suture of the surgeon’s the size of the canine and the surgeon preference. The
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preference (Figure 7.20). If the surgeon prefers an open
castration, the tunic is entered by extending the inci-
sion into the tunic with the laser. Absorbable ligatures
are used to ligate the testicular vessels individually. The
suture size and method chosen will vary depending on
laser is then used to sever the testicle (Figure 7.21).
Most scrotal approaches can be closed using only a few
drops of tissue adhesive at the skin layer (Figures 7.22–
7.24). This author never introduces subcuticular sutures
in patients under 20 pounds.

(a) (b)

(c) (d)

Figure 7.19 (a-d) As the surgeon excises connective tissue he uses moist gauze as a safety backstop to prevent injury.
 70 Elective Laser Surgery Procedures
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Figure 7.22 The surgeon utilizes several simple interrupted

absorbable monofilament subcuticular sutures to close a
Figure 7.20 First transfixion ligature placed. castration by scrotal technique.

Figure 7.23 A drop of tissue adhesive can be seen being applied

to the skin layer for closing a castration by scrotal technique.

Figure 7.21 The laser is used to separate the testicle distal to the
ligatures.
 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 71
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Figure 7.24 Scrotal incision closure complete. Figure 7.25 Initial incision for canine ovariohysterectomy.

(a) (b)

Figure 7.26 (a, b) The laser offers improved visualization and hemostasis for layer by layer dissection.
 72 Elective Laser Surgery Procedures
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Figure 7.29 Linea alba incision complete (note lack of

hemorrhage).

Postoperative Canine Orchiectomy

Figure 7.27 The line alba is tented with the thumb forceps and
the surgeon makes a single small incision.
Most canine neuters performed with a surgical laser are
not sent home with any kind of a protective E‐collar.
Postsurgical pain management including nonsteroidal
anti‐inflammatory drugs (NSAIDs) is encouraged.
Licking or problems with the incisions are rare in the
author’s experience. The few incisions that dehisce can
be managed with skin staples if the patient manages to
open the adhesive skin closure.

Canine Ovariohysterectomy
Aside from techniques utilizing the surgical laser
described herein, the canine spay is essentially unchanged
from the procedure discussed in numerous surgical
texts. The most striking feature of laser‐assisted canine
spay is the level of hemostasis achieved even if the linea
alba incision deviates from the midline into the muscle
layers. The trend from total ovariohysterectomy to ova-
riectomy is easily adapted to laser use.

Preoperative
The patient should be prepared for surgery to the clini-
cian’s standard for a routine sterile laparotomy. An intra-
venous catheter is recommended for this procedure, and
standard presurgical pain control, sedation, induction,
and maintenance of anesthesia may be employed. The
surgeon and anesthesiologist should select drugs and
methods with which they have experience and comfort.

Procedure
Technique is not significantly different than when using
Figure 7.28 Sterile thumb forceps are inserted into the incision a scalpel. Skin thickness is critically important and must
and used to lift the linea alba. be accounted for, especially in extremely young or small
 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 73

dogs. In order to make an efficient incision, the surgeon cused technique where the laser is lifted more than the
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will require a small spot size (0.25 mm) and high‐power
settings relative to skin thickness. Laser settings for sur-
gical approach typically range from 7 to 15 W continuous
wave exposure, using SuperPulse mode if available
(Table 7.2).
When incised with the laser, the skin will often not
bleed (Figure 7.25, Video 7.2a). This allows the surgeon
to easily visualize the midline of the subcutaneous fat
layer. After layer‐by‐layer lasing, the surgeon will near
the linea alba. Visualization is often greatly improved
without bleeding (Figure 7.26). It is recommended that
thumb forceps be used to provide traction on the subcu-
taneous fat, and a defocused laser is used to reflect the
fat layer from the linea alba (Video 7.2b). The laser is
aimed parallel to the body wall and the fat layer lifted and
incised 3–5 mm away from the linea alba. Use of a defo-
Table 7.2 Canine ovariohysterectomy.
Procedure Canine ovariohysterectomy
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25–0.4
Power (W) 10–20
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100
2 mm focal distance will save time if the surgeon does not
have a rapidly adjustable laser delivery system. It will
take a good amount of practice to reflect the tissue
instead of reaching for a Metzenbaum scissor, but the
advantage of this technique is hemostasis. Small vessels
in this area often will bleed and weep creating the poten-
tial for seromas especially in larger breeds or those with
hereditary bleeding disorders; this can be avoided with
laser resection of the subcutaneous tissues.
The linea alba should then be tented with thumb ­forceps
and a single small incision should be made (Figure 7.27
and Video 7.2c). The goal is to insert forceps (or other
instrument such as a groove director) into the incision and
use the instrument to lift the linea alba as the surgeon cuts
along the midline (Figure 7.28). The instrument acts as a
backstop for the laser, while lifting provides sufficient ten-
sion for an efficient cut using the laser. Laser settings dur-
ing this step are unchanged from the skin settings. Such a
laser incision can be extended to the surgeon’s desired
length for a spay procedure, a more extensive pregnant
spay or C‐section, a pyometra s­urgery, or any other
abdominal procedure (Figure 7.29 and Video 7.2d–f).
The isolation and ligation of ovaries and uterus should
proceed in a routine fashion. The broad ligament and sus-
pensory ligaments can be severed with the laser at coagula-
tion settings; the author defocuses from 0.25 to 0.8 mm spot
size to allow for precise severing of the ligaments under
direct visualization. An adjustable handpiece facilitates rapid

(a) (b)

Figure 7.30 (a, b) The broad ligament is excised with excellent laser hemostasis.
 74 Elective Laser Surgery Procedures

change in fluence during the procedure; otherwise manual

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adjustment of different tip sizes is necessary. Skin layer laser

settings will be ­effective at severing ovaries and uterus.
Placing moist gauze pads as a safety margin or using an
instrument backstop is recommended. If using instruments
as backstops, be aware of possible reflected laser beams
toward drape, patient, and operating room personnel. The
author prefers to also use the laser to sever the broad liga-
ment. The broad ligament may be ligated and severed, or cut
using laser hemostasis depending on the surgeon’s prefer-
ence and the vascularity of the structure (Figure 7.30).
Closure of the spay patient should be done to the
­individual surgeon’s preference. Routine placement of skin
sutures is usually avoided by the author; instead, subcuta-
neous and subcuticular sutures (using monofilament) and
Figure 7.31 Feline ovariohysterectomy patient prepared for
tissue adhesive in the skin are used to provide a very aes-
surgery. thetically pleasing incision. (Refer to Video 7.2 for this
procedure.)

(a) (b)

(c) (d)

Figure 7.32 (a–d) Initial incision for feline ovariohysterectomy.

 ­Canine and Feline Laser Orchiectomy, Ovariohysterectomy, and Ovariectom 75
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Figure 7.33 Use of a Metzenbaum scissor to rapidly cut straight to Figure 7.36 Ovary and ovarian pedicle retrieved.
the linea may be most effective due to the low‐fiber nature of
feline subcutaneous fat.

Figure 7.34 The surgeon inserts thumb forceps into the incision
to lift as he cuts along the midline.

Figure 7.37 The laser may be used to sever the suspensory

ligament without bleeding. Note the use of moistened gauze as a
backstop.

Video 7.2 (a) (This video includes audio commentary). Initial skin
incision for laser‐assisted elective canine ovariohysterectomy.

Video 7.2 (b) (This video includes audio commentary). Approach

through subcutaneous fat.

Video 7.2 (c) (This video includes audio commentary). Incising the
linea alba.

Video 7.2 (d–f ) (This video includes audio commentary). The most
striking feature of laser‐assisted laparotomy is the level of
Figure 7.35 Laser dissection proceeds through the linea alba. hemostasis achieved.
 76 Elective Laser Surgery Procedures
Postoperative
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Postoperative recovery is usually unremarkable. Pain
management is encouraged, such as a single injection of
an approved NSAID (either pre‐ or intraoperatively)
followed by an approved oral NSAID for three to four
days postoperatively. E‐collars are avoided by the
author, and follow‐ups are usually a phone call the day
after surgery.
Feline Orchiectomy
Skin thickness is the only major variation in felines that
needs to be accounted for by the laser surgeon. Older
toms will have thicker skin and require a much higher
power setting compared to younger patients. Use of the
laser will eliminate any oozing or bleeding, markedly
decreasing time needed to perform this procedure, and
laser patients seem to lick and bother their incisions less
than steel scalpel patients.
Preoperative
Patients generally can be managed for this procedure by a
short acting IV or intramuscular (IM) anesthetic of the sur-
geons’ choice. An intravenous catheter is ideally used for all
anesthetic procedures but is left up to the surgeon and anes-
thesiologist. Intubation is always desirable if time and cost
are not a factor. Additional analgesia can also be provided by
using an intratesticular local anesthetic placed at the time of
surgery site preparation. A feline neuter is prepared by
clipping (or plucking) and scrubbing the scrotal area.
Procedure
(Refer to Video 7.3 for this procedure.) The feline neuter
is performed at the scrotum. Unlike their canine coun-
terparts, a prescrotal technique is not an option due to
the location of the feline male’s testicles. The testicles are
grasped firmly and used to provide tension across the
skin of the scrotum. The laser is then used to incise the
skin. A single incision may be made along the midline of
the scrotum, or the surgeon may choose to make indi-
vidual incisions for each scrotal sac (Video 7.3a).
To perform a closed neuter technique, the surgeon will
require practice with the laser. If power is too high, skin
and tunic will be incised all at once. If the surgeon prefers
a closed neuter technique the author recommends a
slightly lower setting or power density to help prevent
inadvertently opening the tunic. This is easy to achieve
with a flexible waveguide system by using a larger spot
size (0.8 mm instead of 0.25 or 0.4 mm, refer to Table 7.3).
The ligation method can be left to individual surgeon
preference. The accompanying video illustrates a closed
instrument tie (Video 7.3b). An open castration using
the vas deferens to tie off the vascular pedicle is also a
commonly performed technique. Using absorbable suture
for ligatures is an alternative. The author finds using the
Table 7.3 Feline orchiectomy.
Procedure Feline orchiectomy
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25
Power (W) 6
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100
vas deferens to do a hand tie and then excising the excess
tunic to be a rapid technique in his experience (Video
7.3c). Closure of the skin incision is usually not required in
felines, but a tissue adhesive can be easily applied if the
surgeon desires.
Video 7.3 (a) (This video includes audio commentary). Initial
incision for laser‐assisted elective feline orchiectomy.
Video 7.3 (b) (This video includes audio commentary). The surgeon
performs a closed instrument tie during a feline orchiectomy.
Video 7.3 (c) (This video includes audio commentary). Ablation of
feline testicle following closed instrument tie.
Postoperative
Patients are usually released the same day after full recovery
from anesthesia. Postsurgical pain medications for home
use should be offered to the client and the open incisions
explained. Pain management is encouraged, such as a single
injection of an approved NSAID (Onsior™ or meloxicam SC
either pre‐ or intra‐operatively) followed by an approved
oral NSAID such as Onsior for three to four days postop-
eratively. Elizabethan collars are not routinely used but can
be an option for some patients. Feline and canine neuters
are not routinely seen for follow‐up. Open feline neuters
will close within 24–48 hours even without tissue adhesive.
Feline Ovariohysterectomy
The reader should note that while much of the procedure
described below will parallel the technique employed for
routine canine spay, there are several key differences of
critical importance. As with the canine spay, the trend
from total ovariohysterectomy to just ovariectomy is
easily adapted to laser use using the above technique.
Preoperative
The patient should be prepared for surgery in dorsal
recumbence to the clinician’s standard for sterile surgery
(Figure 7.31). Standard preoperative pain control, seda-
tion, and induction of anesthesia should be utilized and
be with drugs and methods with which the surgeon is
comfortable.

Procedure
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This technique is not significantly different from using a
steel scalpel. A young feline patient may have a very thin
skin layer; consequently, power settings for the laser sys-
tem should be adjusted to compensate.
Video 7.4 (This video includes audio commentary). Initial incision
for laser‐assisted elective feline ovariohysterectomy.
Due to its low‐fiber nature, feline subcutaneous fat is
very difficult to incise with the laser (Figure 7.32 and
Video 7.4). This may make applying traction across sub-
cutaneous fat incisions difficult for beginners and
advanced surgeons alike. Use of a Metzenbaum scissor to
rapidly cut straight down to the linea alba may be a more
effective and efficient method in many cases (Figure 7.33).
The feline patient is less likely to bleed compared to a
canine patient using this technique.
The feline linea alba will vary considerably based on
size and age, but is often relatively small and thin. This
lends to the linea alba being very easily incised with the
laser. The linea alba should be tented with thumb forceps
and a single small incision should be made. The goal is to
insert forceps (or other small instrument such as a groove
director) into the incision and use this as a way to lift as
the surgeon cuts along the midline (Figure 7.34). The
instrument acts as a backstop for the laser while lifting
provides sufficient tension for an efficient cut using the
laser (Figure 7.35). Laser settings during this step are
unchanged from skin settings.
Isolation of ovaries and uterus should proceed in a
routine fashion (Figures 7.36–7.40). The same laser
­settings for incising skin will be effective at severing the
ovarian pedicles and uterus (Table 7.4). Placing moist
gauze pads or using an instrument backstop is recom-
mended as a safety margin (Figure 7.37). The author
­prefers to also use the laser to sever the broad ligament
(Figure 7.39). The broad ligament may be ligated and
severed, or just cut using laser hemostasis depending on
the surgeon’s preference and the vascularity of the
structure.
Closure of the spay patient should be done to the
individual surgeon’s preference. The routine placement
of skin sutures is usually avoided by the author; instead
a subcutaneous and subcuticular suture and tissue
adhesive are used (Figures 7.41 and 7.42).
Postoperative
Postoperative recovery is usually unremarkable. Pain
management is encouraged, such as a single injection of
an approved NSAID (Onsior or meloxicam SC either
pre‐ or intra‐operatively) followed by an approved oral
NSAID such as Onsior for three to four days postopera-
tively. E‐collars are avoided by the author, and follow‐ups
are usually a phone call the day after surgery.
­Feline Onychectom 77
­Feline Onychectomy
Despite advances in technique due to laser surgery, the
feline onychectomy remains controversial. The procedure
should not be performed without proper owner education
about the nature of the procedure and the alternatives that
are available. Once alternatives have been exhausted, the
author believes based on years of practice and collabora-
tion with specialists, if the procedure must be done, it
must be done well.1
If the feline onychectomy is always avoided many cats
will unfortunately be surrendered or forced to live less
secure lives outdoors. In the author’s opinion, the CO2
laser onychectomy is far superior to previous cold steel and
guillotine techniques, outdated methods that have given
the procedure a bad reputation for chronic feline pain. This
laser technique (Table 7.5) allows for rapid postsurgical
healing and both short‐term and long‐term comfort.
Preoperative
The patient should be prepared for routine surgery using
whatever drugs and methods the surgeon is comfortable
with, including both local and systemic pain management.
The CO2 laser feline onychectomy does not utilize a tour-
niquet at any time, so a cephalic IV catheter and fluids
may be employed. Fluid volumes do not need to be high as
there will be very little blood loss using the CO2 laser.
All paws should be cleaned, thoroughly scrubbed, and
prepared as for any routine surgery. The surgery will be
clean but not sterile due to the location and manipula-
tion required. This author does not routinely use a pre‐
or postsurgical antibiotic. If good technique is utilized,
the sterilizing effect of the CO2 laser leads to improved
hygiene when compared with other methods, making
presurgical or postsurgical antibiotics unnecessary.
Patients should be placed in whatever position is com-
fortable for the surgeon. For example, the author places
Figure 7.38 Retrieving the second ovary and ovarian pedicle.
 78 Elective Laser Surgery Procedures
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Figure 7.39 The broad ligament is excised with excellent laser Figure 7.41 Subcutaneous simple continuous closure commencing
hemostasis. following simple interrupted closure of the linea alba.

Figure 7.40 Double ligation of the uterine stump. Figure 7.42 Skin closure complete.

Table 7.4 Feline ovariohysterectomy.

Table 7.5 Feline onychectomy.

Procedure Feline ovariohysterectomy

Procedure Feline onychectomy
Laser type and wavelength (nm) CO2 (10 600)
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25
Spot size (mm) 0.25–0.4
Power (W) 7–10
Power (W) 6–12
Exposure Continuous wave
Exposure Continuous wave
Mode SuperPulse
Mode SuperPulse
Duty cycle (%) 100
Duty cycle (%) 100

the patients in right lateral recumbency and is seated for

the duration of the procedure. The feet should be
wrapped in sterile gauze until the surgery starts. One
foot at a time is unwrapped and individual nails are
removed in sequence. The unwrapped foot is then
­ andaged before the next foot is operated upon. The
b
technique for each nail is similar and is detailed below.
Power settings will vary based on the size and age of
patient.
 ­Feline Onychectom 79

Procedure
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Attachments should be severed with the laser at their P3

attachment points, using P3 itself as a backstop for the
laser, to avoid damaging P2 (Figure 7.43). The initial inci-
sion should be made close to the skin–nail junction,
completely encircle the nail, and avoid the pad area
(Figures 7.44–7.46). The cut skin should be firmly
retracted to expose the deeper subcutaneous structures,
while the nail is grasped with forceps and firmly extended
out and downward.

Common digital extensor tendon

Dorsal elastic
ligament

Deep
1
digital
flexor
tendon
2 Figure 7.45 The surgeon’s incision continues laterally.
3

Collateral
ligament

Figure 7.43 Anatomical diagram of the feline claw. Source:

Fossum et al. (2002a,b). Used with permission of Elsevier.

Figure 7.44 The surgeon’s initial incision dorsally for a laser Figure 7.46 The surgeon’s palmar/plantar skin incision, carefully
assisted feline onychectomy. avoiding the digital pad.
 80 Elective Laser Surgery Procedures

The attachment for the digital extensor tendon and the the joint area to carefully separate the P3–P2 structures
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elastic ligament can be found dorsally on the nail crest. (Figures 7.47 and 7.48). Care should be taken to not
These are easily palpated and sometimes easy to see after injure the smooth cartilage surface of P2. Once the joint
the initial incision. The ligaments located dorsally and area is open and the lateral tendon area is severed, the
laterally are severed, which allows the surgeon access to operator should feel a “pop” and the entire “shelf‐like”

(a) (b)

(c)

Figure 7.47 (a–c) Dissection proceeds through the dorsal elastic ligament.
 ­Feline Onychectom 81
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Figure 7.48 The ligaments located dorsally and laterally are Figure 7.50 Severing deep digital flexor tendon at P3.
severed allowing access to the joint area.

Figure 7.49 The entire “shelf‐like” structure of P3 is revealed.

Figure 7.51 Severing the deep digital flexor tendon on its P3

attachment.

structure of P3 should be visible (Figure 7.49). Careful as it is acting as a backstop for the laser (Figures 7.50 and
torsion left and right allows the surgeon to separate the 7.51). Damage to P3 is not a concern as it will be entirely
deep flexor tendon close to P3 and avoid the pad and fat removed. Care at this stage will reward the surgeon with
pad of the paw. A good deal of char will be formed on P3 an extremely small opening with minimal to no bleeding
 82 Elective Laser Surgery Procedures
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Figure 7.52 After careful technique, the surgeon is rewarded with Figure 7.53 A small amount of tissue adhesive is applied
an extremely small opening with minimal or no bleeding. directly to the surgery site; care should be taken not to bury the
adhesive.

(Figure 7.52). Additional local anesthetic can be applied

at this point and the wounds should be closed with a
­tissue adhesive (Figure 7.53). Care should be taken to not
bury the adhesive. Some surgeons choose to place a skin
suture next, but most patients will heal very well without
this added trauma. Bleeding may occur if sutures are
placed and is not due to the laser incisions. (Refer to
Video 7.5 for this procedure.)

Video 7.5 (a–c) (This video includes audio commentary). laser‐

assisted elective feline onychectomy.

Postoperative
The feet should be lightly wrapped for the first two to
four hours postsurgery (Figures 7.54 and 7.55).
Younger, smaller patients may not need wraps and
can often be released the same day if needed. Older,
larger patients will require more time to heal; they
may also require more postsurgical pain management
due to the increased weight on the incision sites.
Patients are sent home with careful postsurgical care
instructions to avoid overuse of the paws and trauma Figure 7.54 Bandages are applied to the cat’s paws following the
to the surgical sites for the first five to seven days. procedure.

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Figure 7.55 Bandaging complete.
Note
1 Editor’s note: It is the opinion of the Editor that policies
of the American Veterinary Medical Association
(AVMA) regarding elective feline onychectomy should
be strictly adhered to (AVMA 2018). The Editor agrees
that should a veterinarian who is abiding by said AVMA
policies be prepared to perform an elective feline
onychectomy procedure, this procedure should be
performed with the best possible means to eliminate
­References
AVMA. (2018). American Veterinary Medical Association
(AVMA) policies: declawing of domestic cats. https://
www.avma.org/KB/Policies/Pages/Declawing‐of‐
Domestic‐Cats.aspx (accessed 14 September 2018).
Fossum TW, Hedlund CS, Hulse DA, et al. (2002a).
Canine/feline ovariohysterectomy; Feline onychectomy,
­Reference 83
Most can return rapidly to normal activity, and no
long‐term analgesic medications are required beyond
the first few days. Hygiene should be a nonclump-
ing, nondust‐forming ­substance such as “Yesterday’s
News™” or other shredded paper products in cat
boxes. Routine follow‐ups are not required for most
cases, and few if any ever experience any complications
due to the surgery.
The feline onychectomy will always have its detrac-
tors regardless of advances in technique. Client educa-
tion is key when considering when to perform this
procedure. If a client is going to have the procedure
done, the patient deserves to have it done well, allow-
ing the best chance for a successful outcome and
affording the cat a permanent home, giving the client
and the patient a chance for a lifetime of comfort
together. The author would again like to stress the
superior recovery of the laser patient compared to the
standard scalpel technique, particularly for onychec-
tomy, where patients are rapidly weight bearing and
bleeding is extremely rare, making hygiene and c­ omfort
superior to previous techniques.
pain and postoperative discomfort and facilitate the best
possible short‐term and long‐term recovery for the
patient, including the use of laser surgery detailed in this
portion of the text. The Editor recommends that the
reader refer to AVMA policies concerning elective feline
onychectomy, found here at the time of this publication:
https://www.avma.org/KB/Policies/Pages/Declawing‐of‐
Domestic‐Cats.aspx.
Chapter 18 (202–204); Chapter 28 (616–618). In: Small
Animal Surgery, 2nd ed. Elsevier Health Sciences.
Fossum TW, Hedlund CS, Hulse DA, et al. (2002b). Small
Animal Surgery, 2nd ed. Elsevier Health Sciences.
Chapter 18, Figure 18‐43A.
 84
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Oral Laser Surgery Procedures
Jan Bellows
­Introduction
Lasers can be used to ablate by vaporization, resect, dis-
sect, excise, and incise oral tissues as one would use a
scalpel. One important difference compared to scalpel
surgery is that hemostasis can be provided while the tis-
sue is being incised.
Three types of lasers commonly used to facilitate com-
panion animal oral procedures include the carbon dioxide
laser, the semiconductor diode laser, and the therapy laser.
Carbon Dioxide (CO2) Laser
CO2 lasers (Figure 8.1a) are used in oral surgery in a non-
contact technique for cutting and vaporizing soft tissue
with excellent hemostasis, making it particularly useful
on buccal and lingual surfaces. Clinical applications
include excising tight frenulums, gingival enlargement
surgery, neoplasm excision, oral ulcer therapy, adjunc-
tive treatment for caudal stomatitis, crown troughing for
impressions, and crown elongation (Convissar 2009).
Diode laser
Diode lasers in the 800–980 nm range (Figure 8.1b) use
contact optical fibers for periodontal treatment and sur-
gery and incising oral tissue. For contact incisional appli-
cation, mechanical pressure is not necessary; the surgeon
needs only sufficient force to guide the handpiece along
the incision. Clinical application is similar to CO2 lasers
other than adjunctive therapy for caudal stomatitis
(Borrajo et al. 2004).
Therapy Lasers (Photobiomodulation)
Laser units used for photobiomodulation (Figure 8.1c)
are generally classified as Class 3, Class 3B, or Class 4.
Laser therapy is used for accelerated wound healing and
pain reduction. It is thought that its wound healing
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
effects are due to local release of cytokines, chemokines,
and other biological response modifiers, while analgesia may
result from both local and systemic effects including the
release of endorphins (See Chapter 5) (Soares et al. 2018).
Laser Safety in the Oral Cavity
Veterinarians using lasers in the oral cavity must be con-
cerned with possible damage to sensitive oral structures
including tooth pulp, periodontal ligament, and bone. The
actual zone of injury that can be tolerated depends on the
proximity and sensitivity of nearby tissue. The tooth pulp
and periodontal ligament are sensitive to thermal harm
and tolerable of temperature rises of only a few degrees.
Lasers in the oral operating area have great potential to
ignite combustible materials on and around the surgical
site. The endotracheal tube is a significant fire danger.
Ignition of the endotracheal tube may produce a fire with
a blowtorch effect inside the animal’s airway. Special care
must be taken to prevent the tube from coming in con-
tact with the laser beam during surgery. Water‐moistened
gauze should be packed around the endotracheal tube in
the pharyngeal area to avoid injury.
Anesthetic Considerations
Local anesthesia is recommended on all dental proce-
dures that may result in patient discomfort before, dur-
ing, or after the procedure. The most commonly available
local anesthetic agents are lidocaine and bupivacaine
when a single agent is used. In many practices, a combi-
nation of 0.5% bupivacaine hydrochloride with epineph-
rine (Marcaine®) (1 mg/kg) and lidocaine 2% (1 mg/kg) in
a 4 : 1 ratio is used. Mixing 0.8 ml of bupivacaine with
0.2 ml of lidocaine in the same tuberculin syringe accom-
plishes the 4 : 1 ratio. The recommended volume for
regional anesthesia is 0.1–0.3 ml per injection site.
Maximum patient dosage of this mixture would be
0.2 ml/kg bupivacaine or approximately 0.25 ml per jaw
 ­Canine and Feline Oral Conditions Aided with Laser Energ 85

(a) (b)
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(c)

Figure 8.1 (a) CO2 laser. (b) Diode laser. (c) Therapy laser. Source: Courtesy of Cutting Edge Laser Technologies.

quadrant in case all quadrants need anesthesia for a 5 kg
cat or dog. The infraorbital, maxillary, and mandibular
nerve blocks are most commonly used.
­ anine and Feline Oral Conditions
C bacteria to accumulate, lessening the antigenic load.
Aided with Laser Energy
Feline Oropharyngeal
Inflammation – Stomatitis
Carbon dioxide laser ablation may be helpful as an
adjunct therapy in cases where proliferative caudal sto-
matitis is present (Figures 8.2a and 8.3a,b) and multiple
extractions have been performed (Figures 8.2b,c and
8.3c). After laser ablation, much of the inflammatory
mass is replaced with less reactive fibrous scar tissue
(Figures 8.2e and 8.3e). Laser treatment does not cure
feline oropharyngeal inflammation and should not be
recommended as monotherapy for this condition. Laser
rastering (gently “painting” the laser energy on areas of
inflammation) will decrease the surface area for plaque
Often monthly retreatment is necessary for three
months after extractions followed by semiannual
reevaluation and possible laser retreatment. The proce-
dure is performed immediately after extractions where
marked inflammation is present, or in refractory cases.
Preoperative
An anti‐inflammatory dose of dexamethasone sodium
phosphate is administered (0.1 mg/kg IV) before laser
ablation to minimize oropharyngeal swelling. The
patient is placed in sternal recumbence with the maxillae
 86 Oral Laser Surgery Procedures

(a) (b)
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(c)

(e)

(d)

Figure 8.2 (a–e) Laser used during initial surgery after extractions. Source: Bellows (2016a). Reused with permission of Veterinary Practice
News.

supported between two adjustable intravenous fluid Procedure

poles with tape or held open by an assistant. After insur-
ing adequate seal of the endotracheal cuff, moistened
gauze is wrapped around the endotracheal tube in the
pharynx. A smoke evacuator is placed near the patient’s
mouth. Four‐quadrant regional anesthesia with long act-
ing 0.5% bupivicaine is administered.
The CO2 laser is set to 6 W continuous wave with 0.8 mm
spot size (Table 8.1) to thermo‐ablate visible proliferative
tissue of the caudal oral cavity (Figures 8.2d and 8.3d).
Inflamed tissue is ablated layer by layer. This will ­usually
create slight char; its removal with saline‐soaked cotton
tipped applicators is recommended. This process is
 ­Canine and Feline Oral Conditions Aided with Laser Energ 87

(a) (b)
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(c) (d)

(e)

Figure 8.3 (a–e) Refractory caudal stomatitis treated with CO2 laser to resolution. Source: Bellows (2016a). Reused with permission of
Veterinary Practice News.
 88 Oral Laser Surgery Procedures

Table 8.1 Feline oropharyngeal inflammation – stomatitis. Contact Mucositis and Contact Mucosal
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Ulceration
Procedure Feline stomatitis
These conditions occur secondary to mucosal contact
Laser type and wavelength (nm) CO2 (10 600) with tooth surfaces bearing the responsible irritant, aller-
gen, or antigen in plaque and calculus in a susceptible dog
Spot size (mm) 0.8
(Figure 8.4a). These lesions have also been called “kissing
Power (W) 6
lesions” since injuries are located where oral mucous
Exposure Continuous wave membranes rub against plaque‐and‐calculus‐laden teeth.
Mode Non‐SuperPulse Previously known as chronic ulcerative paradental sto-
Duty cycle (%) 100 matitis (CUPS), other present terms given to describe this
condition include ulcerative stomatitis, idiopathic stoma-
titis, lymphocytic‐plasmacytic stomatitis, and plaque‐
repeated multiple times until all visible proliferative tis- reactive stomatitis. The inflammatory lesions rarely affect
sue is removed. Remaining tissue shows decreased ten- teeth or attached gingiva unless accompanied by perio-
dency to spontaneous bleeding when touched with a dontal disease. There may be a genetic predisposition to
gauze sponge or moistened cotton‐tipped applicator. this syndrome in the Maltese, Greyhound, Cavalier King
Treated surfaces are sprayed with 2 mg of lidocaine Charles Spaniel, and the Scottish Terrier.
before extubation (Lewis et al. 2007). In these patients, even a small amount of plaque can
initiate a painful inflammatory reaction. Oral examina-
Postoperative tion findings under anesthesia should be discussed with
Postoperative laser therapy appears to increase patient the pet owner to consider the best way to tailor tooth‐by‐
comfort as evidenced by prompt return to eating. tooth therapy, which usually initially involves dental

(a) (c)

(b)

(d)

Figure 8.4 (a–d) Contact mucositis with ulceration treated with a CO2 laser. Source: Bellows (2017a). Reused with permission of Veterinary
Practice News.

scaling, polishing, and application of a sealant. Even with
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stringent home care, eventually those teeth physically
contacting the inflamed mucosa will need to be extracted
to affect a cure. In some cases, all teeth have to be
extracted resulting in rapid elimination of inflammation
and pain. Biopsy should be performed when lesions are
not symmetrical to rule out other underlying conditions
such as autoimmune conditions or neoplasia.
Procedure
The laser is set between 3 and 6 W continuous wave
exposure (Table 8.2). The use of CO2 laser to photovapor-
ize contact mucositis and mucositis with ulceration
(Figure 8.4b) has met with favorable results in some cases
when combined with strict plaque control (Figure 8.4c,d)
(Lopez et al. 2013; Soares et al. 2018).
Gingivoplasty
Gingivoplasty can be performed where lingually dis-
placed mandibular canine(s) impinge or penetrate the
maxillary mucosa (Figure 8.5a,b). The client should be
advised that multiple treatments may be necessary as the
teeth are not being removed and vaporized gingiva often
regrows. Gingivoplasty can also be used to create an
inclined plane that promotes lateral movement of man-
dibular canine(s), relieving gingival trauma.
Procedure
About 8–10 W of CO2 laser energy in a defocused
method (Table 8.3) is used to vaporize sequential layers
of gingiva (Figure 8.5c) until the mandibular canine tooth
is no longer impinging (Figure 8.5d).
Gingivectomy
The CO2 laser is versatile for precise incising or vapor-
izing of the gingiva.
Table 8.2 Contact mucositis and contact mucosal ulceration.
Contact mucositis/mucosal
Procedure ulceration
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.8, or 2.5 × 0.4
Power (W) 3–6
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100
­Canine and Feline Oral Conditions Aided with Laser Energ 89
Procedure
For the treatment of gingival enlargement (Figure 8.6a),
the CO2 laser is set at 4–8 W continuous wave to shape
the gingiva and aid hemostasis (Table 8.4). Higher CO2
laser power (10–15 W) is used to remove moderate
(<2 mm) amounts of enlarged gingiva (Figure 8.6b,c). For
thicker areas, the CO2 laser may be used in a defocused
method for coagulation to help control bleeding after
scalpel blade gingivectomy (Figure 8.6d). A diode laser
can also be used similar to a scalpel to remove enlarged
gingival tissues (Haytac et al. 2007).
Operculectomy
Operculectomy removes overgrown dense fibrous tissue
(Figure 8.7a), covering an impacted immature tooth
(Figure 8.7b) to aid eruption by removing the gingival
obstruction.
Procedure
Operculectomy can be performed with a CO2 laser using
10 W and 0.3 mm spot size (Table 8.5) to incise a mucosal
flap and expose the underlying crown (Figure 8.7c). The
diode laser can also be used to expose the underlying
crown (Figure 8.7d).
Tongue Surface Surgery
Solitary and multiple tongue lesions (Figure 8.8a) can be
excised using the CO2 laser (Figure 8.8b–d).
Procedure
A laser setting of 10 W and 0.4 mm spot size is commonly
used (Table 8.6). Penetration into the muscularis layer
should be avoided (Figure 8.8d). Absorbable sutures of 4‐0
Monocryl™ or catgut on a P‐3 reverse‐cutting needle are
placed if the post‐surgical defect is greater than 3 mm.
Gum Chewers Lesions
Sublingual and traumatic granulomas (also called gum‐
chewing syndrome) in dogs appear as excessive granula-
tion tissue located bilaterally in sublingual areas
(Figure 8.9b) or on the caudal vestibule mucosa
(Figure 8.9c). It is thought that the lesions occur second-
ary to an accidental bite of redundant tissue, leading to
inflammation. Often the dog will gnaw on the lesions
mimicking human gum chewing. Resection is necessary
if the tissue appears ulcerated secondary to repeated
trauma or if excessive tissue appears to cause painful
chewing. Treatment involves surgical removal of sublin-
gual granuloma and hyperplastic tissue using scissors or
laser, leaving sufficient tissue for closure without
tension.
 90 Oral Laser Surgery Procedures

(a) (c)
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(b)

(d)

Figure 8.5 (a–d) Cat’s mandibular canine penetrating gingiva, relieved with laser ablation. Source: Bellows (2014). Reused with permission
of Veterinary Practice News.

A wide surgical excision followed by closure decreases
the ability to fully open the mouth in some cases where
lesions are located in the caudal vestibule. In such cases,
extraction of the caudal maxillary and mandibular cheek
teeth usually affects a cure.
Procedure
Removal of sublingual tissue folds can be accomplished
using the CO2 laser (Figure 8.9b,d). Following excision,
laser power is decreased to 4 W with a defocused beam
(Table 8.7) to seal small blood vessels. Absorbable suture
of 4‐0 Monocryl or catgut on a P‐3 reverse‐cutting nee-
dle is used to close defects greater than 5 mm.
Oral Mass Excision
Lasers can be used for oral mass excisions (Figure 8.10a)
with controlled bleeding and improved visualization.
 ­Canine and Feline Oral Conditions Aided with Laser Energ 91

Table 8.3 Gingivoplasty. Table 8.4 Gingivectomy.

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Procedure Gingivoplasty Procedure Gingivectomy

Laser type and wavelength (nm) CO2 (10 600) Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.8 (defocused)
Power (W) 8–10 Spot size (mm) 0.25 or 0.3 0.8
Exposure Continuous wave Power (W) 4–8 10–15
Mode Non‐SuperPulse Exposure Continuous wave Continuous wave
Duty cycle (%) 100 Mode Non‐SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100

(a) (b)

(c) (d)

Figure 8.6 (a–d) Removal of gingival enlargement. Source: Bellows (2016b). Reused with permission of Veterinary Practice News.
 92 Oral Laser Surgery Procedures

(a) (c)
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(b)

(d)

Figure 8.7 (a) Clinically missing left mandibular first premolar. (b) Dental X‐ray revealing the “missing” tooth’s presence. (c) Diode laser
excision of gingiva over the partially erupted tooth. (d) Postsurgical appearance crown exposed.

Table 8.5 Operculectomy. Procedure

An excisional outline can be made rapidly with the
Procedure Operculectomy CO2 laser using repeated single pulses (5 W, 0.3 mm
spot size, Table 8.8) to circumscribe the desired target
Laser type and CO2 (10 600) Diode laser (810) tissue (Figure 8.10b). One edge of the incised margin
wavelength (nm)
can be elevated with forceps and the lesion under-
Spot size (mm) 0.25 or 0.3 0.3 mined and harvested at the correct depth of dissec-
Power (W) 10 4 tion with the laser. With the beam defocused, the
Exposure Continuous wave Continuous wave surgical wound can be briskly “painted” in one pass to
seal off small lymphatics, blood vessels, and nerve
Mode Non‐SuperPulse Non‐SuperPulse
endings. Successful excisions provide minimal post-
Duty cycle (%) 100 100
operative discomfort and rapid return to function
(Figure 8.10c).

Laser excision permits histologic evaluation and estab-

lishment of clean margins by a pathologist knowledgea-
ble in laser–tissue interaction. Additionally, because of
the laser’s ability to seal small blood vessels and lymphat-
ics, there is a reduced likelihood of inducing tumor
microemboli during the procedure.
Frenectomy
Frenectomy is used to loosen tight mandibular lips press-
ing debris against the gingiva overlying the mandibular
canines (Figure 8.11a).
 ­Canine and Feline Oral Conditions Aided with Laser Energ 93

(a) (b)
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(c)

(d)

Figure 8.8 (a–d) Sublingual granuloma excised with minimal bleeding. Source: Bellows (2017b). Reused with permission of Veterinary
Practice News.

Table 8.6 Tongue surface surgery. Procedure

Dissect the frenulum toward the mandibular insertion
Procedure Tongue surface surgery with multiple strokes with the CO2 or diode laser
(Table 8.9). Make the first incision vertically from the
Laser type and wavelength (nm) CO2 (10 600) base of the bone where the frenulum attaches between
Spot size (mm) 0.4 the central incisors to the underside of the lip
Power (W) 10 (Figure 8.11b). Make additional horizontal releasing
Exposure Continuous wave incisions as needed to remove the frenula from the oral
cavity (Figure 8.11c,d). Suture the resultant defect with
Mode Non‐SuperPulse
4‐0 Monocryl or catgut on a P‐3 reverse‐cutting
Duty cycle (%) 100 needle.
 94 Oral Laser Surgery Procedures

(a) (b)
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(c) (d)

Figure 8.9 (a–d) Gum chewers lesion excised with minimal bleeding.

Periodontal Pocket Surgery Clinical studies with an 810 nm diode laser have been
conducted on humans and published by Moritz et al. A
It is well accepted that periodontal disease is an inflam-
total of 50 patients with adult periodontitis were randomly
matory condition caused by the presence of bacteria
subdivided into two groups. Subgingival bacteria samples
(Figure 8.12a). A study by Fontana et al. on 40 rats with
were collected in all patients. Patients were treated either
induced periodontal disease demonstrated that a diode
with laser or subgingival irrigations of H2O2. After six
laser of 810 nm caused considerable bacterial elimina-
months, values of the periodontal indices and further
tion following laser energy application (Fontana et al.
microbiologic samples were measured. Total bacterial
2004). In this study, bacterial samples were taken from
count, as well as specific bacteria (e.g. Aggregatibacter
periodontal pockets before and after subgingival laser
actinomycetemcomitans, Prevotella intermedia, and
irradiation. The microbiological analysis showed that
Porphyromonas gingivalis), were assessed. Sites that
bacteria such as Prevotella spp., Streptococcus (beta‐
received the subgingival laser treatment exhibited much
hemolytic), Fusobacterium spp., and Pseudomonas spp.
lower bacterial counts. Furthermore, reduction of values
were significantly reduced.
of bleeding on probing was 96.9% in the laser group
 ­Canine and Feline Oral Conditions Aided with Laser Energ 95

Table 8.7 Gum chewer’s lesions. c­ompared to 66.7% in the control group. The authors
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­concluded that diode laser treatment following scaling

Procedure Gum chewer’s lesions and root planing had a bactericidal effect and reduced
inflammation (Moritz et al. 1998).
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.8 (defocused) Preoperative
Power (W) 4 The typical preparatory protocol for use of a diode laser
Exposure Continuous wave as an adjunct to conventional periodontal therapy
involves ultrasonic scaling and root planing with hori-
Mode Non‐SuperPulse
zontal strokes using a curette. Strip and cleave the optical
Duty cycle (%) 100
fiber prior to insertion in the pocket.

(a) (b)

(c)

Figure 8.10 (a–c) Oral sarcoma excision.

 96 Oral Laser Surgery Procedures

Table 8.8 Oral mass excision. Procedure

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The diode laser can be used in continuous or pulsed mode,

Procedure Oral mass excision and average power can range from 0.8–1.5 W (Table 8.10).
To begin sulcular debridement, the fiber‐optic is inserted
Laser type and wavelength (nm) CO2 (10 600) into the pocket to reach approximately 1.0 mm from the
Spot size (mm) 0.25 or 0.3 bottom of the defect. Insert the fiber in a vertical direction
Power (W) 5 toward the bottom of the pocket with the laser tip ori-
Exposure Continuous wave ented toward the soft tissue facing the pocket. Move the
fiber in a horizontal and vertical fashion at a slow to mod-
Mode Non‐SuperPulse
erate speed, keeping the fiber tip in contact with the
Duty cycle (%) 100 ­epithelium and parallel to the root s­urface (Figure 8.12b).

(a) (b)

(c) (d)

Figure 8.11 (a) Tight frenulum causing periodontal disease of the mandibular canines and first premolars. (b–d) CO2 laser used to excise
frenulum releasing the contact.
 References 97

Table 8.9 Frenectomy. Table 8.10 Periodontal pocket surgery.

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Procedure Frenectomy Procedure Periodontal pocket surgery

Laser type and wavelength (nm) CO2 (10 600) Laser type and Diode laser (810) CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.4
Power (W) 4–6 Fiber diameter (mm) 0.3 4 (defocused)
Exposure Continuous wave Power (W) 0.8–1.5 2
Mode Non‐SuperPulse Exposure Repeat pulse 30 s Continuous wave
Duty cycle (%) 100 Mode Pulsed 33 ms Non‐SuperPulse
Frequency (Hz) 15–17 —
Duty cycle (%) 50 100

(a) (b)

Figure 8.12 (a) Abnormal probing depth and bleeding. (b) Treatment with diode laser energy.

A fine water spray can be used during laser treatment for
rinsing, and constant suction is required to aspirate fumes
that form during ablation of inflamed tissues. The amount
of time to lase is proportional to the pocket depth
(3 mm = 3 s, 4 mm = 4 s).
The CO2 laser has also been shown to be effective in
treating periodontal disease in furcation areas (Table 8.10).
In a study performed on Beagles with surgically induced
furcation exposures, CO2 laser treatment resulted in
g­ ingival growth of 1.2 mm and histological evidence of
new cementum formation. When used in a defocused
method (~4 mm spot size), the laser can provide precise
surface vaporization and wound sterilization. It is indi-
cated for removal of inflammatory or infectious lesions
because the heat of the laser sterilizes both viral and
­bacterial particles.

References
Bellows J. (2014). CO2 laser gingivoplasty for orthodontic
care. Vet. Pract. News. 26(2). p. 34 (Figures 1, 2, 5, 6).
Bellows J. (2016a). Chronic feline stomatitis? Try
extraction, CO2 laser. Vet. Pract. News. 28(9). pp. 40–41
(Figures 4 and 5).
Bellows J. (2016b). Use CO2 laser on gingival enlargement.
Vet. Pract. News. 28(10). pp. 36–37 (Figures 5B, 5E, 5F).
Bellows J. (2017a). Give CO2 laser a try with oral
ulceration. Vet. Pract. News. 29(1). pp. 40–41 (Figures
6A, 6D, 6F, 6G).
 98 Oral Laser Surgery Procedures
Bellows J. (2017b). Flexible fiber CO2 laser – a definitive
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instrument for tongue surgery. Vet. Prac. News. 29(4).
pp. 44–45 (Figures 2A–2D).
Borrajo JL, Varela LG, Castro GL, et al. (2004). Diode laser
(980 nm) as adjunct to scaling and root planing.
Photomed. Laser Surg. 22. pp. 509–512.
Convissar RA. (2009). The top 10 myths about CO2 lasers
in dentistry. Dentistry Today. 28(4). pp. 68, 70, 72–76;
quiz 77.
Fontana CR, Kurachi C, Mendonça CR, et al. (2004).
Microbial reduction in periodontal pockets under
exposition of a medium power diode laser: an experimental
study in rats. Lasers Surg. Med. 35(4). pp. 263–268.
Haytac CM, Ustun Y, Essen E, et al. (2007). Combined
treatment approach of gingivectomy and CO2 laser for
cyclosporine‐induced gingival overgrowth. Quintessence
Int. 8(1). pp. 54–59.
Further Reading
Akoi A, Mizutani K, Takasaki AA, et al. (2008). Current
status of clinical laser applications in periodontal
therapy. Gen. Dent. 56. pp. 674–687.
Andreanna S. (2005). The use of diode lasers in
periodontal therapy. Dentistry Today. 24(11). pp. 66–69.
Castro GL, Gallas M, Nunez IR, et al. (2006). Histological
evaluation of the use of diode laser as an adjunct to
traditional periodontal treatment. Photomed. Laser Surg.
24(1). pp. 64–68.
Ciancio C. (2006). Wound healing of periodontal pockets
using the diode laser. In: Applications of 810 nm Diode
Laser Technology: A Clinical Forum. pp. 14–17. www.
oralhealthgroup.com.
Divers SJ. (2009). CO2 lasers and radiosurgery: what is the
difference? NAVC Clinician’s Brief. pp. 49–52.
Lewis JR, Tsugawa AJ, Reiter AM. (2007). Use of CO2 laser
as an adjunctive treatment for caudal stomatitis in a cat.
J. Vet. Dent. 24. pp. 240–249.
Lopez TC, Martins MD, Pavesi VC, et al. (2013). Effect of
laser phototherapy in the prevention and treatment of
chemo‐induced mucositis in hamsters. Braz. Oral. Res.
27(4). pp. 342–348.
Moritz A, Schoop U, Goharkhay K, et al. (1998). Treatment
of periodontal pockets with a diode laser. Lasers Surg.
Med. 22(5). pp. 302–311.
Soares RG, Farias LC, da Silva Menezes AS, et al. (2018).
Treatment of mucositis with combined 660‐ and
808‐nm‐wavelength low‐level laser therapy reduced
mucositis grade, pain, and use of analgesics: a parallel,
single‐blind, two‐arm controlled study. Lasers Med. Sci.
33(8). pp. 1813–1819.
Harris DM, Yessik M. (2004). Therapeutic ratio
quantifies laser antisepsis: ablation of Porphyromonas
gingivalis with dental lasers. Lasers Surg. Med. 35.
pp. 206–213.
Raffetto N. (2004). Lasers for initial periodontal therapy.
Dent. Clin. North Am. 48. pp. 923–936.
Saglam M, Kantarci A, Dundar N, et al. (2014). Clinical
and biochemical effects of diode laser as an adjunct to
nonsurgical treatment of chronic periodontitis: a
randomized, controlled clinical trial. Lasers Med. Sci. 29.
pp. 37–46.
Ustun K, Erciyas K, Sezer U, et al. (2014). Clinical and
biochemical effects of 810 nm diode laser as an adjunct
to periodontal therapy: a randomized split‐mouth
clinical trial. Photomed. Laser Surg. 32. pp. 61–66.

VetBooks.ir
Laser Surgery Procedures of the Nose and Throat
Ray A. Arza
­Introduction
The CO2 surgical laser has become an indispensable tool
to the veterinary surgeon that has been trained in the
proper use of this great modality. The throat and nose in
the canine and feline patient pose a great challenge to the
surgeon due to its highly vascular tissue and the risks
encountered with postoperative hemorrhage and swell-
ing. The CO2 laser has the benefits of greatly decreasing
hemorrhage and swelling and dramatically minimizing
these postoperative complications. Although lasers have
been used in veterinary medicine for the past 25 years,
there have been significant advancements in this tech-
nology over the past 10 years both in equipment and
knowledge of how to properly use this tool to maximize
benefits and minimize thermal injury to tissue. It is
important to note that an improperly used CO2 surgical
laser is capable of causing just as much thermal injury
and swelling as an electrocautery unit.
This chapter will focus on the use of the flexible hollow
waveguide CO2 surgical laser in performing surgical pro-
cedures for canine brachycephalic airway syndrome
(BAS), also known as brachycephalic airway obstructive
syndrome (BAOS). This syndrome has been reported in
many brachycephalic breeds including English and
French Bulldogs, Boxer, Lhasa Apso, Pekingese, Pug,
Shar‐Pei, and Boston Terrier (Hendricks 1992; Helund
1998). A retrospective study on 90 canine patients by
Fasanella et al., showed that Bulldogs (61%), Pugs (21%),
and Boston Terriers (9%), were the most common breeds
with BAOS (Fasanella et al. 2010). This condition occurs
as a result of the congenital shortening of the facial skel-
eton, and subsequent pathological changes. It has been
reported that the two primary components of BAS are
stenotic nares and elongated soft palate; negative respir-
atory pressure created by these components leads to
everted laryngeal saccules and inflammation of tonsillar
tissues (Aron and Crowe 1985; Hendricks 1992; Fasanella
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
99
et al. 2010). If untreated, these changes in air pressure
may also ultimately lead to collapse of laryngeal carti-
lages, which carries a worse prognosis. In the author’s
experience, early detection and surgical intervention is
critical to prevent the progressive vicious cycle of this
condition. Historically, general practitioners have been
reluctant to perform these procedures due to the risk
factor involved with conventional surgery. Typically, only
severely affected patients are referred to surgeons and by
this time most of these dogs have extensive changes. In
the author’s opinion, the surgical laser with proper tech-
nique greatly decreases postoperative complications and
has excellent prognosis especially when performed early
in life.
­Preoperative Considerations
Specific anesthetic recommendations will not be
addressed here, but general guidelines will be discussed.
IV fluids should be administered via IV catheter to every
patient. A perioperative IV anti‐inflammatory dose of a
corticosteroid is indicated to help reduce postoperative
swelling. Appropriate preanesthetic and induction
agents are used, and the patient is intubated during these
procedures.
­Soft Palate Resection
The patient is positioned in sternal recumbence with
maxilla suspended (Figure 9.1). Complete evaluation of
the throat is done at this time. Many techniques have
been described in the literature to determine the amount
of soft palate to be excised; it has been found that the
most precise method to accomplish this is to use the epi-
glottis as a guide (or template) on where to excise the soft
palate.
 100 Laser Surgery Procedures of the Nose and Throat
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Figure 9.2 Excision line (dotted line) marked with laser in repeat
pulse exposure.

Figure 9.1 Patient positioned in sternal recumbence. Source: Arza

(2015). Reprinted with permission of Veterinary Practice News.

Table 9.1 Elongated soft palate.

Elongated soft Elongated soft

Procedure palate (marking) palate (excision)

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 0.4 0.4
Power (W) 6–8 15–30
Exposure Repeat pulse Continuous wave
Mode Non‐SuperPulse Non‐SuperPulse
Frequency 10 Hz, 10 ms —
Figure 9.3 Saline‐soaked gauze to protect endotracheal tube.
Duty cycle (%) 10 100 Source: Arza (2015). Reprinted with permission of Veterinary
Practice News.

Procedure
With the patient in a deep plane of anesthesia, the
endotracheal (ET) tube is momentarily removed to
“mark” the soft palate using the surgical laser in repeat
pulse exposure (6–8 W, 10 Hz, and 10 ms, Table 9.1). This
is accomplished by placing the elongated part of the soft
palate over the epiglottis (making sure not to pull on the
tongue to the extent that it will affect the position of the
epiglottis) and tracing a dotted line onto the soft palate at
the level of the epiglottis. The dotted line should be
traced along the entire border (not just the tip) of the soft
palate (Figures 9.2 and 9.4). If the patient is not in a deep
plane of anesthesia for this part of the procedure, move-
ment of the soft palate and epiglottis will make it difficult
to accomplish. Once the soft palate has been “marked”
with the dotted line the patient is then reintubated and
the surgeon can proceed with the resection confident
that the proper amount of tissue will be removed.
The ET tube is tied down to the mandible (Figure 9.1)
and saline‐soaked 4 × 4 gauze are used to cover every-
thing below the soft palate including the entire ET tube
(Figure 9.3). This will prevent the laser beam from inad-
vertently hitting any other soft tissue in the back of throat
as well as the ET tube. At this point, the surgical proce-
dure should take 60–90 seconds. The pendulous part of
the soft palate is secured with Allis tissue forceps
(Figure 9.4) (a suture may also be used here, but Allis for-
ceps provide better control of the tissue to be excised).
The laser is then set to 15–30 W continuous wave
(depending on thickness of tissue, see Table 9.1) with a
0.4 mm spot‐size, and an initial partial thickness incision
of 1–2 mm in depth is made all the way across the soft
 ­Soft Palate Resectio 101
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Figure 9.6 Resection from right to left following partial incision

from Figure 9.5. Source: Arza (2015). Reprinted with permission of
Figure 9.4 Incision line. Source: Arza (2015). Reprinted with Veterinary Practice News.
permission of Veterinary Practice News.

Figure 9.7 Surgery complete. Note hemostasis. Source: Arza

Figure 9.5 Partial thickness incision. Source: Arza (2015). (2015). Reprinted with permission of Veterinary Practice News.
Reprinted with permission of Veterinary Practice News.

palate along the dotted line previously described

(Figure 9.5). The partial thickness incision will be the guide
to complete the resection. With increased tension applied
to pull the pendulous tissue toward the surgeon, place the
hand‐piece on the lateral aspect of the partial thickness
incision and cut all the way through the remaining tissue
starting on one side (right to left if right handed) and end-
ing the procedure on the opposite side (Figures 9.6–9.8).

Postoperative
Typically, there is minimal to no hemorrhage present
postprocedure. If hemorrhage does occur, it will nor-
mally be from the left or right branches of the descend- Figure 9.8 Excised tissue. Source: Arza (2015). Reprinted with
ing palatine arteries. By retracting the cut surface with a permission of Veterinary Practice News.
 102 Laser Surgery Procedures of the Nose and Throat

skin hook, it is usually very simple to isolate the one or Procedure

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two bleeders present and ligate. Postoperative swelling

With the patient in sternal recumbence and head resting
could occur, and if excessive may require a temporary
on a rolled towel (Figure 9.9) so the nares are at the level
tracheostomy. This is quite rare and has only occurred
of the surgeon’s eyes, both nares are initially marked
once in over 350 soft‐palate resections performed by this
using the surgical laser in repeat pulse exposure (4 W,
author.
2–5 Hz, and 10 ms) (Table 9.2, Figure 9.10).
Once both nares are externally marked for incision, the
ventromedial aspect of the alar fold is grasped with for-
Stenotic Nares ceps and lateral tension is applied to visualize its internal
aspect. A point is marked as far proximal as possible and
Stenotic nares play a major role in the pathophysiology
an isosceles‐triangular‐shaped wedge is traced with an
of BAS, since changes in air pressure are believed to be
initial superficial incision made at 8–10 W continuous
the main reason for the negative changes that occur in
wave in SuperPulse mode (Table 9.2). The base of the
the upper and lower respiratory tract. Poiseuille’s law
t­riangle is made by the dorsal and ventral points of the
suggests that a 50% reduction in tube radius leads to a
initial external marking on the nares and the apex is the
16‐fold increase in resistance to flow (Trappler and
point made proximally on the medial aspect of the alar
Moore 2011). This dramatic exponential increase in
fold (Figure 9.11). Once a superficial incision delineates
ne­gative pressure during inspiration has an effect on sec-
this triangular wedge, excision of the wedge is performed
ondary changes such as eversion of laryngeal saccules,
with same setting of 8–10 W continuous wave in
edema, and inflammation of tonsillar tissue. If left
SuperPulse mode. SuperPulse is used here to minimize
untreated this may also lead to collapse of laryngeal car-
thermal collateral injury to tissue. However, if bleeding
tilages. Early surgical intervention of elongated soft pal-
ate and stenotic nares is the best way to prevent
development of secondary changes and improve long‐
term prognosis (Hendricks 1992; Helund 1998, 2002).
This author recommends laser surgical correction of
stenotic nares and elongated soft palate by six months of
age. In cases where the nares are severely occluded, cor-
rection as early as three to four months of age is indi-
cated (Helund 2002).
Many surgical procedures have been described for cor-
rection of stenotic nares. The objective is to remove a
wedge of tissue from the alar fold, or to excise the alar fold
and allow it to granulate in. With conventional surgery a
wedge of tissue is removed with sharp dissection and
sutured. This author believes that the CO2 surgical laser
provides the surgeon extensive benefits, including supe-
rior hemostasis which increases precision and the ability
to dramatically increase the opening into the nasal cavity. Figure 9.9 Sternal recumbence, head resting on rolled towel.

Table 9.2 Stenotic nares.

Procedure Stenotic nares (marking) Stenotic nares (alar fold excision) Stenotic nares (alar cartilage ablation)

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Spot size (mm) 0.4 0.4 0.8
Power (W) 4 8–10 10–20
Exposure Repeat pulse Continuous wave Continuous wave
Mode SuperPulse SuperPulse or non‐SuperPulse SuperPulse or non‐SuperPulse
Frequency 2–5 Hz, 10 ms — —
Duty cycle (%) 2–5 100 100

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Figure 9.10 Marked by laser in repeat pulse exposure.
Figure 9.11 Apex of triangle as far proximally as possible.
occurs the laser’s mode could be changed to continuous
wave non‐SuperPulse to maximize hemostasis.
At this point, the external alar fold has been excised
(Figure 9.12), but the alar cartilage ridge which runs deep
into the nasal cavity is still present, and although is left
intact by many surgeons, it poses continued restriction
of air flow and should in all cases be removed. This pro-
cess is extremely difficult with a scalpel due to extreme
hemorrhage, but with good technique is very simple to
ablate via CO2 surgical laser.
The most important part of ablation of the alar cartilage
is to protect the lateral aspect of the nasal septum from 12
to 6 o’clock on the right nostril and 6 to 12 o’clock on left
nostril; this will prevent stricture formation during heal-
ing. A saline‐soaked cotton‐tipped applicator (size deter-
mined by size of patient) is inserted into the nostril and
placed medially and proximally to the alar cartilage that is
to be removed. The author recommends using a 0.8 mm
spot‐size at 10–20 W continuous wave in SuperPulse
mode (Table 9.2) depending on amount of tissue to be
removed. Using the moistened cotton‐tipped applicator
Stenotic Nares 103
Figure 9.12 Alar fold removed from right nostril.
Figure 9.13 Surgery complete. Note hemostasis.
as a backstop, the laser is repeatedly swept from dorsal to
ventral and ventral to dorsal on the lateral aspect of the
cotton. After several passes are performed, the moistened
tip is used to gently remove the “char” on the tissue, and
this process is repeated until the alar cartilage ridge has
been removed proximally enough to be able to insert the
cotton tip applicator with ease into the nasal cavity. The
author recommends using an otoscope from a ventrome-
dial to a dorsolateral direction to view the opening and
determine if there is any redundant alar cartilage tissue
still present that needs to be removed. The surgeon should
be able to easily visualize into the nasal cavity (Figure 9.13).
Postoperative
Postoperative care and complications are minimal. An
antibiotic ointment is prescribed to be applied two to
three times per day. This will keep tissues moist during
healing and keep patients more comfortable.
 104 Laser Surgery Procedures of the Nose and Throat

Everted Laryngeal Saccules Table 9.3 Everted laryngeal saccules.

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Laryngeal saccules are located between the vocal folds Procedure Everted laryngeal saccules
and the lateral wall of the larynx. Saccules are not evident
Laser type and wavelength (nm) CO2 (10 600)
in normal dogs, but eversion occurs in brachycephalic
patients due to the negative pressure present during Spot size (mm) 0.4
inspiration. Everted saccules appear as shiny, avascular, Power (W) 3–4
convex structures protruding from a recession between Exposure Continuous wave
the vocal folds and the lateral wall of the larynx (Harvey Mode SuperPulse
1982a,b; Monnet 2003). It has been reported that early
Frequency (Hz) —
surgical correction of stenotic nares and elongated soft
Duty cycle (%) 100
palate prevents this from occurring. It has been found
from experience that surgical excision of everted saccules
only needs to be done in severe cases that are typically Table 9.4 Tonsillectomy.
seen in older patients with progressive symptoms of BAS.
Eversion of laryngeal saccules is considered to be the first Procedure Tonsillectomy
stage of laryngeal collapse (Pink et al. 2006).
Laser type and wavelength (nm) CO2 (10 600)

Procedure Spot size (mm) 0.4

Surgical correction is only difficult because of access and
visualization of the area, but this can usually be accom-
plished by temporary extubation. Surgery can be per-
formed by grasping and retracting the pendulous tissue
rostrally with Allis tissue forceps and excising with
curved Metzenbaum scissors. Due to the avascular
nature of this tissue, hemorrhage is normally minimal.
The benefit of the CO2 laser with this procedure is pri-
marily that of hemostasis. However, due to limited access to
the area and the proximity of vocal folds, extreme caution
must be used to only excise or vaporize the everted saccule
without affecting the adjacent structures of the larynx,
which tends to increase postoperative swelling and compli-
cations. The use of the surgical laser is recommended for
this procedure only by very experienced laser surgeons. If
the laser is used, protection of the vocal fold can be accom-
plished by placing a moistened tongue depressor between
the everted saccule and the vocal fold. The saccule may then
be excised with a 0.4 mm spot‐size and the laser set at
3–4 W in continuous wave SuperPulse mode (Table 9.3).
Tonsillectomy
Inflammation of the tonsils in the BAS patient is believed
to also be a sequela to the negative pressure in the phar-
yngeal area. Many authors believe that tonsillectomy is
not necessary because reports indicate that tonsillar
inflammation resolves when stenotic nares and elon-
gated soft palates are surgically corrected (Harvey
1982a,b; Poncet et al. 2006). However, this author
prefers to perform a tonsillectomy whenever there is
excessive inflammation present with significant obstruc-
tion of the pharyngeal area. When done with the flexible
Power (W) 3–4
Exposure Continuous wave
Mode Non‐SuperPulse
Frequency (Hz) —
Duty cycle (%) 100
hollow waveguide CO2 surgical laser, this procedure is
extremely simple to perform and has minimal to no
hemorrhage.
Procedure
With the patient in sternal recumbency and maxilla sus-
pended, the pharyngeal area is packed with saline‐soaked
gauze. Care must be taken to completely cover the ET
tube. The tonsillar tissue is retracted using forceps to
visualize the junction of inflamed tonsillar tissue and the
thin layer of connective tissue attaching it to the crypt.
The inflamed tissue is very friable, and should be han-
dled with extreme care to prevent it from tearing and
bleeding. The laser is set to continuous wave at 3–4 W
with a 0.4 mm spot‐size (Table 9.4). The excision is per-
formed by cutting as close to the inflamed tonsillar tissue
as possible. No sutures are necessary, and typically there
will be minimal to no bleeding.
­Conclusion
Due to postsurgical complications reported and encoun-
tered by surgeons, many general practitioners choose
not to recommend these surgical procedures except in
severely affected patients. By not closely evaluating all
brachycephalic dogs early in life, we miss the opportunity

to address and correct these problems before significant
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changes occur in the upper airways of these patients.
The advantages of using the flexible hollow waveguide
CO2 surgical laser in surgical management of BAS are
certainly significant.
When weighing the risks vs. the rewards of doing
this procedure over the first 19 years of practice with-
out having a laser, this author chose not to do this
surgery, and unfortunately many brachycephalic dogs
went untreated and exhibited many of the symptoms
described. After obtaining a hollow waveguide CO2
surgical laser in 1998 and understanding the benefits
of this wonderful technology in decreasing pain,
­References
Aron DN, Crowe DT. (1985). Upper airway obstruction.
General principles and selected conditions in the dog
and cat. Vet. Clin. North Am. Small Anim. Pract. 15(5).
pp. 891–917.
Arza R. (2015). Elongated soft palate resection with a CO2
surgical laser. Vet. Pract. News. 27(10). pp. 32–33
(Figures 1–8).
Fasanella FJ, Shivley JM, Wardlaw JL, et al. (2010).
Brachycephalic airway obstructive syndrome in dogs: 90
cases (1991–2008). J. Am. Vet. Med. Assoc. 237(9). pp.
1048–1051. 10.2460/javma.237.9.1048.
Harvey CE. (1982a). Upper airway obstruction surgery. III.
Everted laryngeal saccule surgery in brachycephalic
dogs. J. Am. Anim. Hosp. Assoc. 18. pp. 545–547.
Harvey CE. (1982b). Upper airway obstruction surgery.
VIII. Overview of results. J. Am. Anim. Hosp. Assoc. 18.
pp. 567–569.
Helund CS. (1998). Brachycephalic syndrome. In: Bojrab
MJ, ed. Current Techniques in Small Animal Surgery,
4th ed. Philadelphia: Williams & Wilkins. pp.
357–362.
­Reference 105
decreasing inflammation, and greatly reducing
­hemorrhage and postoperative complications, it was
found that the rewards of using the laser to correct
stenotic nares, elongated soft palate, and in some
cases, everted saccules and grossly enlarged tonsils,
far outweigh the risks commonly seen when perform-
ing these surgeries with conventional methods of
scalpel, scissors, or electrosurgical units. Over the
past 20 years the author has performed over 350
laser‐assisted soft palate resections with little mor-
bidity and to date not one mortality. Most of these
patients are discharged home the same day of the sur-
gery with no significant postoperative complications.
Helund CS. (2002). Stenotic nares. In: Fossum TW, ed.
Small Animal Surgery, 2nd ed. St. Louis: Mosby.
pp. 727–730.
Hendricks JC. (1992). Brachycephalic airway syndrome.
Vet. Clin. North Am. Small Anim. Prac. 22(5).
pp. 1145–1153.
Monnet E. (2003). Brachycephalic airway syndrome. In
Slatter D, ed. Textbook of Small Animal Surgery, 3rd ed.
Philadelphia: WB Saunders. pp. 808–813.
Pink JJ, Doyle RS, Hughes JM, et al. (2006). Laryngeal
collapse in seven brachycephalic puppies. J. Small Anim.
Pract. 47. pp. 131–135.
Poncet CM, Dupre GP, Freiche VG, et al. (2006). Long term
results of upper respiratory syndrome surgery and
gastrointestinal tract medical treatment in 51
brachycephalic dogs. J. Small Anim. Pract. 47(3).
pp. 137–142.
Trappler M, Moore K. (2011). Canine brachycephalic
airway syndrome: pathophysiology, diagnosis, and
nonsurgical management. Compend. Contin. Educ. Vet.
33(5). pp. E1–E4; quiz E5.
 106
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10
Laser Surgery Procedures of the Ear
Louis N. Gotthelf
­Introduction
With the advent of video otoscopy, many more condi-
tions present in the dogs’ and cats’ ear canals are being
identified. How to approach these conditions still
remains a problem in treating them. Often, a surgical
opening of the ear canal to expose tumors or polyps is
necessary because of limited space available for conven-
tional surgical instruments.
Ear canals are very confined spaces in which to work.
The use of intra‐otic surgical procedures using video
otoscopes has provided a means to access these tissues
without having to open ear canals for exposure. In some
cases, however, intra‐otic procedures cannot be used
due to the location of diseased tissue or because of its
size. Using the laser through the video otoscope results
in much less bleeding at the surgical site, which other-
wise obstructs the view of the procedure. For the patient,
there is less postoperative swelling and pain. Most of the
ears operated on are infected and laser energy effectively
sterilizes the surgical site, so there is minimal ear prepa-
ration required for these procedures. Laser energy allows
for a targeted means of removal or alteration of tissue
within the ear. A laser can simplify a number of proce-
dures, improve near‐term recovery, and provide for
more normal anatomy and return to function. This can
be accomplished by incorporating laser‐directed coagu-
lation, incision, or ablation (vaporization). Disease com-
ponents in the ear can then be more efficiently removed
with cleaning, medicating, and evacuating those that are
predisposing or perpetuating disease.
The three functions of the laser are the following:
Coagulation: In this application, lasers are used to pro-
vide hemostasis. This is accomplished by providing
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
laser energy at lower power usually with longer expo-
sure time. By using the laser in this manner, tissue con-
traction rather than vaporization is achieved. When
­collagen in the end of a bleeding vessel is contracted,
hemostasis is achieved.
Incision: By providing relatively high wattage with a small
focal point, high‐power densities are achieved. This
results in incision of target tissue. This is particularly
useful in situations where a mass is pedunculated and
the base of the mass can be visualized. Depending on
the power density, more or less hemostasis can be
attained.
Ablation: Laser energy can also be applied to the surface
of structures within the ear. In this application, rela-
tively high energy for moderate exposure times is
introduced, resulting in vaporization of the targeted
structure’s surface. By continuing to appropriately
apply energy, tumors can be removed from all parts of
the aural canal and part of the middle ear.
­A Comparison of Diode and CO2
Laser Energy for Ear Surgery
Diode laser energy is delivered by a shielded flexible
quartz fiber in a variety of diameters. Diode laser energy
is absorbed by hemoglobin, oxyhemoglobin, and mela-
nin. This selective absorption may help in treatment if
the abnormal area is more pigmented than surrounding
tissue. Ear lesions can be treated with a diode laser in
contact or noncontact technique. The noncontact tech-
nique is usually used only on pigmented lesions on the
pinna and has not been proven to be useful in a fluid
environment.

In contact technique a diode laser system allows for
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­ recise delivery of laser energy in a fluid environment.
p
The fiber delivery system of diode lasers may become
extremely hot when the laser is activated for a prolonged
period. This is dependent on fiber size, power setting
(wattage), and vascularity of the tissue (thermal diffusion).
In ear surgery, the fiber should be large in diameter. If the
fiber becomes overheated, peripheral thermal damage
will result; it is vital to keep the fiber cool. This can be
accomplished by limiting exposure time (pulse duration)
and by cooling the fiber with an irrigant such as saline.
The ability to operate immersed in fluid makes the diode
laser extremely useful in endoscopy. Continual irrigation
during the procedure increases visualization and decreases
unintentional iatrogenic damage. Irrigation also removes
debris and helps control any heat from the endoscope.
CO2 laser energy is most useful in ablation (vaporiza-
tion) of abnormal ear tissue. It can also be effectively
used to provide hemostasis. In cases where the base of an
auricular mass is visible, the laser can be used in an inci-
sional mode to quickly remove these structures.
The limitations of CO2 laser energy are primarily
related to the wavelength itself (10 600 nm). Since CO2
laser energy is primarily absorbed by water, it cannot be
used in an ear that has been flooded with fluid (such as
saline) to increase visualization. The ear canal must be
cleaned and dried prior to any CO2 laser procedure. The
smoke plume from the laser’s interaction with tissue
must be removed by an appropriate smoke evacuation
system to protect operating personnel from its inhala-
tion. When using the laser deep in the ear canal, smoke
evacuation cannot be done routinely as in other proce-
dures, but the air flush system coming from the laser tip
to keep the tip clear will also help to move smoke plumes
out of the ear canal and removed by a smoke evacuator
placed at the opening.
The issue of smoke evacuation is minimized when
pulse settings are used on the CO2 laser. The air pump
contained within the laser is active even though the laser
energy is not being transmitted during the resting phase
of the pulse. Thus, any smoke plume is dissipated before
the next laser pulse is emitted. The pulsed setting also
allows the surgeon to move the probe to align the impact
zone and control targeting of the laser energy as the
vaporization process continues.
Tissue in the ear canal turns to char as it is vaporized.
Char must be removed periodically during ear proce-
dures to minimize excessive heating of char resulting in
thermal damage to delicate ear tissues. Thermal injury
cannot be avoided when using laser energy in a small
confined cylindrical space but can be minimized. Healing
is usually uneventful as collagen replaces vaporized tis-
sue and re‐epithelialization occurs. This may take two to
three weeks.
­Cerumen Gland ­Cerumen Gland 107
­The Otoscope
Inside the external ear canal, the video otoscope, or
fiber‐optic telescope, can be utilized to facilitate visuali-
zation and direction of laser energy. This is usually
accomplished by extending the direction of laser energy
through special tips that fit into and through working
channels in the otoscopic equipment, allowing the clini-
cian to visualize the area and provide treatment within
the confined space of the external ear canal. Several con-
ditions that can be treated effectively using a video
otoscope‐laser combination include vaporization of
­
ceruminous hyperplasia and cerumen gland adenomas,
decompression and ablation of apocrine cysts, laser
polyp removal, myringotomy, and opening up stenotic
ear canals.
The OtoPet Video Otoscope has a gently arcing 2 mm
channel in its probe that can be used to place a variety of
small surgical instruments into the ear canal, With the
laser tip placed through the video otoscope, target tissue
can be viewed on the video monitor and the instrument
(such as the laser tip) can approach the tissue without
obstructing the surgeon’s view.
The ideal CO2 laser apparatus for delivering laser
energy to the ear is through a hollow waveguide to a tip
inserted into the hand piece. Laser tips are made from
stainless steel, ceramic, or Teflon. In ear surgery using a
video otoscope, the tip most often used is made of a rigid
straight stainless‐steel tube measuring 120–180 mm long
with a 0.8 mm spot size. This waveguide will fit through
the gentle arc of the working channel within the OtoPet
otoscope (Figure 10.1). Other video otoscopes, such as
the Storz Oto‐endoscope, have a very acute angle in the
working channel of the probe, which limits the number
and type of instruments which can be placed within.
This type of probe requires use of a flexible Teflon laser
tip, which is more brittle and difficult to accurately aim
the beam onto targeted tissue.
­Cerumen Glands
Ceruminous lesions in the ear canal are large, fluid filled,
dilated ductular growths derived from the straight apo-
crine glands. They can be found as multiple raised areas
along the ear canal, or as the typical “cobblestone”
appearance to the surface, or as tumors that can be either
solitary or multiple (Figure 10.2). They produce and
secrete a liquefied lipid substance responsible for the
large amount of ceruminous accumulation in these ears.
The actual glandular tissue extends through the thick-
ness of the ear canal to the ear cartilage. Due to the
amount of water in these glands, the CO2 laser is well
suited to vaporize them.
 108 Laser Surgery Procedures of the Ear
(a)
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(b)
Figure 10.1 (a, b) 120 mm × 0.8 mm laser tip (Luxar LXT‐120ST)
threaded through the working channel of the OtoPet Video
Otoscope Probe.
Figure 10.2 Hyperplastic ceruminous glands may grow quite
large, occluding the ear canal.
Preoperative
The patient is placed under general anesthesia for this
procedure. To prevent damage to the eardrum from
unplanned movement of the laser beam, the patient is
Table 10.1 Cerumen glands.
Procedure Cerumen glands
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.8 (120–180 mm 0.25
waveguide)
Power (W) 3–4 3–4
Exposure Repeat pulse Continuous
wave
Mode Non‐SuperPulse SuperPulse
Frequency 2 Hz, 200 ms —
Duty cycle (%) 40 100
placed in lateral recumbency and a small amount of
saline is placed into the ear prior to the procedure to act
as a buffer against the laser.
Procedure
To remove ceruminous gland tumors, a 120 mm or a
180 mm stainless steel waveguide of 0.8 mm spot size is
inserted through the working channel of the scope so that
just the end of the laser tip can be seen at the top of the
video view. The laser should be set at 3–4 W of power
(Table 10.1). The preferred setting is a repeat pulse expo-
sure, which gives two 200 ms pulses per second, with a
short rest period between pulses. During the resting
phase, the smoke is dissipated by air through the laser tip.
If a continuous wave exposure is chosen, then the surgeon
must periodically stop to allow for smoke dissipation.
The procedure proceeds laterally through the tumor
mass, parallel to the ear canal. Vaporizing the mass will
increase the distance between it and the laser tip, defo-
cusing laser energy. Moving the laser tip forward during
the vaporization process prevents defocusing the beam
and thus creating excess thermal energy. Once the mass
is removed, the tip is angled toward the cartilage of the
ear canal to complete a deeper vaporization. To remove
char, a cotton swab moistened with normal saline is peri-
odically used to wipe away charred tissue. This may seem
tedious, but char removal will result in less thermal dam-
age and better postoperative results. Cotton‐tipped
applicators can be abrasive to normal ear canals, but in
hyperplastic or tumorous ear canals being lasered, this
abrasion can actually be beneficial.
When a mass is too large to perform intra‐otic laser
surgery, a lateral ear canal resection is required to expose
the base of the mass so that it can be removed. Laser
excision involves the use of a 0.25 mm spot size at
3–4 W continuous wave exposure in SuperPulse mode.
 ­Apocrine Cyst ­Apocrine Cyst 109

The incision should be done through the full thickness of Procedure

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the epidermis extending to the cartilage to prevent mass

regrowth.
Postoperative
Postoperatively, antimicrobial eardrops with a potent
steroid should be used for a week. Most of these ears are
infected prior to surgery, so treatment continues with
antimicrobial therapy based on cytology and culture.
Thermal injury may be expected in laser ear surgery, so
corticosteroid treatment (both topical and parenteral)
helps to quell inflammation. Care should be taken to use
nonototoxic drugs if the integrity of the eardrum cannot
be determined. Enrofloxacin, miconazole, and aqueous
steroids do not appear to be ototoxic.
Decompression of cysts is done with a spot size of 0.8 mm
and repeat pulse exposure (at 3–4 W of power and two
200 millisecond pulses per second, Table 10.2) to open
up the epithelial covering allowing fluid to escape. Once
cysts are decompressed by opening the cyst cavity with
the laser, the ear canal is cleaned and the remaining cyst
structure is vaporized using 6 W of laser energy in
­continuous wave exposure. In dogs, if the apocrine cysts
occlude the ear canal, cerumen, pus from infection, cells,
and hairs are trapped beyond the cyst and must be
flushed out as well.
Postoperative
A steroid‐antibiotic ointment is instilled into the ear for
a few days to decrease any thermal damage.

­Apocrine Cysts
Table 10.2 Apocrine cysts.
Dilation of the straight apocrine glands exists in both
dogs and cats. In dogs, there are often large cyst‐like
Procedure Apocrine cysts
structures in the ear canal occasionally causing a stenosis.
In cats these are often seen as multiple small dark blue to
Laser type and CO2 (10 600) CO2 (10 600)
black cystic structures along the pinna and at the opening
wavelength (nm)
of the ear canal (cystomatosis, Figure 10.3). Interestingly,
many of these cysts are filled with Malassezia organisms. Spot size (mm) 0.8 0.8
Power (W) 3–4 6
Exposure Repeat pulse Continuous
wave
Preoperative
Mode Non‐SuperPulse Non‐SuperPulse
The patient is placed under general anesthesia for this Frequency 2 Hz, 200 ms —
procedure. If there is wax and debris in the ear canal, it
Duty cycle (%) 40 100
should be flushed out and the ear canal dried.

(a) (b)

Figure 10.3 Cystadenomas in the ear canal of a cat. (a) Masses prior to laser ablation. (b) Same sites following ablation with only char
remaining.
 110 Laser Surgery Procedures of the Ear

­ asopharyngeal Polyps in Cats

N Preoperative
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and Kittens The patient is placed under general anesthesia for this
procedure. Any fluid such as pus or dried mucus should
Although more common in cats than dogs, nasopharyngeal be removed to aid visualization of the fleshy mass. The
polyps can occur in both species. Polyps in dogs are not ear canal is dried prior to laser vaporization.
usually nasopharyngeal polyps. Most often, these masses
are cerumen gland adenomas, large occlusive peduncu-
lated masses attached to the wall of the ear canal. Procedure
Sometimes these tumors grow so large that their growth Removal of small polyp masses can be done with the
extends out until they can be seen at the opening of the laser at 10–15 W in continuous wave exposure to debulk
vertical ear canal. When these tumors become too large, the polyp (Table 10.3). The laser tip should extend
laser debulking is not practical. through the ruptured eardrum into the middle ear to
Some veterinary practitioners might call any ear canal vaporize as much of the polyp stalk as possible.
growth a “polyp,” but this is not the case. A true naso- Alternatively, the largest part of the mass can be surgi-
pharyngeal polyp looks like a fleshy mass occluding the cally cut with a dermal curette or removed intact or in
lumen of the ear deep in the horizontal canal. The polyp pieces using traction and avulsion with an Allis Tissue
is actually a mass of connective tissue covered in epithe- forceps or an endoscopic grasping type of forceps.
lium. The stalk or pedicle of the polyp originates from However, there is more bleeding in the ear canal with
the respiratory tissue lining the tympanic bulla in the these instruments. Radiofrequency snares have been
middle ear or from the eustachian tube. They may be used to cauterize the area as it cuts. When using these
congenital or result from a primary middle ear infection
when infectious organisms from the upper respiratory
tract enter the bulla through the eustachian tube Table 10.3 Nasopharyngeal polyps.
(Bonagura and Twedt 2009). Growth of the polyp mass
from the middle ear through the eardrum creates sec- Procedure Nasopharyngeal polyps
ondary otitis media, as organisms and foreign material
from the external ear canal gain access to the bulla. Otitis Laser type and CO2 (10 600)
media results in significant mucus and pus accumula- wavelength (nm)
tion. These secretions leave the bulla and move to the ear Spot size (mm) 0.8 (120–180 mm waveguide)
canal where they may be seen as liquid material obscur- Power (W) 10–15
ing the polyp, or as an inspissated mass of what appears Exposure Continuous wave
to be ear wax. Diagnosis of a nasopharyngeal polyp may Mode Non‐SuperPulse
remain difficult until this liquid material is removed
Duty cycle (%) 100
(Figure 10.4).

(a) (b)

Figure 10.4 Nasopharyngeal polyp in the horizontal canal of a kitten. (a) Canal filled with pus and mucus. (b) Same ear showing the polyp
mass after removing the liquid debris in the ear canal.
 ­Myringotom ­Myringotom 111

techniques, the laser is used adjunctively in continuous catheter, which is threaded through the myringotomy
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wave to vaporize the remaining polyp stalk, and the laser
tip can be extended into the tympanic bulla to remove
some of the remaining polyp tissue.
Postoperative
Follow‐up care includes treating otitis media with oral
antibiotics (Azithromycin 5 mg/kg every other day for
two to three treatments), and using steroids topically
(Synotic, dimethyl sulfoxide [DMSO], and fluocinolone)
and orally (Prednisone 1–2 mg/kg per day) for one to two
months to prevent polyp regrowth. After treatment, the
eardrum rarely grows back completely.
incision and attached to an infusion device.
The landmarks for incising the eardrum are the pars
flaccida (the loose connective tissue on the top of the
eardrum which contains the eardrum’s blood supply),
and the manubrium of the malleus bone in the middle of
the eardrum. These structures are to be avoided if the
eardrum is to subsequently heal.
Myringotomy can be done with a polypropylene cath-
eter, but the incision it makes tends to be a flap, which
can close rapidly. Using the laser to open the eardrum
results in a circular hole, which takes more time to heal.
This is advantageous in providing a lengthier time for
drainage during therapy.

Preoperative
­Myringotomy
The patient is placed under general anesthesia for this
Many patients with ear disease also have otitis media, procedure. Wax and other debris in the horizontal ear
most with an intact ear drum. The diagnosis of otitis canal are flushed out and the ear canal is dried.
media is often overlooked. But careful consideration of
some of the following clinical signs (Gotthelf 2004) may
Procedure
alert the clinician to the condition:
Incision is done in the 5:00 position in the left eardrum,
History of chronic recurrent ear infections greater than
and in the 7:00 position in the right eardrum (Figure 10.5
six weeks.
and Video 10.1). A single pulse from 200 to 500 ms at
Opacification of the eardrum.
4–6 W may be used if the eardrum is not too thickened
Malodorous liquid discharge of mucus and pus from the
(Table 10.4). If the eardrum is thick, a repeat pulse expo-
ear.
sure at 4 W with two 200 ms pulses is used to incise
Vestibular signs (head tilt, nystagmus).
thicker tissue. The time between pulses can be used to
Facial palsy (including unilateral keratoconjunctivitis
re‐position the tip of the laser to increase the size of the
sicca [KCS]).
myringotomy hole.
Horner’s syndrome (ptosis, miosis, and enophthalmos).
Excessive head shaking especially when the external ear
canal looks normal.
Pharyngeal drainage of mucus from the bulla to the
Canine left eardrum
nasopharynx.
The severe pain associated with otitis media may also
lead to behavioral changes. Since the temporomandibu-
lar joint is adjacent to the horizontal ear canal, pain is Pars flaccida
elicited when the mouth is opened. Pain can also be
detected when palpating the base of the ear where it
Malleus
attaches to the skull. Any radiographic evidence of opaci-
fication or sclerosis of the tympanic bulla is also strongly
suggestive of otitis media. Pars tensa Incision
If the clinician suspects otitis media based on clinical
signs, and the eardrum is intact, it needs to be opened to
investigate the middle ear and provide for therapy. If
there are air or fluid pressure gradients between the mid-
dle ear and the external ear canal, then relieving this
pressure relieves pain associated with otitis media. The
hole in the eardrum allows the retrieval of material from
the middle ear for culture and cytology. Pus and mucus Figure 10.5 Canine myringotomy site, labeled to indicate the best
in the bulla need to be removed using a long p
­ olypropylene place to vaporize a hole in the eardrum.
 112 Laser Surgery Procedures of the Ear

Table 10.4 Myringotomy.

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Procedure Myringotomy

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 0.8 (120–180 mm 0.8 (120–180 mm
waveguide) waveguide)
Power (W) 4–6 4
Exposure Single pulse, Repeat pulse
200–500 ms
Mode Non‐SuperPulse Non‐SuperPulse
Frequency – 2 Hz, 200 ms
Duty cycle (%) – 40

Figure 10.7 Stenotic ear canal in a dog. Hyperplastic glands and

epithelium close down the lumen of the ear canal.

­Opening Stenotic Ear Canals

Stenosis of the ear canal is often found in dogs and cats.
Sometimes, there is a circular band of granulation tissue
from previous trauma that can be removed. More often,
when there is chronic otitis externa, there is a thickening
of glandular and epithelial tissue that reduces the diam-
eter of the lumen of the ear canal (Figure 10.7). As long as
there is no bony proliferation in the ear canal’s cartilage,
the laser can remove much of this hyperplastic tissue and
restore the lumen.

Figure 10.6 Laser myringotomy. A small circular hole is made in
the eardrum to allow fluid in the bulla to escape into the external
ear canal and to maintain equal air pressure on both sides of the
eardrum.
Preoperative
Some cases of stenosis have an inflammatory component
that can be quelled with systemic or intralesional steroid
injections 14–21 days prior to surgery. If the ear canal can
be flushed, it is cleaned with a detergent type of ear cleaner
to dissolve waxy accumulations deep in the ear canal. The
patient should be evaluated for otitis media because
detergent ear cleaners can be ototoxic. The patient is
placed under general anesthesia for this procedure.

When the eardrum is opened, and there is fluid Procedure

pressure behind the eardrum, the patient receives
almost immediate relief of vestibular signs and pain
(Figure 10.6).
Video 10.1 (This video does not include audio commentary).
Laser‐assisted myringotomy.
Postoperative
Postoperatively, nothing ototoxic should be put into the
external ear canal. Medications placed into the bulla
often leak into the horizontal canal.
Using the 0.8 mm spot size waveguide through the video
otoscope (120 or 180 mm in length), laser energy is
applied at 6–7 W continuous wave exposure, which is a
higher wattage than is ordinarily used in the ear canal
(Table 10.5). Using a circular motion with the laser tip, a
small circular segment is ablated, then the char is
removed with a saline‐soaked cotton applicator before
ablation continues. Since higher wattage is used, more
thermal damage will occur, so removing small segments
with a rest period of two weeks between laser applications
is beneficial.

Table 10.5 Stenotic ear canals.
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Procedure Stenotic ear canals
Laser type and CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.8 (120–180 mm waveguide)
Power (W) 6–7
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100
Postoperative
Follow‐up topical corticosteroids (e.g. Synotic or dexa-
methasone sodium phosphate 0.1% ophthalmic drops)
help to prevent a band of connective tissue from form-
ing, which can close the ear canal entirely.
­Procedures of the Pinna
Laser procedures used on the surface of the pinna include
removal of surface growths (such as adenomas and cys-
tomatosis), laser ear trimming, amputation of the tip of
the pinna, cautery of traumatic lesions, and aural hema-
toma repair. Typically, standard laser techniques used on
any skin lesion can be utilized to accomplish desired
goals on the pinna. With traumatic wounds and pinnal
amputations, any exposed cartilage is trimmed appropri-
ately to allow for sutures to be placed in the epithelium to
cover it. Therefore, only laser aural hematoma repair will
be discussed in this section. Here the CO2 laser is clearly
superior to diode laser due to its reduced peripheral
thermal tissue interaction and non‐contact application.
Aural Hematoma
An aural hematoma is an accumulation of blood between
the skin of the pinna and the cartilage. It can be small or
large depending on the amount of hemorrhage. It is most
often found on the concave pinna, but can be found on
the convex pinna, especially resulting from trauma
(Figure 10.8). Left untreated, the blood clot and subse-
quent fibrosis results in folding and creasing of the carti-
lage, resulting in permanent change in the shape and
contour of the pinna (known as “cauliflower ear”).
Although violent shaking of the head and pinna flap
from ear pain is the most common reason for aural
hematoma, an immunological etiology has been pro-
posed, but has not yet been scientifically validated (Joyce
and Day 1997).
­Procedures of the Pinn ­Procedures of the Pinn 113
Figure 10.8 Aural hematoma in a dog.
An essential part of treating aural hematoma is to
find the etiology of the irritation causing head shaking
that led to the hematoma. Otitis externa or media, ear
mites, foreign bodies, trauma, and allergies are com-
monly discovered when treating aural hematoma. Even
water in the ears from recent bathing can result in head
shaking violent enough to be a cause. An aural hema-
toma in one ear can also result from irritation in the
opposite ear.
Many nonsurgical treatments have been tried to treat
this condition. Teat cannulas, drains, steroid injections,
and benign neglect have been recommended, but none
of them are equal or superior to surgical drainage and
repositioning of the skin against the cartilage. Prompt
surgical repair prevents progression of aural hematoma
to a permanent disfigurement.
The objective of aural hematoma surgery is to drain
the hematoma of blood and fibrin strands and to create
granulation tissue that seals the skin to the underlying
cartilage. Regardless of which surgical procedure is
chosen for repair, failure to remove all clots and fibrin
material in the hematoma cavity will result in contrac-
ture and disfigurement of the pinna even with surgery.
After drainage, several nonabsorbable sutures are
placed vertically in the pinna to allow adhesions to
form, re‐establishing attachment of the skin to the car-
tilage. Healing in the pinna is slow, so sutures should
be left in place much longer than for other surgical
wounds (typically four weeks or longer). Due to the length
of time that the sutures remain in place, nonabsorbable
 114 Laser Surgery Procedures of the Ear
suture material is preferred to absorbable suture mate-
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rial, which may ­prematurely hydrolyze and weaken
before healing is complete.
The use of the CO2 laser to surgically treat aural hema-
toma has resulted in good healing with minimal scarring,
as well as minimal contracture of tissue, preventing
d­isfigurement. This is especially true for cats with aural
hematoma. Most alternative procedures for aural hema-
toma in cats result in folding or crinkling of the pinna
upon healing. Laser hematoma repair in felines results in
a flatter pinna when healing is complete.
Preoperative
Concurrent preoperative and postoperative treatment of
underlying otitis externa and otitis media decreases pain
and itching that causes the dog or cat to shake its head.
The patient is placed under general anesthesia for this
procedure. The hair on both sides of the pinna is shaved
and the pinnal skin is surgically prepared. Cotton is
placed in the ear canal to prevent ototoxic chlorhexidine
surgical scrub from entering the ear canal and to prevent
any blood from the hematoma draining into the ear
canal. The cotton ball is removed at the conclusion of
surgery.
Procedure
A “leather punch” technique using the CO2 laser is the
preferred method of opening up the concave pinnal skin
to allow drainage. A wide, 1.4 mm spot size is used for
this procedure, at 10–15 W continuous wave exposure
depending on the thickness of the epithelium (Table 10.6).
Moving the handpiece in a circular motion will ablate a
circular hole in the epithelium of the concave pinna in
any diameter desired by the surgeon. First, a 6–8 mm
diameter hole is created at the most distal end of the
hematoma near the apex of the pinna. That will provide
an escape route for blood, fibrin, and serum to evacuate
the hematoma cavity and decompress it. Next, a saline‐
moistened cotton‐tipped applicator is inserted through
the newly created drainage hole into the hematoma cav-
ity to break down and remove any fibrin clots within the
Table 10.6 Aural hematoma.
Procedure Aural hematoma
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 1.4
Power (W) 10–15
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100
hematoma. The swab is removed and discarded. Then a
new moistened cotton‐tipped applicator is advanced
through the hole to the farthest limit of the hematoma
along the edge of the pinna. That will mark the site for
the next 6–8 mm diameter hole to be created. The mois-
tened cotton tip also provides a backstop to the laser
energy so that the underlying cartilage remains unaf-
fected. This process is repeated until there are several
holes created along the outline of the hematoma
(Figure 10.9). Spacing between holes should be 3–4 cm
apart. Then additional holes are created in the central
portion of the hematoma in the same manner. Once the
concave pinna has evenly spaced drainage holes, sutur-
ing may begin.
The surgeon bears in mind that the blood supply to the
pinna begins at the base of the ear and arborizes distally
toward the tip of the pinna. The blood vessels course ver-
tically along the subcutis. Using a cutting needle attached
to 2‐0 nonabsorbable suture, 2 cm loops are made verti-
cally in the pinnal skin between the drainage holes, first
through the concave pinna, then through the cartilage
and finally out through the convex pinnal skin. The nee-
dle is reinserted in reverse 2 cm vertically from the exit of
suture completing the loop. Sutures are tied on the con-
cave pinna just tight enough to approximate the concave
pinnal skin to the cartilage, but not so snug as to cause
ischemia. The insertion points from the needle them-
selves will also become small attachment points to hold
the skin onto the cartilage during healing.
Postoperative
Bandages and an Elizabethan collar are typically not
required, nor are systemic antibiotics. Granulation
tissue around the periphery of the 6–8 mm drainage
holes will form over four to six weeks to provide
additional attachment points. Complete granulation
Figure 10.9 “Leather punch” technique of aural hematoma repair.

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Figure 10.10 Healed aural hematoma in a dog four weeks
post‐operatively.
can be expected in four to six weeks postoperatively
(Figure 10.10). Suture removal can be done at that time.
Resist temptation to remove sutures in 14 days as you
would for other laser procedures. If sutures are removed
too soon, there is a chance that the dog can shake the
head and the hematoma may re‐form.
Pain relief for pinnal surgery is provided by systemic
opiates. Nonsteroidal anti‐inflammatory drugs (NSAIDs)
are not often helpful in decreasing pain in the
pinna. Systemic steroids used for treatment of otitis
externa may also help remove some pain resulting
­References
Bonagura JD, Twedt DC. (2009). Nasopharyngeal polyps.
In: Kirk’s Current Veterinary Therapy XIV. W.B.
Saunders. p. 425.
Gotthelf LN. (2004). Diagnosis and treatment of otitis
media in dogs and cats. Vet. Clin. North Am. Small
Anim. Pract. 34(2). pp. 469–487.
­Reference ­Reference 115
Figure 10.11 Healed aural hematoma in a cat four weeks
postoperatively. No crinkling of the pinna is seen.
from inflammation, but they may also slow the
­h ealing process.
Postoperative care at home involves removing any
accumulated serum weeping from the drainage holes on
the surface of the concave pinna, using a washcloth soaked
with warm water applied to the pinna twice daily. Dabbing
the pinna is preferred over rubbing the pinnal skin with the
washcloth. This is continued until the serum is no longer
weeping and the concave pinna remains dry. This technique
results in a nice cosmetic pinna with minimal scar tissue
and almost no disfigurement, even in cats (Figure 10.11).
Joyce JA, Day MJ. (1997). Immunopathogenesis of canine
aural haematoma. J. Small Anim. Pract. 38(4).
pp. 152–158.
 116
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11
Periorbital and Eyelid Laser Surgery Procedures1
Daniel M. Core
­Introduction
The eyelids are important in protecting the globe, con-
junctiva, and cornea, and in the production and distribu-
tion of tears. Diseases of eyelids and periorbital tissue are
commonly encountered in small animal practice. These
conditions are more common in dogs and infrequently
encountered in cats. Clinical management of most eyelid
disorders involves surgery (Gelatt and Gelatt 2011). CO2
laser surgery is advantageous for eyelid and periorbital
tissue in that it offers a precise incision with diminished
peri‐incisional injury. Hemorrhage is minimal, and there
is diminished postoperative swelling and pain.
Anatomy
A thorough understanding of anatomy and function is
essential prior to eyelid and periorbital surgery. The eye-
lids are composed of four layers: conjunctiva, tarsus and
connective tissue, muscle, and dermis and epidermis.
The lid margin is a mucocutaneous junction. The eyelids
cover the globe. The globe is enclosed in the orbit, and
the orbit is comprised of bones, muscles, and fascia. The
orbit of the dog and cat is conical in shape. The muscular
structure of the eyelid and globe is complex. The primary
muscle of the eyelid is the orbicularis oculi. This ­circular–
oblong muscle is responsible for eyelid closure. It is
innervated by the facial nerve (CN VII). The levator pal-
pebrae superioris is responsible for eyelid opening and is
innervated by the oculomotor nerve (CN III). The eye-
lids have a rich supply of blood vessels that aid in wound
healing but can prolong conventional surgical time due
to hemorrhage. The lateral, dorsal, and ventrolateral
palpebral arteries supply blood to the lateral eyelid,
­ chiasis results in disease, most cases cause clinical signs
while the medial eyelid is supplied by branches of the
infraorbital artery. Canine eyelids have cilia or eyelashes.
1 This chapter is dedicated to Mom and Dad who always lovingly encouraged the pursuit of knowledge.
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
They are mainly located on the canine superior lid in two
to four irregular rows. Eyelashes are not present in the
cat. There are several glandular structures in the eyelid.
The eyelashes or cilia possess a modified sweat gland
(gland of Moll) and a modified sebaceous gland (gland of
Zeis). These glands are located in the cilia hair follicles.
The meibomian glands are sebaceous and are located
adjacent to the tarsal layer. They are responsible for the
lipid layer of the tear film. These glands vary in number
and are more numerous in the upper or superior lid. The
meibomian glands are oriented such that their opening
or orifice is located in the center of the eyelid margin.
The palpebral conjunctiva contains goblet cells that pro-
duce mucin.
­Distichiasis
Distichiasis is defined as hair or cilia that arise in an
abnormal location or grow in an abnormal direction on
the eyelid. These abnormal hairs arise from the meibo-
mian gland opening (Figure 11.1). Trichiasis is a condi-
tion where normally haired skin comes in contact with
the cornea. Ectopic cilia occur when cilia arise from the
conjunctiva. Distichiasis is a common condition in dogs
but rarely seen in cats. Distichiasis in humans usually
involve the lower lid and can be acquired or congenital.
Commonly affected canine breeds are the Cocker
Spaniel, English Bulldog, Toy and Miniature Poodle,
Boxer, St. Bernard, Golden Retriever, Long‐haired
Miniature Dachshund, Alsatian, Bedlington Terrier,
Shetland Sheepdog, Yorkshire Terrier, and Staffordshire
Terrier (Lackner 2001). Although not every case of disti-
of epiphora, blepharospasm, and corneal ulceration
along with occasional generalized blepharitis secondary
 ­Distichiasi 117
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Figure 11.1 English Bulldog with multiple distichia. Figure 11.2 Correct laser‐tip positioning for patient with
distichiasis.
to excessive scratching and rubbing. Diagnosis is based
upon observation of aberrant hair. Many cases are seen
as chronic recurrent cases of ulcerative keratoconjuncti-
vitis. A focal light and magnification along with fluores-
cein stain aids in diagnosis. Treatment involves removal
of aberrant hair. Manual epilation is usually temporary
and a permanent means of destruction of the hair follicle
is required to affect a cure. Cryosurgery, electro‐epilation,
and surgical wedge resection of the eyelid margins are
alternative methods of treating distichiasis. CO2 laser
ablation of the hair follicle is an excellent means of treat-
ing distichiasis because of its precision and simplicity,
with minimal inflammation, hemorrhage, and scarring.
The laser destroys the hair follicle and removes the aber-
rant hair.

Preoperative Figure 11.3 Back stop (a moistened tongue depressor) used to

Surgery involves general anesthesia. The patient is posi-
tioned in lateral recumbence with the affected eye up.
The head is elevated. A sterile water‐based nonirritating
lubricant and a moistened gauze or backstop are used to
protect the cornea.
Procedure
Laser protocol varies with experience of the laser sur-
geon. Experienced laser surgeons elect higher power
settings. The laser tip is positioned perpendicular to
the lid margin (Figures 11.2 and 11.3). An attempt to
protect cornea from laser.
place the hair as close as possible to the tip of the laser
handpiece aids in precision. The hair should not be
inserted into the handpiece tip prior to activating the
laser, as this could damage or otherwise compromise
the tip. Use a spot size of 0.25–0.4 mm at 3–5 W power
(Table 11.1). A very short laser burst of continuous
wave exposure in SuperPulse mode, or three single
pulses of single pulse exposure in non‐SuperPulse
mode, is applied to each cilia and is usually sufficient to
destroy the hair follicle.
 118 Periorbital and Eyelid Laser Surgery Procedures

Postoperative (Figure 11.4a). Breeds which have an increased incidence

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of entropion include the Chow Chow, Shar Pei, St.

Inflammation and hemorrhage are not usually observed.
Bernard, Cocker Spaniel, and English Bulldog. It is infre-
Therapy laser treatment may be used immediately after
quently observed in cats. Entropion is common in older
surgery; care should be taken to protect the eye from the
humans and generally affects the lower lid. Patients often
therapy laser beam. Topical antibiotics and mydriatics
present with excess lacrimation, epiphora, and severe
are used if corneal ulceration is present. Postoperative
blepharospasm. Corneal ulceration is often present along
topical antibiotics (with or without hydrocortisone) are
with periorbital dermatitis and blepharitis secondary to
applied three times daily for one week. Occasionally, an
scratching. Entropion treatment is aimed at returning
E‐collar is required. Owners should be advised that aber-
the eyelid margin to its normal position (Gilmer 2002).
rant lashes may recur within four to six weeks if the hair
CO2 laser surgical treatment can be non‐incisional or
follicle is not completely destroyed.
incisional.

­Entropion
Nonincisional Laser Entropion Surgery
Entropion is a condition in which a portion of the eyelid Nonincisional CO2 surgery is reserved for mild cases of
is inverted toward the globe, resulting in corneal irrita- entropion. Application of CO2 laser energy (Table 11.2)
tion, epiphora, and corneal ulceration. Entropion can be to the collagen fibers of the eyelid margins causes con-
genetic, congenital, developmental, spastic, or cicatricial traction. As a result of this contraction, the eyelid margin
“rolls out” away from the globe toward its normal posi-
tion. This procedure has been used commonly in humans
Table 11.1 Distichiasis. for skin resurfacing, rejuvenation and scar reduction,
and in the successful treatment of lower lid entropion
Procedure Distichiasis (Babuccu 2012). Nonincisional CO2 laser surgery for
mild entropion is easily performed, does not require
Laser type and CO2 (10 600) CO2 (10 600) sutures, and can result in excellent correction.
wavelength (nm)
Spot size (mm) 0.25–0.4 0.25–0.4 Preoperative
Power (W) 3–5 3–5 General anesthesia is generally required for this proce-
Exposure Continuous wave Single pulse, dure. The patient is positioned in lateral recumbence
100–200 ms with the affected eye facing up while the head is ele-
Mode SuperPulse Non‐SuperPulse vated. A sterile water‐based nonirritating lubricant and
a moistened gauze or backstop are used to protect the
Duty cycle (%) 100 –
cornea.

(a) (b)

Figure 11.4 (a) Upper and lower entropion in a Labrador Retriever. (b) Proper eyelid margin position in entropion patient. Note secondary
inflammatory change of eyelids.
 ­Entropio 119

Procedure Incisional Laser Entropion Surgery

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A series of “x’s” or “grids” (such as in a hashtag pattern, #),

More severe cases of entropion, or cases not responding
1–3 mm long and 2–3 mm apart, are created on the
to the nonincisional technique, require an incisional CO2
affected lid 2–3 mm from the lid margin while holding
laser surgical procedure. The surgery is a modified
the laser handpiece perpendicular to the eyelid (Godbold
Hotz–Celsus technique. In this procedure, the entropion
2011). Alternatively, laser energy can be applied to the
is corrected by removing a section of epidermis from the
eyelid in rows 3 mm apart parallel to the lid margin
eyelid. The orbicularis muscularis is incised or a portion
(Figures 11.5 and 11.6). These incisions are partial thick-
is removed depending on preferred technique. The
ness. As the laser energy is applied, the lid will begin to
amount of tissue to be removed is determined prior to
roll away from the cornea. Rows are continued until the
surgery by measuring and marking with ink. Incisional
lid margin is in its normal position.
CO2 laser corrective surgery for entropion (Table 11.3)
produces excellent therapeutic and cosmetic results.
Postoperative
There is minimal swelling and patients are surprisingly
Postoperative inflammation is usually minimal. A ther-
comfortable after surgery. Surgical time is significantly
apy laser may be applied to the surgical site while the
diminished due to the absence of intra‐operative hemor-
patient is recovering from anesthesia, with care taken to
rhage. Complete upper and lower entropion can be cor-
protect the eye from the beam. An E‐Collar and an anti-
rected with this procedure. This technique can also be
biotic ophthalmic ointment are used for seven days.
employed where the entropion is located at the lateral
Analgesics are used as needed. Occasionally, systemic
canthus. A Y‐V procedure can be used when there is seg-
corticosteroids are administered in an anti‐inflammatory
mental entropion.
dose to prevent self‐trauma. Follow‐up exams are
­performed at 7 and 14 days after surgery.

Table 11.2 NonIncisional laser entropion surgery.

Nonincisional laser
Procedure entropion surgery

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.4
Power (W) 8–10
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100

Figure 11.6 Postoperative appearance of entropion corrected

with nonincisional laser technique.

Table 11.3 Incisional laser entropion surgery.

Incisional laser entropion

Procedure surgery

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25 or 0.4
Power (W) 10–15
Exposure Continuous wave
Mode SuperPulse
Figure 11.5 Application of laser in nonincisional repair of Duty cycle (%) 100
entropion in a Shar Pei.
 120 Periorbital and Eyelid Laser Surgery Procedures
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Figure 11.7 Modified Hotz–Celsus laser repair of an upper and
lower entropion in an English Bulldog (note the absence of
hemorrhage).
Preoperative
The patient is anesthetized and positioned in lateral
recumbence with the affected eye facing up. The eyelids
are cleansed with a mild surgical disinfectant and flushed
with sterile saline. A sterile water‐based nonirritating
lubricant and a moistened gauze or backstop is used to
protect the cornea.
Procedure
The initial skin incision is made 1–2 mm parallel to the
lid margin just distal to the pigmented portion of the lid
margin ends. A second incision is directed parallel to the
initial incision. The amount of tissue removed is deter-
mined by severity of the entropion. The orbicularis mus-
cle is incised and the strip of eyelid between the incisions
is removed (Figure 11.7). The amount of the surgical cor-
rection should allow for 0.5–1.0 mm of additional ever-
sion of the eyelid margin that occurs during postoperative
healing (Gelatt and Gelatt 2011). The edges of the wound
are opposed with 5‐0 or 6‐0 monofilament suture in a
simple interrupted pattern (Figure 11.8). It is important
the edges of the incision are opposed, as overlapping
causes scarring. Also, care must be taken to prevent
sutures from contacting the cornea.
Postoperative
The surgical site may be treated with laser therapy while
the patient is recovering from anesthesia, with care taken
Figure 11.8 Postoperative appearance of incisional modified
Hotz–Celsus entropion repair.
to protect the eye from the beam. It is not uncommon for
the eyelid to appear mildly everted in the immediate post-
operative period. This should disappear within 24 hours of
the procedure. An Elizabethan collar is required. Topical
antibiotics and mydriatics are used if corneal ulceration is
present. Nonsteroidal anti‐inflammatory drugs (NSAIDs)
paired with opioids are used for postoperative pain man-
agement. Sutures are removed in 10–14 days.
­Lagophthalmos
Lagophthalmos is the inability to completely close the
eyelid. Proper eyelid closure and a normal blink reflex
are essential in maintaining a proper tear film and healthy
corneal surface. Brachycephalic breeds with exophthal-
mic globes such as the Pekinese, Shih Tzu, Pug, and
Lhasa Apso are at risk for lagophthalmos. These breeds
are predisposed to develop recurrent central corneal
ulceration that may perforate (Gelatt and Gelatt 2011).
Affected patients usually present with recurrent, cen-
trally located corneal ulcerations. In many cases, the
central corneal ulceration will parallel the lid margins.
Owners often comment that their pet sleeps with eyelids
incompletely closed. Surgical correction is aimed at
reducing the palpebral fissure, which will also decrease
corneal exposure, resulting in improved corneal health.
Most procedures used for entropion correction also
 ­Nasal Facial Fold Trichiasi 121

Table 11.4 Lagophthalmos. and a topical antibiotic solution and systemic analgesics
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are administered until suture removal in 10–14 days.

Procedure Lagophthalmos

Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25
Power (W) 3–4
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100
result in reducing the palpebral fissure. There are many
techniques available to correct lagophthalmos. Medial
canthoplasty utilizing a pocket approach is a surgical
technique that offers a strong repair. This is referred to as
the Harlens–Jenson technique. This procedure is per-
formed very well with CO2 laser (Table 11.4) by provid-
ing a precise incision, minimal hemorrhage and a
cosmetic result. Other surgical techniques that remove a
portion of the lid margins of the superior and inferior
lids and suturing the edge will also correct lagophthal-
mos, but the repair is weaker (Gelatt and Gelatt 2011).
Preoperative
The patient is anesthetized and positioned in lateral recum-
bence with the affected eye facing up. The head is elevated.
A sterile water‐based nonirritating lubricant and a mois-
tened gauze or backstop are used to protect the cornea.
­Nasal Facial Fold Trichiasis
Nasal facial fold trichiasis is common in brachycephalic
breeds (Figures 11.9 and 11.10).
The hair of the folds come in contact with the nictitating
membrane, conjunctiva, and cornea that results in epi-
phora, blepharospasm, conjunctivitis, corneal pigmenta-
tion, and in many cases corneal ulceration. Many patients
with chronic facial fold trichiasis are presented with kera-
toconjunctivitis sicca or “dry eye” due to exhaustion of
tear production. Although it is possible to conservatively
manage this condition with application of lubricating
ointment and trimming of the hair, most cases require
surgical excision of the facial fold. Owners should be made
aware that this procedure could alter the facial appear-
ance, a concern especially for show‐quality pets.
Preoperative
This surgery requires general anesthesia. The patient is
positioned in ventral recumbence. After the facial folds
are gently clipped, a gentle surgical scrub is applied
and flushed with sterile saline. A sterile water‐based
nonirritating lubricant and a moistened gauze or back-
stop is used to protect the cornea.

Procedure
The laser is used to prepare pockets in the medial lower
lid by splitting the lid margin. The lower lacrimal punc-
tum and canaliculus are carefully avoided. The incision is
centered on the anterior third of the margin. A similar
incision is made in the upper lid margin opposite of the
lower incision. The length of the incision should insure
closure of the lids. A flap of tissue is prepared from the
inner portion of the upper lid incision. The lid margin of
the upper lid and the medial canthal hairs are carefully
removed to prevent contact with the cornea. Absorbable
6‐0 sutures are placed in the superior flap and sutured
within the lower inferior flap. A nonabsorbable 4‐0 to
5‐0 monofilament horizontal suture is used to anchor
the superior flap to the lower pocket.

Postoperative
The surgical site may be treated with laser therapy while
the patient is recovering from anesthesia, with care taken Figure 11.9 Severe facial fold pyoderma with trichiasis in an
to protect the eye from the beam. An E‐Collar is applied English Bulldog.
 122 Periorbital and Eyelid Laser Surgery Procedures

Procedure antibiotic ointment, and analgesics. Suture removal is

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performed 10–14 days following surgery.

The facial folds are excised using a symmetrical elliptical
incision (Table 11.5). Both nasal folds should be excised
equally so that there is cosmetic symmetry. The subcu-
ticular layer is closed with a 4‐0 absorbable suture in a
simple continuous layer, and the skin edges opposed
with 4‐0 to 5‐0 nonabsorbable sutures in a simple inter-
rupted pattern.
Postoperative
The surgical site may be treated with laser therapy, while
the patient is recovering from anesthesia, with care taken
to protect the eye from the beam. Additional postopera-
tive care consists of application of an E‐Collar, topical
­ yperplasia or Prolapsed Third
H
Eyelid Gland (“Cherry Eye”)
Hyperplasia of the third eyelid gland (also known as pro-
lapse or protrusion of the gland of the nictitating mem-
brane, or “cherry eye”) is one of the most common
disorders of the third eyelid in dogs (Figure 11.11). It is
most commonly seen in young dogs (less than one year).
This condition is over‐represented in the Cocker Spaniel,
English Bulldog, Beagle, Pekinese, Boston Terrier, Bassett
Hound, Lhasa Apso, and Shih Tzu. This condition occa-
sionally occurs in young cats, especially the Burmese.
The exact pathogenesis is unknown, and it occurs bilat-
erally in many cases. Affected patients usually present
with a protruding red mass at the nasal canthus. The
gland of the nictitating membrane is responsible for a
large amount (approximately 25–40%) of the aqueous
portion of the tear film (Gelatt and Gelatt 2011).
Depending on the chronicity of the condition, the patient
will exhibit epiphora and blepharospasm, with kerato-
conjunctivitis seen in some cases. Topical antibiotics
(with or without corticosteroids) may be used in mild or
early cases. This form of conservative treatment reduces
inflammation and in some cases, the gland will return to
its normal position. This treatment is not effective in

Figure 11.10 Inflammatory change secondary to trichiasis in an

English Bulldog.

Table 11.5 Nasal facial fold trichiasis.

Procedure Nasal facial fold trichiasis

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.4
Power (W) 15–20
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100
Figure 11.11 “Cherry eye” or hyperplasia of the third eyelid.
 ­Hyperplasia or Prolapsed Third Eyelid Gland (“Cherry Eye” 123

many cases and surgical intervention is required. Prior to Procedure

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the 1980s, surgical excision of the gland was advised.

An incision is made on the caudal surface of the nictitating
However, there was a high postsurgical incidence of
membrane’s conjunctival mucosa between the prolapsed
keratoconjunctivitis sicca, and this procedure is no
gland and the lid margin of the third eyelid. This incision is
longer recommended.
made parallel to the lid margin (Figure 11.12). A second
There are three goals in any surgical procedure to cor-
conjunctival mucosal incision is performed on the nictitat-
rect prolapse of the gland of the nictitating membrane:
ing membrane between the prolapsed gland and the bulbar
1) Anatomic reduction of the gland; conjunctival fornix (Figure 11.13). These incisions should
2) Normal movement of the nictitating membrane; parallel each other and extend just proximal and distal to
3) Preserving the gland’s role in tear production (Gelatt the borders of the gland. The mucosa of each incision is
and Gelatt 2011). bluntly elevated gently from the sub mucosa. The mucosa
of the gland itself is not disturbed. A 5‐0 to 6‐0 absorbable
There are multiple surgical procedures that are pres-
suture in a simple continuous pattern is used to imbricate
ently employed to treat prolapse of the gland of the nicti-
the edges above and below the gland. The suture needle is
tating membrane. These procedures are divided into
introduced on the nasal canthal aspect of the anterior sur-
those that anchor the gland within the orbit and those
face of the nictitating membrane above the dorsal conjunc-
that cover the gland with adjacent conjunctival mucosa,
tival incision (Figure 11.14). A simple continuous pattern
reducing the prolapse. The most common and most suc-
connecting both conjunctival edges is continued laterally
cessful CO2 laser surgical procedure is the modified
to the extent of the mucosal incision. Following the final
Morgan Pocket technique, using settings as shown in
suture loop on the conjunctival mucosal membrane, the
Table 11.6.
needle is driven through the posterior surface of the nicti-
tating membrane to the anterior surface. As the suture is
Preoperative tightened, the gland retracts and the conjunctiva covers the
gland. A second simple continuous layer can be applied by
This procedure is performed under general anesthesia.
reintroducing the needle through the anterior nictitating
The patient is positioned in lateral or sternal recum-
membrane to the posterior surface and covering the first
bence with the affected eye facing up. The head is ele-
layer from lateral to medial. When the last loop of the sec-
vated to allow better surgical access. The eyes are flushed
ond layer is completed, the needle is driven through the
with sterile saline and a sterile water‐based nonirritating
lubricant and a moistened gauze or backstop is used to
protect the cornea. The nictitating membrane is grasped
with atraumatic forceps, such as DeBakey forceps, and
extended anteriorly. Alternately, stay sutures can be used
to aid in positioning the nictitating membrane. This
exposes the caudal conjunctival surface of the nictitating
membrane and the gland of the third eyelid. If the laser
delivery system is equipped with an air blower to keep
the handpiece clear of debris, this air flow should be dis-
connected prior to incision to avoid embolism of the
third eyelid’s delicate tissues.

Table 11.6 Cherry eye.

Procedure Cherry eye

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 3–4
Exposure Continuous wave
Mode Superpulse
Duty cycle (%) 100 Figure 11.12 Initial incision on the caudal surface of nictitating
membrane’s conjunctival mucosa.
 124 Periorbital and Eyelid Laser Surgery Procedures
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Figure 11.13 Second conjunctival mucosa incision located
between prolapsed gland and bulbar conjunctival fornix.
Figure 11.14 Suturing nictitating membrane incision.
posterior nictitating membrane to the anterior surface.
The ends of the suture are tied and cut short on the ante-
rior surface (Figure 11.15). The surgeon must be careful
not to connect the nasal and lateral edges of the conjuncti-
val mucosal incisions as this could interrupt the flow of
aqueous tears to the cornea.
Postoperative
The surgical site may be treated with laser therapy
while the patient is recovering from anesthesia, with a
Figure 11.15 Surgical suture knots cut close to the anterior
surface of the nictitating membrane.
moistened sponge in place to protect the eye from the
beam. An E‐Collar is employed, and topical antibiotics
and analgesics are continued for 7–10 days. Recurrence
is possible especially in large breeds. However, in most
cases, the double suture layer is effective in preventing
recurrence. Because this surgery does not involve tack-
ing, there is no restriction of the third eyelid movement.
The lack of intraoperative hemorrhage and the precision
of the conjunctival mucosa incision are hallmark advan-
tages when the CO2 laser is used for this surgery.
­CO2 Laser Surgery for Neoplasia
of the Eyelid
The most common surgical procedure of the eyelid is exci-
sion of eyelid tumors. Eyelid neoplasms are very common
in the dog. They can occur in any breed at any age but tend
to occur more frequently in older patients. The majority of
canine eyelid neoplasms is benign and arise from the mei-
bomian gland. The most common malignant neoplasms of
the eyelid are melanoma, squamous cell carcinoma, mast
cell tumor, and hemangiosarcoma. Contrary to canines,
the frequency of feline malignant eyelid neoplasia is high.
Squamous cell carcinoma comprises 60% of total malig-
nant neoplasms of the eyelid in cats and fibrosarcoma,
basal cell carcinoma, melanoma, and hemangiosarcoma
have also been reported (Gelatt and Gelatt 2011).
 ­CO2 Laser Surgery for Neoplasia of the Eyelid 125

Preoperative used by itself. More extensive masses require other

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reconstructive blepharoplasty and grafts. Patient prepa-

General anesthesia is usually required for eyelid neo-
ration is similar to that with partial excisional lid surgery.
plasm excision. The patient is positioned in lateral or
A 0.4 mm spot size and 8–12 W in continuous wave
sternal recumbence with the affected eye facing up. The
exposure and SuperPulse mode is the preferred laser
head is elevated to allow improved surgical access. After
minimal clipping of the hair, a gentle surgical disinfect-
ant is applied to the surgical field followed by a sterile
saline flush. A sterile water‐based nonirritating lubricant
and a moistened gauze or backstop are used to protect
the cornea.

Procedure
The laser technique varies with the size and location of
the neoplasm. Masses that affect only the skin and sub-
cutaneous layer and those which affect only the tarsal or
conjunctival layer can be excised in a partial thickness
manner (Figures 11.16–11.18). This is performed by
using a chalazion clamp or tongue depressor as a back-
stop. A 0.25–0.4 mm spot size and a laser setting of
3–5 W on continuous wave exposure and SuperPulse
mode is used to excise the mass (Table 11.7). Most par-
tial thickness CO2 laser excisions do not require suture,
produce minimal scar and cicatricial effects, and have
pleasant cosmetic results.
For larger, invasive neoplasms, CO2 laser full thickness
V‐plasty of the eyelid is performed. If the eyelid mass
involves less than 35% of the lid margin, V‐plasty can be
Figure 11.17 Immediate postoperative photo of incised fibroma.

Figure 11.16 Ulcerated fibroma on the inferior lid on an English Figure 11.18 Postoperative photo of excised fibroma. Surgical
Bulldog. margins were clear of neoplastic cells.
 126 Periorbital and Eyelid Laser Surgery Procedures

s­etting; higher power settings can be used depending on buried to prevent corneal irritation. The first buried
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the experience and expertise of the surgeon (Table 11.7). suture is appositional and is critical for eyelid alignment
A V‐shaped full thickness eyelid incision is performed to (Figure 11.23). This suture is very similar to a s­ ubcuticular
completely remove the mass (Figures 11.19–11.21). It is suture. As tension is applied to the suture, the margins
suggested that the length of the V‐incision be double the
amount of lid margin removed (Gelatt and Gelatt 2011).
If possible, the puncta and lacrimal drainage should be
identified and avoided (Figure 11.22). Hemorrhage is
usually minimal or absent. Wound closure consists of
two layers. The tarsal, muscular, and conjunctival layer is
closed with 5‐0 to 6‐0 absorbable suture (preferably pol-
yfilament) in a simple interrupted pattern with the knots

Table 11.7 Eyelid neoplasia.

Procedure Eyelid neoplasia

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 0.25 or 0.4 0.4
Power (W) 3–5 8–12
Exposure Continuous wave Continuous wave
Mode SuperPulse SuperPulse
Duty cycle (%) 100 100

Figure 11.20 V‐plasty incision of eyelid mass.

Figure 11.19 Meibomian gland adenoma of upper eyelid at nasal Figure 11.21 Tongue depressor back stop to prevent corneal
canthus. damage from laser.

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Figure 11.22 Twenty‐four‐gauge catheter prepositioned within
lacrimal puncta.
Figure 11.23 Initial subcutaneous appositional suture with 5‐0
absorbable suture in a V‐plasty eyelid repair.
of the incision are drawn together. The remaining inci-
sion is closed in a similar manner. When this buried
layer is completed, there should be no noticeable notch
or “V” at the edges of the incision. The skin is closed with
­Conclusio 127
Figure 11.24 Postoperative photo of completed V‐plasty of
meibomian adenoma of an eyelid.
5‐0 to 6‐0 monofilament suture. It is important that the
depth and distance of suture placement be identical so
the resulting incision is appositional. Skin sutures should
be positioned and trimmed to prevent corneal irritation
(Figure 11.24).
Postoperative
Aftercare for superficial masses involves an E‐Collar
and a topical antibiotic (with or without a corticoster-
oid) for seven days. For masses requiring larger resec-
tions or grafts, postoperative analgesia is provided along
with an E‐Collar and topical antibiotics for 7–14 days.
Sutures are removed in 10–14 days. All tissue removed
should be submitted for histopathological review.
Postoperative laser therapy on neoplastic disease is
contraindicated.
­Conclusion
Pathology of the eyelid and periorbital tissue is com-
monly encountered in small animal practice. Many of
these conditions are best managed surgically. CO2 laser
on these tissues offers incisional precision, minimal
hemorrhage, diminished surgical time with less postop-
erative pain and inflammation, and excellent cosmetic
results.
 128 Periorbital and Eyelid Laser Surgery Procedures
­References
VetBooks.ir
Babuccu O. (2012). An alternate approach for involution
entropion; a preliminary study. Laser Med. Sci. 27(5).
pp. 1009–1012.
Gelatt K, Gelatt J. (2011). Small Animal Ophthalmic
Surgery: Practical Techniques for the Veterinarian.
New York, NY: Elsevier.
Gilmer M. (2002). Laser in ophthalmology. Vet. Clin. North
Am. 32(3). pp. 649–672.
Godbold J. (2011). Ophthalmic procedures (Entropion)
Atlas of CO2 Laser Surgical Procedures. Stonehaven Park
Veterinary Hospital Laser Surgery Center, Jackson,
Tennessee.
Lackner P. (2001). Techniques for surgical correction of
adnexal disease. Clin. Tech. Small Anim. Pract. 16(1).
pp. 40–50.

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12
Ophthalmic Lasers for the Treatment of Glaucoma
Noelle La Croix and Jay Wayne
­Lasers in Ophthalmic Procedures
The most common laser utilized in veterinary ophthal-
mology is the 810 nm diode laser on a continuous wave
or micropulse setting (Bras and Maggio 2015). Similar to
the visible spectrum, the near‐infrared spectrum of
diode lasers can pass through both cornea and lens to
reach the posterior segment of the eye (Figure 12.1) (van
den Berg and Spekreijse 1997). An ultraviolet, mid‐infrared,
or far‐infrared spectrum laser does not share this
­penetrance (van den Berg and Spekreijse 1997; Soderberg
et al. 2016). The 810 nm wavelength of the diode laser is
also more readily absorbed by target tissue containing
melanin when compared with wavelengths produced by
neodymium‐doped yttrium aluminum garnet (Nd:YAG)
lasers (Figure 12.2) (Gabel et al. 1978; Brancato et al.
1991; Ash et al. 2015). In addition, diode lasers are pref-
erentially utilized in intraocular surgery due to their
affordability, portability, and ability to be supplied with
energy provided by common electrical outlets (Bras and
Maggio 2015).
The kinetic energy generated by a diode laser disrupts
both hydrogen bonds and van der Waals forces to dena-
ture collagen. In response to this energy, tropocollagen
fibrils denature from a triple helical structure to a more
randomized coil. The fibrils then contract as covalent
cross‐linking bonds shorten their longitudinal axes but
thicken their perpendicular axes (Vogel and Venugopalan
2003). Within the eye, collagenous fibers of the ciliary
body are thus contracted and can be permanently dam-
aged by energy of a penetrating diode laser. A diode laser
can thus generate a thermal burn with subsequent atro-
phy of the ciliary body, lessening the impact of glaucoma.
Thermal burns produced by diode lasers similarly cause
atrophy of ocular neoplasms. Diode laser thermal dam-
age is also used to accelerate the process of scarification
to prevent retinal detachments. Notably, the effects of
diode lasers are not readily apparent but rather develop
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
129
within one to two weeks postoperatively (Bras and
Maggio 2015).
Covalent bonds between the surface proteins of con-
nected cells within tissues can be broken by thermal
energy produced by a laser. Typically, the total mechani-
cal breakdown (disintegration) of a tissue requires a ther-
mal elevation in tissue temperature to 100 °C. To prevent
this tissue disintegration, diode laser energy is applied
for only milliseconds (Vogel and Venugopalan 2003).
­ iode Lasers for Glaucoma
D
Treatment
Glaucoma is the result of progressive dysfunction and
death of retinal ganglia. Retinal ganglia are nerve cells
that transmit retinal imagery through the optic nerve to
the midbrain. Increases in intraocular pressure (IOP) are
associated with death of retinal ganglia, but the mecha-
nism by which this occurs remains elusive. Retinal gan-
glion cell death may result from restricted axoplasmic
flow, physical pressure, or via secondary ischemia. Once
a retinal ganglion cell has died, it is not replaced by new
retinal ganglia (Quigley 2011).
An increase in IOP is the most consistent risk factor
that has been correlated with retinal ganglia cell death.
The IOP is exerted by a fluid (aqueous humor) resid-
ing between the lens and cornea of the eye. This aque-
ous humor supplies nutrition and oxygen to the
avascular tissues of the eye which include the lens,
anterior vitreous, posterior cornea, and trabecular
meshwork. Aqueous humor is secreted by the ciliary
body, flows between the lens and iris, and then travels
through the pupil into the anterior chamber
(Figure 12.3) (Miller 2001).
Aqueous humor is drained from the eye by two path-
ways, described as conventional (trabecular) and non-
conventional (uveoscleral) outflow. In conventional
 130 Ophthalmic Lasers for the Treatment of Glaucoma
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Ultraviolet C & B (100–315 nm) Cornea

Ultraviolet A (315–400 nm) Lens

Visible (380–790 nm) Retina

Infrared A (750–1400 nm) Retina

Infrared B & C (1400–8000 nm) Surface

Figure 12.1 Wavelengths of light and penetrance of the eye.

100 outflow, aqueous humor flows through the trabecular

meshwork, angular aqueous plexus, and intrascleral
plexus before exiting through episcleral veins. In dogs,
30
the majority of aqueous humor outflow is conventional.
Absorption (%)

Diode (810 nm)

In nonconventional outflow the aqueous humor flows
10 through ciliary muscle bundles and the supraciliary and
Nd:YAG (1064 nm) suprachoroidal spaces, before draining through the
sclera (Samuelson 2013).
3 Glaucoma is designated as a primary (inherited) defect
or secondary to other defects including intraocular hem-
0 orrhage, lens displacement, uveitis, intraocular cancer,
400 500 600 700 800 900 1000 1100 intumescent cataract formation, and complications fol-
lowing intraocular surgery (Plummer et al. 2013).
Wavelength (nm) Primary glaucomas are typically described as either
Figure 12.2 Light absorption by human pigment epithelium. “open‐angle” or “closed‐angle.” The majority of human
Source: Data from Gabel et al. (1978). glaucomas are open‐angle. In open‐angle glaucoma the
opening to the trabecular meshwork, or drainage angle,
is open to the flow of aqueous humor. However, the
flow through the meshwork is compromised by an
accumulation of debris, a loss of trabecular endothelia,
C I a decrease in meshwork pore size, or changes in tra-
becular vacuoles (Jonas et al. 2017). As an analogy, con-
A sider the opening of the trabecular meshwork similar to
D
a drain, whereas the meshwork itself is piping leading
away from that drain. In open‐angle glaucoma, the
drain is open, but the pipes leading away from it are
P clogged. Therefore, open‐angle glaucoma typically pro-
gresses gradually, without significant pain, as the drain
L slowly clogs, and IOP gradually elevates. With steady
increases in IOP, pressure‐induced ischemia of the
optic nerve can occur (Fechtner and Weinreb 1994).
But in humans, this ischemia can often be prevented by
autoregulatory vasodilation. Thus, the common open‐
angle glaucoma of humans does not generally lead to a
Figure 12.3 Anatomy of the canine eye: a normal canine lens (L),
complete loss of vision with continuous monitoring of
iris (I), cornea (C), anterior chamber (A), posterior chamber (P), and IOP and appropriate intervention by an o­ phthalmologist
drainage angle (D). Source: Courtesy of Paul Miller. (Jonas et al. 2017).

Unfortunately, most primary glaucomas of dogs are
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classified as closed‐angle. In closed‐angle glaucoma, the
iris is positioned so that access to the opening (drainage
angle) of the trabecular meshwork is severely restricted.
In our plumbing analogy, the drain itself is malformed
and has smaller drainage holes. Certain dog breeds (e.g.
American Cocker Spaniel, Basset Hound, Chow, English
Cocker Spaniel, and Siberian Husky) are associated with
goniodysgenesis, or pectinate ligament dysgenesis, that
decreases the size of the drain. However, the malforma-
tion of the drainage angle is not the only factor predis-
posing a dog to developing closed‐angle glaucoma
(Plummer et al. 2013).
Breeds with goniodysgenesis do not usually develop
glaucoma at a young age. The first incidence of glaucoma
is typically between five and six years. In young dogs, the
anterior chamber can compensate for iris dilation with-
out angle closure. However, intraocular lenses increase
in size and volume with age. Larger lenses cause the iris
to bow forward, decreasing anterior chamber depth. A
small anterior chamber repositions the iris so that its
movement during dilation blocks the drainage angle
(Figure 12.4) (Miller 2008). This can lead to an acute
entrapment of aqueous fluid behind the iris, rapidly
increasing IOP (Tsai et al. 2013). This IOP increase is
extremely painful and death of retinal ganglia quickly fol-
low as there is little time for autoregulation to protect the
retina. In this way, the common canine closed‐angle
glaucoma is often blinding.
The progression of potentially blinding canine
closed‐angle glaucoma can be limited by the use of sur-
gical lasers. There are primarily three procedures in
which a laser can be used to impede increases in IOP:
2 ary body. The procedure causes partial destruction of the
1
Figure 12.4 Canine closed‐angle glaucoma: the iris prevents fluid
from moving past the pupil (1) causing closure of the drainage
angle (2). Gray arrows represent restricted aqueous humor flow.
Source: Miller (2008). Reproduced with permission of Elsevier.
­Diode Lasers for Glaucoma Treatmen 131
argon laser trabeculoplasty (ALT) (Igarashi et al. 2003),
argon or Nd:YAG laser peripheral iridotomy (LPI)
(Brinkmann et al. 1992), and cyclophotocoagulation
(CPC) (Gilmour 2002).
ALT has been shown to lower the IOP of human eyes
by opening the drainage angle directly or through the
release of inflammatory cytokines. This ALT procedure
is primarily effective in cases of open‐angle glaucoma
(Moore et al. 2015). However, the ALT procedure is
contraindicated for the more common closed‐angle
­
glaucoma of dogs. The canine iridocorneal angle is typi-
cal of a carnivore and significantly different anatomically
from that of primates (Samuelson 2013). For these rea-
sons, the ALT procedure is rarely performed to decrease
canine IOP.
In human closed‐angle glaucoma, both Nd:YAG and
argon lasers have been used to create small holes within
the iris, allowing aqueous humor to flow freely from pos-
terior to anterior chamber. This procedure, known as a
LPI, prevents occurrence of pupillary block glaucoma.
The Nd:YAG‐based LPI procedure has been performed
in glaucomatous dogs. Initially, 91% of eyes treated by
LPI decreased their retention of aqueous humor behind
the iris. However, all iridotomy sites eventually closed
within one day to four years of the LPI. The subsequent
recurrence of increased IOP resulted in a majority of the
dogs becoming blind (Brinkmann et al. 1992). This
study’s poor results, and expenses associated with
Nd:YAG lasers, precluded any further study of this type
of LPI for dogs. A diode laser‐based LPI procedure has
yet to be published. However, diode lasers typically cause
thermal burns rather than generating holes within
tissues. A diode laser‐based LPI would probably be
­
unsuccessful in decreasing IOP of dogs with closed‐angle
glaucoma.
Fortunately, one laser‐based procedure has been suc-
cessful and used with some regularity in the treatment of
canine closed‐angle glaucoma. The procedure, known as
CPC, utilizes the energy of a diode laser to ablate the cili-
ciliary body through epithelial and coagulation necrosis
(Figure 12.5). Coagulation necrosis cell death is generally
caused by ischemia or infarction. However, coagulation
necrosis can also be induced by high temperatures.
Diode laser energy is thought to be selectively absorbed
by the outer pigmented epithelia and by the inner non-
pigmented aqueous humor‐producing epithelia of the
ciliary processes. Thermal burning by the laser also
causes vascular occlusion and nonperfusion of the ciliary
processes (Bras and Maggio 2015).
The CPC procedure should decrease aqueous fluid
production by the anterior nonpigmented epithelia of
the ciliary body, resulting in subsequent decrease in IOP.
The CPC procedure can cause collateral damage,
 132 Ophthalmic Lasers for the Treatment of Glaucoma
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Figure 12.5 Ciliary body epithelia necrosis secondary to
cyclophotocoagulation. Source: Courtesy of Richard Dubielzig and
Leandro Teixeira.
Figure 12.6 Thermal burn and retinal detachment secondary to
cyclophotocoagulation: arrows indicate an area of thermally
damaged sclera, and the asterisk indicates a retinal detachment.
Source: Courtesy of Richard Dubielzig and Leandro Teixeira.
i­ncluding marked disruption of the ciliary epithelium
with severe adjacent damage to the ciliary muscle, cor-
neal stroma, and sclera (Figure 12.6) (Bras and Maggio
2015). Collateral damage of the long ciliary nerves and
their secondary corneal branches can also lead to cor-
neal ulceration and decreased tear production
(Figure 12.7) (La Croix et al. 2004). These undesirable
corneal consequences are believed to be secondary to
decreased corneal sensitivity and decreased produc-
tion of nerve epithelial trophic factors (Crabtree et al.
2017). Severe complications of CPC include inflamma-
tion, acute elevations (spikes) in IOP, and retinal
detachments that can cause blindness (Figure 12.8)
(Bras and Maggio 2015).
Figure 12.7 Long ciliary nerve necrosis secondary to
cyclophotocoagulation. Source: Courtesy of Richard Dubielzig and
Leandro Teixeira.
Figure 12.8 Retinal detachment secondary to
cyclophotocoagulation: asterisks indicate drainage vein dilation.
Source: Courtesy of Richard Dubielzig and Leandro Teixeira.
In CPC diode laser energy can be directed at the cili-
ary processes through the sclera (transscleral cyclo-
photocoagulation, TSCP) or directly to the ciliary
processes endoscopically (endoscopic cyclophotoco-
agulation, ECP). The latest TSCP procedures use
micropulse (micropulse transscleral cyclophotocoagula-
tion, mTSCP) rather than a continuous wave of energy
from the diode laser. This laser micropulsing decreases
the time in which heat can collaterally damage adjacent
tissue (Sebbag et al. 2017; Sapienza et al. 2017). Veterinary
studies comparing efficacy of TSCP, mTSCP, and ECP
have yet to be published. Presently, all of these methods
of CPC are being used to treat both primary and second-
ary glaucomas of both dogs and cats (Bras and Maggio
2015; Sebbag et al. 2017; Pelych and La Croix 2017). The
CPC performed on glaucomatous horses is most com-
monly TSCP (Harrington et al. 2013).
 ­Diode Lasers for Glaucoma Treatmen 133

The variety of lasers available to treat glaucomatous Table 12.1 Typical settings for transscleral
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animals will invariably increase in the future. For now, cyclophotocoagulation (TSCP).
CPC procedures have been shown to delay onset but not
prevent eventual blindness in glaucomatous animals. It is Procedure TSCP
believed that in patients treated with CPC procedures the
Laser type and Diode laser (810)
ciliary processes ultimately regenerate, leading to recur-
wavelength (nm)
rence of glaucoma (Bras and Maggio 2015). All CPC pro-
Delivery system 600 μm glaucoma probe (G‐Probe)
cedures require either intravenous (for mTSCP) or
inhalant (for TCSP and ECP) anesthesia, which carries Sites (°) 24–55
associated risks. Control of IOP during the postoperative Power (mW) 1000–1500/site
period following CPC procedures is critical as the trauma Exposure Continuous wave
of the procedure itself can lead to IOP spikes and subse- Duration (ms) 1500–4000/site
quent visual loss (Bras and Maggio 2015). Clients must be
Energy (J) 2.25–4.0/site
made aware of the risks of these procedures and their lim-
Duty cycle (%) 100
ited ability to abate the progression of glaucoma.

Preoperative Treatments for TSCP,

mTSCP, and ECP
The goal of CPC is destruction of the ciliary processes
that produce aqueous humor. However, the diode laser
also causes disruption of the blood‐aqueous barrier that
may lead to secondary inflammation. This inflammation
can ultimately result in retinal detachment, synechiae, or
glaucoma. Therefore, topical and systemic preoperative
anti‐inflammatories are often used to dampen the
inflammatory response or shorten its duration (Bras and
Maggio 2015).
Steroidal topical anti‐inflammatory drops that pene-
trate into the anterior chamber include prednisolone
acetate and dexamethasone. Topical nonsteroidal anti‐
inflammatories that can be used include diclofenac,
ketorolac, bromfenac, nepafenac, and flurbiprofen. Figure 12.9 Transscleral cyclophotocoagulation (TSCP).
Topical steroidal and nonsteroidal drops can be used in
tandem. Systemically, oral prednisone or injectable dexa- 50–2000 mW). The diode laser can be used in a continu-
methasone is used at standard anti‐inflammatory dosages. ous or micropulse mode, with exposure durations
Oral or subcutaneous carprofen can be used in lieu of between 10–9000 ms repeated at intervals of 50–1000 ms
other systemic steroids at a dose of 2.2 mg/kg prior to sur- (see Table 12.1 for typical settings). The energy is deliv-
gery. In addition, intravenous flunixin meglumine (Fort ered via a transscleral 600‐μm glaucoma probe. The fiber
Dodge, St. Joseph, MO) at 0.5–1.1 mg/kg, provided during of this G‐probe has a polished, and hemispheric tip pro-
anesthetic induction, can help reduce postoperative truding from a scleral footplate that allows precise con-
inflammation and intraocular fibrin formation. A single sistent placement of laser energy in relation to the sclera.
intravenous dose of mannitol at 1 g/kg can be given one The hemispheric tip extends 0.55 mm beyond the foot-
hour prior to CPC to reduce the incidence of postsurgical plate to allow for scleral indention for better penetration
IOP spikes. Any previously prescribed systemic and topi- of energy past the sclera to reach target ciliary processes
cal anti‐glaucoma medications are continued throughout (Figure 12.9) (Bras and Maggio 2015).
CPC and are only tapered following an adequate reduc-
tion in IOP (Bras and Maggio 2015; Bras 2017). Procedure (TSCP)
The TSCP procedure is performed under general anes-
thesia with the patient placed in either sternal or lateral
Transscleral Cyclophotocoagulation (TSCP)
recumbence. An eyelid speculum exposes the sclera
Commercially available veterinary TSCP devices utilize and perilimbal silk stay sutures are placed at 9 and 3
a laser aiming beam of 630–670 nm (0–0.1 mW) and an o’clock positions; stay sutures allow for manipulation
810 nm treatment diode laser (capable of delivering and secure positioning of the globe without trauma
 134 Ophthalmic Lasers for the Treatment of Glaucoma

i­ntroduced by forceps. The stay sutures also mark the Micropulse Transscleral
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position of the medial and lateral long ciliary artery and Cyclophotocoagulation (mTSCP)
nerves that must not be lasered during TSCP proce-
There is normally collateral damage to intraocular tis-
dures. Laser damage of the long ciliary nerves can result
sues introduced by traditional diode laser‐based TSCP.
in loss of corneal sensation, neurotrophic keratitis, and
Typical collateral damages include retinal detachments,
even corneal rupture. Laser damage of the long ciliary
thermal burns of the ciliary body or sclera, severe inflam-
arteries can lead to hypoperfusion of the anterior uvea
mation (R. Dubielzig, personal communication), and
(Bras and Maggio 2015).
postoperative spikes of IOP (Bras 2015). Micropulse
A G‐probe is positioned 3 mm from the limbus so that
technology was introduced to TSCP procedures
laser energy is maximally applied to the ciliary body
(mTSCP) to reduce collateral thermal damage of TSCP
(Figure 12.9). During lasering, the cornea is continuously
(Sebbag et al. 2017).
flushed with cold (0–2.2 °C) sterile saline. This saline
The photocoagulation effects produced by a tradi-
rinse prevents corneal desiccation and limits collateral
tional continuous 810 nm diode laser can only be
thermal damage to corneal nerves that could lead to sub-
adjusted by the amount of energy supplied and by the
sequent ulcerations (S.E. Kirschner, personal communi-
duration of its application. Micropulse lasers (capable of
cation). Typically, between 24 and 45 sites along the
2000–2800 mW of continuous power) further divide
ciliary processes are lasered during TSCP. However,
light into less energetic packets applied in narrowed
effects on the ciliary body are not immediately visibly
durations. Each micropulse duration is surrounded by
apparent to the operating surgeon performing the proce-
time periods in which the laser is not supplying energy to
dure. The surgeon’s goal is to disrupt the ciliary processes
the tissue. Surgeons can adjust the power of each micro-
with restricted amounts of energy while avoiding power
pulse and the intervals of time between each pulse. This
levels associated with postoperative complications.
is described as the “duty cycle” of the laser. For example,
When the threshold between desirable tissue coagula-
a micropulse laser emitting energy only 33% of its active
tion and undesirable disintegration is exceeded, an audi-
time (or without emission for 67% of its active time) is
ble “pop” is produced during TSCP. This “pop” implies
described as having a 33% duty cycle (see Table 12.2 for
that laser energy is excessive and should be reduced to
typical settings). The interrupted bursts of energy pro-
limit tissue necrosis, postoperative inflammation, and
duced by micropulse lasers are thought to limit thermal
other complications. Surgeons performing TSCP
energy spreading to adjacent tissues. Essentially, micro-
increase the energy supplied by their laser at a site until
pulse lasers limit collateral thermal damage by allowing
the first “pop” is heard. Energy levels are then subtly
tissues time to cool between exposures of laser energy
decreased so that subsequent “pops” are not produced
(Sebbag et al. 2017; Sapienza et al. 2017; Pelych and La
at other sites. Surgeons typically divide lasered sites
Croix 2017).
equally between the dorsal and ventral sclera (Bras and
Maggio 2015).
Preoperative (mTSCP)
Postoperative (TSCP) The preoperative treatments for mTSCP and TSCP
At the conclusion of a TSCP procedure, IOP of the ­procedures are identical (see above).
lasered eye is determined by applanation or rebound
tonometry. If IOP exceeds 25 mmHg, then passive aque-
ocentesis (anterior chamber paracentesis) is performed
Table 12.2 Typical settings for micropulse transscleral
to remove aqueous humor and lower IOP to approxi-
cyclophotocoagulation (mTSCP).
mately 15 mmHg. The IOP of the surgical eye is also
closely monitored, preferably within a hospital, for at
Procedure mTSCP
least 24 hours postoperatively. Any acute IOP spikes can
be decreased by further aqueocentesis or intravenous Laser type and wavelength (nm) Diode laser (810)
injections of mannitol. If overnight hospitalization is not
Delivery system MP3‐probe
possible, then the IOP of the lasered eye should be deter-
Sites (°) 320–340
mined in the morning of the day following surgery. The
IOP of the lasered eye is then usually re‐evaluated in Power (mW) 2000
expanding intervals of one, two to three, and then four to Exposure Micropulse
six weeks postoperatively. However, daily monitoring is Duration (ms) 18 000
warranted for one to two weeks postoperatively if any Energy (J) 12
significant fluctuations in IOP are observed (Bras and
Duty cycle (%) 33
Maggio 2015).

Procedure (mTSCP)
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The mTSCP can be performed under sedation with dex-
medetomidine (Dexdomitor™, Zoetis, Parsippany, NJ)
with the patient placed in either sternal or lateral recum-
bence. As in TSCP, an eyelid speculum exposes the sclera
and perilimbal silk stay sutures are placed at 9 and
3 o’clock positions. The stay sutures allow manipulation
and positioning of the globe while marking the position
of the medial and lateral long ciliary artery and nerves to
be avoided during lasering (Sebbag et al. 2017).
In TSCP procedures, a G‐probe is applied at multiple
individual sites along the limbus to coagulate the ciliary
processes. In contrast, during mTSCP procedures an
MP3‐probe is applied in a sweeping motion parallel to
the limbus for a specific period of time. The shorter edge
of an MP3‐probe footplate (Figure 12.10) is placed on the
limbus and a surgeon activates the laser with a foot pedal.
As in a TSCP procedure, a continuous flush of cold
(0–2.2 °C) sterile saline is applied throughout the mTSCP
procedure (S.E. Kirschner, personal communication).
One or two quick laser pulses are applied as the MP3‐
probe is slowly slid along the entire span of the dorsal
limbus (typically requiring about 90 seconds in total) fol-
lowed by a similar second spanning of the ventral limbus.
No audible “pops” should be produced during the
mTSCP procedure, as small packets of energy should
coagulate the ciliary body without thermal burning
(Figure 12.11) (Sebbag et al. 2017). The thermal burn
complications associated with TCSP procedures are
therefore greatly reduced by mTSCP.
Figure 12.10 Micropulse transscleral cyclophotocoagulation
(mTSCP).
­Diode Lasers for Glaucoma Treatmen 135
Postoperative (mTSCP)
The postoperative treatments for mTSCP and TSCP
procedures are identical (see above).
mTSCP vs. TSCP
The first commercially available lasers used by veteri-
nary ophthalmologists to treat glaucoma performed
only TSCP. Common postoperative IOP spikes associ-
ated with TSCP led to routine addition of an intro-
duced drainage valve (Ahmed® glaucoma valve, New
World Medical, Rancho Cucamonga, CA) during the
procedure. The Ahmed glaucoma valve functioned to
limit IOP spikes for two to three weeks postoperatively
before the effects of TSCP on the ciliary body limited
aqueous humor production (Sapienza and van der
Woerdt 2005). The mTSCP procedure was then intro-
duced to limit collateral damage. In addition, mTSCP
procedures have been shown to be effective in treating
glaucoma of dogs with slower gradual increases in IOP.
The mTSCP procedure has also been effective in limit-
ing glaucoma in dogs with goniodysgenesis and those
with elevations in IOP following cataract surgery.
Many of these patients retain vision following a single
mTSCP procedure, and the procedure can be repeated
if necessary. However, both TSCP and mTSCP proce-
dures are generally not applicable in patients with
acute spikes in IOP (Sapienza 2016). A dog’s eye
blinded within 24–48 hours of an IOP spike of
60 mmHg or more typically suffers from closed‐angle
glaucoma with acute pupillary blockage. The effects of
mTSCP and TSCP lasers will not affect the ciliary pro-
cess quickly enough to preserve vision in these ani-
mals. Fortunately, ECP procedure can be therapeutic
for acute spikes in IOP.
Diode Endoscopic Cyclophotocoagulation (ECP)
The TSCP and mTSCP procedures do not allow sur-
geons to directly visualize, or assess their accuracy in
striking, the ciliary processes. An endoscopic technology
was developed for surgeons to directly visualize ciliary
processes during laser surgery. An ECP procedure com-
bines an 810 nm diode laser, a helium‐neon aiming beam,
a xenon illuminating light source, and fiber‐optic video
technology into one handpiece. This ECP handpiece has
a 30 mm fiber‐optic endoscopic extension with a diame-
ter of 1 mm that is approximately equivalent to a 19–27‐
gauge needle (Figure 12.12). The fiber‐optic technology
of ECP allows an ophthalmic surgeon to enter the eye
and directly view and laser the ciliary processes. Surgeons
commonly make one to two limbal incisions to reach the
majority of the ciliary processes with a curved endoscope
(Figure 12.13). Alternatively (and less commonly), a
 136 Ophthalmic Lasers for the Treatment of Glaucoma
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Ciliary body/iris epithelium
necrosis
Figure 12.12 Endoscopic curved cyclophotocoagulation probe.
Figure 12.13 An endoscopic cyclophotocoagulation (ECP) probe
introduced through a limbal incision. Source: Bras and Maggio
(2015). Reproduced with permission of Elsevier.
curved endoscope can reach the majority of ciliary pro-
cesses with three to four incisions through the pars
plana. A curved endoscopic probe can reach up to 300°
of the ciliary processes through a single limbal incision,
which is preferable to the more limited 180° accessed by
a straight endoscopic probe (Uram 2003).
During ECP a surgeon monitors progress on a video
screen rather than through a microscope aimed directly
Figure 12.11 Ciliary epithelia necrosis secondary to
micropulse transscleral cyclophotocoagulation
(mTSCP). Source: Courtesy of Richard Dubielzig and
Leandro Teixeira.
200 μm
Figure 12.14 Surgeon viewing progress of an endoscopic
cyclophotocoagulation (ECP) procedure. Source: Bras and
Maggio (2015). Reproduced with permission of Elsevier.
at the patient’s eye (Figure 12.14). The video image has a
specific “top” and “bottom.” For example, when a surgeon
approaches the ciliary processes from the limbus in an
eye with an intraocular lens, the top of the image is pos-
terior to the iris, while the bottom of the image is the
intraocular lens (Bras 2017). The field of view of the
endoscopic video camera is between 300 and 500 μm,
and traces of blood or other debris easily blur this view.
Excessive debris can also diffuse the xenon illumination,
misalign the aiming beam, and block the diode laser.
Periodic cleaning of the distal viewing end of the endo-
scope with cellulose sponges (WECK‐CEL® sponges,
Beaver‐Visitec International, Waltham, MA) assist in

restricting accumulation of debris during the procedure.
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Black spots on video images can be due to debris or
­scotomas (blind spots) secondary to damage of the fiber‐
optic cables. Any physical damage to the integrity of the
endoscope will necessitate its replacement (Uram 2003).
Interestingly, ECP images are not greatly affected by
pupillary dilation, incidental room lighting, or even micro-
scopic illumination. However, the level of xenon illumina-
tion from an endoscope is critical. As an endoscope
approaches the ciliary processes, excessive xenon illumi-
nation can overexpose the image, so it should be reduced.
Conversely, as a surgeon pulls an endoscope back from the
ciliary processes for a more panoramic view, xenon illumi-
nation must be increased (Uram 2003).
Preoperative (ECP)
The preoperative treatments for ECP are identical to
those of TSCP and mTSCP with three modifications,
since ECP incisions will open and expose intraocular tis-
sues to surgical equipment. First, oral (cephazolin or
amoxicillin/clavulanic acid) and topical antibiotics (neo-
mycin‐polymyxin‐gramicidin, tobramycin, or ofloxacin)
are applied preoperatively to prevent secondary infec-
tions. Second, prostaglandin analogs (latanoprost,
bimatoprost, travoprost, or tafluprost) as anti‐glaucom-
ics are discontinued 24 hours prior to surgery to prevent
miosis. Third, surgical eyes are dilated with three rounds
of topical tropicamide and phenylephrine eyedrops. The
dilation of the pupil is necessary for appropriate instru-
ment access to the posterior iris and ciliary processes
(Bras and Maggio 2015).
An eyelid speculum exposes the sclera, and ocular
positioning is optimized by neuromuscular blocks.
Intravenous atracurium (0.2 mg/kg) centers the cornea
beneath the operating microscope and reduces extraoc-
ular muscle tension and subsequent vitreous pressure
(Glover 1997).
Procedure (ECP)
Following a standard 2–3 mm triplanar self‐sealing inci-
sion, 0.3 ml of preservative‐free epinephrine (1 : 10 000
dilution) is injected into the anterior chamber to facili-
tate pupillary dilation and vasoconstriction. Preservative‐
free 2% lidocaine hydrochloride (0.3 ml) is injected to
further facilitate mydriasis and intraocular anesthesia
(Bras and Maggio 2015). Preservative‐free solutions are
injected to eliminate toxic effects on the corneal
endothelium.
The anterior and posterior chambers are then filled
with sodium hyaluronate‐based viscoelastic (VISCOAT®,
Alcon Laboratories, Fort Worth, TX). The ciliary sulcus
is elevated with the iris moving rostrally, while the lens or
lens capsule is moved posteriorly for access to the ciliary
­Diode Lasers for Glaucoma Treatmen 137
processes. Ciliary sulcus inflation is repeated multiple
times during surgery to expose the ciliary processes
while avoiding damage to the iris and lens. Exposure of
the ciliary processes is simpler in aphakic and pseu-
dophakic patients. Hydroxypropyl methylcellulose‐
based viscoelastics should never be used in an ECP
procedure as they will absorb laser energy, do not satis-
factorily open the area behind the iris, and do not remain
in the ciliary sulcus during the extended periods of sur-
gery (Bras and Maggio 2015).
The placement of the endoscope is carefully moni-
tored under the operating microscope whenever enter-
ing or leaving the eye to prevent any inadvertent collateral
damage. When the tip of the endoscope is lost from the
view of the operating microscope, the surgeon’s view is
solely limited to a video monitor. The posterior iris is
positioned in the superior field of view, the lens or lens
capsule in the inferior field of view, and optimally the
remaining field of view will then contain six ciliary pro-
cesses (Figure 12.15a) (Bras 2015).
Both sides of each ciliary process must be ablated to
render it nonfunctional. The anterior portion of a cili-
ary process is known as its “head,” whereas the poste-
rior portion is known as the “tail.” Both the heads and
tails of each ciliary process are treated for maximal
effect. However, the posterior one‐third of the tails
near the pars plana are spared to prevent postoperative
retinal edema. Only the heads of the ciliary processes
can be ablated in phakic eyes entered via limbal inci-
sions (Figure 12.15b). Therefore, in phakic eyes, the
ECP treatment can be combined with phacoemulsifica-
tion to expose the tails of the ciliary processes. At least
90–120° of the ciliary processes must be ablated by the
ECP procedure to render any hypotensive effect (Bras
and Maggio 2015).
An effective ECP procedure should cause CPC of the
ciliary processes. There are two ways to accomplish this:
each individual ciliary process can be lasered sequen-
tially, or the laser can be swept (“painted”) across several
processes at a time. Individual treatment is tedious but
assures that all the processes are ablated. Power levels
during ECP generally range from 100 to 1000 mW in
Continuous wave operation. Many surgeons start at
250 mW and adjust the power based upon the ciliary
shrinking and blanching they observe (see Table 12.3 for
typical settings). The duration of continuous wave is
controlled by a foot pedal (Bras and Maggio 2015).
The effects of ECP are dependent on laser power, dura-
tion, focus, and distance from each ciliary process. The
tip of the endoscope is positioned so that six ciliary
­processes are within the field of view at any time which
corresponds with a 2 mm distance between each ciliary
process and the tip of the endoscope. The helium‐neon
 138 Ophthalmic Lasers for the Treatment of Glaucoma

(a) (b)
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Figure 12.15 (a) Six ciliary processes visualized during endoscopic cyclophotocoagulation (ECP); (b) ablation of the heads of the ciliary
processes during ECP.

Table 12.3 Typical settings for endoscopic cyclophotocoagulation At the conclusion of an ECP procedure, viscoelastic is
(ECP). removed from the anterior chamber with irrigation and
aspiration. Viscoelastic is retained within the ciliary
Procedure ECP ­sulcus to reduce postoperative inflammation. Incisions
are closed routinely and 0.15 ml dexamethasone sodium
Laser type and wavelength (nm) Diode laser (810) phosphate (4 mg/ml) is injected intracamerally (Bras and
Delivery system 1 mm × 30 mm endoscope Maggio 2015).
Sites (°) 90–360
Power (mW) 250
Postoperative (ECP)
Controlling postoperative inflammation and IOP is cru-
Exposure Continuous wave
cial following ECP. Hospitalization with IOP evaluation
Duration (ms) To effect by tonometry every 2–4 hours for 24–48 hours postop-
Duty cycle (%) 100 eratively may be necessary to quickly respond to any
spikes in IOP. Anti‐glaucoma medications are required
to stabilize IOP until the maximal effects of ECP are
aiming beam of the ECP probe produces sharp outlines appreciated approximately two weeks postoperatively
at this distance and assures maximal focus of the 810 nm (Bras 2017).
laser on each ciliary process. The tip of the endoscope is
typically cleaned several times during the procedure to
Success Rates of TSCP, mTSCP, and ECP
prevent debris from interfering with the focus of the
laser and aiming beams (Uram 2003). Evaluations of TSCP procedures performed on normal
Dogs with dilute color coats are homozygous for a canine eyes indicate a significant decrease in IOP and
recessive gene encoding melanophilin, which results in atrophy of ciliary processes 28 days postoperatively
altered pigment distribution in structures including the (Nadelstein et al. 1997). The TSCP procedure has also
ciliary processes. The visual blanching of shrinking cili- been evaluated in dogs with naturally occurring closed‐
ary processes undergoing ECP procedures are therefore angle glaucoma. One study found TSCP adequately
not readily visualized in these dogs. Many surgeons controlled IOP of 50% of treated dog eyes one year
therefore increase diode laser power to 1000 mW to postoperatively, but there were poor visual outcomes
assure the effects of ECP in these color dilute dogs. and significant postoperative complications (Nadelstein
Histological evaluation of color dilute ciliary bodies et al. 1997; Cook et al. 1997). In another TSCP study
treated with ECP indicates that the procedure is cyclode- utilizing a slower coagulation technique (reduced
structive despite lack of visual feedback during these sur- power with longer durations), 92% of treated dog eyes
geries (Bras 2015). had adequately controlled IOP but only 50% of the eyes

remained sighted one year postoperatively (Hardman
VetBooks.ir
and Stanley 2001). A TSCP procedure combined with
an introduced Ahmed glaucoma valve kept IOP con-
trolled in 76% of treated dog eyes, but only 41% of those
eyes were visual one year postoperatively (Sapienza and
van der Woerdt 2005).
There have not been any peer‐reviewed studies of suc-
cess rates in glaucomatous dogs treated by mTSCP pro-
cedures. Nonreviewed studies have claimed adequate
control of IOP in mTSCP treated eyes ranging from 43%
after six months (Sebbag et al. 2017), to 54% after two
months (Sapienza et al. 2017), and to 80% after five
months (Pelych and La Croix 2017). Complications in
these studies have included neurotrophic corneal ulcera-
tions, decreased corneal sensitivity (Crabtree et al. 2017),
and the necessity for recurrent mTSCP procedures.
Corneal ulcerations typically occurred secondary to
damage of corneal nerve bundles located near the sclera
of lasered areas. Decreased corneal sensitivity and sec-
ondary corneal ulcerations have been vastly eliminated
by introduction of cold saline flushes during mTSCP
(S.E. Kirschner, personal communication). Postoperative
IOP spikes occur more frequently with increased power
settings (2800 mW) utilized during mTSCP procedures
(Sebbag et al. 2017). Decreased power settings (2000 mW)
utilized during mTSCP procedures are associated with
the need for recurrent procedures (Sapienza et al. 2017).
Further controlled studies will be necessary to determine
the most effective protocols for controlling canine glau-
coma by mTSCP. Presently, in clinical practice, mTSCP
procedures are typically only performed on dogs with
slow gradual increases in IOP.
In one retrospective study of ECP performed on 292
dogs with either primary or secondary glaucoma, 80% of
treated eyes had adequately controlled IOP and 70% of
those eyes remained visual one year postoperatively.
Vision was retained in 50% of ECP treated eyes three
years postoperatively (Bras et al. 2005). The ECP proce-
dure does not expose corneal nerve bundles to laser
energy that significantly decreases the risk of neuro-
trophic corneal ulcerations. Complications reported
with ECP have included intraocular inflammation, post-
operative spikes in IOP, and cataract formation. As with
TSCP and mTSCP procedures, if IOP is not controlled
­References
Ash C, Town G, Bjerring P, et al. (2015). Evaluation of a
novel skin tone meter and the correlation between
Fitzpatrick skin type and skin color. Photonics Lasers
Med. 4. pp. 177–186.
Brancato R, Leoni G, Trabucchi G, et al. (1991).
Histopathology of continuous wave neodymium:yttrium
­Reference 139
within two weeks of an ECP procedure, it can be repeated
(Bras and Maggio 2015).
Outside of controlled studies, “success rates” are often
defined by owners of companion animals. Owners tend
to view success only in relation to the entirety of their
pet’s lifespan. Unfortunately, the ciliary body epithelium
can and will eventually regenerate following any CPC
procedure. The IOP of a glaucomatous animal cannot
typically be controlled indefinitely with a solitary laser‐
based procedure. Recurrent surgical procedures are not
considered “successes” by most pet owners. Another key
factor is long‐term maintenance of vision. Visual loss is
most significantly associated with IOP spikes following
laser‐based procedures, especially 24–72 hours postop-
eratively. Controlling these spikes will typically require
hospitalization and frequent IOP monitoring during this
critical period. Long‐term monitoring of IOP through-
out the pet’s lifetime will also help ensure maintenance of
vision.
The ECP procedure is currently significantly costlier
than TSCP and mTSCP procedures. Owners may not be
financially capable or willing to invest in any of these
procedures. They must be informed of known risks,
complications, after‐care, and potential outcomes of
these surgeries. However, these surgeries are sometimes
the best option to retain vision in animals with painful
and blinding glaucoma.
­Conclusion
Advancements in diode laser technologies have helped
veterinary ophthalmologists develop new surgical proce-
dures to retain vision in animals suffering from glaucoma.
More basic peer‐reviewed research will be needed to
determine the optimal treatment regimens for laser‐based
CPC procedures designed to treat glaucoma. Histological
changes induced by these procedures to the ciliary pro-
cesses, corneal nerves, and drainage angle must also be
evaluated in controlled studies. Companion animal owners
need to be made aware of the benefits and risks associated
with these procedures. Laser technology has introduced
new tools to treat glaucoma and preserve vision. Such
modalities will no doubt improve in the future.
aluminum garnet and diode laser contact transscleral
lesions in rabbit ciliary body. A comparative study.
Invest. Ophthalmol. Visual Sci. 32. pp. 1586–1592.
Bras ID, Robbin TE, Wyman M, et al. (2005). Diode
endoscopic cyclophotocoagulation in canine and feline
glaucoma. Vet. Ophthalmol. 8. p. 449.
 140 Ophthalmic Lasers for the Treatment of Glaucoma
Bras ID. (2015). ECP in canine and feline glaucoma:
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surgical techniques. 46th Annual Conference of the
American College of Veterinary Ophthalmologists.
Bras D, Maggio F. (2015). Surgical treatment of canine
glaucoma: cyclodestructive techniques. Vet. Clin. North
Am. Small Anim. Pract. 45. pp. 1283–1305.
Bras ID. (2017). ECP update in canine and feline glaucoma.
1st Annual Veterinary Ophthalmic Surgery Meeting.
Brinkmann MC, Nasisse MP, Davidson MG, et al. (1992).
Neodymium:YAG laser treatment of iris bombe and
pupillary block glaucoma. Prog. Vet. Comp. Ophthalmol.
2. pp. 13–19.
Cook C, Davidson M, Brinkmann M, et al. (1997). Diode
laser transscleral cyclophotocoagulation for the
treatment of glaucoma in dogs: results of six and
twelve month follow‐up. Vet. Comp. Ophthalmol. 7.
pp. 148–154.
Crabtree EE, Sebbag L, Sapienza JS, et al. (2017). The
effects of micropulse transscleral cyclophotocoagulation
on corneal sensitivity recordings in 22 eyes using a
Luneau Cochet‐Bonnet aesthesiometer. 48th Annual
Conference of the American College of Veterinary
Ophthalmologists.
Fechtner RD, Weinreb RN. (1994). Mechanisms of optic
nerve damage in primary open angle glaucoma. Surv.
Ophthalmol. 39. pp. 23–42.
Gabel VP, Birngruber R, Hillenkamp F. (1978). Visible and
near infrared light absorption in pigment epithelium and
choroid In: Shimizu K, ed. International Congress Series
No. 450 XXIII Concilium Ophthaimologicum.
Amsterdam: Elsevier. 650–662.
Gilmour MA. (2002). Lasers in ophthalmology. Vet. Clin.
North Am. Small Anim. Pract. 32. pp. 649–672.
Glover TD. (1997). Constantinescu GM. Surgery for
cataracts. Vet. Clin. North Am. Small Anim. Pract. 27.
pp. 1143–1173.
Hardman C, Stanley RG. (2001). Diode laser transscleral
cyclophotocoagulation for the treatment of primary
glaucoma in 18 dogs: a retrospective study. Vet.
Ophthalmol. 4. pp. 209–215.
Harrington JT, McMullen RJ, Jr., Cullen JM, et al. (2013).
Diode laser endoscopic cyclophotocoagulation in the
normal equine eye. Vet. Ophthalmol. 16. pp. 97–110.
Igarashi O, Iijima M, Hase K, et al. (2003). Application of
argon laser iridotomy (LI) and goniopalsty (LG) in dogs.
Vet. Ophthalmol. 6. p. 364.
Jonas JB, Aung T, Bourne RR, et al. (2017). Glaucoma.
Lancet. 390. pp. 2183–2193.
La Croix NC, Gilmour MA, Dubielzig RR, et al. (2004).
Effects of diode laser cyclophotocoagulation on corneal
nerve morphology in the dog. Vet. Ophthalmol. 7. p. 445.
Miller PE. (2001). Glaucoma: diagnosis and therapy. Proc.
Waltham/OSU Symp. Small Animal Ophthalmol. 25.
pp. 51–63.
Miller PE. (2008). The glaucomas. In: Maggs DJ, Miller PE,
Ofri R, eds. Slatter’s Fundamentals of Veterinary
Ophthalmology, 4th ed. St. Louis: WB Saunders.
pp. 230–257.
Moore DB, Gianconi JA, Seibold LK, et al. (2015). Laser
Trabeculoplasty: ALT vs SLT. American Academy of
Ophthalmology, EyeWiki. http://eyewiki.aao.org/
Laser_Trabeculoplasty%3A_ALT_vs_SLT (accessed 1
May 2018).
Nadelstein B, Wilcock B, Cook C, et al. (1997). Clinical and
histopathologic effects of diode laser transscleral
cyclophotocoagulation in the normal canine eye. Vet.
Comp. Ophthalmol. 7. pp. 155–162.
Pelych LN, La Croix NC. (2017). Micropulse in practice.
11th Annual Meeting of the North East Veterinary
Ophthalmology Society.
Plummer CE, Regnier A, Gelatt KN. (2013). The canine
glaucomas. In: Gelatt KN, Gilger BC, Kern TJ, eds.
Veterinary Ophthalmology, 5th ed. Ames: Wiley.
pp. 1050–1145.
Quigley HA. (2011). Glaucoma. Lancet. 377. pp. 1367–1377.
Samuelson DA. (2013). Ophthalmic anatomy. In: Gelatt
KN, Gilger BC, Kern TJ, eds. Veterinary Ophthalmology,
5th ed. Ames: Wiley. pp. 39–170.
Sapienza JS, van der Woerdt A. (2005). Combined
transscleral diode laser cyclophotocoagulation and Ahmed
gonioimplantation in dogs with primary glaucoma: 51
cases (1996–2004). Vet. Ophthalmol. 8. pp. 121–127.
Sapienza J. (2016). Micropulse lasers. 10th Annual Meeting
of the North East Veterinary Ophthalmology Society.
Sapienza J, Kim K, Rodriiguez EN, et al. (2017). Short term
findings in 30 dogs treated with micropulse transscleral
diode laser cytophotocoagulation for refractory
glaucoma. 48th Annual Conference of the American
College of Veterinary Ophthalmologists.
Sebbag L, Allbaugh RA, Strong TD, et al. (2017).
Micropulse transscleral cyclophotocoagulation in dogs
with glaucoma: preliminary results. 48th Annual
Conference of the American College of Veterinary
Ophthalmologists.
Soderberg PG, Talebizadeh N, Yu Z, et al. (2016). Does
infrared or ultraviolet light damage the lens? Eye
(London). 30. pp. 241–246.
Tsai S, Almazan A, Lee SS, et al. (2013). The effect of
topical latanoprost on anterior segment anatomic
relationships in normal dogs. Vet. Ophthalmol. 16.
pp. 370–376.
Uram M. (2003). Endoscopic Surgery in Ophthalmology.
Philadelphia: Lippincott Williams & Wilkins.
Vogel A, Venugopalan V. (2003). Mechanisms of pulsed laser
ablation of biological tissues. Chem. Rev. 103. pp. 577–644.
van den Berg TJ, Spekreijse H. (1997). Near infrared light
absorption in the human eye media. Vision Res. 37.
pp. 249–253.

VetBooks.ir
13
Dermatologic Laser Surgery Procedures
David Duclos
­Introduction
The CO2 laser is very useful in Veterinary Dermatology
Practice. This chapter will focus on a few selected case
examples where the CO2 laser is either better than tradi-
tional steel scalpels or where it is the only mode of treat-
ment for skin disease.
There will be a small zone of coagulation necrosis
along borders of tissue removed with the laser, so it is
advisable to inform histopathologists how any tissue
biopsies were obtained. All usual safety concerns apply
to dermatologic use of the CO2 laser: appropriate eye
protection for all operating room personnel and the
patient, and any necessary protective measures around
the endotracheal tube, eyes, and the anal area where
combustible gases may be encountered.
­Actinic Keratosis (Solar)
Overview
Solar‐induced precancerous or cancerous lesions are pri-
marily seen in cats, although dogs will have them on their
ventrum. Lesions develop in nonpigmented and lightly
haired regions where the skin is exposed to ultraviolet
light. These solar‐induced lesions are thought to represent
the earliest precursor of cutaneous squamous cell carci-
noma (Lober and Lober 2000). The lesions are single or
multiple, plaque‐like, or papillated, with prominent scale,
crust, or scabs (Figure 13.1). Since these can progress into
cancer, early removal is preventative. The CO2 laser offers
the only noninvasive treatment for these animals.
Procedure
The procedure is performed under general anesthesia.
Ablation is performed with the 3 mm wide ablation tip,
or a handpiece of 0.8 mm spot size (Table 13.1 and
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
141
Figure 13.2). Initial settings vary with the amount of sur-
face scale and crusting; once surface lesions are ablated,
then the setting may be lowered to 4 W at 5 or 10 Hz and
20–40% duty cycle (Table 13.1 and Figure 13.3).
Aftercare and Prognosis
Aftercare consists of pain medication for the first
7–10 days. No topical medication is needed in these
cases (Figure 13.4). The animals show little to no discom-
fort after the procedure. Since the lesions are UV light‐
induced and the damage has already occurred years
before, new lesions are expected and will need to be
ablated as needed. The usual expectation is repeat pro-
cedures needed every 6–12 months.
­Bowenoid in situ Carcinoma
Overview
Bowenoid in situ carcinoma is another precancerous
disease of cats associated with a papilloma virus. These
lesions differ from solar‐induced disease in that they
are not associated with sun exposure. They are multi-
focal crusted plaques in any location on the body, both
sun‐exposed and nonsun‐exposed. Crusted lesions
represent a very small portion of the actual lesion; clip-
ping of the hair around the crusted lesion will reveal
their true extent (Figures 13.5 and 13.6). The lesions
consist of a crusted portion that is palpable and large
peripheral zones of melanized epidermis that are not
palpable and hidden by hair (Figure 13.7). Veterinary
dermatology literature mentions the use of imiquimod
5% cream (Aldera®) in treatment of this disease (Gill
et al. 2008; Miller et al. 2018). The author has p­reviously
published CO2 laser use in this disease’s treatment
(Duclos 2006). The CO2 laser is superior to imiquimod
cream. The laser procedure takes 30 minutes to an
 142 Dermatologic Laser Surgery Procedures
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Figure 13.3 Laser ablation.

Figure 13.1 Cat before surgery.

Table 13.1 Actinic keratosis.

Procedure Actinic keratosis

Laser type and CO2 CO2 CO2

wavelength (nm) (10 600) (10 600) (10 600)
Spot size (mm) Wide 0.8 0.8
ablation tip
Power (W) 8 4 4
Exposure Repeat Repeat Repeat pulse
pulse pulse
Mode SuperPulse SuperPulse SuperPulse Figure 13.4 One year post ablation. Few new lesions are present.
Frequency (Hz) 20 10 5
Duty cycle (%) 40 20 40 imiquimod cream. Imiquimod is often irritating to the
cat, causing it to lick.
The outer layers of these lesions consist of dry keratin,
requiring higher wattage until this keratin layer is
removed. Once dry layers are ablated, fluence may be
decreased as can be seen on the second and third col-
umns of Table 13.2.

Figure 13.2 Laser ablation focusing handpiece.
hour and the cat is free of lesions for some time after-
ward. Small touch‐up surgical procedures are needed
on average about every 12 months after the first proce-
dure. The imiquimod cream on the other hand is a
daily application from small packets. Lesions may be
too widespread and too difficult to find in the haircoat,
preventing effective and convenient application of
Procedure
The cat is placed under general anesthesia. All lesions are
identified and hair is clipped from them. Both crusted
and pigmented parts of the lesions will need to be ablated.
Settings will vary with the depths of the surgery. When
ablating raised crusts, laser energy needs to be high due
to low water content in the keratin material. As lesions’
outer portions are ablated, the power is shifted lower as
needed. Ablation only needs to go to the level of the epi-
dermis where normal skin is observed (Figure 13.8). Since
these lesions are entirely in the outer layers of the skin,
the hair is not affected and this will all regrow. One needs
to pay attention to the surgical depth by watching the der-
mis for hair follicle units. The hair follicles contain the
germ cells that will regrow the skin and hairs. Hair follicle
 ­Bowenoid in situ Carcinom ­Bowenoid in situ Carcinom 143
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Figure 13.7 Cat with Bowen’s under the neck.

Table 13.2 Bowenoid in situ carcinoma.

Procedure Bowenoid in situ carcinoma

Laser type and CO2 CO2 CO2 (10 600)

wavelength (nm) (10 600) (10 600)
Spot size (mm) Wide Wide 0.8
ablation tip ablation tip
Power (W) 25 12 12
Figure 13.5 Cat with Bowen’s prior to clipping.
Exposure Repeat Repeat Repeat pulse
pulse pulse
Mode SuperPulse SuperPulse SuperPulse
Frequency (Hz) 20 20 20
Duty cycle (%) 73 20 20–40

Figure 13.6 Cat with Bowen’s after clipping.

units are seen as “comedone‐like” features in the dermis

(Figure 13.9). Most Bowenoid lesions are large so the
3 mm wide ablation tip is used for most of the procedure;
however, some cats will have lesions on the paws, and in
Figure 13.8 Cat with Bowen’s under the neck post‐laser surgery.
and around digits and nail folds. In these areas a smaller
0.8 mm spot size and lower power settings will be used.
Aftercare and Prognosis
About 17% of cats will have some lesions that have pro-
gressed to squamous cell carcinoma that means lesions Aftercare will vary with case severity. All of them will
are in the dermis and possibly even deeper (Gross et al. need 7–10 days of pain medication. In some cases with
2005). These lesions will need to be sutured and should deeper areas affected, there will be some postoperative
also be biopsied whenever possible. serum seepage requiring daily cleaning with water and
 144 Dermatologic Laser Surgery Procedures
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Figure 13.9 Cat with lesion ablated. Note the visible follicular units.
Figure 13.10 Bowen’s lesion that has progressed to squamous
cell carcinoma.
shampoo, with topical triple‐antibiotic ointment to the
more bothersome lesions if necessary. Although it may
vary, pets will experience the most discomfort the first
week postoperatively. Cats who have had the disease for
a long time will have more extensive lesions and need
more surgical ablation. Usually, when these owners see
how well their cat responds with this procedure, they
elect repeat surgery before they become very severe
again (Figures 13.10 and 13.11).
Figure 13.11 Cat in Figures 13.7 and 13.8 under neck, three
months postsurgery.
Figure 13.12 Dog with pigmented viral plaques on body
presurgery.
­Pigmented Viral Plaques
Overview
A papilloma imbued, pigmented viral plaque (similar to
Bowenoid in situ carcinoma in cats) occurs in dogs.
This condition is currently diagnosed as canine pig-
mented viral plaques. They present as deeply pigmented
ovoid to circular plaques (Figure 13.12). They occur most
often on the ventral abdomen and ventral thorax; how-
ever, some dogs present with these lesions in every body
location. There is typically a strong breed predilection
for Pugs and Miniature Schnauzers and on occasion in
Boston Terriers and French Bulldogs. They develop in
young dogs and progress over time. Transformation into
malignant squamous cell carcinoma is rare. These repre-
sent primarily a cosmetic condition. Because of the asso-
ciation with papilloma virus, they create concern among
pet owners, day care, boarding, and show facilities.
Removal is thus frequently desired. As with Bowen’s dis-
ease, the CO2 laser offers excellent results. These lesions
 ­Pigmented Viral Plaque ­Pigmented Viral Plaque 145
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Figure 13.14 Dog with pigmented viral plaques on pinna six

weeks post‐surgery.

Figure 13.13 Dog with pigmented viral plaques on pinna pre‐surgery.

are confined to the epidermis and do not penetrate into

the dermis, so even when lesions are widespread and
numerous, removal results in complete hair regrowth
and permanent cure (Figures 13.13 and 13.14).

Procedure
General anesthesia is required. Laser settings will need
to be high due to low water content of these heavily pig-
mented, and keratinized plaques. Hair needs to be
clipped around these lesions because, like the Feline
Bowenoid lesions, there is pigmentation around the
plaques and all of the pigmented epithelia will need to be
ablated (Figure 13.15). Use a high laser setting to get
through heavily pigmented, keratinized lesions, then
lower the power as needed when progressing deeper
(Table 13.3 and Figures 13.16 and 13.17). A smaller
0.8 mm spot size may be needed for smaller lesions or in
areas like the paws and around the ears and face.
Aftercare and Prognosis
Aftercare consists mainly of two weeks of pain meds,
although most of these dogs do not show visible pain
Figure 13.15 Dog with pigmented viral plaques on neck and ear
presurgery.
(Figures 13.18 and 13.19). Some lesions may need topical
antibiotic ointments and gentle topical cleaning of the
wounds. These patients generally do not have any imme-
diate recurrence. They are usually young dogs when
these lesions occur. When they get older some small
lesions could reappear; however, at that point they are
usually small, the dogs are no longer on the show circuit,
and because they are not noticeable do not cause any
concern. If they do, a repeat procedure would clear up
these new lesions.
 146 Dermatologic Laser Surgery Procedures

Table 13.3 Pigmented viral plaques.

VetBooks.ir

Procedure Pigmented viral plaques

Laser type and CO2 (10 600) CO2 (10 600) CO2 (10 600)
wavelength (nm)
Spot size (mm) Wide ablation Wide 0.8
tip ablation tip
Power (W) 30 15 12
Exposure Repeat pulse Repeat pulse Repeat pulse
Mode SuperPulse SuperPulse SuperPulse
Frequency (Hz) 29 20 10–20 Figure 13.18 Dog with pigmented viral plaques on body
presurgery.
Duty cycle (%) 73 60 20–60

Figure 13.19 Dog with pigmented viral plaques on body

Figure 13.16 Laser ablation of pigmented viral plaques in a dog. postsurgery.

Figure 13.20 Cat’s squamous cell on nose presurgery.

eyelids in the cat and ventral abdomen in the dog

Figure 13.17 Laser ablation in a dog showing the completed
sites. Note the follicular units visible; these are the source of re‐
epithelialization and hair regrowth.
­Squamous Cell Carcinoma
Overview
Squamous cell carcinoma most often occurs as a single
well‐circumscribed tumor often on sun‐damaged skin.
Typical body locations are the pinna, nasal planum, and
(Figures 13.20 and 13.21). Some dogs develop tumors of
the nail bed, some of which may be squamous cell carci-
noma (Figure 13.22). Early detection and removal is
curative. These tumors rarely metastasize, but local tis-
sue destruction is common. If they are in areas where the
local invaded tissue is a nonremovable structure, like the
jaw, tongue, or nose, excision is not the treatment of
choice. In this chapter, focus will be on the types of squa-
mous cell tumors where removal is curative. Many of
these are removed via CO2 laser with minimal adjacent

VetBooks.ir
Figure 13.21 Cat’s squamous cell on pinna presurgery.
Figure 13.22 Dog Squamous cell carcinoma claw presurgery.
Figure 13.23 Cat’s squamous cell on pinna post laser surgery.
tissue damage, so the laser is preferable if it means less
damage to normal structures such as the nose and ears
(Figures 13.23 and 13.24). In the case of the nail bed in
dogs, the laser makes claw amputation bloodless and
thus easier to amputate while preserving as much func-
tion of the digit as possible.
­Squamous Cell Carcinom ­Squamous Cell Carcinom 147
Figure 13.24 Cat’s squamous cell on pinna three weeks
postsurgery.
Figure 13.25 Cat’s squamous cell on nose presurgery.
Procedure
The nature of the lesion should determine choice of abla-
tion or excision technique. When the squamous cell lesion
is small, has not been present long, and there is no sign of
visible extension, then excision with a 0.25 spot size or
ablation with a 3 mm wide ablation tip can be done.
In some cats where a nasal or pinnal lesion has been pre-
sent for a long time and invasion has progressed into the
nasal planum or down the pinna, then excision of the nasal
planum or the entire pinna is needed. As it is bloodless,
removal of the entire planum nasale is very simple with
the CO2 laser; the adjacent skin is sutured to close the
edges of the wound, and the center of the wound is allowed
to heal by second intention (Figure 13.25). The excised
tumor should always be submitted for histopathologic
examination and evaluation of surgical margins. Also, the
surgical ablation or excision site needs to be monitored
closely during healing (Figure 13.26). If the wound does
not heal, this indicates that the tumor had not been com-
pletely removed. Re‐evaluation is needed to determine if a
repeat laser procedure is indicated or if the tumor has
already spread beyond areas where excision is possible.
 148 Dermatologic Laser Surgery Procedures
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Figure 13.26 Cat’s squamous cell on nose postsurgery. Figure 13.28 Squamous cell carcinoma claw amputation via laser.

Table 13.4 Squamous cell carcinoma.

Procedure Squamous cell carcinoma

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 0.25 0.25
Power (W) 25 12
Exposure Repeat pulse Repeat pulse
Mode SuperPulse SuperPulse
Frequency (Hz) 29 20
Duty cycle (%) 73 40

Figure 13.29 Squamous cell carcinoma claw amputation via laser.

incision. After this, aiming the laser tip toward P3 pre-

vents any damage to the joint surface of P2. The laser
beam will spark as you follow the bone of P3 down,
around and under the bone until it is removed. The aim
is both to avoid damage to P2’s joint surface and to spare
the digital pad. P3 has a long ventral extension into the
digital pad and following the bone helps to find this
­portion of P3 (Figure 13.29). Once this is reached, the
entire P3 is removed and the digital pad is then sutured
to the skin above P2 (Figures 13.30 and 13.31).

Aftercare and Prognosis

Figure 13.27 Squamous cell carcinoma of a canine claw.
In the case of dogs with claw tumors, excision of P3
and sometimes P2 will be curative. Use a 0.25 mm spot
size and high power (Table 13.4). The incision starts on
the dorsal part of the digit (Figure 13.27), cutting down
until the dorsal elastic ligament is severed (Figure 13.28),
then moving to one side of the joint and cutting down
until the collateral ligament is severed. When the
­collateral ligament is cut, joint fluid will be seen in the
Aftercare entails pain meds. In cats where the entire
nasal planum was removed, daily cleansing of the site is
needed for the first 7–14 days. Complete healing usually
takes about four weeks (Figure 13.26). Wound protection
is also indicated in the case of claw amputation in the
dog. A bandage should be kept on the paw until suture
removal in two to three weeks (Figure 13.32). Also, as
mentioned earlier monitor closely for surgical sites that
do not heal, as this is an indication the entire tumor
was not excised. If the tumor is still present, careful

a­ ssessment will be needed to decide either if further sur-
VetBooks.ir
gery is indicated or if referral to an oncologist for evalu-
ation and possibly adjunctive measures (such as radiation
and chemotherapy alongside additional surgical
removal). In the majority of cases, complete excision is
achieved on the first ablation or excision with the CO2
Figure 13.30 Squamous cell carcinoma claw amputation via laser.
Figure 13.31 Dog post‐claw amputation.
Figure 13.32 Carcinoma claw amputation four weeks postsurgery.
­Follicular Tumor ­Follicular Tumor 149
laser. In cats with pinnal or nasal lesions, new tumors
will likely appear over time, usually a year or more after
the initial surgery, and early removal is usually a minor
procedure.
­Follicular Tumors
Overview
Follicular tumors are common in dogs and rare in cats.
They appear clinically as round to ovoid, firm dermal
masses that are usually less than 2 cm in diameter
(Figure 13.33). There is partial to complete alopecia pre-
sent. They occur most often on the dorsal trunk. They
have a genetic predilection so that dogs with these
tumors often will develop new ones in different sites
over time. The tumors are further categorized based on
the level of the follicle from which they develop.
Histopathologic categories include infundibular, isth-
mus, matrical, and hybrid. Histopathologic diagnoses
include but are not limited to: trichoepithelioma, infun-
dibular keratinizing acanthoma, tricholemmoma, pilo-
matricoma, and trichoblastoma. Clinically they are hard
to distinguish and the names only come from the tumors’
histopathologic evaluation. Some dogs will have more
than one follicular tumor type. These are often still
Figure 13.33 Follicular tumor presurgery.
 150 Dermatologic Laser Surgery Procedures

referred to in some veterinary practices as “sebaceous assist in continued removal. Occasionally, the exudate
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cysts”; this is because of the grumous nature of their
keratinaceous contents and is a holdover from older
human and veterinary literature. Since 1969 it has been
known that these are follicular tumors and not sebaceous
cysts (Pinkus 1969). Unfortunately, this misnomer per-
sists in veterinary medicine. Sebaceous secretion is a
milky fluid, not semisolid. After almost 50 years, it is
about time veterinary medicine catches up to the correct
diagnoses of these tumors and starts calling them by
their correct name.
Procedure
is copious; the surgeon should express the contents
out through this opening and clean away the incision
with sterile saline‐soaked gauze before continuing
(Figures 13.36 and 13.37). This may actually assist with
excision because the tumor size is then smaller and will
come out easily through the small incision (Figure 13.38).
These tumors have easily detectable walls that the laser
exposes by ablating adipose tissue alongside of the wall.
The borders of the tumor become very visible and can be
followed around the entire underside and sides until
the whole tumor is excised. Once the tumor is removed,
the incision can be closed with sutures (Figure 13.39).

Tumor sites need to be clipped and scrubbed for sterile

surgery. Use a sterile surgical technique since these
tumors often go deep into the panniculus and will need
to be sutured. Removal of these follicular tumors is
remarkably easy with the CO2 laser. Laser excision can
be done through a very small incision. The first passes
are aimed to cut through the epidermis and dermis. The
laser setting begins with a 0.25 mm spot size at high
power to cut through skin (Table 13.5 and Figure 13.34).
Once skin is penetrated, power may be decreased since
only fat is being ablated away and lower power settings
will help to differentiate the tumor wall from surround-
ing normal subcutaneous fat, and to avoid cutting
through the tumor wall. Direct the laser tip ventrally and
laterally away from the tumor excision toward normal
skin. The increased water content of the adipose tissue
that surrounds the tumor allows good differentiation
between the tumor wall and normal tissue. The tumor is
then peeled out using the laser to excise around it. By
starting with small excisions most of these can be pulled
through the small opening. The incision can always be
made larger if the tumor is larger than expected.
Occasionally, the tumor wall is incised and keratin will
come out (Figure 13.35). In such cases, a redirection of
the laser beam to go around this area of the tumor will
Figure 13.34 Follicular tumor surgical excision (small incision).

Table 13.5 Follicular tumors.

Procedure Follicular tumors

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 0.25 0.25
Power (W) 25 12
Exposure Repeat pulse Repeat pulse
Mode SuperPulse SuperPulse
Frequency (Hz) 29 20
Duty cycle (%) 73 40
Figure 13.35 Follicular tumor presurgery.

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Figure 13.36 Follicular tumor surgical excision (small incision),
expressing contents of tumor.
Figure 13.37 Follicular tumor surgical excision (small incision),
expressing contents of tumor.
Figure 13.38 Follicular tumor surgical excision (small incision).
Most of these tumors are less than 2 cm in diameter and
the incision is usually 1/2 to 1/3 of the clinically per-
ceived size of the tumor.
Aftercare and Prognosis
As with any incision, these need to be protected from
self‐mutilation. Client compliance will be needed to help
with plans to keep the pet away from suture sites. Pain
medicine should be dispensed if needed. Some cases
have one or more tumors that have ruptured; these
­Hamartomas (Fibro‐adnexal and Collagenous ­Hamartomas (Fibro‐adnexal and Collagenous 151
Figure 13.39 Follicular tumor surgical excision (small incision).
Figure 13.40 Fibro‐adnexal Hamartoma presurgery.
require larger incisions due to surrounding foreign body
reaction to the tumors’ contents. In these cases, antibiot-
ics are needed postoperatively for two to three weeks.
­Hamartomas (Fibro‐adnexal
and Collagenous)
Overview
Another aberration of the follicular unit consists of what
pathologists call hamartomas. Hamartomas are “tumor
like” lesions (Figure 13.40) caused by a disturbance of nor-
mal tissue growth, which then surpass the surrounding
areas (Bettenay and Hargis 2006). Two common hamar-
toma types in dogs are fibro‐adnexal and collagenous.
The collagenous type is simply excessive collagen that
causes the epidermis to elevate (Figure 13.41). The fibro‐
adnexal type are nodular, disorganized groups of follicular
and adnexal units (sebaceous glands, collagen and hair
follicles) often with areas of inflammation (Figure 13.42).
Using the CO2 laser to remove these is easier than with
conventional scalpel surgery. The laser allows removal of
 152 Dermatologic Laser Surgery Procedures

only the lesional tissue and leaves the adjacent normal Sterile ­surgical technique should be practiced. For a
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skin, thus allowing easier closure of surgical sites.
Procedure
Before surgery, clipping, surgical scrub and prep should
be done to minimize contamination during surgery.
Figure 13.41 Collagenous hamartoma axilla, presurgery.
fibro‐adnexal hamartoma, use a 0.25 mm spot size and a
73% duty cycle. Set the laser for 35 W repeat pulse expo-
sure in SuperPulse mode (29 Hz) or at 12 W repeat pulse
(20 Hz) exposure in SuperPulse mode (Table 13.6). These
tumors most often are on pressure points on the paws, so
closure of the surgical site will be impossible if there is
not enough normal skin present after excision
(Figure 13.43). Use the same technique as that used in
removing follicular tumors: keep the laser pointed
toward the tumor and incise right next to its border.
You can always clean up the incision edge after
removal if there are parts of the tumor left in the skin
(Figures 13.44–13.46). The goal will be to save as much
normal skin as possible to allow incision closure
(Figure 13.47). In this tumor excision, even when not all
of the incision can be closed, most of it can and then the
remainder will heal by second intention.
For collagenous types, a 3 mm wide ablation tip is used.
Ablate the tumor down until normal dermis is present.
These will heal nicely without closure since they are only
in the upper layers of dermis and skin rapidly grows back
over the surgical bed (Figure 13.48).

Figure 13.42 Fibro‐adnexal Hamartoma presurgery. Figure 13.43 Fibro‐adnexal Hamartoma presurgery.

Table 13.6 Hamartomas.

Procedure Hamartomas

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Spot size (mm) 0.25 0.25 Wide ablation tip Wide ablation tip
Power (W) 35 12 20 12
Exposure Repeat pulse Repeat pulse Repeat pulse Repeat pulse
Mode SuperPulse SuperPulse SuperPulse SuperPulse
Frequency (Hz) 29 20 29 20
Duty cycle (%) 73 73 73 40

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Figure 13.44 Fibro‐adnexal Hamartoma excision.
Figure 13.45 Fibro‐adnexal Hamartoma excision.
Figure 13.46 Fibro‐adnexal Hamartoma excision.
Aftercare and Prognosis
Aftercare for fibro‐adnexal tumors involves systemic
antibiotics and keeping the paw bandaged, since these
surgeries are all around the paw where sterility during
surgery is not possible. Pain medication is advised d­uring
­Interdigital Follicular Cyst ­Interdigital Follicular Cyst 153
Figure 13.47 Fibro‐adnexal Hamartoma postexcision.
Figure 13.48 Fibro‐adnexal Hamartoma six weeks postexcision.
the first two weeks of healing. Healing time is four to five
weeks. Aftercare for collagenous types is minimal, as
dogs rarely bother them. Pain medication is advised.
Dispensing a topical such as the Douxo® spot on pipettes
to apply a few drops to the site daily for the first one to
two weeks assists with healing.
­Interdigital Follicular Cysts
Overview
Cysts are defined as nonneoplastic, simple sac‐like struc-
tures with an epithelial lining. The cyst is named by its
pre‐existing epithelium lining from which the cyst arises.
Interdigital follicular cysts are a unique disease process
which is part of the whole syndrome of pododermatitis in
dogs. Interdigital follicular cysts are different from other
causes of pododermatitis. They have a specific clinical
presentation and do not respond to usual treatments for
pododermatitis. Clinical features of this syndrome
(Figure 13.49) are that they usually only involve the front
paws and the lateral interdigital spaces (IV–V). They
have a history of recurrent draining fistulous tracks that
always recur between these same two interdigital spaces,
 154 Dermatologic Laser Surgery Procedures
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Figure 13.49 Interdigital follicular cysts, presurgery.
Figure 13.50 Interdigital follicular cysts, presurgery (draining tract).
(IV–V) (Figure 13.50). The palmar side of the paw directly
opposite the fistulous tracts is an area of partial to com-
plete alopecia, and numerous pores representing residual
follicular ostia plugged with keratin (comedones) that
connect the cysts to tract or nodule on the overlying epi-
dermis (Duclos et al. 2008). Keratin can be expressed
from these cysts through these ostia (Figure 13.51). These
cysts repeatedly rupture into the surrounding dermis and
subcutaneous tissue that incites a vigorous inflammatory
response, causing eventual perforation through the dor-
sal interdigital epidermis. The dorsal paw above the ven-
tral comedones exhibits partial alopecia, swelling,
erythema, and fistulous tracts. These draining lesions are
often mistaken for interdigital pyoderma. There may be
partial response to antibiotic therapy initially, but these
lesions typically will continue to rupture even while on
adequate doses of antibiotics. Veterinary textbooks tend
to ignore this condition and simply state some cases of
pododermatitis are chronic and difficult to manage
(Miller et al. 2013). This condition differs from other
causes of pododermatitis in that it only affects the same
lateral interdigital spaces, and not the other digital spaces.
Figure 13.51 Interdigital follicular cysts, presurgery (expression of
keratin from comedones).
Figure 13.52 Interdigital follicular cyst surgery.
These lateral interdigital spaces present as chronic,
recurrent draining fistulas on the dorsal aspect, with vis-
ible comedones and alopecia with thickend skin on the
palmar and plantar aspect. The CO2 laser ablation proce-
dure described here and previously (Duclos et al. 2008;
Morris and Kennis 2013) offers complete resolution of
these lesions. A biopsy should be taken during the proce-
dure for definitive diagnosis of follicular cysts.
Procedure
The ablation procedure begins with general anesthesia,
clipping of affected paws, and surgical scrub for sterile
procedure. This will not be a completely sterile proce-
dure, but it should be approached in a sterile manner
with sterile gowns, gloves, towels, drapes, and sterile
instrument packs. Bear in mind that your approach will
be made on the palmar surface, NOT the dorsal surface.
A 3 mm wide ablation tip is used throughout the proce-
dure. Use a continuous wave exposure (not repeat
pulse) in a non‐SuperPulse mode for the upper layers of
 ­Interdigital Follicular Cyst ­Interdigital Follicular Cyst 155

Table 13.7 Interdigital follicular cysts.

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Procedure Interdigital follicular cysts

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Spot size (mm) Wide ablation tip Wide ablation tip Wide ablation tip
Power (W) 30–35 25 to 12 12
Exposure Continuous wave Repeat pulse Repeat pulse
Mode Non‐SuperPulse SuperPulse SuperPulse
Frequency (Hz) — 29 10–20
Duty cycle (%) 100 73 30–50

Figure 13.53 Interdigital follicular cysts (surgery‐deep layers, with Figure 13.54 Interdigital follicular cysts, surgery‐probe to follow
expression of keratin still in the tissue). draining tract.

the procedure (Figure 13.52). As you progress deeper,

switching to repeat pulse exposure in SuperPulse mode
is recommended (Table 13.7). This procedure is very
technical so prior training with someone who has done
this procedure is advisable. The laser is a fine tool for this
procedure because of the nature of the target tissue
interaction. The CO2 laser interacts primarily with water,
and since the contents of the cysts are lower in water
content than the surrounding paw tissue, the keratin in
the cysts is left visible as the surrounding tissue evapo-
rates (Figure 13.53). Attention should be paid to the dor-
sal surface where either current or previous fistulous
tracts are identifiable. Inserting a sterile surgical probe
into these dorsal lesions and then observing where they Figure 13.55 Interdigital follicular cysts, surgery‐probe to follow
lead to on the palmar surface will guide the surgeon to draining tract.
the areas of most concern (Figures 13.54 and 13.55).
Also, applying digital pressure to the tissue to express the second column of Table 13.7 will enable the surgeon to
keratin from the cysts will direct the ablation to all the avoid these vessels. Ablation continues until all of the fol-
affected areas (Figure 13.56). Careful attention must be licular cysts are removed. When getting close to large
paid not to cut the digital or the common digital arteries digital vessels, some small bleeding will occur that the
and veins. When progressing deeper and encountering laser does not coagulate readily. This is an indication that
capillary bleeding, decreasing the power as noted on the the large vessel is very close. Scrutiny at very low power
 156 Dermatologic Laser Surgery Procedures
will allow removal of tissue adjacent to the vessel, so the
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vessel will be seen and can be avoided (Figure 13.57).
Aftercare and Prognosis
Aftercare in this procedure will primarily be keeping
the paws wrapped for four to five weeks until the entire
area has re‐epithelialized. The bandages need to be
changed every three to four days for the first two weeks,
then every five to seven days until healed. At each band-
age change, the paw is gently cleaned with surgical
scrub, then the wound is packed with antibiotic oint-
ment and wrapped. The use of medical‐grade honey
can also be used. The patient needs to be on systemic
antibiotics until the last bandage is removed. Pain meds
will be needed for the first two to three weeks, and
some dogs will need pain meds for four weeks. Most
cases will be cured with one procedure, though rarely a
second procedure may be necessary. The more experi-
enced the surgeon is with this surgical procedure the
less often recurrences occur.
Figure 13.56 Interdigital follicular cysts, surgery (expression of
keratin still in the tissue).
Figure 13.57 Interdigital follicular cysts, surgery (blood vessels
visibly unharmed by laser surgery).
­Follicular Cysts – Elbow Callus
Overview
Elbow callus follicular cysts are similar to interdigital
follicular cysts, only in a different location. Elbow callus
can develop fistulous draining tracts that only partially
respond to antibiotics. Some dogs have multiple fistu-
lous tracts around the periphery of the callus
(Figure 13.58). The affected callus is erythematous with
visible follicular ostia (comedones). Keratin can be
expressed from these affected calluses (Figure 13.59).
The clinical history consists of draining lesions that do
not resolve with repeated antibiotic treatments. The
dogs usually lick at these lesions frequently.
Procedure
The ablation procedure begins with general anesthesia,
clipping of affected elbows, and surgical scrub for a ster-
ile procedure. It should be approached in a sterile man-
ner with sterile gowns, gloves, towels, drapes, and sterile
instrument packs. A 3 mm wide ablation tip is used
throughout the procedure (Table 13.8). (For a thickened
callus, the laser may be set for continuous wave
Figure 13.58 Follicular cysts and draining tracts elbow, presurgery.
Figure 13.59 Follicular cysts and draining tracts elbow, presurgery.
 ­Sebaceous Gland Tumors (Adenoma, Epithelioma, Carcinoma ­Sebaceous Gland Tumors (Adenoma, Epithelioma, Carcinoma 157

Table 13.8 Elbow follicular cysts.

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Procedure Elbow follicular cysts

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) Wide ablation tip Wide ablation tip
Power (W) 25 to 12 8
Exposure Repeat pulse Repeat pulse
Mode SuperPulse SuperPulse
Frequency (Hz) 29 10–20
Duty cycle (%) 73 40

Figure 13.62 Follicular cysts during ablation surgery.

Figure 13.60 Follicular cysts and draining tracts elbow,

ablation surgery.

Figure 13.63 Follicular cysts and draining tracts elbow, three

weeks postsurgery.

plenty of adjacent normal skin remains to suture the

wounds closed (Figure 13.62).

Aftercare and Prognosis

Figure 13.61 Follicular cysts and draining tracts elbow, ablation
surgery.
Most of these dogs have both elbows affected, which will
need to be kept wrapped postoperatively. Systemic anti-
biotics and pain medications are given for two weeks.
After two to three weeks, the wounds should be healed
and sutures can be removed. In this disease, one laser
ablation procedure usually results in permanent cure
(Figures 13.63 and 13.64).

Superpulse instead of repeat pulse) (Figure 13.60). Focus ­ ebaceous Gland Tumors (Adenoma,
S
on the callus areas with erythema and comedones. As
Epithelioma, Carcinoma)
you progress deeper, the cysts are not very visible. Digital
pressure on the tissue will express keratin from the callus
Overview
if cysts are still present (Figure 13.61). Ablation contin-
ues until all cystic tissue with keratin has been removed. Sebaceous gland tumors are solitary or multiple. They
In most cases of elbow callus follicular cysts, the laser are dome‐shaped, often with a slight papillomatous
gives such good visualization of affected tissue that appearance (Figure 13.65). They are light pink in color
 158 Dermatologic Laser Surgery Procedures
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Figure 13.64 Follicular cysts and draining tracts elbow, four
weeks post‐surgery.
Figure 13.65 Nodular sebaceous gland tumor presurgery.
Figure 13.66 Nodular sebaceous gland tumor, carcinomatous
type, presurgery.
although some are melanized. They are usually less than
1 cm in diameter. The overlying skin is alopecic and some
tumors bleed easily or are irritating to the dog, who then
chews or licks at them. Most of these tumors are benign,
although they can range from intermediate malignancy
Figure 13.67 Multiple nodular sebaceous gland tumors, ablation
surgery.
(sebaceous ­ epitheliomas) to malignant (carcinomas)
(Bettenay and Hargis 2006). The more malignant ones
tend to be those that are hemorrhagic or irritate the dog
(Figure 13.66).
These tumors are genetically linked; animals who
develop them are predisposed to develop more as they
age. It is not uncommon to remove 10–30 of these
tumors, only to have to remove 10 or more once again in
6–12 months (Figure 13.67). Breeds such as Cocker
Spaniels or Miniature Poodles tend to have numerous
tumors. The tumors occur mostly on the trunk and head,
but some occur on legs, paws, and ears. These tumors
need to be removed for various reasons, some of which
are just cosmetic, or because they are bothersome to
groomers and owners. Because of their sebaceous origin,
they will accumulate an oily to wax‐like accumulation
around them. Removal of these tumors is one of the
more common uses of the CO2 laser in dermatology.
Procedure
CO2 laser ablation of these tumors is a simple procedure
often done with light sedation. Single tumors can be
removed with local anesthesia via lidocaine block. The
hair may or may not need to be clipped. Preferred spot
size varies with tumor size, with 0.8 mm spot size most
often used. For larger ones, a 3 mm wide ablation tip
helps to complete the procedure faster (Figures 13.67–
13.70). Laser settings are best done with SuperPulse
mode to decrease the extent of collateral damage. Higher
settings are used for upper layers of the tumor, then
power is decreased at deeper layers (Table 13.9). Gentle
digital pressure is applied on the skin around the tumor
to push it up to where it can be visualized and ablated
(Figure 13.71). Some of these tumors are large enough
 ­Ceruminous (Apocrine) Cystomatosi ­Ceruminous (Apocrine) Cystomatosi 159

Table 13.9 Sebaceous gland tumors.

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Procedure Sebaceous gland tumors

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) Wide ablation tip Wide ablation tip
Power (W) 30–35 25 to 12
Exposure Repeat pulse Repeat pulse
Mode SuperPulse Non‐SuperPulse
Frequency (Hz) 29 20
Duty cycle (%) 73 40

Figure 13.68 Multiple nodular sebaceous gland tumors, ablation

surgery.

Figure 13.71 Multiple nodular sebaceous gland tumors, ablation

surgery (base of tumor).

Figure 13.69 Multiple nodular sebaceous gland tumors, final that one or two sutures are needed, though the majority
portion of ablation surgery. do not need them.

Aftercare and Prognosis

Aftercare consist mainly of just leaving them alone.
Bathing the dog two to three times per week is helpful to
keep ablation sites clean. Topical antibiotic creams can
be dispensed to apply to sites that seem to bother the
dog. They heal by second intention over a three‐ to four‐
week period.

­Ceruminous (Apocrine) Cystomatosis

Figure 13.70 Multiple nodular sebaceous gland tumors, ablation
surgery.
Overview
Apocrine (ceruminous) cysts are an uncommon but
problematic condition that affects cats. The classic clini-
cal appearance is of blue‐colored nodules, vesicles or
bulla in the external ear and pinna. Occasionally, these
 160 Dermatologic Laser Surgery Procedures

Table 13.10 Ceruminous (apocrine) cystomatosis.

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Procedure Ceruminous cystomatosis

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) Wide ablation tip or Wide ablation tip or
0.8 mm 0.8 mm
Power (W) 12–25 8
Exposure Repeat pulse Repeat pulse
Mode SuperPulse Non‐Super Pulse
Frequency (Hz) 29 10–20
Duty cycle (%) 73 20–40
Figure 13.72 Apocrine cysts ear, feline, presurgery.

Figure 13.74 Apocrine cysts ear, feline, ablation‐surgery.

Figure 13.73 Apocrine cysts ear, feline, ablation‐surgery.

can occur around the lower lips and chin (Figure 13.72).
These lesions contain a dark brown liquid. They often
grow, in time causing obstruction of the ear canals result-
ing in chronic ear infections and discomfort for the cat.
This is a condition where the CO2 laser provides the only
reasonable mode of treatment (Figure 13.73).

Procedure
The procedure involves having the patient under general
anesthesia. The pinna hair may or may not need to be
clipped around the lesions. When these lesions involve
Figure 13.75 Apocrine cysts ear, feline, ablation‐surgery.
the chin or lips, hair will need to be clipped. Ears need to
be thoroughly cleaned via video otoscopy. During this
cleaning conduct an evaluation of the ear canals for any ablation progresses on the pinna and near the ear canal
lesions within. The majority of these cats have normal to avoid deep damage. In some of the lesions, the 0.8 mm
ear canals. However, because of the obstruction of the tip may be chosen (Table 13.10 and Figures 13.74 and
external ostia of the ear, the canals are typically impacted 13.75). Ablation depth is down to the dermis and in some
with wax and possibly infected. Lesions are usually areas to the level of the auricular and pinnal cartilage.
extensive so a 3 mm wide ablation tip is most often used. Some of these are large tumors and in these some of the
Settings are high in the early portion and decreased as auricular cartilage is also removed (Figure 13.76).

Aftercare and Prognosis
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Ablation sites will seep serum for the first week and the
ear needs daily topical ear medication (antibiotic, anti-
fungal, and corticosteroid). An antibiotic is administered
­systemically, and pain medication is important during
the first one to two weeks. The cat will need to have the
Figure 13.76 Apocrine cysts ear, feline, ablation‐surgery.
Figure 13.77 Apocrine cysts ear, feline, four weeks
postablation‐surgery.
­External Ear Hyperplasi ­External Ear Hyperplasi 161
e­xternal ears gently cleaned (usually at the veterinary
clinic), every three to four days until there is a good sur-
face scab over the sites. These ears are usually infected
prior to surgery. Therefore, obtaining cytology of the
ears is important and dispensing the appropriate topical
ear medication for the ears is necessary. Lesions are
expected to heal ­ completely in three to four weeks
(Figure 13.77). In some cases, ear canals will need
another cleaning with the video‐­otoscope, and topical
ear meds may need to be continued for another week
afterward.
­External Ear Hyperplasia
Overview
Hyperplasia of the external ear most often involves simi-
lar hyperplastic ear canals and marked ear canal stenosis.
However, there are rare cases in which the hyperplasia is
confined only to the outer ear with normal vertical and
horizontal ear canals (Figure 13.78). In these cases, abla-
tion of outer hyperplastic tissue via laser will improve the
dog’s ear disease management. The cause of hyperplasia
is chronic inflammation, so underlying ear disease needs
to be managed along with ablation of the hyperplastic
tissue, which is obstructing the ear canals openings
(Figure 13.79). The CO2 laser provides a bloodless way
to remove this obstruction and return the ears to a state
in which m­ edical ear treatment can be facilitated.
Careful selection of cases is ­necessary, since dogs with
marked hyperplasia that extends into the ear canal are
not candidates for this procedure. Ears will need to be
thoroughly cleaned and thoroughly evaluated under
sedation via video‐otoscopy in order to make the deci-
sion to perform this procedure. Only very rarely will
some dogs solely have hyperplasia in the outer ear
canal. Most with ear disease will have complete ear
Figure 13.78 Ear hyperplasia presurgery.
 162 Dermatologic Laser Surgery Procedures
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Figure 13.79 Ear hyperplasia ablation/excision surgery. Figure 13.80 Ear hyperplasia ablation/excision surgery.

Table 13.11 External ear hyperplasia.

Procedure External ear hyperplasia

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) Wide ablation tip Wide ablation tip
or 0.8 mm or 0.8 mm
Power (W) 12–25 8
Exposure Repeat pulse Repeat pulse
Mode SuperPulse Non‐SuperPulse
Frequency (Hz) 29 10–20
Duty cycle (%) 73 20–40

Figure 13.81 Ear hyperplasia ablation/excision surgery. The

cotton applicator identifies the ear canal.
canal involvement, for which total ear canal ablation is
the only acceptable option.

Procedure
A 3 mm wide ablation tip is used both for ablation and as
a cutting tip during this procedure (Table 13.11 and
Figure 13.80). The animal is placed under general
­anesthesia. Similar to cats with ceruminous gland cysts,
these ears need to be thoroughly cleaned and ear
medication dispensed based on cytology of the ear
­
canals. Typically, clients will not be able to put ear meds
into the ears until obstructive hyperplastic tissue is
removed. Settings will need to be high during the major-
ity of the procedure. The normal anatomy of the exter-
nal ear is often deranged and the opening of the ear
canal is not easily recognized. Prior to beginning the
procedure, a thoroughly moistened cotton tip applicator Figure 13.82 Ear hyperplasia ablation/excision surgery.
 ­Reference ­Reference 163

is placed into the ear canal and left there during the
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­procedure (Figure 13.81). This enables constant identifi-

cation of this opening and helps the surgeon to avoid
damage to this structure. The ­ procedure ends with
sculpting and smoothing out the opening to the vertical
ear canal. The laser provides good hemostasis during
and after the procedure.

Aftercare and Prognosis

Once all tissue is ablated the area is allowed to heal by
second intention. The ear canal opening is usually very
small at this time, so instillation of ear medication into
the ear is done by placing a 16‐gauge Teflon catheter into
the ear in which to instill ear medication. This catheter is
not left in the ear, but used on the dosing syringe at each
application into the ear canal. This is done every three
days at the veterinary office. The area is sensitive and
instillation of meds into this small orifice will not be
­possible for clients (Figure 13.82). A systemic antibiotic
and pain medication are required during the healing
process. It will take three to four weeks for the ear to
heal. The ear canal opening will gradually become easier
to find and instill medication. As the ear is healed, the
client will be able to apply ear treatments at home Figure 13.83 Ear hyperplasia four weeks postablation/excision
(Figure 13.83). surgery.

­References
Bettenay SV, Hargis AM. (2006). Practical Veterinary
Dermatopathology for the Small Animal Clinician. Teton
NewMedia.
Duclos D. (2006). Lasers in veterinary dermatology. Vet.
Clin. North Am. Small Anim. Pract. 36(1). pp. 15–37,
available from: PM:16364776.
Duclos DD, Hargis AM, Hanley PW. (2008). Pathogenesis
of canine interdigital palmar and plantar comedones and
follicular cysts, and their response to laser surgery. Vet.
Dermatol. 19(3). pp. 134–141, available from:
PM:18477329.
Gill VL, Bergman PJ, Baer KE, et al. (2008). Use of
imiquimod 5% cream (Aldara™) in cats with multicentric
squamous cell carcinoma in situ: 12 cases (2002–2005).
Vet. Comp. Oncol. 6(1). pp. 55–64, available from:
PM:19178663.
Gross TJ, Ihrke PJ, Walder EJ, et al. (2005). Skin Diseases of
the Dog and Cat. Blackwell Scientific. pp. 578–581.
Lober BA, Lober CW. (2000). Actinic keratosis is
squamous cell carcinoma. South. Med. J. 93(7).
pp. 650–655, available from: PM:10923948.
Miller WH, Campbell KL, Griffin CE. (2013). Muller and
Kirk’s Small Animal Dermatology, 7th ed. Elsevier.
pp. 201–202.
Miller WH, Griffin CE, Campbell KL. (2018). Muller and
Kirk’s Small Animal Dermatology. Elsevier. pp. 783–784.
Morris DO, Kennis RA. (2013). Clinical dermatology. Vet.
Clin. North Am. Small Anim. Pract. 43(1). p. ix, available
from: PM:23182333.
Pinkus H. (1969). “Sebaceous cysts” are trichilemmal cysts.
Arch. Dermatol. 99(5). pp. 544–555, available from:
PM:4181052.
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14
Urogenital and Perianal Laser Surgery Procedures
William E. Schultz
­Introduction
The highly vascular tissues of the urogenital and peria-
nal areas make visualization very difficult when using
conventional surgical methods. Surgical lasers have dra-
matically changed the abilities of the surgeon by allow-
ing a bloodless or near‐bloodless surgical field. Surgical
hemorrhage is dramatically reduced or not present dur-
ing laser surgery, affording excellent tissue visualization
for more accurate and defined approach to target tis-
sues. Less collateral damage is present that gives short-
ened healing and better wound integrity, assets so
important in these areas where the problem of self‐
mutilation is otherwise common postoperatively (Omi
and Numano 2014).
The high absorption rate of 10 600 nm wavelength of
the CO2 laser by intracellular water makes it the best
practical laser for soft tissue surgeries. The high intensity
and power of the laser beam is sufficient for sealing most
blood vessels, lymphatics, and nerve endings, while
destroying surface pathogens on incision and ablation
margins, producing a sanitizing effect. Collateral ther-
mal effects to surrounding tissue are minimal when the
laser is set and used appropriately for the target tissue.
The laser tip does not touch the tissue, thus further low-
ering the risk of infection. A flexible hollow‐waveguide
fiber and ergonomic tipless handpiece make today’s CO2
laser a highly efficient and versatile tool for everyday sur-
geries. Conventional surgery requires tissue friction at
the blade for cutting, while lasers allow for very delicate
and intricate cutting and ablation due to the lack of fric-
tion (Omi and Numano 2014).
Discussion will include routine urogenital procedures
as well as some procedures that are done less frequently.
Surgical protocol includes a full chemistry panel the
morning of surgery followed by pre‐medication. This
author uses a combination of acepromazine, atropine,
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
and butorphanol for most cases. Brachycephalic breeds
are not given atropine. Induction for cats may be with
kitty magic (dexdomitor, buprenorphine, and ketamine;
Bryant 2010) or Alfaxalone, while dogs are induced with
Propofol. Both species are then maintained on an inhala-
tion anesthetic such as sevoflurane for the procedure.
Intravenous fluids with respiratory and cardiac monitor-
ing are used in all procedures. When under anesthesia,
an injection of morphine or another opiate is given
alongside an injectable nonsteroidal anti‐inflammatory
drug (NSAID). Postoperative medications may include
antibiotics, NSAID therapy with pain medication, and in
many cases, the use of an E‐collar or inflatable collar to
prevent self‐trauma. The full coverage body suits that are
available are also excellent for postoperative protection
after truncal and some urogenital procedures.
­Canine Vasectomy
Overview
Working dogs, sporting dogs, and agility dogs may have
better drive when intact. With this consideration some
owners want to retain the hormone levels of an intact
male but limit reproduction. The procedure should be dis-
cussed with the client with the understanding that the dog
will retain secondary sexual characteristics. Aggression,
mounting and breeding, inappropriate urination, enlarged
prostate, escape to find a bitch in heat, perianal adenomas,
and testicular tumors are all discussion points. With client
understanding, the procedure is easily completed. The use
of a laser for the procedure, like in many other surgical
procedures, allows for a clean field of view and better tis-
sue identification. This article will discuss laser inguinal
vasectomy. The procedure has also been done via
­laparoscope (Silva et al. 1993).
 ­Canine Unilateral Cryptorchid Orchiectom 165

Table 14.1 Canine vasectomy.

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Procedure Canine vasectomy

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 15
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100

Figure 14.1 Initial vasectomy incision.

Preoperative
The dog is surgically prepped while in dorsal recum-
bence. The pampiniform plexus is palpated at the base of
the testicle and followed to the level of the pelvis 1–3 cm
cranial to the scrotum on either side. The plexus is easily
palpated through the skin in the inguinal area giving the
location for a linear incision over the plexus.

Procedure
The laser is set to 15 W SuperPulse and a 0.25 mm spot
size is used (Table 14.1). The incision is 2–3 cm in length
and made full skin thickness (Figure 14.1). Blunt dissec-
tion will reveal the plexus (Figures 14.2 and 14.3). Gentle Figure 14.2 Blunt dissection to reveal plexus.
dissection is used to separate the vas deferens
(Figures 14.4 and 14.5). The vas is dense white tissue and
is easily identified against the blood vessel structure of
the plexus. The vas is separated to a length of 1–2 cm. A
hemostat is placed in the center and ligations with 2‐0 to
3‐0 monofilament suture material are completed
(Figures 14.6 and 14.7). Either the laser or steel scalpel is
used to remove the section between the two ligatures
(Figures 14.8–14.10). The incision is closed with contin-
uous interrupted 2‐0 to 3‐0 monofilament suture mate-
rial with glue in the skin (Figure 14.11). See Video 14.1
for this procedure.
Video 14.1 (This video includes audio commentary). Laser surgical
vasectomy procedure. Figure 14.3 Plexus revealed.

Postoperative ­ anine Unilateral Cryptorchid

The dog is sent home with pain medication and activ-
ity restraint for 7–10 days. Licking is rare but if this is a
problem a restraint collar is placed for several days.
Scrotal edema and hemorrhage at the surgery site is
unlikely. Vasovasostomy has been done in humans and
experimentally in dogs. Discussion about future repro-
duction of the male is imperative to prevent the attempt
at reconstruction (Hamidinia et al. 1983; Seidmon
et al. 1990).
C
Orchiectomy
Overview
Unilateral and bilateral cryptorchidism occurs frequently
and is a commonly encountered problem in veterinary
medicine. Most dogs will have both testicles in the scro-
tum between 10 days and 8 weeks (Concannon et al.
2001). With normal external genitalia it is unlikely the
dog will be a hermaphrodite and the retained testicles
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Figure 14.4 Vas deferens revealed.
Figure 14.5 Isolating the vas for ligature.
Figure 14.6 Initial ligature placement.
will be present in some form. Surgical removal of the
retained testicle is important to prevent temperature‐
induced damage to the testicle (Prapaiwan et al. 2016).
Finding the testicle may be made easier with palpation
and ultrasound scanning of the abdomen prior to ­surgery
(Tannouz et al. 2009). If the testicle is out of the inguinal
ring and in the flank, it may be easily palpated in some
cases, but if the testicle is small and soft, this may present
problems for location.
Figure 14.7 Ligature placement complete.
Figure 14.8 Removal of a vas segment.
Figure 14.9 Laser resection of the vas.
Preoperative
The dog is placed in dorsal recumbence and the caudal
abdomen is shaved for a paramedian incision along the
cranial aspect of the sheath. The abdomen is draped with
the sheath moved to the opposite side of the abdomen
from the incision (Figure 14.12).
Procedure
If the surgery concerns a unilateral cryptorchid case, the
external testicle should not be removed before the
 ­Canine Unilateral Cryptorchid Orchiectom 167

Table 14.2 Cryptorchid orchiectomy.

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Procedure Cryptorchid orchiectomy

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 10–15
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100

Figure 14.10 Completed removal of the segment.

Figure 14.13 Initial incision is made between the pudendal

vessels and the sheath.
Figure 14.11 Closure following vasectomy.

Figure 14.14 Blunt dissection is used to deepen the incision.

Figure 14.12 The pudendal vessels are identified prior to making
incision.
retained testicle has been found. Being right‐handed,
this author prefers to make the incision into the abdo-
men (Table 14.2) on the left paramedian aspect of the
sheath. The incision is 4–6 cm long and is between the
pudendal vessels and the sheath (Figure 14.13). The skin
is opened and blunt dissection is used to reach the
abdominal fascia (Figures 14.14 and 14.15). In many
cases, the linea alba may not be pronounced as in an
ovariohysterectomy incision. When the linea is visible
the laser is used to make the abdominal incision, being
careful to avoid going too deep and hitting the urinary
bladder (Figure 14.16). When the linea is not visible an
approximation of the midline is made and the muscle
fascia is opened with the laser followed by blunt dissec-
tion into the abdomen (Figure 14.17). A Snook hook is
used in similar fashion to finding the uterus during
ovariohysterectomy (Figure 14.18). The tip is inserted
down the body wall on the side of the retained testicle
and the tissue encountered is raised to the incision
(Figure 14.19). The vas deferens or the pampiniform
plexus will be encountered (Figure 14.20). If the vas is
elevated, continued tension is used to exteriorize the
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Figure 14.15 The incision is continued to the midline with blunt
dissection.
Figure 14.16 The midline is opened with the laser.
Figure 14.17 The midline incision is enlarged with blunt
dissection.
t­ esticle from the abdomen (Figure 14.21). When the vas
is found, the testicle is usually in a cranial position. If the
pampiniform plexus is found and the vas is not present,
the testicle will be found caudally. If both the ­pampiniform
plexus and the vas deferens are found together, the com-
bined tissues should be followed caudally toward the
inguinal canal. If the combined tissues extend to the
canal, the testicle is found externally to the abdomen.
Another incision over the inguinal canal will be ­necessary
to find the testicle. In some dogs, the retained testicle
Figure 14.18 A Snook hook is used to capture either the vas
deferens or the pampiniform plexus.
Figure 14.19 The vas deferens is identified.
Figure 14.20 The vas deferens is exteriorized.
may be of normal size, but in some, it may only be a ves-
tige at the junction of the vas and the pampiniform
plexus. When the testicle is found, both the vas deferens
and the pampiniform plexus are ligated separately
(Figures 14.22–14.24). A size of 2‐0 resorbable monofila-
ment sutures are acceptable for the ligations. The muscle
fascia is closed, and the subcuticular tissues are closed
with appropriate resorbable sutures. Skin glue is used on
the external tissues. In the case of a unilateral cryp-
torchid, the external testicle is then removed. See Video
14.2 for this procedure.

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Figure 14.21 Traction is applied to the vas deferens to remove
the testicle.
Figure 14.22 The testicle is being removed.
Figure 14.23 The fully exteriorized testicle.
Video 14.2 (This video includes audio commentary). Laser surgery
for retained testicle (cryptorchid orchiectomy).
Postoperative
Most patients, if not all, will need a restraint collar post-
operatively. Strict restriction to a leash is important
because most of these cases are young busy dogs.
­Paraphimosi 169
Figure 14.24 Ligations of the vas deferens and pampiniform
plexus are completed before full removal of the retained testicle.
­Paraphimosis
Overview
Paraphimosis may be the result of priapism, excessive
sexual activity, entanglement of preputial hair, trauma,
scarring caused by trauma or surgery, and restricted pre-
putial coverage. Occasionally, suturing after a prescrotal
castration can damage the retractor penis muscle, caus-
ing paraphimosis. Previously surgeons also added phal-
lopexy to the procedure, but this has not been necessary
with sheath advancement (Wasik and Wallace 2014).
When paraphimosis is encountered shortly after a pre-
scrotal castration, an incision in the prescrotal area and
isolation of the damaged retractor penis muscle is pos-
sible. The incision is made using 10–15 W continuous
wave SuperPulse and a 0.25 mm spot size to open the
original site. Blunt dissection is used to identify the
retractor penis muscle both cranially and caudally to
the area of damage. The muscle is shortened by Z‐plasty
sufficient to have the penis remain in the sheath.
Absorbable suture of 2‐0 to 3‐0 is used and the incision is
closed in the subcutaneous tissues.
The following surgical description is of a particular
canine patient that developed paraphimosis immediately
following castration a year before presenting to our clinic
(Figure 14.25). Two previous surgeries were attempted in
the interim to correct the problem. The first of the unsuc-
cessful surgeries involved placing a purse‐string suture in
the opening of the sheath. The second surgery involved
opening the end of the sheath with tissue removal and
closure to permanently narrow the opening. Both proce-
dures failed with the result of a fistulous tract on the ven-
tral surface of the sheath just caudal to the opening and
persistent paraphimosis. When the paraphimosis has
been present many months, the retractor penis muscle is
damaged and atrophied to the point that reconstruction
is not possible. In these cases, the surgical procedure of
choice is to advance the sheath (Table 14.3).
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Figure 14.25 Paraphimosis appearance prior to surgery. Source: Figure 14.26 Measurement of the exterior portion of the penis.
Schultz (2016). Reprinted with permission of Veterinary Source: Schultz (2016). Reprinted with permission of Veterinary
Practice News. Practice News.

Table 14.3 Paraphimosis.

Procedure Paraphimosis

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 10–15, 5–8
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100

Preoperative
At the initial examination, the distal penis showed
­desiccation damage. The exposed penis was treated daily
for two weeks with a lubricant to decrease the damage
prior to surgery.
The dog is placed in dorsal recumbence and the
­abdomen prepped for surgery. The penis was measured
at 2 cm proximal to the opening of the sheath
(Figure 14.26). This measurement is used during surgery
for the distance to advance the sheath for correction of
the paraphimosis. At the time of surgery, the distance is
marked on the abdomen with a marking pen ensuring
the sheath is moved cranially to adequately cover the
exposed penis (Figure 14.27).
Procedure
An incision is made in a semicircular pattern around the
end of the sheath and continues to the mark made crani-
ally on the abdomen (Figure 14.28). The incisions meet
at the caudal aspect of the sheath incision (Figure 14.29).
Figure 14.27 A mark is made on the abdominal wall for the
cranial margin of the incision, the fistula is also visible. Source:
Schultz (2016). Reprinted with permission of Veterinary
Practice News.
The tissue is removed (Figure 14.30) and the sheath is
advanced to the mark to verify the correct distance for
advancement (Figure 14.31). The cranial aspect of the
sheath is anchored to the abdominal fascia at the proxi-
mal aspect of the incision (Figures 14.32–14.36). If the
sheath is sutured to the skin the incision will shift cau-
dally resulting in failure to correct the paraphimosis.
Several anchor sutures are placed in the muscle fascia
centrally to the proximal aspect of the sheath incision.
The skin is then closed circumferentially and each pas-
sage from skin margin to skin margin includes a deep
bite into the abdominal fascia ensuring stability of the
sheath to the abdominal wall (Figure 14.37).
 ­Paraphimosi 171
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Figure 14.28 The incision starts at the junction of the cranial Figure 14.31 The sheath is advanced confirming retraction of the
aspect of the sheath and abdominal wall. Source: Schultz (2016). penis. Source: Schultz (2016). Reprinted with permission of
Reprinted with permission of Veterinary Practice News. Veterinary Practice News.

Figure 14.29 The incision is continued making a triangular Figure 14.32 The anchor sutures are placed in the muscle fascia.
incision. Source: Schultz (2016). Reprinted with permission of Source: Schultz (2016). Reprinted with permission of Veterinary
Veterinary Practice News. Practice News.

Figure 14.33 The suture is then anchored to the cranial ventral

Figure 14.30 The dermal layers are removed. Source: Schultz aspect of the sheath incision. Source: Schultz (2016). Reprinted
(2016). Reprinted with permission of Veterinary Practice News. with permission of Veterinary Practice News.
 172 Urogenital and Perianal Laser Surgery Procedures
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Figure 14.34 The pattern is repeated. Source: Schultz (2016).

Reprinted with permission of Veterinary Practice News. Figure 14.37 Sutures are continued circumferentially until entire
incision closed. Source: Schultz (2016). Reprinted with permission
of Veterinary Practice News.

Figure 14.35 The suture is tightened and the sheath anchored to

the abdominal wall. Source: Schultz (2016). Reprinted with
permission of Veterinary Practice News.

Figure 14.38 The laser is used to freshen the margins of the

fistula from a previous surgery. Source: Schultz (2016). Reprinted
with permission of Veterinary Practice News.

The area of the fistula was opened circumferentially,

and the subcutaneous area was dissected from the
mucosal layer (Figure 14.38). Absorbable sutures were
used for closure of the fistula using a two‐layer closure
with the mucosal layer closed first then the skin. The
skin was then closed with interrupted sutures
(Figure 14.39).

Postoperative
Figure 14.36 Interrupted skin sutures are placed with the abdominal
fascia included in the deep aspect of the sutures. Source: Schultz A restraint collar is imperative during healing. Skin
(2016). Reprinted with permission of Veterinary Practice News. sutures are removed in 10–14 days (Figure 14.40).

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Figure 14.39 The completed surgery. Source: Schultz (2016).
Reprinted with permission of Veterinary Practice News.
Figure 14.40 Suture removal at two weeks showing positional
stability of the sheath and retraction of the penis with closed
fistula. Source: Schultz (2016). Reprinted with permission of
Veterinary Practice News.
­Vulvoplasty
Overview
Redundant tissue that partially or completely occludes
the vulvar area is a common problem (Figure 14.41).
The fold will scald with urine and is the source for recur-
rent dermatitis, vaginitis, and cystitis (Hammel and
Bjorling 2002). Removal of the fold provides comfort
and relief of symptoms. When done with conventional
surgical methods, vulvoplasty may be very hemorrhagic,
resulting in poor visibility. When done with CO2 laser,
vulvoplasty is virtually free of hemorrhage with excel-
lent visibility. The procedure involves removal of the
fold dorsal and lateral to the vulva. Many of the cases
­Vulvoplast 173
Figure 14.41 The site is shaved and prepped for surgery.
Figure 14.42 The redundant tissue is lifted into final position to
determine the extent of the correction incision.
have mild‐to‐severe ­perivulvar dermatitis at presenta-
tion. Aggressively treating with topical antibacterial
wipes and oral antibiotics prior to surgery will lessen
complications postoperatively.
Preoperative
The dog is placed in sternal recumbence with the pel-
vis and tail elevated. It is helpful to have a tilt table or
to place beanbags under the pelvis to elevate the pelvis
for better visualization during surgery. The redundant
tissue is elevated manually to determine the extent of
the reduction incision (Figure 14.42). In some cases,
the use of a marker pen to define the area to be removed
will help define the incision and keep bilateral
symmetry.
 174 Urogenital and Perianal Laser Surgery Procedures

Procedure
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The laser is used (Table 14.4) to make an incision starting

at the dorsal aspect of the tissue to be removed and con-
tinued ventral and lateral to the vulvar tissues
(Figures 14.43 and 14.44). In many cases, a crease is pre-
sent in the lateral aspect of the vulvar fold and this may
be used as a guide for the outer portion of the incision.
The incision is continued ventrally and proceeds to the
lateral aspect of the vulva (Figure 14.45). However, in
some cases, redundant tissue is present to the ventral
aspect of the vulva with the incision continued to remove
that tissue. The second aspect of the incision is made at
the margin of the irritated skin (if present) and contin-
ued around the perivulvar tissues (Figure 14.46). If the
perivulvar tissue is not showing dermatitis, the incision
is made about 1–1.5 cm from the vulvar tissues. The skin Figure 14.44 In many cases, a fold will exist in the areas just
is dissected from the body fat (Figures 14.47–14.49). In lateral to the vulva giving a landmark for tissue removal.
many cases, subcutaneous fat is present, and this is
ablated using the laser at 15 W continuous wave and a 0.4
or 0.8 mm spot size (Figures 14.50 and 14.51). The use of

Table 14.4 Vulvoplasty.

Procedure Vulvoplasty

Laser type and CO2 CO2 (10 600)

wavelength (nm) (10 600)
Spot size (mm) 0.25 Wide ablation tip
Power (W) 15 15
Exposure Continuous Continuous wave
wave
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100 Figure 14.45 The medal incision is made to the margin of the
affected tissue.

Figure 14.43 Initial incision is made at the dorsal aspect and Figure 14.46 The medial incision is continued around the vulva
follows around the perivulvar area. and ends at the distal aspect of the first incision.

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Figure 14.47 Subcutaneous dissection through the pelvic fat is
done to remove the redundant skin.
Figure 14.48 With the skin the deep fat may also be removed.
Figure 14.49 The incision is continued removing the skin and
subcutaneous fat.
­Vulvoplast 175
Figure 14.50 After the skin is removed the site is examined to
determine if more fat needs removal.
Figure 14.51 If excessive fat is present it is ablated with the laser.
the ceramic 3 mm wide ablation tip is a new and excellent
tip to use for the fat ablation. The vulvar tissue is approx-
imated into position to determine if further tissue needs
to be resected (Figures 14.52–14.54). It is imperative that
the incisions be made to allow the vulvar folds to remain
closed. Too large an incision in the lateral aspects will
result in the vulva remaining open, causing dryness and
irritation.
The incision is closed with interrupted absorbable cru-
ciate pattern sutures in the subcutaneous tissues with
each pass taking a deep bite to close dead space
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Figure 14.52 The vulva is approximated into position to evaluate
proper position before suturing.
Figure 14.53 The incision may be adjusted to achieve proper
positioning of the vulva.
Figure 14.54 During positioning the fat may shift and final touch
up of any remaining fat is done prior to suture placement.
Figure 14.55 Closure begins at the 12:00 position.
Figure 14.56 Closure is continued left and right around the
incision keeping proper alignment of the margins.
(Figures 14.55–14.57). Closing the dead space obviates
the need for a drain tube. The skin is also closed using a
cruciate pattern of interrupted sutures (Figures 14.58
and 14.59).
Postoperative
When perivulvar dermatitis is still present, the area is
cleansed several times daily using antibacterial wipes.
Antibacterial wipes are also used to prevent scabbing
of the incision line during the first week. Suture
removal is in 14 days. A restraint collar is used in
breeds that can reach the area. Diapers or a body suit
that will cover the area may also be needed if
­postoperative scooting is noted.

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Figure 14.57 During closure the fit of the tissues is constantly to
give normal position to the vulva.
Figure 14.58 Interrupted skin sutures are placed completing the
procedure.
­Anal Gland Excision
Overview
Dogs that have chronic infection of anal glands, extremely
thick anal gland material, and little control of anal gland
fluid expression are all candidates for anal gland removal.
Visualization of the glands is critically important in this
procedure. Laser and blunt dissection allow for complete
visibility and removal of the glands. Many veterinarians
avoid this surgery because of potential nerve damage.
The visibility allowed by laser and blunt dissection
reduces the risk to negligible.
Preoperative
The patient is in sternal recumbence with the pelvis and
tail elevated. A surgical table that tips with the hind legs
­Anal Gland Excisio 177
Figure 14.59 Final position is examined. In this case
postoperative treatment of the dermatitis will be necessary for
proper healing. Healing will be rapid because urine contamination
has been corrected.
off the end of the table facilitates positioning. Towels,
beanbags, or pads are placed on the edge of the table.
The anal glands are expressed completely. Powdered
dental impression material is mixed to consistency that
will pass through a tomcat catheter or a tapered cathe-
ter‐tipped syringe. The gel impression materials may
work but may be too thick for filling the anal glands.
Experimentation before surgery may be necessary to
achieve the correct consistency of material to easily pass
through the catheter or the syringe. The material will be
set up within minutes, making application speed essen-
tial. The duct is visualized, and the tip of the catheter is
inserted into the anal gland, filling the gland completely
with material (Figures 14.60 and 14.61). When both
glands are filled, the area is not touched until the mate-
rial has completely set up. The impression material will
be set up in less than three minutes. Final surgical prep
and draping are then possible. During surgery, it is
important to pack the caudal rectum with saline soaked
gauze to prevent gas escape and possible methane
explosion.
Procedure
A 0.25 mm spot size is used throughout the procedure.
The laser is set for 10–15 W continuous wave exposure
on SuperPulse mode (Table 14.5). Incisions are made
from 3 to 5 o’clock and from 9 to 7 o’clock position on
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Figure 14.60 Dental impression material is placed into the gland. Figure 14.62 The incision is made through the skin but not into
Source: Schultz (2013). Reprinted with permission of Veterinary the anal gland. Source: Schultz (2013). Reprinted with permission
Practice News. of Veterinary Practice News.

Figure 14.63 Blunt dissection via mosquito hemostat is used to

separate the sphincter muscles from the surface of the gland.
Figure 14.61 It is important to fill the gland completely noted by Source: Schultz (2013). Reprinted with permission of Veterinary
overflow during filling. Source: Schultz (2013). Reprinted with Practice News.
permission of Veterinary Practice News.

the edge of the perineum (Figure 14.62). The incision is

carefully deepened using blunt dissection until the
gland is visualized (Figure 14.63). The surface muscles
Table 14.5 Anal gland excision. are bluntly dissected, followed by the margins of the
gland; blunt dissection then continues around the
Procedure Anal gland excision gland. In cases that have had previous ruptures or
severe irritation, the surface of the gland may be tightly
Laser type and CO2 (10 600) CO2 (10 600) adhered to the muscles due to scar tissue. The laser is
wavelength (nm)
then set for 3–5 W continuous wave exposure on
Spot size (mm) 0.25 0.25 SuperPulse mode for the dissection of scar tissue and
Power (W) 10–15 3–5 muscle tissue (Figure 14.64). Traction on the gland will
Exposure Continuous wave Continuous wave assist in the dissection of the surface muscles and scar
Mode SuperPulse SuperPulse
tissue. With the lower wattage, it is possible to dissect
the muscles while avoiding perforation of the anal
Duty cycle (%) 100 100
glands (Figures 14.65–14.67). The single artery is found

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Figure 14.64 Use the laser to dissect tissue not easily removed
with blunt dissection. A much lower setting is used with traction
on the gland allowing for close dissection of muscle and
connective tissue. Source: Schultz (2013). Reprinted with
permission of Veterinary Practice News.
Figure 14.65 Dissection continues on the cranial aspect of the
anal gland. Source: Schultz (2013). Reprinted with permission of
Veterinary Practice News.
at the ventral aspect of the gland and may need to be
cauterized or ligated. If the vessel is small, the laser may
be defocused in order to cauterize the artery.
Dissection is completed when the gland is fully mobile
and only attached by the duct (Figure 14.68). The duct is
ligated adjacent to the rectum (Figure 14.69) and the
gland removed (Figures 14.70–14.72). If the gland is per-
forated at any time, the opening of the gland is clamped
with a hemostat to keep the material from leaving
the gland. Contamination of the incision may occur if the
gland is inadvertently opened during surgery. When the
gland has been removed, the incision is flushed with
saline until completely clean before closure. Closure is
done with 2‐0 or 3‐0 monofilament absorbable suture
­Anal Gland Excisio 179
Figure 14.66 Cranial dissection continues. Care is taken on the
cranial ventral aspect in the area of the small artery to the gland.
Source: Schultz (2013). Reprinted with permission of Veterinary
Practice News.
Figure 14.67 Full dissection of the gland requires identification of
the duct. Source: Schultz (2013). Reprinted with permission of
Veterinary Practice News.
material depending on the size of the dog (Figure 14.73).
A vertical mattress pattern is used that closes the deep
and subcutaneous tissues (Figure 14.74). Usually only
two vertical mattress sutures will need to be placed. Use
care when taking a deep bite of tissue to avoid underlying
nerve tissue. Subcutaneous sutures may be placed if the
deep sutures do not appose the skin. Skin sutures or glue
are not used. The loose patterns for closure allow drain-
age in case of contamination during surgery.
Postoperative
Owners should be informed that, should either incision
open postoperatively, the incision should then be allowed
to heal by second intention. A restraint collar or body
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Figure 14.68 The gland is elevated and the duct is dissected.
Source: Schultz (2013). Reprinted with permission of Veterinary
Practice News.
Figure 14.69 The duct is ligated. Source: Schultz (2013). Reprinted
with permission of Veterinary Practice News.
suit work well, and diapers are used if any scooting
occurs postoperatively. The surgical site is kept clean
daily with antibacterial wipes for the first week. Although
rarely performed, cats are done using the same
technique.
­Urethral Prolapse
Overview
Urethral prolapse is encountered in some young male
canines, usually brachycephalic breeds (Carr et al. 2014).
The penile urethra is prolapsed past the end of the penis
and may cause bleeding at urination and a spray of urine
if the penis is out of the sheath at urination (Figure 14.75).
Surgical correction is the treatment of choice. The
Figure 14.70 The laser is used to cut the duct between the
ligation and the gland. In many cases, the duct is very short and
using hemostats on either side of the incision is not possible.
Source: Schultz (2013). Reprinted with permission of Veterinary
Practice News.
Figure 14.71 The gland is removed from the surgical site. Source:
Schultz (2013). Reprinted with permission of Veterinary Practice
News.
­ verriding concern is to prevent retraction of the penile
o
urethra during surgery. To accomplish this successfully,
incremental incisions must be made, with a suture placed
after each incision to assure the penile urethra remains
in position.
Preoperative
Full blood work, urinalysis, and urine culture are needed
to rule out infection. The dog is placed in dorsal recum-
bence and Allis forceps are used to secure the distal penis
to the sheath (Figure 14.76). A metal urinary catheter is
inserted in the urethra (Figures 14.77 and 14.78). Plastic
catheters will melt during the procedure and should not

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Figure 14.72 The removed glands showing clean dissection.
Source: Schultz (2013). Reprinted with permission of Veterinary
Practice News.
Figure 14.73 Closure is done with a subcutaneous suture pattern
closing the deep space. The margins are opposed but not closed
tightly. Care must be taken when placing the deep aspect of the
sutures to prevent local nerve damage. Source: Schultz (2013).
Reprinted with permission of Veterinary Practice News.
be used. The continuous wave delivery mode will control
hemostasis during the procedure (Table 14.6). The sur-
geon should also use caution in noting where laser light
may be reflected off the metal catheter.
Procedure
The initial incision line is 1–2 mm in length and made at
the visible end of the penis through the prolapsed tissue
to the metal catheter (Figures 14.79–14.82). The opened
area is then sutured using 3‐0 or 4‐0 interrupted
­monofilament suture material depending on the size of
the patient (Figures 14.83–14.85). The incisions and
­Urethral Prolaps 181
Figure 14.74 No skin sutures are placed and the site is very clean
at 10 days. Source: Schultz (2013). Reprinted with permission of
Veterinary Practice News.
Figure 14.75 The penis is exteriorized. Source: Schultz (2017).
Reprinted with permission of Veterinary Practice News.
suturing are continued sequentially until complete
removal of the prolapse is achieved. With small incisions
and closure of each incision as it is made, the penile
­urethra will not retract and is easily held for suture place-
ment. The prolapsed tissue is held with tension, allowing
healthy penile urethra to be exposed and sutured
(Figures 14.86–14.90). This gives assurance that the
mobile tissue of the penile urethra has been completely
removed (Figures 14.91 and 14.92).
Postoperative
It is not uncommon for bleeding to occur when aroused
during the healing period. If this happens, light‐to‐
moderate sedation is helpful to control excitement and
­erections that cause the hemorrhage. Trazodone or
 Table 14.6 Urethral prolapse.

Procedure Urethral prolapse

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Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 10
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100

Figure 14.76 Allis forceps are used to secure the distal penis to
the sheath. Source: Schultz (2017). Reprinted with permission of
Veterinary Practice News.

Figure 14.79 The prolapsed tissue is grasped with tissue forceps

and extended to the limit of the prolapse. Source: Schultz (2017).
Reprinted with permission of Veterinary Practice News.

Figure 14.77 A metal urinary catheter is placed in the penile

urethra. Source: Schultz (2017). Reprinted with permission of
Veterinary Practice News.

Figure 14.80 The initial incision is made in the central ventral

aspect of the prolapsed tissue. Source: Schultz (2017). Reprinted
with permission of Veterinary Practice News.

Figure 14.78 The catheter is advanced several centimeters for

stability during the procedure. Source: Schultz (2017). Reprinted
with permission of Veterinary Practice News.
 ­Urethral Prolaps 183
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Figure 14.81 The incision is widened but not completed. Source: Figure 14.84 Care is taken when placing the suture to secure the
Schultz (2017). Reprinted with permission of Veterinary Practice urethra to the penile tissue. Source: Schultz (2017). Reprinted with
News. permission of Veterinary Practice News.

Figure 14.82 Retraction on the prolapse opens the incision for Figure 14.85 The suture is checked visually and the ends cut
visualization of the penile urethra. Source: Schultz (2017). close to the knot to prevent irritation. Source: Schultz (2017).
Reprinted with permission of Veterinary Practice News. Reprinted with permission of Veterinary Practice News.

Figure 14.83 Forceps are used to secure the penile urethra Figure 14.86 The incision is continued incrementally around the
allowing for suture placement to the distal penis. Source: Schultz catheter and prolapsed tissue. Source: Schultz (2017). Reprinted
(2017). Reprinted with permission of Veterinary Practice News. with permission of Veterinary Practice News.
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Figure 14.87 Each time the incision is widened sutures are placed Figure 14.90 Final examination of the surgical site. Source: Schultz
keeping the penile urethra in proper position. (2017). Reprinted with permission of Veterinary Practice News.

Figure 14.88 The incision is continued until complete removal of

the prolapsed tissue. Figure 14.91 The site with the catheter removed. Source: Schultz
(2017). Reprinted with permission of Veterinary Practice News.

Figure 14.89 The last suture is placed in the dorsal aspect of the Figure 14.92 Two weeks postoperative at suture removal. Source:
penile urethra and penis. Schultz (2017). Reprinted with permission of Veterinary Practice
News.
 ­Vaginal Prolaps 185
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Figure 14.93 Completed healing after suture removal.

a­ cepromazine both work very well to control postop-

erative excitement that could lead to hemorrhage at
the ­surgical site. Restraint collars are only used if the
patient has the ability to reach the penis and sheath
area. Suture removal is scheduled two weeks postop- Figure 14.94 The site is draped for surgery.
eratively (Figure 14.93). Some may need sedation for
removal and the appointment should be scheduled
accordingly. Table 14.7 Vaginal prolapse.

Procedure Vaginal prolapse

­Vaginal Prolapse Laser type and CO2 (10 600) CO2
wavelength (nm) (10 600)
Overview
Spot size (mm) 0.25 0.25
During the estrogen phase of heat cycles, bitches have Power (W) 15–20 15
an increased thickening of vaginal tissue for protection Exposure Continuous wave Continuous
during breeding. In some cases, the floor of the vagina wave
will continue to thicken and may eventually prolapse Mode SuperPulse SuperPulse
(Figure 14.94). Hound breeds are over‐represented
Duty cycle (%) 100 100
with this problem. During diagnosis, it is important to
determine if this is vaginal floor prolapse or uterine
prolapse. The vaginal floor prolapse is attached ven-
trally and will allow palpation of the cranial vaginal Preoperative
area with dorsal digital palpation. The differential for a
The patient is placed in sternal recumbence with a pad
uterine prolapse is that the vaginal opening is central
under the pelvis and the tail elevated. This is another
and dorsal palpation of the vagina is not possible. The
case for a surgical table that tips up at one end.
prolapsed tissue may desiccate and ulcerate due to the
protrusion, and urethral obstruction may also be a
complication.
Procedure
Ovariohysterectomy will usually correct the problem
within a brief period. A Caslick suture pattern may be An episiotomy using 15–20 W at continuous wave expo-
used in early stages, but this will not prevent the prolapse sure and SuperPulse mode (Table 14.7) starts at the dor-
returning in future heat cycles. Recurrence is high, and if sal aspect of the vulva and is continued dorsally until the
the bitch is important for breeding the hyperplastic tis- hyperplastic tissue is fully exposed (Figures 14.95–
sue may be removed with return to normal function 14.97). Tension is placed on the incision margins for
(Concannon et al. 2014). exposure (Figure 14.98). The hyperplastic tissue is
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Figure 14.95 A scalpel handle is used to apply tension to the Figure 14.97 The incision is enlarged until the cranial base of the
episiotomy incision. prolapsed tissue is accessible.

Figure 14.96 The incision is continued dorsally with continued Figure 14.98 Allis tissue forceps are used for visibility.
pressure from the scalpel handle.
 ­Vaginal Prolaps 187
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Figure 14.99 The urethral catheter is easily inserted after the Figure 14.100 The incision for removal of the prolapse is started
episiotomy with the prolapsed tissue elevated. in the central cranial position.

e­ levated and a urinary catheter is placed (Figure 14.99).

In some cases, the catheter may be placed before the epi-
siotomy, but visibility is much greater after the episiot-
omy incision. The laser is then set for 15 W continuous
wave exposure and SuperPulse mode for the dissection
of the hyperplastic tissue. The margins are easily
­identifiable and care is taken during ventral dissection
to avoid the urethra. The incision is continued around
the ­hyperplastic tissue until removal is complete
(Figures 14.100–14.103).
Closure may be done sagittally or transversely depend-
ing on the size and position of the open incision
(Figures 14.104 and 14.105). Most will close very well
transversely with good maintenance of vaginal diameter.
Submucosal tissue is closed using 2‐0 or 0 monofilament
absorbable suture material depending on the size of the
patient. The mucosa is then closed with interrupted
sutures of the same material. Care is taken to avoid the
pelvic urethra during closure. It is also important to
check the urethral catheter during closure to be certain
no sutures are placed around or near the urethra
(Figure 14.106).
Closure of the episiotomy is in two layers. The first
layer closes the vaginal mucosa (Figure 14.107), while the Figure 14.101 The incision is continued laterally to the extent of
second layer closes the fascial and subcutaneous tissues the hyperplastic tissue. The margins are easily identifiable.
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Figure 14.102 Tension on the prolapsed tissue allows for more Figure 14.104 The incision is closed transversely starting in the
rapid cutting with the laser. center with identification of the urethra distally.

Figure 14.103 The incision is continued paying attention caudally Figure 14.105 Careful alignment of the incision will result in
to the urethra and not cutting deeply in the area of the urethra. equal bilateral tissue alignment.

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Figure 14.106 With complete removal of the hyperplastic tissue
the catheter remains inserted during closure of the episiotomy
incision.
Figure 14.107 Initial closure of the vaginal mucosal layer using
continuous pattern.
­Perineal Urethrostomy (Overview 189
Figure 14.108 Fascial and subcuticular closure begins after fully
closing the mucosal layer.
(Figures 14.108–14.110). It is important to have the dor-
sal commissure of the vulva properly aligned during clo-
sure. No skin sutures are placed when the subcuticular
layer closure is acceptable.
Postoperative
Most patients are comfortable immediately postopera-
tive. If scooting is encountered, the use of diapers or
underwear will protect the incision. A restraint collar
may be needed if licking is a concern.
­Perineal Urethrostomy (Overview)
The perineal urethrostomy in the dog and cat are two
surgeries in which the CO2 laser is incredibly efficient.
Increased visibility in delicate tissue allows for more
accurate incisions and identification of tissue layers dur-
ing closure. In both cases, the surgery is done because of
urethral obstruction.
In the cat, the penile urethra narrows and stones or a
mixture of stones and mucus will plug the tract. With the
advent of urinary care diets, this surgery is now rarely
performed. Diet changes and catheterization are first‐
resort life‐saving procedures. Some cats may refuse
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Figure 14.109 The subcuticular layer is nearing closure. It is
important to be sure the labial margins meet centrally.
Figure 14.110 No skin sutures are needed when the subcuticular
layer closes properly.
foods aimed at clearing the crystalluria, and the potential
for narrowing of the penile urethra due to repeated cath-
eterization may leave no choice but surgery.
In the dog, the penile urethra passes through the os
penis, and stones passing from the bladder effectively
block the urethra at the os. Removing stones during cys-
totomy followed by diet change may control the stones,
but in refractory cases, full control of stone formation
may not be possible (Brockman 2011). Opening the ure-
thra proximal to the junction of the urethra and the os
penis will allow for a much larger urethral opening, thus
avoiding blockage in the future. Preoperative urine cul-
ture and sensitivity with appropriate antibiotics and diet
change should be considered before either surgery. In
either case, surgery is performed only after initial
obstructive disease is controlled and any metabolic
­problems have been corrected.
Feline Perineal Laser Urethrostomy
Pre‐operative
The cat is placed in sternal recumbence with the tail
­elevated and the legs extended off the end of the surgical
table. The perineal area is prepped and a tomcat catheter
is inserted into the urinary bladder.
Procedure
A spot size of 0.25 mm is used throughout the procedure.
A laser setting of 15 W continuous wave exposure and
SuperPulse mode is used for initial incisions (Table 14.8).
The incision is made from the dorsal aspect of the scro-
tum surrounding the entire scrotum and sheath
(Figures 14.111 and 14.112). If the male is intact, the
­testicles are removed and the cords ligated. The scrotal
tissue and sheath are removed, and the penis is dissected
free of scrotum and sheath (Figures 14.113 and 14.114).
Table 14.8 Feline perineal urethrostomy.
Procedure Feline urethrostomy
Laser type and CO2 CO2
wavelength (nm) (10 600) (10 600)
Spot size (mm) 0.25 0.25
Power (W) 15 10
Exposure Continuous Continuous
wave wave
Mode SuperPulse Non‐
SuperPulse
Duty cycle (%) 100 100

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Figure 14.111 Initial incision started at the dorsal aspect of the
scrotum.
Figure 14.112 The incision is continued around the entire
scrotum and sheath.
Figure 14.113 The subcutaneous tissues are incised and the
dermal tissue reflected to the end of the penis.
The penis is then raised dorsally and blunt dissection is
used to identify the ventral attachment to the pelvis. The
attachment is very narrow and is centrally located
(Figure 14.115). This tissue is cut with Mayo or
Metzenbaum scissors. The dissection continues to the
bulbourethral glands that are attached to the ischium
bilaterally. The laser is then set for 10 W continuous
wave exposure in non‐SuperPulse mode and the bul-
bourethral gland is dissected free from the ischium
­Perineal Urethrostomy (Overview 191
Figure 14.114 The dermal tissues are removed at the distal
aspect of the penis.
Figure 14.115 The central ventral attachment of the penis to the
pelvis is bluntly dissected free.
Figure 14.116 The bulbourethral glands are removed at the
ischial attachments bilaterally.
(Figures 14.116 and 14.117). The attachment area to the
ischium is small and incisions into the gland are avoided
due to excessive bleeding. After the bulbourethral glands
and the ventral attachment to the pelvis have been cut,
the penis will move caudally allowing for a larger open-
ing of the urethra. Iris scissors are used to open the
penile urethra dorsally (Figures 14.118–14.120). The
incision is continued proximally until the lumen of the
urethra is at least 5 mm in diameter. Simply inserting a
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Figure 14.117 A hemostat is used to confirm separation of the
bulbourethral glands from the pelvis.
Figure 14.118 Iris scissors are used to open the sheath dorsally.
Figure 14.119 The incision in the urethra is advanced cranially.
straight mosquito hemostat to the level of the hinge
without undue pressure will give the proper distance to
make the incision (Figure 14.121). The urethra is initially
opened to the level of the skin incision, then opened
incrementally until at the proper diameter by checking
with the hemostat. A hemostat is then placed trans-
versely on the penis at mid shaft. The distal half is ampu-
tated (Figure 14.122), and the hemostat remains until
surgical closure of the proximal aspect is completed. The
hemostat adds weight to the penis, keeping the penis
positioned for suturing.
Figure 14.120 The incision is then advanced incrementally until a
mosquito hemostat is easily inserted to the hinge joint.
Figure 14.121 The hemostat is inserted in the urethra to
determine diameter.
Figure 14.122 The distal aspect of the penis is clamped and
removed with the laser.
Closure begins at the dorsal aspect of the urethros-
tomy using interrupted 4‐0 monofilament sutures cen-
trally and then proceeding bilaterally to suture the
urethra to the skin (Figure 14.123). After four to six
sutures are placed in the proximal aspect (Figure 14.124),
the hemostat is removed and the distal aspect of the
penis is sutured to the ventral aspect of the skin incision
(Figure 14.125). Sutures are then continued on both lat-
eral margins (Figure 14.126). In most cases, this will leave

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Figure 14.123 Initial closure of the incision is started at the dorsal
aspect of the urethral opening to the skin.
Figure 14.124 Three sutures have been placed around the
urethral opening.
Figure 14.125 The distal aspect of the severed penis is attached
to the ventral aspect of the incision.
open tissue in both ventral aspects of the original inci-
sion. These areas are closed separately (Figure 14.127). A
tomcat catheter is sutured in place for the first
18–24 hours, and urine flow is monitored during this
time (Figure 14.128). See Video 14.3 for this procedure.
Video 14.3 (This video includes audio commentary). Feline laser
surgical perineal urethrostomy procedure.
­Perineal Urethrostomy (Overview 193
Figure 14.126 The interrupted suture pattern is completed.
Figure 14.127 The completed surgical site.
Figure 14.128 A tomcat catheter is sutured in place overnight.
Postoperative
The cat is immediately placed in a restraint collar, and
the incision is medicated topically with antibiotic oint-
ment. Scabs are gently removed daily if present. Typically,
the cat is placed under anesthesia for suture removal, but
some will allow suture removal while awake.
Canine Penile Laser Urethrostomy
Due to the os penis surrounding the penile urethra, a
bottleneck is present in the male dog. This area is easily
obstructed when stones pass from the urinary bladder.
 194 Urogenital and Perianal Laser Surgery Procedures
Preoperative
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The dog is placed in dorsal recumbence, and the caudal
abdominal area is pepped for surgery. A catheter is
placed to empty the bladder. Care must be taken to
­prevent melting of the catheter.
Procedure
The laser is set for 15 W continuous wave exposure on
SuperPulse mode for the initial incision (Table 14.9). The
incision is made 1–2 cm proximal to the os penis and is
3–4 cm in length. The skin is parted and the laser is then
set to 10 W continuous wave exposure and non‐
SuperPulse mode to open the urethra. The presence of
the catheter allows for identification of the penile ure-
thra. If visible, the retractor penis muscle is moved later-
ally and the corpus cavernosum is avoided when making
the incision to the urethra. Once again, care must be
taken to prevent melting of the catheter. Once the ure-
thra is opened, the catheter may be removed and a mos-
quito hemostat is placed in the lumen as a guide for the
remaining incision. The urethra is then opened the full
length of the skin incision.
Closure is with interrupted 3‐0 to 4‐0 monofilament
interrupted sutures depending on the size of the dog.
Both open ends of the urethra are done first to ensure
proper location of the urethra and the openings are
checked for patency after the sutures are placed. The
urethra is sutured directly to the skin using an inter-
rupted pattern. The urethral tissue is very strong and
holds the sutures very well. When using the laser, hem-
orrhage may still be present, but the hemorrhage is dra-
matically less than when using steel.
Postoperative
A restraint collar is placed before the dog is completely
awake and remains until one day after sutures are
removed. Postoperative hemorrhage is not uncommon
and a mild tranquilizer, trazodone, or acepromazine may
Table 14.9 Canine perineal urethrostomy.
Procedure Canine urethrostomy
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.25 0.25
Power (W) 15 10
Exposure Continuous wave Continuous
wave
Mode SuperPulse Non‐
SuperPulse
Duty cycle (%) 100 100
be necessary to control excitement that leads to erection
and bleeding. The hemorrhage may occur for several
days, and hospitalization and a quiet kennel environ-
ment will allow for much more rapid return to normalcy.
Sutures are removed in two weeks, with some dogs need-
ing light sedation for removal.
­Cystotomy for Urolithiasis
Overview
Hematuria and tenesmus symptoms are an alert to the
clinician that uroliths may be present. Transitional cell
carcinoma and uncomplicated urinary tract infections
are also on the list of rule‐outs. Imaging and urinalysis is
indicated. Radiography with plain file, radiography with
double‐contrast ultrasound, and advanced imaging are
valuable diagnostically. The quality and ease of ultra-
sound make this method one of the best for diagnostics.
Once found, uroliths may be managed with medication
and diet change, or may be removed through surgery or
ablation by lithotripsy. Surgical removal is often the pro-
cedure of choice in general practice.
Preoperative
The patient is placed in dorsal recumbence, and the
lower abdomen is prepped for surgery. It is not necessary
to insert a urinary catheter prior to cystotomy.
Procedure
The procedure is similar for dogs and cats. This article
will involve a feline cystotomy.
The laser is set for 10 W continuous wave exposure
and SuperPulse mode for all incisions (Table 14.10). A
caudal midline incision is made in the skin and the sub-
cutaneous fat is either sharply or bluntly dissected to the
abdominal midline (Figure 14.129). Sharp dissection of
the fat is less traumatic and is the preferred approach.
The abdominal midline is opened with the laser with
caution on depth to avoid damage to the urinary bladder.
In many cases, the preoperative tenesmus does not allow
for a cystocentesis. The urinary bladder is elevated from
the abdominal incision (Figure 14.130). Before opening
the bladder, a sterile sample may be taken for urinalysis
with culture and sensitivity (Figure 14.131). An incision
in the bladder is made with the laser (Figure 14.132), and
may be widened with sharp dissection if needed
(Figure 14.133). If a single large stone or multiple large
stones are present, the use of a mosquito or Carmalt
hemostat may be used for stone extraction
(Figures 14.134–14.136). In larger bladders digital
 ­Cystotomy for Urolithiasi 195

Table 14.10 Cystotomy.

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Procedure Cystotomy

Laser type and wavelength (nm) CO2 (10 600)

Spot size (mm) 0.25
Power (W) 10
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100

Figure 14.132 Bladder opened with laser.

Figure 14.129 Initial incision in caudal abdomen.

Figure 14.133 Bladder incision widened with sharp dissection.

Figure 14.130 Urinary bladder exteriorized.

Figure 14.134 Carmalt hemostat inserted to retrieve stone.

Figure 14.131 Cystocentesis for urinalysis, culture, and sensitivity. Figure 14.135 Stone removal.
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Figure 14.136 Stone is saved for analysis.
Figure 14.137 Initial flush of the bladder with saline.
Figure 14.138 Bladder and urethra flushed with saline.
Figure 14.139 Groove director.
removal may be possible. When it is determined that all
stones are removed, the bladder is flushed using saline
and a red rubber catheter (Figures 14.137 and 14.138).
The flush will remove any small crystals and is used to
flush the pelvic urethra. Initially, the fluid is expelled
Figure 14.140 Closure of bladder with continuous pattern.
through the cystotomy site and then, as the catheter is
inserted into the neck of the bladder, the fluid is expelled
through the pelvic urethra. If there is a concern that
stones may be adhered to the bladder, the use of a groove
director may be used to probe the bladder and urethra
(Figure 14.139). When inserted, the groove guide will
give a metallic ping on contact with stones.
When all stones and crystals have been removed, the
bladder is closed with a continuous apposing or double
inverting pattern using 3‐0 monofilament absorbable
sutures (Figure 14.140). The muscle fascia and subcuta-
neous tissues are closed using 3‐0 monofilament absorb-
able suture material. See Video 14.4 for this procedure.
Video 14.4 (This video includes audio commentary). Feline laser
surgical cystotomy procedure.
Postoperative
A restraint collar is only used if the patient is concerned
with the incision. Broad spectrum urinary antibiotics are
started pending culture and sensitivity results. The stone(s)
are submitted for analysis. Frequently, the type of stone is
identified by the physical appearance, but the stone should
be sent for analysis because some stones may have a core
of a different material than the outer visible aspect.
­Conclusion
All surgeries described in this chapter may be done with
either steel blades or laser. However, hemostasis and
postoperative complications are dramatically reduced
while visibility is greatly improved with the aid of a laser.
A scalpel requires friction to cut, and when used on deli-
cate tissue, the incisions are not exact. Surgical lasers
offer extreme precision, do not require friction, and the
depth of the incision may be more accurately controlled,
giving the laser surgeon a distinct advantage over other
surgical modalities.

The use of a surgical laser dramatically increases the
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ability of the surgeon to identify tissue during surgery,
dramatically reduces intra‐operative hemorrhage, and
­References
Brockman DJ. (2011). Surgical decision making in dogs and
cats with acute urethral obstruction. www.ivis.org/
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Bryant S. (2010). Anesthesia for Veterinary Technicians.
Wiley Blackwell. p. 141
Carr JG, Tobias KM, Smith L. (2014). Urethral prolapse in
dogs: a retrospective study. Vet. Surg. 43(5). pp. 574–580,
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Concannon PW, England G, Verstegen III J, et al. (2001).
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changes of the vas deferens after vasectomy and
vasovasostomy in dogs. Surg. Gynecol. Obstet. 156(6).
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Hammel SP, Bjorling DE. (2002). Results of vulvoplasty for
treatment of recessed vulva in dogs. J. Am. Anim. Hosp.
Assoc. 38(1). pp. 79–83.
Omi T, Numano K. (2014). The role of the CO2 laser and
fractional CO2 laser in dermatology. Laser Ther. 23(1).
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­Reference 197
allows for controlled incision depth, making laser sur-
gery a critical addition to any general or surgical
practice.
Prapaiwan N, Sukayna Manee S, Srisuwatanasagul S.
(2016). Immunolocalization of oxytocin receptor in
relation to estrogen receptor beta in the reproductive
tissues of unilateral abdominal cryptorchid dogs. www.
ivis.org/proceedings/iscfr/2016/181.pdf (accessed 20
June 2018).
Schultz W. (2013). Laser removal of anal glands. Vet. Pract.
News. 25(7). pp. 40–41 (Figures 1–14).
Schultz W. (2016). How to use CO2 laser for paraphimosis.
Vet. Pract. News. 28(5). pp. 46–47 (Figures 1–14).
Schultz W. (2017). CO2 laser correction of urethral prolapse.
Vet. Pract. News. 29(7). pp. 54–55 (Figures 1–9).
Seidmon EJ, Krisch EB, Baer HM, et al. (1990).
Vasovasostomy in dogs using the carbon dioxide
milliwatt laser: Part II. Lasers Surg. Med. 10(5).
pp. 433–437.
Silva LD, Onclin K, Donnay I, et al. (1993). Laparoscopic
vasectomy in the male dog. J. Reprod. Fertil., Suppl. 47.
pp. 399–401.
Tannouz GS, Mamprim MJ, Lopes MD, et al. (2009).
Prevalence of cryptorchidism in dogs through
ultrasound scanning. www.ivis.org/proceedings/
wsava/2009/lecture35/8.pdf (accessed 20 June 2018).
Wasik SM, Wallace AM. (2014). Combined preputial
advancement and phallopexy as a revision technique for
treating paraphimosis in a dog. Aust. Vet. J. 92(11).
pp. 433–436.
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15
Oncological Laser Surgery Procedures
Devin Cunningham and F. A. (Tony) Mann
­Introduction
Surgical removal of solid neoplastic lesions continues to
be a mainstay of oncological therapy in both people and
animals. The goal of surgical excision is to remove the
tumor completely without adversely affecting the
patient’s quality of life. As the field of surgical oncology
continues to advance, so too should the instruments
used to treat neoplastic lesions (Holt and Mann 2002;
Poston 2007; Farese et al. 2012; Paczuska et al. 2014,
2017). Laser surgery has many potential benefits for use
in surgical oncology, especially compared to traditional
use of a scalpel blade.
The carbon dioxide (CO2) laser is the most common
surgical laser used by veterinarians, and this is the laser
that has been used for surgical oncology in this study.
Unless otherwise noted, the CO2 laser is used in the sur­
gical oncology descriptions in this chapter. The CO2
laser is useful in surgical oncology for incisions, exci­
sions, and tissue ablation (Jacques 1992; Holt and Mann
2002). The higher wavelength of the CO2 laser is readily
absorbed in water, making the CO2 laser very useful for
cutaneous and subcutaneous neoplasms due to less lat­
eral thermal damage than the diode laser (Katzir 1993;
Holt and Mann 2002). Diode lasers are optimal for cut­
ting or biopsy of vascular tissue such as liver or spleen
due to the short wavelengths that are more readily
absorbed by hemoglobin than the CO2 laser. Hemoglobin
absorption also makes the diode laser better at hemosta­
sis compared to CO2 lasers (Holt and Mann 2002).
Lasers have several advantages over traditional scal­
pels in surgical oncology. Sealing of blood vessels by
lasers allows the surgeon to have a cleaner surgical field
to improve identification of tissue planes (Dinstl and
Tuchmann 1990; Jacques 1992; Holt and Mann 2002;
Berger and Eeg 2006). The hemostatic capabilities of the
laser allow for improved tissue visualization and assur­
ance of being in the correct tissue plane to achieve the
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
appropriate deep margin. The exquisite visualization of
tissues helps guide proper depth of incision and ensures
achievement of adequate surgical margins. Another ben­
efit of the improved visualization of the tissues is that the
surgeon can get closer to the tumor without encroaching
it and risking neoplastic contamination of the surgical
field. The ability to defocus the beam aids in coagulation
especially in ulcerative neoplastic lesions (Holt and
Mann 2002; Berger and Eeg 2006). Even though the CO2
laser is not as effective at hemostasis as the diode laser, it
can still seal vessels up to 0.5 mm in diameter (Holt and
Mann 2002; Berger and Eeg 2006). Postoperative swell­
ing is decreased due to sealing of lymphatic vessels, and
the CO2 laser creates less char on the skin and subcu­
taneous tissues than the diode laser. Infections can
interfere with wound healing and delay the start of
complementary treatment (such as chemotherapy or
radiation therapy) (Dinstl and Tuchmann 1990; Holt and
Mann 2002; Poston 2007). Lasers can vaporize infectious
organisms (bacteria, fungi, and viruses) such as those
associated with necrotic tumors, which may decrease the
risk of surgical site infections (Mullarky et al. 1985; Holt
and Mann 2002). The sealing of small nerves endings can
help minimize postoperative pain (Holt and Mann 2002;
Berger and Eeg 2006).
Another benefit of lasers for surgical oncology is the
potential to reduce chances of recurrence or metastasis.
The noncontact mode prevents dragging instruments
through neoplastic lesions and reduces the chance of
tumor seeding that could otherwise occur with use of a
scalpel blade (Holt and Mann 2002; Berger and Eeg
2006). The laser also allows precise cutting of skin on the
initial incision and can be more accurate in acquiring
clean surgical margins. The accuracy stems from the
ability to cut along the planned surgical margins due to
the increased visibility provided by the hemostatic prop­
erties of lasers and because there is limited distortion of
tissue due to the noncontact mode (Holt and Mann 2002).

There is debate about whether laser surgery can lead to
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increased survival, decreased chance of distant metasta­
sis, and improved tumoricidal activity compared to a
scalpel blade. Studies (Lanzafame et al. 1986; Rimbach
et al. 1992) have shown decreased local recurrence rates,
increased survival rates, and fewer lung metastasis with
the CO2 laser vs. traditional scalpel blade excision.
Paczuska et al. showed no significant difference in sur­
vival time and time to metastasis between CO2 laser and
scalpel blade excision of mammary gland adenoc­
arcinoma in mice (Paczuska et al. 2017). Unfortunately,
there is insufficient veterinary literature to support or
disprove the tumoricidal effects due to lack of standardi­
zation of power settings, differences in detection tech­
niques for neoplastic cells, and varied tumor type and
behavior (Paczuska et al. 2017).
Cutaneous and subcutaneous neoplasms are the most
common form of neoplasia excised with lasers. Lasers may
be useful in the treatment of a variety of cutaneous and
subcutaneous tumors, such as squamous cell carcinoma,
mast cell tumor, melanoma, soft tissue sarcoma, mammary
gland adenocarcinoma, perianal adenoma, apocrine gland
anal sac adenocarcinoma (AGASACA), sebaceous ade­
noma, histiocytoma, papilloma, and many more. Due to
high water content in the skin and subcutaneous tissue, the
CO2 laser is the preference over the diode laser. Some car­
bon dioxide lasers utilize handpieces to focus the energy.
Such handpieces come in a variety of forms that can be
invaluable in different surgical situations by changing the
spot size or focal distance (Holt and Mann 2002).
In addition to excising masses, CO2 lasers can be
used to ablate and desiccate the surface of tumors.
Ulcerative tumors can contaminate the surgical field,
but through defocusing the beam, desiccation of the
surface is possible. Ablation of tumors with the laser
can be used to remove small, benign tumors. It is
important to not ablate unknown masses. Each tumor
type has different biologic behavior, and an apparently
benign lesion could be malignant and may reoccur or
have distant metastasis. We recommend obtaining tis­
sue for histopathology before ablating a tumor. When
clean margins are not possible, ablation with lasers can
be used to facilitate cytoreduction prior to chemother­
apy or radiation therapy.
Noncutaneous neoplasms treatable by CO2 lasers
include thyroid tumors and oral tumors. Thoracic
tumors and deep abdominal tumors are cumbersome to
excise with the CO2 laser. However, partial splenecto­
mies with lasers have been reported (Reynolds et al.
1986), but mainly for the purpose of hemostasis of the
cut surface of the spleen. Due to the highly vascular
nature of commonly neoplastic abdominal organs, the
diode laser would be preferential to the CO2 laser due to
the better hemostasis that can be achieved (Reynolds
­Cutaneous Neoplasi ­Cutaneous Neoplasi 199
(a)
(b)
(c)
200 μm
Figure 15.1 Histopathology of an apocrine duct adenoma in an
11‐year‐old domestic short haired cat illustrating the inked margin
(blue arrow), tumor (a), normal tissue (b) and burn artifact (c). The
burn does not interfere with interpretation of a clean margin
because normal tissue can be seen between the inked burn and
the tumor. Source: Mann (2015). Reused with permission of
Veterinary Practice News.
et al. 1986). Laser surgery has rarely been employed for
intrathoracic and intraabdominal procedures.
All masses should be submitted for histological exami­
nation. Excisions for cure (wide margins) and marginally
excised specimens should be marked with India ink or
ink from a commercially available marking system to
facilitate surgical margin identification by the pathologist.
Laser excision causes some histologic artifact (Figure 15.1)
known as char, but to date that artifact has not interfered
with tumor identification or determination of margin
contamination.
­Cutaneous Neoplasia
Cutaneous neoplasia is one of the most common
applications for lasers in veterinary medicine. The CO2
laser can be used on both benign and malignant lesions
and can be used for excision or ablation. Benign masses
of the skin include sebaceous adenoma, papilloma, and
trichoepithelioma, to name just a few of the many cuta­
neous neoplasms. Benign growths may not require as
wide a margin as malignant tumors; however, one may
not know the malignancy of the mass until the results of
histopathology are available. Therefore, wide margins
are always recommended. Skin margins should be equal
to the diameter of the mass if the mass is less than or
equal to 2 cm, or 2–3 cm if the mass is greater than 2 cm.
The deep margin should be at least one tissue plane
below the mass. One may consider ablation of masses
less than 1 cm in diameter. However, ablation precludes
 200 Oncological Laser Surgery Procedures

the acquisition of tissue for histopathology to confirm incision is being made, thereby separating the tissue eas­
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that the mass was benign. ily and reducing the formation of char. If there is too
much tension, incomplete vaporization and tearing of
vessels along the incision will lead to increased hemor­
Procedure
rhage (Holt and Mann 2002; Berger and Eeg 2006). The
Patient positioning (dorsal vs. lateral vs. ventral recum­ power setting used for the subcutaneous tissue is typi­
bence) is based on the location of the mass and surgeon’s cally the same as that used for the skin incision. A spot
preference. Prepare the skin around the cutaneous mass size of 0.25–1.4 mm may be used at the surgeon’s discre­
to ensure an adequate surgical field for achieving appro­ tion, but 0.4 mm is the most common diameter used.
priate margins and avoiding hair contamination during Apply tension to allow the incised edges of the skin to
closure. After appropriate sterile preparation and drap­ separate as the subcutaneous tissue is incised but avoid
ing, a sterile sleeve may be used to cover the delivery sys­ touching the tumor during this process. Once the deep
tem of the CO2 laser if there is concern for contamination. tissue plane is identified, the laser beam is angled and the
The handpiece should be sterile; therefore, the sterile specimen is elevated to lift the tumor and its normal tis­
sleeve is unnecessary if care is taken to keep the delivery sue margins from the wound bed as excision is com­
system from touching gloved hands or any portion of pleted (Figure 15.2b). Any char formed on the remaining
the sterile field. The planned incision may be traced on the exposed surface of the wound bed should be wiped away
skin with a marker, or the laser can be used to outline the with a sterile saline‐soaked gauze sponge. The wound is
incision around the mass (Figure 15.2a) with a 0.4 mm then closed in standard oncological surgical fashion.
spot size and 10–15 W of power (Table 15.1).
Skin incisions are typically made with a 0.4 mm diam­
eter spot size. Prior to 2016, power settings were typi­
Table 15.1 Cutaneous neoplasms.
cally 6–8 W, but higher power settings of 15 W have been
used since. Continuous wave in non‐SuperPulse or
Cutaneous neoplasms
SuperPulse modes may be used. The advantage of the Procedure (excision) (ablation)
SuperPulse mode is that it provides short periods of rest
for the tissues, further decreasing the amount of char Laser type and CO2 (10 600) CO2 (10 600)
formation and collateral thermal necrosis (Berger and wavelength (nm)
Eeg 2006). SuperPulse mode is recommended for the Spot size (mm) 0.25–1.4 (0.4) 0.8–1.4 or 3 mm
entire incision (skin and all tissues). SuperPulse mode is wide ablation tip
favored for all oncological surgery applications except Power (W) 10–15 10 or more
for ablation. For cutting, the tip of the hand piece should Exposure Continuous wave Continuous wave
be held 2–3 mm from the skin and oriented as perpen­
Mode SuperPulse Non‐SuperPulse
dicular as possible to the incision site to prevent uneven or non‐SuperPulse
power densities affecting vaporization. Lateral tension
Duty cycle (%) 100 100
should be applied perpendicular to the incision as the

(a) (b) Figure 15.2 Suspected mastocytoma of

the right pelvic limb of a dog. Margins
have been marked with the laser tip by
making pinpoint incisions, and then
connecting the dots (a). After incising skin
and subcutaneous tissues to reach the
deep margins, the laser tip is held at a 45°
angle to incise the tissue deep to the
tumor (b).
 ­Cutaneous Neoplasi ­Cutaneous Neoplasi 201

Mast cell tumors can secrete heparin and histamine (a)

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that may result in intraoperative peritumoral bleeding

even when using the laser appropriately (Simpson et al.
2004; Marconato et al. 2008; Farese et al. 2012). Wider
margins than necessary for avoiding the tumor may help
minimize peritumoral hemorrhage. Meticulous atten­
tion to coagulate vessels before cutting them will also
help keep the surgical field free of blood. Vessel coagula­
tion is a technique that can be used to provide hemosta­
sis by defocusing the laser beam and using a sweeping
motion over the vessel which in turn will “weld” together
the walls of the exposed vessels (Figure 15.3). This sweep­
ing motion should not be used when incising tissue. Such (b)
vessel coagulation is typically reserved for vessels no
greater than 1 mm diameter (Berger and Eeg 2006).
Other methods of hemostasis (electrocoagulation or
ligation) may be necessary for larger vessels.
Soft tissue sarcomas include a variety of different sarco­
mas that can be difficult to differentiate from each other
but behave similarly. Soft tissue sarcomas are locally inva­
sive tumors that can be cured via appropriate surgical exci­
sion (Simpson et al. 2004; Dennis et al. 2011). Low‐grade
soft tissue sarcomas have a low recurrence rate as long as
adequate surgical margins are achieved (Dennis et al.
2011). However, it is possible that with clean margins soft
tissue sarcomas can reoccur at the original site, possibly
due to the asymmetric growth patterns between the fascial
planes or satellite lesions that can occur away from the
mass (Simpson et al. 2004; Dennis et al. 2011). Soft tissue
sarcomas are excised with the CO2 laser in similar fashion
as described above for mast cell tumors, but without as
much concern for the peritumoral effects. It is important
to ensure that the handpiece is held perpendicular to the
incision with appropriate tension until it is time to change (c)
the angle of incision to incise the deep margin.
Perianal adenoma is another cutaneous neoplasm that
can be treated with laser surgery (Figure 15.4). Improved
hemostasis with a laser is a huge benefit due to the highly
vascular tissue of the perianal area. For excision of peri­
anal masses, dermal margins can be outlined as described
above and the entire excision done with the laser in
SuperPulse mode. Small lesions (less than 1 cm diame­
ter) may be amenable to ablation as long as histopathol­
ogy has confirmed that the tumor is a perianal adenoma.
Ablation is achieved with a spot size of at least 0.8 mm
and 10 W (or higher) power setting in non-SuperPulse
mode (Table 15.1). A handpiece equipped with a 3 mm
ablation tip can achieve ablation more rapidly than with
routine tips and spot sizes (Figure 15.5).
Figure 15.3 Vessel coagulation for hemostasis by isolating an
artery in the surgical field (a), defocusing the CO2 laser beam and
Postoperative “painting” over the isolated artery (b), and then re‐focusing the
CO2 laser to incise the “welded” artery (c).
Malignant masses typically require wide margins based on
the size of the mass as previously discussed. Masses with
 202 Oncological Laser Surgery Procedures
incomplete margins may have residual neoplastic cells in
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the surrounding tissue, creating a risk for recurrence. If
wide margins and the appropriate deep plane are not
­possible, then adjunctive treatment, such as chemother­
apy or radiation therapy, should be considered.
Figure 15.4 An ulcerated perianal adenoma amenable to CO2
laser excision after ablation of ulcerated portions.
Figure 15.5 Handpiece with 3 mm ablation tip (Luxarcare LLC,
Woodinville, WA) used for time‐efficient desiccation of ulcerated
surfaces and ablation of small masses, as long as histopathology
of the masses has been performed.
­Subcutaneous Neoplasia
Some of the more common subcutaneous neoplasms are
AGASACA, soft tissue sarcoma, mastocytoma, and
lipoma, but there are various other tumors that can
develop in the subcutaneous tissue. Excision of these
tumors can be achieved with laser settings as previously
described for the skin and subcutaneous tissue
(Table 15.2). An ellipse of skin over the tumor is often
excised with the subcutaneous tumor to ensure that no
superficially located tumor cells remain. Then, the incision
is deepened to one tissue plane below the tumor before
changing the angle of the laser beam. Achieving a clean
deep margin may require excision of muscle or the fascia
covering the underlying muscle. The CO2 laser has great
utility in this instance for two reasons: (i) there is little to
no bleeding from the muscle and (ii) the laser does not
stimulate muscle contraction as is noted when electro­
surgery is used in these cases. Lack of muscle stimulation
aids in postoperative analgesia because the muscles
should not be sore from excessive work.
Lipomas are typically benign masses that do not
require wide surgical margins. Lipoma excision is
­typically limited to large lipomas that inhibit the patient’s
ability to ambulate normally or cause some other
physical disability. Common areas where lipomas become
such a problem are the axilla, thoracic wall, inguinal
area, and caudal thigh. Incision of the skin can be made
using the settings previously described directly over the
mass; excision of overlying skin is not typically required
for lipomas. Marginal excision is usually sufficient for
lipoma removal. Rather than “shelling out” the lipoma
with instrument or digital dissection, the laser may be
used to achieve excision. The laser is advantageous here
because it facilitates visualization and differentiation of
normal subcutaneous fat from the lipoma. Lipoma excision
may be difficult when the lipoma courses between muscle
Table 15.2 Subcutaneous neoplasms.
Subcutaneous neoplasms
Procedure (e.g. lipoma, AGASACA)
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.25–1.4 (0.4)
Power (W) 10–15
Exposure Continuous wave
Mode SuperPulse
or non‐SuperPulse
Duty cycle (%) 100
 ­Oral Tumor ­Oral Tumor 203

bellies. Using the laser, bloodless dissection of lipoma laser will delay intraoperative bleeding until the bony
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from the adjacent muscle is readily achieved. cuts must be made.

Apocrine gland anal sac adenocarcinoma can be tedious
to remove due to the vascularity of the perineal region
and difficulty identifying the anal sac itself. Excision is
performed similarly to lipoma excision, even though
AGASACA is a malignant tumor. Typically, a curvilin­
ear skin incision is made lateral to the anus (on the
side of the mass). The AGASACA is removed via
marginal excision with the goals of (i) reduction of
tumor burden in preparation for adjunctive chemother­
apy and (ii) control of hypercalcemia, a paraneoplastic
syndrome associated with secretion by the tumor of a
parathyroid‐like substance. Using the laser for
AGASACA excision is advantageous for minimizing
hemorrhage in this vascular region of the body and,
because of the overall improved tissue visualization, the
laser helps avoid complications such as inadvertent
neurovascular damage.
Procedure
Marking the incision with the laser using spot sizes and
settings intended for a skin incision is particularly help­
ful in areas such as the oral cavity where a marker would
not work (Figure 15.6). As with skin tumors, ulcerated
surfaces pose a threat of bacterial and neoplastic con­
tamination ­during excision. Defocusing the beam and
using a power setting of 10–15 W is useful in order to
desiccate the ulcerated surface and will help control
such contamination (Table 15.3, Figure 15.7). Desicca­
tion is achieved with multiple passes in a “painting”
motion, usually in non‐SuperPulse mode. A higher
power ­setting than that intended for incision may be
Table 15.3 Oral tumors.

Oral tumors
­Oral Tumors Procedure (excision) Oral tumors (ablation)

Laser type and CO2 (10 600) CO2 (10 600)

Melanoma, fibrosarcoma, and squamous cell carcinoma
wavelength (nm)
are the most common neoplasms of the oral cavity in
dogs and cats. Oral tumors can be painful and interfere Spot size (mm) 0.25–1.4 (0.4) 0.4 (defocused technique)
or 3 mm wide ablation tip
with mastication. The location and size of these tumors
greatly dictate the surgical treatment options. Surgical Power (W) 10–15 10–15
removal of an oral mass usually involves mandibulec­ Exposure Continuous wave Continuous wave
tomy or maxillectomy that causes notable intraoperative Mode SuperPulse or Non‐SuperPulse
bleeding. Making the mucosal incision with the CO2 non‐SuperPulse
Duty cycle (%) 100 100

Figure 15.6 Outlining the incision for a partial maxillectomy with Figure 15.7 Desiccation of an ulcerated surface of a recurrent
a CO2 laser. Source: Mann (2015). Reused with permission of maxillary sarcoma using a defocused CO2 laser. Source: Mann
Veterinary Practice News. (2015). Reused with permission of Veterinary Practice News.
 204 Oncological Laser Surgery Procedures

used for desiccation, and use of a handpiece with a 3 mm

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wide ablation tip will optimize the speed of completing

the desiccation.
Occasionally, cytoreduction can be performed for
nonresectable oral tumors, with the intention to follow
with chemotherapy or radiation. After cytoreduction,
the remaining tumor bed may be ablated with the laser at
a high‐power setting, in non‐SuperPulse mode, changing
to the wide ablation tip. Ablation is achieved by “brush­
strokes” of the laser across the residual mass. Once the
tissue has been ablated, excess char should be removed
by wiping with moist gauze.

­Thyroidectomy
Figure 15.8 A vascular canine thyroid tumor with vermiform
Thyroidectomy is useful in the treatment of both benign vessels covering the surface of the mass; such vessels are
(thyroid adenoma) and malignant (thyroid carcinoma) amenable to vessel coagulation before tumor excision.
masses (Gear et al. 2005). Benign masses are typically
found in cats with hyperthyroidism, and up to 90% of
dogs with thyroid tumors are nonclinical (Ham et al. Table 15.4 Thyroidectomy.
2009). Typically, canine thyroid carcinomas are large,
poorly encapsulated, and sometimes invasive to Procedure Thyroidectomy
surrounding structures (Dennis et al. 2011). Canine
thyroid tumors can be very vascular, and the CO2 laser’s Laser type and CO2 (10 600)
hemostatic properties can be very beneficial in terms of wavelength (nm)
keeping the surgical field clear of blood for a more pre­ Spot size (mm) 0.25–1.4 (0.4)
cise excision. Power (W) 10–15
Exposure Continuous wave
Mode SuperPulse or non‐SuperPulse
Procedure
Duty cycle (%) 100
Thyroidectomy in dogs is performed with an extracap­
sular technique. The dog is placed in dorsal recum­
bence with the neck in hyperextension through and the usefulness of the laser for tumor excision will
support of towels. A skin incision can be made with diminish. Although the coagulation technique provides
previously described skin settings from the larynx to just hemostasis for the vermiform surface vessels, larger
cranial of the manubrium (Table 15.4). The subcutaneous vessels feeding the mass may require other forms of
tissue is incised using lower power settings to reveal hemostasis (such as electrosurgery, hemoclips, and
the sternohyoideus muscles. Blunt dissection can be sutures). After removal of the mass, the muscle
used to separate the sternohyoideus muscle bellies to ­layers, subcutaneous tissue, and skin can be closed
avoid the laser damaging the underlying trachea. routinely.
Canine thyroid tumors are highly vascular with many
vermiform vessels covering the surface of the mass
Postoperative
(Figure 15.8). Using the same power settings as for
subcutaneous incisions, the laser beam is defo­ Removal of the thyroid gland through the extracapsular
cused, and these vessels are coagulated to minimize technique will remove the parathyroid glands associated
hemorrhage during tumor manipulations. The with that thyroid gland. If only one thyroid lobe is removed,
SuperPulse mode may be left on for vessel coagulation. it is unlikely that the patient would develop hypocalcemia
Care must be taken to avoid incising these surface due to the presence of the contralateral parathyroid
vessels, or else the surgical field will become bloody glands, but if both thyroid lobes must be removed, there is

risk for hypocalcemia because all four parathyroid glands
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may be lost. Hypocalcemia can take up to a week to nor­
malize following surgery, but on average takes about
36 hours (Gear et al. 2005; Ham et al. 2009). Therefore, it
is important that blood calcium concentrations are meas­
ured frequently (typically once or twice daily) until the
­References
Berger N, Eeg PH. (2006). Introduction of CO2 laser energy
in veterinary medical and surgical services. Veterinary
Laser Surgery: A Practical Guide. Ames, IA: Blackwell
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Prognostic factors for cutaneous and subcutaneous
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Dinstl K, Tuchmann A. (1990). Experience with CO2
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to oncologic surgery for the general surgeon. In: Tobias
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Feldman EC, Nelson RW. (2004). Canine thyroid tumors
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Canine and Feline Endocrinology and Reproduction, 3rd
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Fossum TW. (2013). Surgery of the thyroid and parathyroid
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Gear RN, Neiger R, Skelly BJ, et al. (2005). Primary
hyperparathyroidism in 29 dogs: diagnosis, treatment,
outcome and associated renal failure. J. Small Anim.
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Ham K, Greenfield CL, Barger A, et al. (2009). Validation
of a rapid parathyroid hormone assay and intraoperative
measurement of parathyroid hormone in dogs
with benign naturally occurring primary
hyperparathyroidism. Vet. Surg. 38. pp. 122–132.
Holt TL, Mann FA. (2002). Soft tissue application of lasers.
Vet. Clin. Small Anim. 32. pp. 569–599.
Jacques SL. (1992). Laser‐tissue interactions:
photochemical, photothermal and photomechanical.
Surg. Clin. North Am. 72. pp. 551–558.
Katzir A. (1993). Application of lasers in therapy and
diagnosis. In: Arthuer C, Martin S, and Yelles M, eds.
Lasers and Optical Fibers in Medicine. San Diego, CA:
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patient is normocalcemic. If clinical signs associated with
hypocalcemia occur, daily ionized calcium concentration
should be measured and calcium supplementation should
be performed until clinical signs have subsided (Feldman
and Nelson 2004; Gear et al. 2005; Ham et al. 2009; Fossum
2013; Seguin and Brownlee 2018).
Lanzafame RJ, Rogers DW, Nairn JO, et al. (1986).
Reduction of local tumor recurrence by excision with
the CO2 laser. Lasers Surg. Med. 6(5). pp. 439–441.
Mann FA. (2015). The utility of carbon dioxide laser in
oncological surgery. Vet. Pract. News. 27(4). pp. 42–43
(Case 2, Figure 7; Case 3, Figures 2 and 3).
Marconato L, Bettini G, Giacoboni C, et al. (2008).
Clinicopathological features and outcome for dogs with
mast cell tumors and bone marrow involvement. J. Vet.
Int. Med. 22. pp. 1001–1007.
Mullarky MA, Norris CW, Goldberg ID. (1985). The
efficacy of CO2 laser in the sterilization of skin seeded
with bacteria: survival at the skin surface and in the
plume emissions. Laryngoscope. 95(2). pp. 186–187.
Paczuska J, Kielbowicz Z, Nowak M, et al. (2014). The
carbon dioxide laser: an alternative surgery technique
for the treatment of common cutaneous tumors in dogs.
ACTA Vet. Scand. 56. pp. 1–4.
Paczuska J, Switalska M, Nowak M, et al. (2017).
Effectiveness of CO2 laser in an experimental mammary
gland adenocarcinoma model. Vet. Comp. Oncol. 16(1).
pp. 1–8.
Poston GJ. (2007). Is there a surgical oncology? In: Poston
GJ, Beauchamp RD, and Ruers TJM, eds. Textbook of
Surgical Oncology. London, UK, Informa Healthcare,
p. 1.
Reynolds M, LoCicero J, Michaelis LL. (1986). Partial
splenectomy with the CO2 laser: an alternative
technique. J. Surg. Res. 41(6). pp. 580–586.
Rimbach S, Wallwiener D, Pollmann D, et al. (1992).
Experimental CO2 laser surgery on the Lewis lung
carcinoma tumor model in C56BL/6 mice. In: Lasers in
Gynecology: Possibilities and Limitations. Heidelberg:
Springer: pp. 417–423.
Seguin B, Brownlee L. (2018). Thyroid and parathyroid
gland. In: Tobias KM, Johnston SA, eds. Veterinary
Surgery: Small Animal. Elsevier. pp. 2043–2058.
Simpson AM, Ludwig LL, Newman SJ, et al. (2004).
Evaluation of surgical margins required for complete
excision of cutaneous mast cell tumors in dogs. J. Am.
Vet. Med. Assoc. 224. pp. 236–240.
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16

Laser Photodynamic Therapy Procedures

Katalin Kovács
­Introduction
Photodynamic therapy (PDT) is a procedure involving
two elements: a photosensitizer that is preferentially
retained in target cells and tissue, and a source of light of
a specific wavelength to activate the photosensitizer.
Illuminating the photosensitizer creates singlet oxygen
that reacts with surrounding organic compounds, caus-
ing selective necrosis of the target cells and tissue.
The idea is not new. Six thousand years ago the
Egyptians treated vitiligo, psoriasis, and leukoderma
caused by leprosy through the local or systemic applica-
tion of plants containing photosensitive chemicals (pars-
nip, parsley, and blackseed), then activating them by
exposing the patient to sunlight (Deniell and Hill 1991).
Ancient Buddhist texts describe the same process being
used in India, and there are descriptions of the treatment
found in China as well.
Oscar Raab at Munich University noted that the toxic-
ity of some drugs increased dramatically when exposed
to light. Walter Hausmann injected hematoporphyrin in
mice, activated it in sunlight, and described the subse-
quent damage caused to peripheral vessels. He con-
ducted an experiment on himself to demonstrate the
photochemical reaction of hemoporphyrin, 200 mg of
which he administered intravenously followed by expo-
sure to sunlight; the result was two months of edema,
hyperpigmentation, and rubor. In the early 1900s, the
first basal cell carcinoma (BCC) patients were treated
with the photosensitizer eosin, activated by light from a
carbon arc lamp.
Hematoporphyrin was used for malignant tumor diag-
nosis due to the fluorescent effect of the photosensitizer,
and lamps were used for its activation in the early 1960s.
Lasers were first used for activation of photosensitizers
in 1978 to increase selectivity of the light.
Currently, PDT is being studied by thousands of
­scientists and practitioners using many different types of
photosensitizers and light sources. PDT was approved by
the US Food and Drug Administration as a cancer treat-
ment in 1995 and has been used more frequently in human
oncology, but there have been only a few veterinary clinical
studies, and it is not yet a common veterinary technique
(Kovács et al. 2009; Kovács 2011, 2015). Its role in cancer
therapy has changed very rapidly with newer and improved
photosensitizers in development. PDT could realistically
play a significant role in future cancer treatment. In veteri-
nary medicine the most common application of PDT is for
treating squamous cell carcinoma (SCC).
­Basic Principles
Photosensitizers
Possessing a heterocyclic ring structure similar to that of
chlorophyll or heme in hemoglobin, photosensitizers
transform light energy into chemical reactions, producing
singlet oxygen atoms that cause cell damage. Singlet oxy-
gen has a short lifetime in biological systems and a very
short radius of action (0.02 μm). Hence, the reaction takes
place within a limited space, making it ideal for applica-
tion to localized sites without affecting distant cells or
organs. The most effective photosensitizers have high
selectivity in tumor cells; high‐tumor tropism leads to
high‐tumor cytotoxicity. Photosensitizers have low toxic-
ity in darkness and a quick elimination rate from the body,
especially from the skin. They are easily soluble in water.
Photosensitizers are categorized by their chemical
structures and divided into three groups:
1) Porphyrin‐based photosensitizers (ALA, Photohem,
Photofrin, Visudin, Foscan, Foslip, Fospeg, Teoporfin,
and Photodit);
2) Chlorophyll‐based photosensitizers (chlorins, purpu-
rins, and bacteriochlorins);
3) Dye photosensitizers (phtalocyanid, napthocyanine,
methylene blue, and methylene‐violet‐blue).

Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.

© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser

Photosensitizers have many generations in each
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group. First‐generation photosensitizers were devel-
oped in the 1970s. The second generation of photosen-
sitizers (c. 1980s) have higher selectivity to cancer cells
than to normal cells, are eliminated from the body
faster, have low accumulation in the skin, and a shorter
drug‐to‐light interval. The third generation of photo-
sensitizers were modified to become biologic conju-
gates (e.g. liposome conjugate or antibody conjugate)
(Dougherlg and Marcus 1992).
Photosensitizers work by targeting cell structures. The
porphyrine‐based mTHPC (Tetra m‐hydroxyphenyl chlo-
rin, under the trade name Foscan) localizes in the nuclear
envelope, while ALA (5‐Aminolaevulinic acid, a second‐
generation photosensitizer) localizes in the mitochondria,
and methylene blue in the liposomes. Photosensitizers are
administered intravenously, orally, or topically. With topi-
cal administration the achievable treatment depth is
reduced to about 5 mm because of the limited penetration
of the substances into the tissue; only superficial lesions
can be treated effectively in this manner. Photosensitizer
solutions must be protected in storage using a light‐
impenetrable material such as aluminum foil prior to
administration. Once removed from their packaging, they
must be administered immediately (Sharman et al. 1999).
Light Delivery, Exposure, and Activation
Photosensitizers are absorbed by low wavelengths.
Noncoherent light (350–800 nm) was used early in PDT
development, being cheap, safe, and easy to use, but dis-
advantages included low light intensity, thermal side
effects, and difficulty controlling the light dose. Presently,
lasers are more commonly used light sources, such as
the KTP (potassium‐titanyl‐phosphate) pumped dye
laser (664 nm), or the pumped copper carbon dye laser
(630 nm). Most recently, 630 and 762 nm diode lasers
have been used for PDT, because of their portability and
relatively low cost. The advantage of using laser light of a
specific wavelength for PDT is that monochromatic light
cooperates with a matched photosensitizer very effec-
tively. It is also easily delivered to the treatment area
through quartz optical fibers. The fiber length is 1.5–3 m
long, and the aperture is 400–600 μm in diameter. Many
variations of optical fiber and specially designed illumi-
nator tips (such as the microlens cylindrical diffuser)
help to treat the area more selectively. Each fiber is easy
to use with a common endoscope, laryngoscope, and
bronchoscope.
Exposure time depends on tumor location (superficial
or deep) and histological examination or culture results.
Energy density is measured in joules per square centim-
eter (J/cm2) (e.g. superficial skin and mucus membrane
50–150 J/cm2). Power density, measured in watts per
  ­PDT for Cancer Treatmen 207
square centimeter (W/cm2), depends on the fiber’s
treated area and laser output power.
Any given set of PDT light‐dose parameters is specific
to the type of light delivery system used. For example the
PDT light‐dose parameters for Foscan photosensitizer
using a 652 nm laser with a microlens optical fiber would
be inappropriate with other laser systems.
Light Activation Method
PDT‐induced tissue necrosis occurs when the target
lesion has received a sufficient dose of light. It is neces-
sary to illuminate the entirety of the target tissue, and
illuminating a 0.5 cm margin of normal tissue around the
target is recommended where possible. In the case of
large lesions impossible to illuminate using a single spot
of laser light, one has to cover the whole area with multi-
ple illuminations, while avoiding overlapping the areas
because overlapped tissue receives a higher dose of light,
resulting in a deeper necrosis. Illuminations should be
delivered at right angles (90°) as close to the lesion as
possible. The laser delivery system should be set up
according to manufacturer’s instructions and the laser’s
software, which guides the user step‐by‐step through the
illumination process. During laser operation, the staff
must wear protective goggles specific to the laser’s wave-
length, and the patient must be covered for protection.
A microlens fiber in noncontact mode is used that must
be held as close as possible without creating potential
thermal side effects. In contact mode, a special cylindri-
cal fiber should be used within target tissue.
Drug‐to‐Light Interval
Drug‐to‐light interval is the period of time between
photosensitizer administration and its activation by
light. Depending on its generation, each photosensi-
tizer has its own penetration or incubation time for tis-
sue uptake; a first‐generation photosensitizer would
take longer (24–48 hours), then a second or third gen-
eration. Before use, it is advised to ask the photosensi-
tizer manufacturer for tissue uptake information.
Without allowing for sufficient target tissue uptake,
shorter drug‐light intervals may cause vascular trauma.
Longer drug‐light intervals allow high cell accumula-
tion of photosensitizer within target tissue, causing
higher level of target cell damage.
­PDT for Cancer Treatment
Cancers of the head and oral cavity can be extremely
aggressive and are associated with very poor prognosis.
SCC in particular is the most common cancer found in
 208 Laser Photodynamic Therapy Procedures
cats and dogs, appearing most often on the nose, ears,
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and in the oral cavity. Locally invasive but slow to metas-
tasize, it is often associated with poorly pigmented skin
and exposure to ultraviolet light.
PDT is an effective treatment for solitary tumors, but
is not able to treat all forms of cancer. Although the pho-
tosensitizer is given systemically the primary tumor is
treated locally by activation with laser light. PDT is thus
a local therapy particularly useful on early primary or
early recurrent cancer. Useful on the surface of the skin,
mouth, tongue, lip, larynx, lung, gastrointestinal tract,
and genitalia, it is also effective in treating unreachable,
problematic, or inoperable areas, such as nasal tissues,
ear canals, and periorbital areas. It is effective on super-
ficial carcinoma and mucosal dysplasia and an excellent
therapy for treatment‐resistant SCC and basal cell
carcinoma.
The goal of PDT is the primary neoplasm’s destruc-
tion. PDT‐induced tissue destruction of neoplasms
involves three principal mechanisms: the direct elimina-
tion of cancer cells from inside out; the destruction of
tumor‐associated vascular systems (vascular spasm, sta-
sis, and thrombus); and the activation of immune
response against tumor cells.
Advantages of PDT are high selectivity to cancer tis-
sues, with short presence in connective tissues. PDT can
be repeated as many times as needed, but a four‐week
interval is necessary between each treatment to avoid
treatment overlap. Awareness of the neoplasm’s biology
and stage prior to treatment enables the veterinarian to
determine dosage of photosensitizer and laser light, pre-
dicting a therapeutic effect. Volume of tissue destruction
depends on light penetration depth. Early detection of
tumors in pets and the evaluation and selection of an
individual patient’s tumor characteristics are critical to
achieving positive results with PDT.
PDT Cancer Treatment Requirements
●● Metastasis should not be present.
●● It should be possible to illuminate the tumor
completely.
●● The owner understands and accepts the guidelines and
safety measures for exposure to light to avoid unwanted
phototoxicity.
Contraindications of PDT for Cancer
Treatment
●● Metastasis
●● A tumor’s close proximity to a major blood vessel,
where PDT may lead to such vessel’s erosion
●● Poor or unstable pet condition
●● Insufficient respiratory capacity
Cardiovascular disease
●●
●● Hepatic disease
●● Renal disease
●● Porfirin allergy
●● Lupus.
Treatment and Associated Safety Measures
PDT is associated with significant pain at treatment sites
both peri‐ and posttreatment. Following slow intrave-
nous injection of the photosensitizer and elapse of the
drug‐to‐light interval, general anesthesia with prophy-
lactic analgesia is recommended for PDT administra-
tion. Perioperative steroids have been shown to reduce
postoperative pain. If overexposed to light, normal tissue
will swell or become necrotic. Lighting in the treatment
room should be reduced or defocused to lower intensi-
ties than normal. Periods of exposure to bright light
should be kept to a minimum. Some pulse oximeters
produce light of a wavelength close to that used for acti-
vation of photosensitizers and should therefore be repo-
sitioned at least every five minutes to avoid the risk of
local burns if in the immediate vicinity of treatment
areas. Normal tissue around the target lesion should be
shielded with light‐absorbing material such as dark green
or blue surgical drapes, surgical sponges, or swabs. Towel
clamps and metal surgical instruments must be covered
to prevent light reflection.
Posttreatment Management and Associated
Safety Measures
It is important to convey the post‐PDT lesion’s expected
appearance to the pet’s owners. After illumination,
treated lesions will discolor and swell. Two to four days
later, inflammatory exudate and slough appear on the
treatment area. The tumor has the typical appearance
and odor of necrotic, drying tissue. The normal tissue
around the treated area may appear dusky but does not
become necrotic. About four weeks posttreatment,
necrotic tissue dissolves or falls off. Eight to twelve weeks
posttreatment, the site is clear and covered by new
healthy tissue.
Analgesia protocols vary among hospitals. Steroids or
non steroidal anti‐inflammatory drugs (NSAIDs) are
used orally daily for two weeks and antibiotic therapy for
one week following therapy. Antibiotics (metronidazole,
amoxicillin, or clindamycin depending on the case)
should be started after the treatment to prevent bacterial
overgrowth in necrotic tissue. Protect treated areas with
an Elizabethan collar if necessary.
Nutritional and fluid balance should be maintained as
PDT may temporarily interfere with normal eating and

drinking. Common side effects in dogs and cats include
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polydipsia, with accompanying elevated risk of gastric
torsion in medium and large breed dogs the first day
f­ollowing treatment. Clonic convulsion may occur after
photosensitizer injection, especially in felines. Within
24 hours after treatment, the area will be swollen and
enlarged; lethal asphyxia can develop if such treatment
areas are near the throat or larynx. Alongside pain, dys-
phagia, and hampered respiration, side effects also
include injection site reaction, dermal burns, hemor-
rhage, and edema.
Protection from light is critically important during the
first week. The patient must be fully covered when taken
home from the veterinary hospital. The patient must also
remain in a darkened room with covered windows to
avoid exposure to light. It is recommended to use only
one light bulb in the patient’s room (60 or 11 W energy
saver or less), which must not be placed close to the
patient.
From the second to the fourth week, the patient can
gradually return to normal indoor lighting, but must
remain indoors during daylight hours and may go out
only after dark. It is important to avoid exposure to direct
sunlight or other bright light, including light through
windows.
One month after PDT, the patient may spend
10–15 minutes outdoors in the shade. If the patient does
not have any skin redness, burning, blistering or fur lost
after 24 hours, 30 minutes can be spent outdoors three
times per day.
For three months following PDT, the patient must
avoid direct sunlight or strong light. Eye examinations
involving bright light must be avoided.
For 30 days following the photosensitizer administra-
tion, emergency surgical procedures must be undertaken
only if absolutely necessary and the potential benefits
outweigh the risk to the patient. Patients seen by emer-
gency rooms during the post-PDT phase should be
informed of the risks of exposing the patient to light and
take appropriate measures to protect the patient. Care
must be taken to avoid direct illumination of the patient
with surgical lamps during these procedures, particu-
larly if the patient develops gastric torsion. Exposure of
abdominal organs to light could cause fatal necrosis.
Photosensitivity of the skin is normal for one to two
months following PDT, and cats with concurrent renal or
liver disease may demonstrate photosensitivity for up to
three months. Direct sunlight and bright artificial indoor
and outdoor lights must be avoided for three weeks.
Dogs can be walked only in the dark and bright street
lamps must be avoided. The dog’s whole body must also
be covered with dark‐colored clothing. Laser therapy
(photobiomodulation) should be avoided during the
patient’s entire convalescence.
  ­PDT for Antibacterial Treatmen 209
Table 16.1 Photodynamic therapy of neoplasms.
Photodynamic therapy of
Procedure neoplasms
Laser type and wavelength Diode laser (652)
(nm)
Fiber diameter 400–600 μm microlens
Photosensitizer mTHPC (0.1–0.25 mg/kg IV)
Drug‐to‐light interval (h) 6
Power (mW) 500
Dose (J/cm2) 10–30 (noncontact)
30 (contact)
Treatment frequency Once every 4 wk
PDT Treatment of Neoplasms
Inoperable SCC and other neoplasms have been treated
with PDT under general anesthesia using the photosen-
sitizer mTHPC and a 652 nm diode laser (Table 16.1),
finding it to be extremely well tolerated by dogs and cats.
Following PDT an Elizabethan collar was applied, and
the animals were fed moistened maintenance diets.
Removal of necrotic tissue took place over a period of
weeks, with the observation of healthy tissue formation
beneath. Repeated treatment every four weeks was nec-
essary in several cases with aggressive tumor growth rate
and high mitotic index, to arrive at complete neoplasm
eradication.
Only minor side effects could be detected as a result
of the treatment, including general photosensitivity
and minor edema at the treatment area. The patients’
symptoms appeared significantly alleviated after the
first treatment. Appetite and vitality improved.
Subsequent histopathological samples were taken on
the sixth week and at three months to follow changes
in the deeper layers of tissue. Tumors did not relapse
within 6–12 months after treatment. Extraordinary
regeneration and beautiful results could be observed
(Figures 16.1–16.5).
­PDT for Antibacterial Treatment
Drug‐resistant microbial flora causes frustration to
pet owners and veterinarians alike. Antimicrobial
PDT (A‐PDT) involves the application of liquid
p­hotosensitizer directly to areas of infection and its
activation by laser light through an optical fiber or
defocused laser handpiece (Millson et al. 1996;
Chan and Lai 2003; Sigusch et al. 2005; Kovács 2017).
A‐PDT seems to be a unique and interesting therapeutic
 210 Laser Photodynamic Therapy Procedures

(a) (b)
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(c) (d)

Figure 16.1 (a) A 3 cm × 5 cm ameloblastic fibro‐odontoma in a one‐year‐old intact male feline. (b) Fospeg was administered at 0.15 mg/kg
slow IV, followed by a drug‐to‐light interval of six hours, and irradiation with a 652 nm laser at 0.5 W, 10 J/cm2 noncontact and 30 J/cm2
within the tumor. (c) The same cat several weeks later, following sloughing of the tumor. (d) 100% regression.

approach in veterinary medicine. Singlet oxygen
­produced by PDT can cause damage to cell mem-
branes and cell walls. Microorganisms killed by singlet
oxygen include viruses, bacteria, and fungi. A‐PDT
not only kills bacteria but may also lead to inactiva-
tion of bacterial endotoxins such as lipopolysaccha-
rides by decreasing their biological activity;
lipopolysaccharides treated by PDT do not stimu-
late production of proinflammatory cytokines by
mononuclear cells.
In A‐PDT, toluidine blue and methylene blue photo-
sensitizers are used. Both have similar chemical and
physiochemical characteristics. Blue‐violet in color, tolu-
idine blue solution stains granules within mast cells, and
both proteoglycans and glycosaminoglycans within con-
nective tissue. Methylene blue is a redox indicator, blue
in an oxidizing environment and colorless upon reduc-
tion. Light‐activated methylene blue has been reported
to be beneficial in killing influenza virus, Helicobacter
pylori, and Candida albicans. Methylene blue and tolui-
dine blue are effective photosensitizing agents for inacti-
vation of both Gram‐positive and Gram‐negative
bacteria.
A‐PDT requires low‐power visible light of a specific
wavelength. Most photosensitizers are activated by red
and near‐infrared light between 630 and 850 nm, with
corresponding light penetration depths from 0.5 to
2.0 cm. Total light dose, dose rates, and depth of destruc-
tion vary with each tissue treated and photosensitizer
used. Currently, light sources applied in A‐PDT are those
of helium‐neon lasers (633 nm), gallium‐aluminum‐
arsenide diode lasers (630–690, 810, 830 or 906 nm), and
   ­PDT for Antibacterial Treatmen 211

(a) (b)
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(c)

Figure 16.2 (a) A 7 cm × 5 cm × 4 cm oral papillary carcinoma (planocellulare non‐keratoides) with high mitotic index in a 10‐month‐old
male canine. (b) Tumor necrosis following Fospeg solution injected slow‐IV over five minutes, a drug‐to‐light interval of six hours, and
irradiation of 20 J/cm2 noncontact on the tumor surface and 30 J/cm2 within the tumor each 0.4 mm distance between the fiber, output
power 0.5 W. The treatment was repeated four weeks later with a drug‐to‐light interval of one hour. (c) Tumor regression was 100%.
 212 Laser Photodynamic Therapy Procedures

(a) (b)
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(c) (d)

(e) (f)

Figure 16.3 (a) A 13‐year‐old spayed female feline with nasal squamous cell carcinoma of high mitotic index. (b) Tissue sloughing
following slow IV injection of Foslip (0.1 mg/kg), a drug‐to‐light interval of six hours, and 30 J/cm2 noncontact irradiation on the tumor
surface. (c) Treatment was repeated five weeks following the first at the same parameters. (d) Treatment was repeated once more four
weeks following the second at the same parameters. (e) Appearance following the third treatment with most necrotic tissue removed.
(f ) 100% tumor regression.
  ­Conclusio 213

(a) (b)
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(c)

Figure 16.4 (a) A 12‐year‐old spayed female feline with squamous cell carcinoma of high mitotic index in the nose and ears. (b) Sloughing
of the nasal neoplasm following Foslip 0.25 mg/kg slow IV, a drug‐to‐light interval of six hours, and noncontact irradiation on the tumor
surface at 20 J/cm2 (treatment was repeated four weeks later under the same parameters). (c) 100% regression of the nasal SCC.

argon lasers (488–514 nm), the wavelengths of which ­Conclusion

range from visible light to the blue of argon lasers, or
from the red of the helium‐neon laser to the infrared of
diode lasers.
Dogs, cats, and rabbits has been treated with the pho-
tosensitizer methylene‐violet‐blue and a diode laser of
810 nm wavelength, which penetrates up to 3–4 cm into
tissues instead of a few millimeters in conventional
670 nm‐based PDT systems (Table 16.2). Following a
drug‐to‐light interval of five minutes, a light dose of
10–100 J/cm2 was administered depending on the case.
Thermal side effects were avoided by reducing the
laser’s power output to 500 mW. Treatment was
repeated if necessary, at a maximum frequency of once
per week. This treatment appeared effective for tonsil-
litis, otitis externa (Figure 16.6), and facial abscess
(Figure 16.7).
PDT is less invasive and more precise at targeting neo-
plasms than conventional surgery. Unlike radiation ther-
apy, it can be repeated many times at the same site if
needed. It has no long‐term side effects when used prop-
erly and posttreatment safety measures are followed.
Little or no scarring remains after the site heals, and
100% tumor regression can be attained in those patients
that receive needed repeat therapy. Regeneration after
treatment for neoplasms appears excellent, with pre-
served anatomical and functional integrity, enabling
patients to continue an excellent quality of life.
Antibacterial PDT in pets also appears very effective
without high risk, offering an alternative method of
treatment for resistant and recurrent infections and
regressing them to a manageable state.
 214 Laser Photodynamic Therapy Procedures

(a) (b)
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(c)

Figure 16.5 (a) A 13‐year‐old spayed female feline with squamous cell carcinoma of high mitotic index in the nose and ears. (b) The cat
was administered Foslip at 0.1 mg/kg slow IV, followed by a drug‐to‐light interval of (six hours and noncontact irradiation at 30 J/cm2 on
the tumor surface. This is the appearance of the nose following a second treatment four weeks later at the same dose and light
parameters. (c) Tumor regressed 100%.

Table 16.2 Antimicrobial photodynamic therapy.

Procedure Antimicrobial photodynamic therapy

Laser type and wavelength (nm) Diode laser (810)

Fiber diameter 400–600 μm microlens
Photosensitizer Methylene‐violet‐blue (topical)
Drug‐to‐light interval (min) 5
Power (mW) 500
Dose (J/cm2) 10–100
Treatment frequency Once per week
 (a) (b)
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(c)

Figure 16.6 (a) Canine otitis externa. (b) Methylene‐violet‐blue was applied to the canal. A five minutes drug‐to‐light interval was
followed by a light dose of 100 J/ear. Anesthesia was not needed because the procedure was not painful. (c) Improvement from initial
presentation following A‐PDT therapy.

(a) (b)

(c) (d)

Figure 16.7 (a) A rabbit with a facial abscess. Pets (especially rabbits) often suffer from facial abscesses due to food lodged between
teeth. Classic therapy includes tooth extraction, abscess surgical elimination, and antibiotic therapy, with poor results. (b) Application of
methylene‐violet‐blue topically within the abscess cavity under general anesthesia. (c) After a drug‐to‐light interval of five minutes, the
area is illuminated with 50–100 J/cm2 of 810 nm light in contact mode. (d) Treatment site several weeks later, with improved appearance
over antibiotic therapy alone. Treatment frequency can be up to once per week, but not more often.
 216 Laser Photodynamic Therapy Procedures
­References
VetBooks.ir
Chan Y, Lai CH. (2003). Bactericidal effects of different
laser wavelengths on periodontopathic germs in
photodynamic therapy. Lasers Med. Sci. 18. pp. 51–55.
Deniell MD, Hill JS. (1991). A history of photodynamic
therapy. Aust. N.Z. J. Surg. 61. pp. 340–348.
Dougherlg TJ, Marcus SL. (1992). Photodynamic therapy.
Eur. J. Cancer. 28. pp. 1734–1742.
Kovács K, Jakab CS, Szász A. (2009). Laser‐assisted
removal of a feline eosinophilic granuloma from the
back of the tongue. Acta Vet. Hung. 57(3). pp. 417–426.
Kovács K. (2011). Laser related medical trials – experience
with treatment of inoperable oral and maxillofacial
tumors with laser photo‐dynamic therapy in small
animals. Photodiagn. Photodyn. Ther. 8(2). p. 139.
Kovács K. (2015). PDT in squamous cell carcinoma: treatment
of skin cancer of cats. Lasers Surg. Med. 47(26). p. 36.
Kovács K. (2017). New treatment of chronic proliferative
and obstructive otitis externa in dogs with combination
of hard‐, photodynamic‐ and low‐level lasers. Lasers
Med. Sci. 32(8). p. 1686.
Millson CE, Wilson M, Macrobert AJ, et al. (1996). The
killing of helicobacter pylori by low‐power laser light in
the presence of a photosensitizer. J. Med. Microbiol. 44.
pp. 245–252.
Sharman WM, Allen CM, Van Lier JE. (1999).
Photodynamic therapeutics: basic principles and clinical
applications. Drug Discovery Today. 4. pp. 507–517.
Sigusch BW, Pfitzner A, Albrecht V, et al. (2005).
Efficacy of photodynamic therapy on inflammatory
signs and two selected periodontopathogenic species
in a beagle dog model. J. Periodontol. 76.
pp. 1100–1105.

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17
Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures1
David S. Sobel
­Introduction
Lasers in minimally invasive surgery (MIS) can be traced
to the late 1970s with the use of CO2 lasers in gynecologi-
cal surgery (Bruhat et al. 1979; Tadir et al. 1989). While the
subsequent 20 years offered the introduction of a variety
of new laser systems for MIS (neodymium:yttrium alu-
minum garnet [Nd:YAG], holmium:yttrium aluminum
garnet [Ho:YAG], potassium‐titanyl‐phosphate [KTP],
KDP, argon, and diodes) many general surgeons in human
fields have wavered between use of lasers and other forms
of surgical energy, largely opting for advanced electrocau-
tery and harmonic instrumentation.
As CO2 lasers gained footing in general small animal soft
tissue surgery, the subset of small animal surgeons and
internists focusing on MIS and endoscopy began looking
for ways to incorporate lasers into endoscopic applications.
Equine surgeons were at the forefront of veterinary endo-
scopic laser surgery, using Nd:YAG lasers in endoscopic
approaches to the upper airway and nasopharynx (Chapter
19) (Tate et al. 1990; Rothaug and Tulleners 1999).
Today, the spectrum of surgical lasers available to both
primary care small animal practitioners as well as those
practicing in a tertiary care environment has broadened.
The field is largely dominated by CO2, Nd:YAG, diode,
and Ho:YAG lasers.
For the MIS surgeon, internist, or primary care clinician
in small animal practice, the accessibility of laser technol-
ogy has been a clinical and practical advancement. The
ability to access and surgically intervene in anatomic loca-
tions that would otherwise be inaccessible but for open
surgery takes endoscopy from purely a diagnostic proce-
dure to an interventional therapeutic modality.
1 The Editor and Author have endeavored to compile information on endoscopic laser settings for the reader; however, certain fields of the
Chapter 17 tables of laser settings will ultimately depend on the reader’s own equipment selection and the individual surgical case. These fields
are indicated with an asterisk in the tables.
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
217
This chapter will cover applications of both diode and
Ho:YAG lasers in small animal practice. Details of diag-
nostic endoscopy are covered in excellent detail in other
texts (Tams and Rawlings 2010; McCarthy 2005;
Lhermette and Sobel 2008; Hotson Moore and Ragni
2012). The endoscopic laser surgical procedure itself is
largely dictated by type and size of endoscopic equip-
ment being used, as the diameter of the endoscope’s
working channel, flexible or rigid, dictates the diameter
of the laser delivery fiber. Laser settings are also dictated
by laser equipment available and to the specific patholo-
gies being encountered during the procedure. This chap-
ter thus describes endoscopic laser procedures with
less‐specific guidelines and recommendations for laser
settings than those described elsewhere in this text. The
reader is encouraged to become familiar with contact
and noncontact applications of the diode laser prior to
utilizing it in an endoscopic setting.
­Equipment and General Principles
The use of an 810 nm diode laser (Figure 17.1) is pre-
ferred. Diodes at the 980 nm wavelength (Figure 17.2) are
also of great utility and provide excellent superficial tis-
sue vaporization but are somewhat less effective in fluid
and hemorrhagic mediums (Figure 4.12). While there are
a variety of highly powerful diodes on the market, a
15–20 W device is adequate in the vast majority of cases.
The Ho:YAG laser emits light energy in the infrared
spectrum at 2100 nm (Figure 17.3). While light at this
wavelength is attenuated by water, the unique character-
istics of the holmium laser allow for efficiency even in an
 218 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
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Figure 17.1 Surgical diode laser, 810 nm, 15 W. Figure 17.2 Surgical diode laser, 980 nm, 20 W.

aqueous medium. The laser energy is transmitted to the

tissue directly, in the presence of a “cavitation bubble”
providing separation between the fiber tip and the tissue.
This mechanism, often referred to as the “Moses effect,”
is unique to the Ho:YAG laser and accounts for its effi-
cacy as a lithotripter as we will see later in this chapter
(Elihali et al. 2017).
Both diode and holmium lasers transmit their energy
via solid optical fibers. Often, the technology of each
fiber is proprietary to the manufacturer, but generally
these devices consist of a solid silica quartz‐based optical
fiber encased in some form of plastic or silicon cladding.
Connection to the laser energy source is accomplished
via one of several variants of SMA connectors.
It is important to ensure that all endoscopes are care-
fully examined for leaks (via a leak tester for flexible
Figure 17.3 Ho:YAG laser. Source: Courtesy of Karl Storz SE & Co.
endoscopes) and other damage to the instrument chan-
KG, Germany.
nel prior to use. Additionally, laser fibers must be exam-
ined to ensure the tip is not fractured or chipped, the
core is intact throughout and the silicone cladding is Fibers ranging in size from 200 to 1000 μm are available
smooth and intact. Damage to the fiber can allow laser in a variety of tip shapes, for both contact and noncon-
light to “leak” from the fiber at unpredictable angles, and tact applications (Figure 17.4). Most commonly, this
if this should occur within the interior of the endoscope, author will use the maximum allowable diameter fiber
expensive damage can result. with a flat carbonized tip for contact use. For the most

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Figure 17.4 Ho:YAG solid quartz fiber with SMA adapter. Source:
Courtesy of Karl Storz SE & Co. KG, Germany.
commonly used rigid endoscopes, this will allow for a
maximum 325 μm flat fiber. For small diameter flexible
scopes commonly employed for upper airway endo-
scopic surgery, a 200 μm fiber may be the maximal per-
missible diameter.
Surgical diodes allow the operator to control the power
and pulse frequency. Power is a function of the energy
input to the laser chamber (J) and the pulse frequency
(Hz). A repetition rate of 20 Hz yields a pulse rate of up to
16 ms. Ho:YAG systems can produce up to 150 W of
power, although rarely are powers above 25 W achieved.
Typically, powers of 8–12 W are used at the outset to
achieve the desired tissue results. Ultimately, the opera-
tor can make intraoperative adjustments to power and
pulse frequency based on tissue response to the laser. By
design, smaller diameter fibers allow for a lower maxi-
mum energy capacity to avoid damage to the instrument
itself. As such, the highest outputs will require fibers of
the greatest diameters.
The mechanics of a contact technique laser procedure
involve placing the fiber in direct apposition to the tissue
prior to firing. If transection of the base of the lesion is
intended, the fiber is moved in a linear fashion across the
stalk, observing tissue blanching on either side of the cut.
If the lesion is broad and diffuse in appearance, the fiber
is generally advanced in a grid‐like manner across the tis-
sue in a repetitive manner until all of the grossly abnor-
mal tissue has been either vaporized or devitalized. It is
not necessary to meticulously pick out all the devitalized
tissue; this will slough naturally with normal thermal
injury‐induced dehiscence.
In an ideal world, the surgeon would have at their dis-
posal the full range of laser energy sources in the hospi-
tal. This would allow for the best tool to be employed in
the most applicable clinical case. However, the choice of
laser type, wavelength, and power for the veterinary sur-
geon in practice will be dictated largely by the types of
­Equipment and General Principle ­Equipment and General Principle 219
cases that present to the clinician. While each laser
­discussed here has specific clinical advantages and dis-
advantages, clinical caseload and type as well as econom-
ics will advise the veterinarian’s choice of device.
Manufacturer‐provided technical training combined
with appropriate clinical training is imperative before
using a laser on a patient. Fortunately, practice with
lasers can be easily facilitated with the use of biological
specimens acquired from the local butcher. Organ meats,
particularly deeply colored organs such as liver and
heart, provide an excellent medium to gain an apprecia-
tion of how the laser will interact with animal tissues.
Chicken or pork skin are excellent for practice on less‐
pigmented tissues. If at all possible it is opportune to
have multiple different laser types and wavelengths avail-
able, to experiment with the visual and deep surgical
thermal effects of different devices. The surgeon then
has the opportunity to evaluate laser–tissue interactions
both superficially and below the surgical site using dif-
ferent energy and frequency settings, with different size
fibers in both contact and noncontact technique.
To perform any of the laser endoscopic surgical proce-
dures described in this chapter, the surgeon will need to
have at minimum a basic level of training in diagnostic
endoscopy. Additionally, the standard level of endo-
scopic equipment is required with specific adaptations
to the procedure performed, species, and size of the
patient. More detailed descriptions of small animal diag-
nostic and surgical endoscopy are available in a variety of
other excellent texts (Tams and Rawlings 2010; McCarthy
2005; Lhermette and Sobel 2008; Hotson Moore and
Ragni 2012).
An almost limitless variety of endoscopes (rigid and
flexible, fiber‐optic, and video) are available to the veteri-
nary practitioner. The specific choice of endoscope will
be discussed with each procedure. Additional required
instrumentation will include some form of high‐resolu-
tion video monitor, a high‐quality medical grade endo-
scopic camera (for rigid endoscopy and fiber‐optic
endoscopes), an endoscopic extracorporeal light source,
and associated fiber‐optic light guide cable. Sheaths,
cannulae, insufflators, biopsy forceps, retrieval baskets
and forceps, and a vast array of hand instruments are
similarly available. The surgeon must choose the appro-
priate accessories based on the specifics of the procedure
at hand (Figures 17.5–17.7).
Most endoscopic equipment can be sterilized using
ethylene oxide gas or cold soaked in a commercially
available aldehyde liquid solution. When using any of
these sterilizing methodologies care must be taken to
ensure that the chemical products are compatible with
the endoscopic instrumentation and that appropriate
ventilation and safety measures are taken in accordance
with appropriate occupational safety regulations.
 220 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures

(a) (b)
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(c)

Figure 17.5 (a–c) Small diameter rigid endoscope. Source: Courtesy of Karl Storz SE & Co. KG, Germany.

(a) (b)

Figure 17.6 (a, b) Video endoscopy equipment for the veterinary practice. Source: Courtesy of Karl Storz SE & Co. KG, Germany.

Aggressive rinsing of sterilizing solution must precede
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any use of equipment on the patient. Automated steriliz-
ing equipment for endoscopes is available and often
manufacturer specific. Many endoscopic accessories,
and indeed some rigid endoscopes, can be processed in
autoclaves. It is critical that manufacturers’ recommen-
dations be followed regarding cleaning and sterilization
to avoid damaging equipment making it unsafe for use in
the clinical setting and potentially voiding warranty.
­Respiratory Tract Laser Endosurgery
Nasal Neoplasia, Inflammatory Polyps,
and Laser Turbinectomy
Diagnostically, endoscopic access to the rhinarium,
paranasal sinuses, and nasopharynx is superior to open
surgical access, with reduced surgical morbidity,
improved visualization and more rapid return to normal
function. Indeed, there are locations in the nasal pas-
sages that would otherwise be virtually inaccessible save
for MIS intervention (Sobel 2012).
Equipment
Depending on patient size and anatomy, this author uses
a 2.7 mm 30° rigid endoscope, a 1.9 mm 30° rigid endo-
scope, and a variety of flexible endoscopes to enable vis-
ualization of the caudal nasopharynx (via J maneuver)
(Figure 17.7). The proximal trachea can similarly be
examined with rigid endoscopy, but more distal aspects,
to the level of the carina and distally, warrant a flexible
scope of appropriate size to provide adequate visualiza-
tion and afford interventional access.
Ideal diagnostic imaging protocols will include a com-
puted tomography (CT) or magnetic resonance imaging
(MRI) of the rhinarium and paranasal passages preced-
ing endoscopy. It is beneficial to be situated to move
immediately from initial imaging to endoscopy utilizing
a single anesthetic procedure. As a practical matter, if CT
or MRI modalities are not available, high‐quality digital
radiography can be performed prior to endoscopy.
Figure 17.7 Small diameter flexible endoscope. Source: Courtesy
of Karl Storz SE & Co. KG, Germany.
­Respiratory Tract Laser Endosurger ­Respiratory Tract Laser Endosurger 221
Lateral, open mouth VD, and frontal sinus skyline views
are standard for nasal studies.
Examination
Endoscopic examination of rhinarium in cats and dogs
typically begins with a caudal visualization of the poste-
rior nares at the level of the choanae with a retroflexed
“J” maneuver flexible endoscope. These smaller‐diameter
two‐way flexible endoscopes are well designed to allow
for access to structures dorsal to the soft palate and
establish patency of the posterior nares and ventral nasal
meatus. The patient is positioned in sternal recumbence,
with the patient’s head propped on towels, still allowing
a slight ventral deviation of the tip of the nose to permit
adequate gravity drainage. The patient’s mouth is held
open with a mouth gag and the endoscope inserted into
the caudal pharynx. The monitor and endoscopic tower
are generally positioned at approximately the level of the
patient’s shoulder, and the operator works from the
­rostral position. This visualization allows for the most
natural and spatially accurate visualization of the anatomy.
In this position, the surgeon can examine the caudal
nasopharynx and the posterior nares adequately. Biopsies
or aspirates can be obtained and if needed, laser fibers can
be introduced to perform operative procedures at the
posterior nares (Figure 17.8).
Rostral rhinoscopy is then performed with selection of
an appropriate endoscope based on the patient’s size.
Typically, sterile saline irrigation is used to allow for con-
tinuous flushing of blood and nasal exudate from the site
of interest, maintaining a clear, high‐quality image. It is
incumbent on the surgeon and anesthetist to ensure that
proper endotracheal intubation is performed. A well‐fitted
endotracheal tube with a properly inflated cuff will
ensure that fluid does not wash into the trachea and dis-
tal pulmonary structures. This author will often pack the
caudal pharynx with dry gauze to allow for absorption of
Frontal sinus
Cribriform plate of ethmoid bone
Ethmoidal conchae
Dorsal nasal concha
Dorsal meatus
Middle meatus
Alar fold
Ventral
meatus
Vomer Ventral nasal
concha
Figure 17.8 Diagram of the canine rhinarium and paranasal
sinuses. Source: From Evans and Christensen (1979). Used with
permission of Elsevier.
 222 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
Table 17.1 Rhinoscopic laser intervention.
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Procedure Rhinoscopic laser intervention
Laser type and wavelength (nm) Diode (810 or 980)
Fiber diameter (μm)
Power (W) 6–12
Frequency (Hz) Continuous wave or up to 20
Energy (J) * 0.8–1.7
Contact technique Contact
extraneous irrigant and hemorrhage. Feminine hygiene
pads, cut to size, provide excellent absorption of fluid
within the confines of this small space. Rhinoscopy
without fluid irrigation, or “dry” rhinoscopy, can also be
performed with minimal or intermittent fluid washing of
the optical lens and air insufflation to maintain a clear
surgical image. This minimizes the risk of iatrogenic
aspiration pneumonia.
Examination of the rhinarium should proceed in a
systematic manner to ensure that examination is
complete. If preoperative imaging is available, this
can help strategize and interpret correct examina-
tion. The endoscope is inserted into the nose, and
the dorsal nasal meatus is examined first. It is unu-
sual to be able to advance the endoscope terminally
to the cribriform plate but to the extent that the
anatomy allows, complete examination is performed.
Next the middle nasal meatus and ethmoid turbi-
nates are evaluated. Lastly, the ventral nasal meatus
is traversed. This is best accomplished by retracting
the endoscope rostrally, then re‐introducing the
scope with a gentle ventromedial angulation. The
approach can be considered akin to the passing of a
nasogastric tube. The ventral nasal meatus can then
be examined to the posterior nares and nasophar-
ynx, depending on the size of the patient relative to
the size of the endoscope. This examination is simi-
larly repeated on the contralateral side. By consen-
sus, it is usually advised that the less or unaffected
side is examined first.
Even completely normal nasal mucosa is delicate
and will bleed with minimal manipulation. Gentle and
cautious technique is needed to ensure that the acuity
of visual observations is not compromised by exces-
sive hemorrhage. It is wise to take diagnostic samples
and perform surgical interventions after the exam is
completed. Invariably, these procedures will result in
some degree of bleeding that may compromise the
field of view.
Ho:YAG (2100)
Dependent on endoscope
*
6–10
Contact and non‐contact
Laser Intervention
The immediate goal of the surgical intervention is important
to consider and it is worth noting that in many cases, in
an effort to conserve resources and minimize anesthetic
episodes, laser excision may be performed as part of the
initial intervention; that is prior to definitive diagnosis
via histopathology. As such, the astute clinician will need
to make an imperfect set of decisions with respect to the
goals of the intervention. Often, the immediate intent is
to palliate and ameliorate clinical signs. Improving nasal
airflow, facilitating more normal swallowing, and control
of epistaxis are reasonable goals for the endoscopic
intervention. While certain nasal pathologies may benefit
from other more definitive therapies (e.g. radiation ther-
apy for certain primary nasal n ­ eoplasms), the palliative
benefit of debulking makes laser surgery a reasonable
adjunct to diagnostic rhinoscopy.
Once an anatomic lesion is identified (and appropriate
samples taken for histopathology, cytology, and bacterial
culture and sensitivity), then resection, debulking, or
ablation may be considered. The size and location of the
lesion are critical considerations in determining whether
the lesion can effectively and safely be addressed with the
laser. The bony confines of the rhinarium are largely tol-
erant of thermal injury imparted by the laser. One impor-
tant relative contraindication is lesions that intimately
involve or are adjacent to the cribriform plate. This
­relatively thin bony shelf separates the caudal extent of
the dorsal nasal meatus from the calvarium, and in par-
ticular the olfactory centers of the frontal cortex of the
brain. Thermal injury in this site can lead toward breech
of the cribriform plate, offering infectious or neoplastic
infiltration into the brain case as well as massive intrac-
ranial hemorrhage. CT or MRI are very helpful in identi-
fying the caudal extent of these lesions and involvement
of the cribriform plate. Radiography is less sensitive to
defining lesions in this location. Endoscopic visualiza-
tion can be valuable, but it is often difficult to define the
caudal extent of lesions with the use of endoscopy alone.
 ­Respiratory Tract Laser Endosurger ­Respiratory Tract Laser Endosurger 223

The presence of hemorrhage and irrigant will largely

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dictate the type of laser and wavelength that can be used

efficiently at the surgical site. Typically, surgical diodes
utilizing wavelengths of 810–980 nm are used, as these
wavelengths are less attenuated by water and saline. It is
worth noting that the coefficient of absorption curve
demonstrates a notable uptick at approximately 810–
830 nm (Figures 4.1 and 4.12). This correlates with
absorption of light by biological pigments, particularly
melanin and hemoglobin. This allows diodes operating
within these wavelengths to provide greater tissue vapor-
ization at lower energy outputs, which will impart excel-
lent tissue vaporization, superior hemostasis, and
minimal collateral thermal injury beyond the desired
surgical site (Table 17.1).
In addition to anatomic location, it is important to con- Figure 17.10 Nasal adenocarcinoma and Ho:YAG resection.
sider the gross appearance of the lesion prior to attempt-
ing laser surgery. Sessile singular lesions with narrow
points of attachment lend themselves to complete suc-
cessful resection. More diffuse broad‐based lesions are
more difficult to resect en bloc and may respond better to
more diffuse vaporization and debulking.
Recently, the Ho:YAG laser is beginning to be used in
rhinoscopic surgery (Table 17.1, Figures 17.9–17.12).
Endoscopic surgical techniques are quite similar here to
that previously described. Initial impressions suggest
that the holmium laser is more efficient than even high‐
power diodes. The speed and efficiency of tissue vapori-
zation seems subjectively greater, while operative times
are moderately less (unpublished data). The high degree
of fiber vibration and fluence predisposes toward tissue
liquefaction and a “splatter” of this tissue residue. This
does make it more challenging to keep the endoscope
lens and the surgical site clean. Further work will need to
be done to determine if there is evidence‐based rationale
Figure 17.11 Nasal adenocarcinoma and diode laser resection.
to the use of the holmium laser vs. the diode.

Figure 17.9 Nasopharyngeal polyp and Ho:YAG resection. Figure 17.12 Nasal mass and Ho:YAG resection.
 224 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
Postoperative and Prognosis
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Owners should be made aware of the potential for dark
charred material being observed in nasal exudate post-
operatively, particularly with sneezing. Hemorrhage
should be minimal, particularly with the coagulative
benefit of the 810 m diode, but often mechanical disrup-
tion of highly friable tissue will bleed notably during the
procedure. This warrants careful evaluation of the source
of the bleeding and more meticulous spot welding of
specific hemorrhage spots.
Morbidity from laser rhinoscopic surgery is minimal,
while mortality is quite low and likely related to comor-
bidities and anesthetic complications. Owners may tran-
siently note more epistaxis, but more commonly
hemorrhage is well controlled with the laser. Charred
material may be noted in exudate and can be alarming to
owners but is an expected part of the postoperative
course. Short courses of NSAID pain control are appro-
priate and are rarely of long‐term necessity.
Clinical benefit and prognosis following surgery is
highly variable and determined more substantially by the
underlying pathology rather than the surgical modality.
For many neoplastic pathologies, it is likely unreasonable
to expect laser endoscopic surgery to be curative. Rather,
as a method of surgical debulking as adjunctive to radia-
tion or chemotherapy, reducing tumor burden has been
shown to be of positive benefit. More importantly, par-
ticularly for clients unable to avail their pets definitive
therapy, laser surgery has remarkable palliative benefits
with reasonable cost, minimal surgical morbidity, and a
short recovery time.
For patients with primary nasal adenocarcinoma
(Figures 17.10 and 17.11), control of clinical signs has
a mean duration of 6.5 months, with substantial con-
trol beyond 10 months, using laser debulking as a sole
therapy (unpublished data). Statistical outliers dem-
onstrate adequate control of clinical signs greater
than two years.
Duration of clinical response for other nasal neoplasms
is shorter, although the subjective clinical response by
owners is similarly positive. Squamous cell carcinoma,
osteosarcoma, and chondrosarcoma respond for notably
shorter durations. Nasal lymphosarcoma responds
favorably in terms of reduction of clinical signs (simply
those due to the space‐occupying nature of the lesion)
but the disease must be approached from a systemic and
local standpoint for adequate long‐term remission or
cure.
Benign pathologies respond quite well to laser surgery.
Sessile polyps either in the rhinarium or in the caudal
pharynx, as in the case of typical nasopharyngeal pol-
yps of cats, can be curatively excised en bloc with
the diode. Aggressive laser turbinectomy for chronic
intractable inflammatory rhinitis is a subjectively
­preferable alternative to open rhinotomy and turbinec-
tomy; the reduction in hemorrhage is marked, and surgi-
cal morbidity is lessened.
Both congenital and acquired nasopharyngeal ste-
nosis (or nasopharyngeal atresia in the neonate) have
been described in dogs and cats. A combination of
both diode laser excision and balloon dilatation has
been performed with limited benefit. While this pro-
cedure has not been subjected to appropriate clinical
study, the results anecdotally have been less than
encouraging. It has been experienced that virtually all
of the patients that underwent this procedure (both
with and without adjunctive local steroid administra-
tion) have had recurrence of the stenosis within sev-
eral months postoperatively. As such, the diode laser
should likely not be considered as adequate therapy
for this condition. However, with US Food and Drug
Administration (FDA) approval of the Ho:YAG laser
for certain stenotic and stricture type lesions, there
may yet be benefit to laser surgery for this condition.
At this time, interventional radiology for stent place-
ment is the best therapy offered. Stents placed with
both endoscopic and fluoroscopic guidance have been
largely successful (Berent 2016).
Endobronchial Masses
Mass lesions of the trachea and main stem bronchi can
be accessed endoscopically for both visual examination
and retrieval of tissue for clinicopathological examina-
tion. Depending on patient size, both rigid and flexible
endoscopes can be used to gain access to the proximal
third of the trachea, while the distal two‐thirds and the
main stem bronchi require flexible endoscopic equip-
ment to safely examine.
Similarly, diode lasers can be used in concert with
endoscopes to resect or debulk lesions in the large air-
ways in certain clinical scenarios.
Of paramount importance is control and maintenance
of the airway during the pre, intra‐, and postoperative
periods. Preoxygenation is advised for all patients under-
going airway surgery. Patients with significant mechani-
cal obstruction of the airway must be carefully evaluated
prior to induction of anesthesia to ensure safe comple-
tion of the surgery. Patients that are hypoventilatory or
hemodynamically unstable should be stabilized prior to
surgery. In the emergent case, control of the airway by
orotracheal intubation or tracheostomy (distal to the
anatomic obstruction if possible) should be instituted
along with ventilatory support.
Intubation and airway control not only allow for main-
tenance of a patent airway but also creates a potential
 ­Respiratory Tract Laser Endosurger ­Respiratory Tract Laser Endosurger 225
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Figure 17.13 Tracheal mass. Figure 17.14 Tracheal mass post resection.

access point for endoscopic instrumentation. The com- Table 17.2 Endobronchial mass resection.
bination of patient size, endotracheal tube size, and
diameter of the endoscope will determine the feasibility Procedure Endobronchial mass resection
of this approach. When appropriate, the ability to control
the airway and manipulate the endoscope concurrently Laser type and Diode (810 or Ho:YAG
maximizes the safety of the procedure. Y‐adaptors to wavelength (nm) 980) (2100)
anesthetic tubing can be used to facilitate passage of a Fiber diameter (μm) Dependent on endoscope
flexible endoscope while maintaining inhalation anes- Power (W) 12–15 *
thetic and airway control. Patients can be positioned in Frequency (Hz) 5000–2000 4–10
either lateral or sternal recumbence based on practi-
Energy (J) * 0.8–1.7
tioner preference and experience.
Contact technique Contact Non‐contact
Both diode and Ho:YAG lasers have been used to
resect luminal airway masses. These anatomic locations
have a lower tolerability of thermal injury. To that end, it
is important to ensure that the deep margins of any sur- Table 17.3 Everted laryngeal saccule resection.
gical resection allow for the maintenance of healthy
tissue. Everted laryngeal saccule
Rarely do luminal airway masses possess narrow Procedure resection
stalks. As such, resection largely involves top‐down
serial resections, using the fiber in contact technique, Laser type and wavelength (nm) Diode (810 or 980)
to increase the functional diameter of the airway Fiber diameter (μm) Dependent on endoscope
(Figures 17.13 and 17.14). Diode powers of up to Power (W) Up to 12
12–15 W can be necessary, particularly for mass
Frequency (Hz) Up to 20 000
lesions that are relatively less vascular (Table 17.2).
While histopathology will definitively determine the Energy (J) *
nature of any airway mass, it is unlikely that endoluminal Contact technique Contact
resection will yield clean surgical margins.

orally introduced instrumentation to allow adequate

Everted Laryngeal Saccules
Patients with everted laryngeal saccules as part of brach-
ycephalic obstructive airway syndrome (BOAS) can
undergo successful resection of the saccules under direct
endoscopic guidance. This often requires diode powers
of up to 12 W (Table 17.3) and can require additional
medial traction to be placed on the tissue of the saccule
itself. This may prove technically difficult in patients
with severe or complete (Grade III–IV) laryngeal
­collapse, but the excellent hemostasis provided for with
the diode laser may prove to be important in reducing
postoperative morbidity. Typically, patients are positioned
 226 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures

in sternal recumbence, and depending on the size and

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morphology of the patient it may be necessary to have an

assistant hold the patient’s head and extend the neck to
allow for a straighter and more direct approach to the
caudal pharynx.
Complications from laser surgery of the airway can
include pneumothorax and pneumomediastinum (if
excessive thermal energy is used and care is not taken to
preserve the integrity of deep tissues), hemorrhage and
resultant aspiration pneumonia (if adequate control of
the airway and intraoperative hemostasis is not ensured),
and postoperative laryngeal and tracheal edema.

­Laser Otoendoscopy
Figure 17.15 Aural mass.
Aural Masses
Aural masses of the horizontal and vertical canals of
the canine and feline patient are routinely examined
via otoendoscopy. This can be performed as either an
awake (or lightly sedated) procedure in the exam room,
or as an operative procedure under general anesthesia
(Ordeix and Scarampella 2008). As a general rule, it is
preferred to perform any operative procedure on the
distal ear canal under general anesthesia. This mini-
mizes the risk of iatrogenic injury to the patient and
equipment and improves the speed and efficiency of
the intervention.
With the patient in lateral recumbence, the opera-
tive side is positioned “up.” Positioning of the endo-
scopic tower on either the dorsal or ventral side of the
patient is the preference of the operator; this author
generally tries to position himself along the patient’s
dorsal side with the tower at head level along the ven- Figure 17.16 Diode laser resection of a benign aural polyp.
tral aspect of the patient. It is acknowledged that when
the contralateral ear is examined a change in position-
ing of the surgeon and equipment may be needed. It is and flushing, or under direct irrigation to provide a deep
advantageous to gain comfort working on both sides cleaning (with associated suction). A variety of purpose‐
of the patient to minimize delays during patient repo- made otoendoscopes are available. Alternatively, standard
sitioning. If appropriate, preoperative cleaning of the multipurpose rigid endoscopes can be employed for
ear can minimize operative time and improve diag- otoendoscopy.
nostic imaging. Masses of the aural canals tend to be sessile and
With the endoscope held in the dominant hand, pistol stalked, even when multifocal and polypoid
style, the pinna is grasped with gentle dorsal traction to (Figure 17.15). As such the diode laser can be used to
open the vertical canal. The instrument is inserted into transect the base of these lesions with excellent hemosta-
the vertical canal and the examination is performed. This sis (Figures 17.16–17.18). If the lesion should be lodged
is often a tight fit with the endoscope and the magnifica- at the bottom of the vertical canal, visualization of a stalk
tion of the image necessitates small deliberate move- or point of attachment may be difficult. In these cases,
ments to maintain proper image orientation and the lesion can be ablated from a top‐down vaporization
minimize iatrogenic injury. approach until a point of origin can be visualized. At that
Depending on the amount and character of the aural point, it is often feasible to transect the base of the mass.
exudate, this procedure can be performed as either a Diode laser power in the region of 10–12 W is generally
“dry” procedure following appropriate aural cleansing appropriate (Table 17.4).
 ­Laser Endoscopic Surgery of the Alimentary Trac ­Laser Endoscopic Surgery of the Alimentary Trac 227

Table 17.5 Myringotomy.

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Procedure Myringotomy

Laser type and wavelength (nm) Diode (810 or 980)

Fiber diameter (μm) 325 or less
Power (W) <8
Frequency (Hz) Continuous wave
Energy (J) *
Contact technique Contact

middle ear disease. Indeed, even unintentional iatrogenic

myringotomy can help alleviate underlying otitis media
Figure 17.17 Diode laser resection of an aural mass. and associated clinical signs.
One of the most challenging parts of managing patients
in need of myringotomy is the very rapid closing and
healing of the tympanum. While it may appear counter-
intuitive, the delayed healing often noted as a component
of thermal injury can actually be of benefit when per-
forming myringotomy. Slowing down the healing of the
tympanum provides a longer period of drainage for the
middle ear, helping minimize the likelihood of recur-
rence of middle ear disease.
Myringotomy via CO2 laser has been described in
Chapter 11. A myringotomy may also be performed
via diode laser, with a diode fiber of no greater than
325 μm and power less than 8 W (Table 17.5). This
author tends to avoid punctate myringotomy in favor
of a “cruciate” pattern, with two cuts from the top of
the pars tensalis toward the cranial corner of the pars
flaccidum, and then another cut crossing the first in
Figure 17.18 Postoperative view of the ear canal following diode the opposite direction. This pattern slows tissue heal-
laser mass excision. ing further, allowing for a longer period of patency,
and as such a longer opportunity for drainage and
Table 17.4 Aural mass resection and ablation. gentle flushing of the middle ear in the postoperative
period. Adequate drainage and appropriate antimicro-
Procedure Aural mass resection/ablation bial, anti‐inflammatory, and ceruminolytic topical
aural medications will allow for excellent healing of
Laser type and wavelength (nm) Diode (810 or 980) the tympanum (Gotthelf 2012).
Fiber diameter (μm) Dependent on otoscope
Power (W) 10–12
Frequency (Hz) Continuous wave L­ aser Endoscopic Surgery
Energy (J) * of the Alimentary Tract
Contact technique Contact
Strictures
The diode and holmium lasers have been used success-
Myringotomy
fully to manage both stricture‐type lesions and masses of
Historically, great care has been advised to practitioners the gastrointestinal tract. The esophagus, stomach, and
to avoid either contact with or inadvertent puncture of colon are all anatomic sites that allow for adequate endo-
the tympanum. However, it appears that myringotomy is scopic intervention. While masses in the small bowel can
often an under‐appreciated therapy for many forms of often be accessed, particularly in the proximal half of the
 228 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
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Figure 17.19 Severe erosive esophagitis and stricture.
duodenum, it is unusual for endoluminal resection to
provide meaningful resolution of clinical signs.
Acquired strictures of the esophagus (Figure 17.19)
can be addressed with a combination of both balloon
dilatation and holmium laser resection. Lesions with a
notable component of fibrotic or granulation tissue as a
sequela to mechanical or chemical trauma lend them-
selves better to laser surgery. Laser surgery should not be
attempted in the acute phase of healing as excessive ther-
mal injury in this time frame can be catastrophic.
Initial therapy following identification of esophageal
injury is centered on minimizing ongoing mechanical
injury to the affected area. To this end, a percutaneous
endoscopic gastrostomy (PEG) tube or a low‐profile gas-
trostomy button should be placed to allow alimentation
and hydration to be accomplished without the mechanical
trauma to the healing region of the esophagus. Medical
management to address reflux and provide mucosal pro-
tection is important during the acute phase of healing as
well. Approximately, two weeks following initial identifi-
cation of the esophageal injury, re‐examination via
esophagoscopy should be performed. If a stricture is
­present and there is minimal evidence of active injury,
endoscopic intervention can be performed.
Ideally, Ho:YAG resection should be performed prior
to balloon dilation. At 8–12 W of power and using a
325 μm fiber at 15 Hz, between 0.5 and 0.8 J of energy is
produced, allowing for a controlled resection of the most
luminal portions of the stricture (Table 17.6). The sur-
geon should not attempt to establish complete patency
of the esophagus with the laser alone. How much of the
lesion to attempt to resect with the laser is a somewhat
subjective decision based on the surgeon’s experience.
Suffice to say that resection should not proceed to the
base of the grossly visible stricture. Following laser resec-
tion, appropriate procedures for balloon dilatation
Table 17.6 Esophageal stricture resection.
Esophageal stricture
Procedure resection
Laser type and wavelength (nm) Ho:YAG (2100)
Fiber diameter (μm) 325
Power (W) 8–12
Frequency (Hz) 15
Energy (J) 0.5–0.8
Contact technique *
Figure 17.20 Balloon dilatation of esophageal stricture.
should be performed (Figure 17.20) (Leib et al. 2001).
The PEG tube should be left in and serial esophagoscopy
should be performed every two to three weeks to evalu-
ate healing.
Esophageal Masses
Esophageal masses can be addressed similarly, but for
neoplastic masses, laser debulking is palliative. In these
situations, diodes (both 810 and 980 nm) and Ho:YAG
can be considered (Table 17.7). Again, medical and nutri-
tional management should be part of the patient’s care
with mass lesions of the esophagus. Laser settings on
long cycle cutting frequencies for diodes with power up
to 10–12 W are generally adequate. With Ho:YAG, ener-
gies up to 1.2 J with similar frequency can produce vapor-
izing powers up to 18 W with a 550 μm fiber. Again, the
surgeon should not attempt to achieve complete resec-
tion; maintaining integrity of the esophageal wall is of
paramount importance. If endosurgical laser resection
does not provide adequate duration of control of clinical
signs, consideration for an IR‐ or IE‐placed stent can be
of benefit (Lam et al. 2013).
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Table 17.7 Esophageal mass debulking.

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Procedure Esophageal mass debulking

Laser type and Ho:YAG Diode laser

wavelength (nm) (2100) (810 or 980)
Fiber diameter 550 μm Dependent
on endoscope
Power (W) Up to 18 10–12
Frequency (Hz) Long cycle Long cycle
Energy (J) 1.2 *
Contact technique * *

Gastric Masses Figure 17.21 Benign mass in the pylorus of a dog.

Gastric masses, both benign and neoplastic, can be
­successfully managed with endoscopically guided laser
surgery. Benign masses (Figures 17.21 and 17.22) often
present with a narrow stalk and can be easily transected
with diode lasers (810 or 980 nm). The maximum fiber
size that can be allowed for the given endoscope should
be employed, but powers from 8 to 10 W are often
adequate (Table 17.8). An endoscope with multiple
­
instrument channels to allow for introduction of both a
grasping device (for traction) and the laser fiber are help-
ful but certainly not necessary for successful resection.
Material should be recovered for histopathology and
representative biopsies from around the resection site as
well as throughout the stomach to ensure complete
resection and evaluate the gastric mucosa for more
­diffuse disease.
Broader masses in the stomach (Figure 17.23) can be
debulked. This is particularly of benefit for mass lesions
at the cardia and pyloric antrum where masses can
­present as obstructive lesions with resultant clinical Figure 17.22 Ho:YAG excision of benign pyloric mass.
signs. Diode lasers of 810 nm are preferred due to their
­effective hemostatic capabilities. Vaporization should
be performed in a combination of both contact and
noncontact modes (which may require a change of
fiber or occasional cleaving) from a top‐down grid Table 17.8 Gastric mass resection and debulking.
approach. Powers up to 15 W in a short cycle mode are
indicated. Again, care must be taken to ensure integrity Gastric mass Gastric mass
Procedure resection debulking
of the deeper layers of the gastric wall and to avoid
using laser energy on any lesion of questionable integ-
Laser type and Diode laser Diode laser (810)
rity; ulcers, and to a slightly lesser extent, erosions, wavelength (nm) (810 or 980)
should be avoided.
Fiber diameter (μm) Maximum allowed by endoscope
Power (W) 8–10 15
Bowel Masses Frequency (Hz) * Short cycle
Energy (J) * *
Patients with large bowel masses, particularly those in
Contact technique * Contact and
the descending colon and rectum, often present with
non‐contact
dyschezia, hematochezia, and tenesmus. Where these
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Figure 17.23 Carcinoma of the body of the stomach of a dog. Figure 17.24 Diode laser debulking of a colonic mass.

signs are due to obstructive or bleeding masses, laser

resection can be an effective management technique.
More proximal lesions are technically more difficult to
address and adequately resect. Traditional open or lap-
aroscopic surgery may be of greater benefit for lesions
orad of the mid‐transverse colon. Further, polypoid
and stalked lesions, benign or neoplastic, are easily
managed with laser surgery. While full‐thickness
resection may be warranted for certain cancers, this is
rarely possible or advised with laser surgery. However,
local control can be an important component to main-
taining quality of life.
Adequate colonic prep is key to well‐performed colo-
noscopy. Quality visualization and resection of lesions is
handicapped by poor colon prep. Colonic prep protocols
are varied and provided elsewhere, but a prolonged
Figure 17.25 Ho:YAG debulking of a colonic mass.
24–36‐hours food fast with two doses of an oral‐colonic
lavage solution (Go‐Lytely, Nu‐Lytely, OCL) at doses of
30 ml/kg of body weight per os (reconstituted as per
manufacturer’s instructions) in the afternoon and evening colon thus allowing the use of larger diode laser fibers.
prior to the procedure is advocated. These hyperosmolar Masses can be resected either en bloc via a stalk transec-
PEG‐3350 solutions produce profuse diarrhea and tion, or more broadly, generally in contact (Figures 17.24
patients should be hospitalized for administration. and 17.25). The excellent hemostasis afforded by the
Additional warm water enemas should be performed the 810 nm diode allows for good visualization of the gross
evening prior and morning of the procedure until the boundaries of the lesion but cannot be relied upon to
effluent runs clean. determine clean surgical margins. In addition to retriev-
For distal lesions, large‐diameter rigid endoscopes ing mass tissues for histopathology, representative biop-
or proctoscopes may be appropriate equipment sies of other regions are advised to help determine the
choices, but more likely an appropriately sized endo- extent of disease.
scope should be utilized. Flexible endoscopes are There are sporadic reports in the human literature of
needed to adequately navigate the entirety of the colon, iatrogenic thermal injury as the result of spark gap igni-
through to the ascending colon and ileocolic region. tion of large bowel methane gas. While the surgeon
Again, the patient size dictates the endoscope size, should be advised of this possibility, adequate colon prep
which in turn dictates the fiber size. Larger diameter and room air insufflation minimize the likelihood of this
endoscopes are often able to be used with ease in the potential complication.
 ­Laser Endoscopy of the Lower Urinary Trac ­Laser Endoscopy of the Lower Urinary Trac 231

L­ aser Endoscopy of the Lower into the bladder and the urethra examined antegrade to
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Urinary Tract the level of the os penis. Diagnostic and therapeutic pro-
cedures are then performed (Figure 17.26). The bladder
Cystoscopy and General Anatomic and body wall are then closed in a routine fashion. A uri-
Considerations nary catheter is left in for 24 hours postoperatively to
allow the bladder to remain decompressed.
Endoscopy of the urethra, vagina, and urinary bladder Urethrocystoscopic and vaginoscopic examination is
has allowed for marked reduction in morbidity associ- technically less problematic in the female canine patient
ated with diagnostic interventions of the urinary tract than its male counterparts. The relatively linear approach
while providing unrivaled quality of diagnostic imaging. from the vaginal vault to the bladder allows for the use of
Indeed, there are anatomic regions that but for endos- rigid endoscopes with excellent optics of varying size
copy, are largely inaccessible save for aggressive surgical and types, largely dictated by the size of the patient.
intervention. The juxtaposition of surgical lasers with Cystoscopic examination with the patient in sternal
these endoscopic modalities allows for minimally inva- recumbence is generally performed. The vulva is clipped
sive surgical procedures that minimize pain, morbidity, and prepped for aseptic procedures. The endoscope is
and dysfunction. However, the ease of endoscopic access introduced into the vaginal vault. From here the clitoral
to various parts of the canine and feline urinary tract is a fossa, vaginal vault and vagina can be examined
function of their unique anatomies and availability of (Figure 17.27). The endoscope is then passed into the
appropriate instrumentation.
The distal canine urethra is markedly distensible and
can be accessed by a wide variety of both flexible and
rigid endoscopes. However, once the base of the os penis
is reached, a flexible endoscope of appropriate small size
will be needed to continue the examination through the
os and pelvic flexure to the bladder. While there are a
limited number of very small‐diameter flexible endo-
scopes available (particularly scopes engineered and
marketed as ureteroscopes in the human field), these
scopes are expensive, delicate, and have working ­channels
that markedly limit the size and scope of instrumenta-
tion available for both diagnostic and therapeutic use.
Canine patients larger than 40 kg can be fully examined
more easily with standard and commonly available flex-
ible urethroscopes. A two‐way deflecting flexible scope
with an outer diameter of 3.8 mm and a working channel
of 2.1 mm is employed. For male feline patients, available Figure 17.26 Polypoid bladder mass(es).
transurethral equipment is limited and makes transure-
thral examination a logistic conundrum.
The acceptable alternative for the small male canine
and most feline patients is to perform laparoscopic‐
assisted cystoscopy (alternatively referred to as “percuta-
neous transabdominal cystoscopy”). Briefly, a standard
ventral midline laparoscopic exploratory approach is
made, usually using either a 5 or 2.7 mm mini‐laparo-
scope. A Foley or red‐rubber urinary catheter is placed
transurethrally in a sterile fashion, and the bladder is ade-
quately distended. Using standard laparoscopic instru-
mentation, the bladder is grasped near the apex and is
brought up to the body wall via one of the operative por-
tal sites. The bladder is secured to the body wall and can-
nula site with stay sutures. A #11 or #15 scalpel blade is
used to make a stab incision to the bladder. A smaller
diameter rigid endoscope is then placed into the bladder
directly. Alternatively, a flexible endoscope is introduced Figure 17.27 Vaginal vestibule.
 232 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures

urethra with the aid of sterile saline irrigation and disten- Fortunately, the need for open intervention or salvage
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tion. The urethra and bladder can then be accessed for a procedures is rare. Generally, in the rare occurrence of
variety of interventions. perforation, assuming a lumen can still be adequately
identified, the placement of a Foley or red‐rubber cathe-
ter left indwelling for 48–72 hours allows for adequate
Transitional Cell Carcinoma and TURN
healing of the iatrogenic damage of the urethra. Similar
By far the most common neoplasm of the canine lower complications can occur in the bladder but are less
urinary tract is transitional cell carcinoma (TCC). common owing to the larger field of view and the
Anatomic distribution of this neoplasm ranges from the greater distensibility of the bladder mucosa (Figures 17.29
vaginal vault, the urethra and bladder, and every possible and 17.30). Still, perforation can be managed in the same
combination. manner as for the urethra.
Problematically for a long‐term management, the real- In an effort to manage TCC of the bladder more
ity is that TCC, while an epithelial neoplasm, frequently aggressively with diode lasers, an ultrasound‐guided
has extended beyond the mucosa at the time of diagno- approach to this cystoscopic surgery has been described.
sis. Carcinoma in situ is an unusual finding. This is in With the patient in dorsal recumbence, the cystoscope is
contrast to the disease in human patients where initial introduced in a standard fashion. An assistant performs
diagnosis often finds the cancer confined to the mucosa, transabdominal ultrasound, allowing for visualization of
lending to less complicated and invasive excision. the bladder mass. High‐quality ultrasound will allow the
Further, this neoplasm has a predilection for occurrence
in the urethra and trigone of the bladder, making aggres-
sive surgical excision with resultant clean surgical mar-
gins quite difficult.
The advent of diode lasers in endoscopic surgery has
allowed access to these anatomic sites for palliative sur-
gery and excellent control of clinical signs. Both 810 and
980 nm diodes are often used for endourologic transure-
thral resection of neoplasia (TURN) of TCC with similar
benefit. As previously noted, the diameter of the fiber is
dictated by the diameter of the working channel of the
endoscope, but suffice to say, larger is better and more
efficient. Powers between 10 and 15 W are generally
adequate on a long cutting cycle in contact technique
(Table 17.9). A flat or sculpted pointed tip are ideal for
the delicate dissection needed. The thin mucosa of the
urethra (in contrast to other anatomic locations dis-
cussed in this chapter) warrants caution on the part of Figure 17.28 TCC of the urethra and Ho:YAG resection.
the surgeon (Figure 17.28). With aggressive neoplasms, it
can be difficult to visually delineate the margins of neo-
plastic and nonneoplastic tissues. Perforation of the
uroepithelium, particularly in the urethra, is not unheard
of and does warrant quick action and identification.

Table 17.9 Transurethral resection of neoplasia (TURN).

Procedure TURN

Laser type and wavelength (nm) Diode (810 or 980)

Fiber diameter (μm) Maximum allowed by
endoscope
Power (W) 10–15
Frequency (Hz) Long cycle
Energy (J) *
Contact technique Contact
Figure 17.29 TCC of the bladder and laser resection.

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Figure 17.30 Postlaser resection of urethral TCC.
operator to visualize the mass as well as the distinct
­layering of the bladder wall. The laser fiber is introduced
via the endoscope to the bladder. Both the endoscope
and the fiber appear as hyperechoic linear structures on
the ultrasound screen. The combination of the endo-
scopic view concurrent with the ultrasound image allows
the surgeon to be more aggressive in resection of the
mass whilst visualizing and maintaining the integrity of
the bladder wall (Cerf and Lindquist 2015).
Transitional Cell Carcinoma and TURP
In the male canine patient, TCC arising from or extend-
ing to the prostate is an occasional clinical finding. Less
common is primary neoplasia of the prostate. In these
cases, transurethral resection of the prostate (TURP) can
be performed. Ho:YAG TURP is considered by many as
the standard of care for benign prostatic hyperplasia
(BPH) in humans, and the procedure can be adapted to
veterinary patients. This procedure can be performed
trans‐urethrally in patients large enough to accommo-
date passage of the endoscope through the os penis or via
laparoscopic‐assisted cystoscopy in other patients. In
either event, the procedure involves identifying the col-
liculus seminalis as the point of entry for the laser fiber.
The uroepithelium over the colliculus is incised and
the two lobes of the prostate are identified. The laser is
then used in contact at energies of 1.2–1.7 J at 8–15 Hz
(Table 17.10), using a 525‐μm fiber to ablate as much of
the prostatic and neoplastic tissue as needed to establish
an increase in luminal diameter (Figure 17.31). As previ-
ously described, concurrent use of transabdominal ultra-
sound will allow the surgeon to image the prostatic
capsule. This can be of tremendous benefit as it is often
difficult to establish the margins of the prostatic capsule
under direct endoscopic examination. As a rule, less
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Table 17.10 Transurethral resection of the prostate (TURP).
Procedure TURP
Laser type and wavelength (nm) Ho:YAG (2100)
Fiber diameter (μm) 525
Power (W) *
Frequency (Hz) 8–15
Energy (J) 1.2–1.7
Contact technique Contact
Figure 17.31 Ho:YAG TURP.
aggressive resection is better than compromising the
integrity of the prostatic capsule. An indwelling urinary
catheter is left in place for 24–72 hours as needed to
facilitate early‐stage healing at the incisional site of the
urethra.
Congenital Anomalies of the Lower Urinary
Tract
Developmental disorders of the urogenital system are
among the more common presenting indications for
endourological intervention in small animal practice.
Persistent mesonephric remnants, vaginal strictures, and
ectopic ureters are frequent anomalies.
Persistent Mesonephric Remnants
Persistent mesonephric remnants arise from incomplete
closure of the embryonic communication between the
primordial kidney (mesonephros) and the bladder. Most
commonly, this is manifest in the female patient as a per-
sistent band of tissue arising from the dorsal roof of the
vaginal os to the ventral floor. In many patients, this
band is innocuous and an innocent finding. However, in
 234 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
the puppy with recurrent urethritis and cystitis this can
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be considered a contributing factor. The general understanding
as to the mechanism behind this component of the clini-
cal problem is that this band provides persistent traction
on the urethral os, preventing complete collapse and clo-
sure of the distal urethra when the dog is not actively
micturating. This allows for persistent reflux of urine,
pooling in the vaginal vault, to wash back through the
urethra and to the bladder. A related condition, vaginal
strictures or stenosis, is similar in mechanism. In these
cases, thickened lateral walls of the distal vagina mechan-
ically act similarly and maintain patency of the urethra.
These bands can be simple strands of connective tissue
that are a millimeter or two in width or a more complex
layered structure, akin to septal vaginal wall, several mil-
limeters thick and extending cranially for several
centimeters.
Under direct endoscopic examination, these lesions
can be easily identified and resected with either the 810
or 980 nm diodes (Table 17.11). With the fiber in contact,
up to 12–14 W of power can be needed to transect these
bands, depending on the thickness and complexity of
their structure. However, correction is quick and clini-
cal improvement is usually quite rapid. Similarly, the
Ho:YAG laser (Table 17.11) can be employed in contact
at 1.2 J between 8 and 10 Hz, with the largest fiber allowed
by the endoscope instrument channel.
Ectopic Ureter
Ectopic ureter is a common congenital anomaly in canine
patients, occurring more frequently in females, but seen
occasionally in male dogs as well (Bartges 2017). Ongoing
leaking of urine, particularly with the dog at rest, is often
the first owner complaint during puppyhood. In these
patients, the ureter developmentally bypasses the normal
point of aperture in the bladder, terminating more dis-
tally in the urethra, vagina, or vaginal vault (Figure 17.32).
Ectopic ureter can be bilateral or unilateral with a single
ectopic opening or multiple openings at various points
Table 17.11 Persistent mesonephric remnant resection.
Persistent mesonephric remnant
Procedure resection
Laser type and wavelength Diode (810 or 980) Ho:YAG
(nm) (2100)
Fiber diameter (μm) Maximum allowed by endoscope
Power (W) 12–14 * A sculpted pointed‐tip fiber (usually no greater than
Frequency (Hz) 15 8–10
Energy (J) * 1.2
Contact technique Contact Contact
Figure 17.32 Canine ectopic ureter.
along its length. Diagnosis is traditionally made via con-
trast excretory urography. Diagnostic ultrasound can be
of some benefit in the hands of skilled operators; dilata-
tion of the ureter or concurrent ureterocoeles can be
visualized, but ultrasound is often not definitive. The
diagnosis can also be made via cystourethroscopy. Two
general anatomic variants of ectopic ureters are generally
seen. The first and most common variant is the mural
ectopic ureter. In these cases, as seen from the serosal
surface, the ureter can seem to enter the bladder wall at
its normal anatomic position. However, the ureter does
not open in the bladder; rather it travels within the blad-
der and urethral wall, terminating and opening distal to
the trigone. Less commonly, the ureter does not make
communication with the bladder wall until a point distal
to the bladder; that is the ureter does not travel intimately
with the bladder and urethral wall but still opens at an
aberrant point into the urethra or vagina.
While mural ectopic ureters are markedly more com-
mon, excretory urography or contrast‐enhanced CT will
differentiate these variants.
Diode laser correction of these anomalies has been
described and performed with significant success (Berent
2015). Diagnostic urethrocystoscopy (or other imaging
modalities) must be performed to identify the ectopia
and their points of opening. Once the suspicious lesion is
identified, the surgeon must wait and be able to say with
confidence that the suspected opening is indeed patent
and functional; urine must be seen leaving the aperture.
Some endourologists advocate for the use of intraopera-
tive furosemide to aid in visualizing the passage of urine.
325 μm) is ideal for this surgery, although small‐diameter
flat fibers are often used. Alternatively, right‐angled fir-
ing fiber can be used if available. These fibers are encased
in a cladding that has, at its terminus, a reflective surface
 ­Laser Endoscopy of the Lower Urinary Trac ­Laser Endoscopy of the Lower Urinary Trac 235

on the inside of a right‐angled opening, directing the

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light 90° from the long axis of the fiber. Some surgeons
advocate for the placement of a red‐rubber or ureteral
catheter into the ectopic ureter. This can act as a buttress
to provide greater traction on the medial wall of the
ectopia as well as provide protection to the lateral wall
and minimize the risk of perforation.
The operative procedure involves cutting the medial
wall of the ectopic ureter along its length (Figures 17.33–
17.35), on a short cycle at powers of up to 10 W
(Table 17.12), until a point of aperture is established
proximal to the urethral sphincter on the trigonal side of
the bladder. The operator must ensure that the lateral
side of the ectopic ureter is not compromised. Care must
be taken to minimize thermal injury to the urethral
sphincter itself, although some degree of mucosal injury Figure 17.34 Diode laser correction of ectopic ureter.
is expected. Each ureter must be examined to ensure that
there is a normal bladder point of opening. Typically,
clinical resolution is rapid and dramatic. Recently, lim-
ited reports of the use of the Ho:YAG laser suggest its
efficacy is similar to that of diodes in the management of
ectopic ureters. While case numbers are limited, ener-
gies of 1.2 J and up to 8–10 Hz have been useful.

Laser Lithotripsy
The Ho:YAG laser is unique among the commonly avail-
able surgical lasers in its ability to fragment and “dust”
urinary tract calculi (Figure 17.36). Obviously, in addi-
tion to its soft tissue surgical effects, this makes Ho:YAG
a very valuable addition to the armament of the small
animal laser surgeon.
In human urology, the Ho:YAG is used frequently to
perform lithotripsy of renal and ureteral calculi under
endoscopic visualization. In small animal practice, this
laser is more commonly used to fragment stones of the Figure 17.35 Diode laser correction of ectopic ureter.

Table 17.12 Ectopic ureter correction.

Procedure Ectopic ureter correction

Laser type and Diode (810 or 980) Ho:YAG

wavelength (nm) (2100)
Fiber diameter (μm) 325 μm with sculpted, Dependent on
pointed tip, or use a endoscope
right angled firing fiber
Power (W) Up to 10 *
Frequency (Hz) Short cycle 8–10
Energy (J) 0.5–0.8 1.2
Contact technique Contact Contact
Figure 17.33 Diode laser correction of ectopic ureter.
 236 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
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Figure 17.36 Urinary tract calculi.
bladder and urethra, although renal and ureteral calculi
can be effectively addressed depending on limitations of
endoscopic equipment and patient size.
Understanding the mechanism of the Ho:YAG on uri-
nary tract calculi has been somewhat controversial. As
previously discussed, laser light at 2100 nm produces a
“Moses effect,” creating a zone devoid of fluid medium in
the region between the tip of the fiber and the stone.
Previously, the direct mechanism of action between laser
and stone was thought to be photoacoustic; that is the
laser energy produced high‐frequency sound waves of
sufficient energy to ablate the calculi. This would be akin
to the mechanism of action of extracorporeal lithotripsy.
More recent work suggests that the mechanism of action
is photothermal, producing thermally induced structural
changes to the calculus, rendering the crystalline struc-
ture weakened and unable to maintain its previous
cohesion.
The techniques for gaining access to the given area of
the urinary tract are as previously described. The fib-
ers used are generally 325–550 μm, but the energy and
frequency settings are largely dictated by the crystal-
line composition of the stone. Unless there has been
preoperative stone analysis to determine the type of
calculus, the exact power settings needed for effective
lithotripsy are likely determined by the surgeon at the
time of the procedure, by visually appreciating the
laser’s effect on the stone. Broadly speaking, energies
from 1.2 to 2 J at frequencies between 8 and 15 Hz are
employed (Table 17.13). However, there is a tradeoff
between low and high energy pulses. At relatively
higher pulses (2 J or higher), there is greater stone frag-
mentation with subsequent larger stone fragments and
more rapid effect on the stone. However, there is a
greater risk of retropulsion of the stone fragments
Table 17.13 Lithotripsy.
Procedure Lithotripsy
Laser type and wavelength (nm) Ho:YAG (2100)
Fiber diameter (μm) 325–550
Power (W) *
Frequency (Hz) 8–15
Energy (J) 1.2–2
Contact technique Contact or non‐contact
Figure 17.37 Ho:YAG laser lithotripsy.
beyond the field of view of the endoscope. Lower
energy pulses (0.2 J) will produce smaller stone frag-
ments, more “dust” and less retropulsion of stone frag-
ments. Operative time will be greater in many instances
at lower pulses. Stone composition seems to not be a
salient factor in the success of Ho:YAG lithotripsy. Size
as a predictor of successful surgical outcome seems to
be an independent variable, although operative time is
clearly affected (Sea et al. 2012).
In most cases, stone cavitation and fragmentation are
most efficient when the fiber is held in direct contact
with the stone (Figures 17.37–17.39). Intraoperatively,
the operator will appreciate that as the stone is frag-
mented, pieces can be retropulsed away from the tip of
the fiber as a result of the vibration of the fiber. The
noncontact laser will be effective although the efficiency
of stone fragmentation will be lessened. The tradeoff
will be relatively less stone debris and fragments being
forced away from the visual field. All this being said,
contact technique will prove the most efficient method

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Figure 17.38 Ho:YAG laser lithotripsy.
in laser lithotripsy. Care must be taken to avoid pushing
the stone further into anatomic regions that may com-
plicate retrieval or result in obstruction. Additionally,
care must be taken to guard the fiber tip from inadvert-
ent contact with the bladder or urethral wall. Stone dust
can be flushed out with irrigation solution. Larger
stones can be removed with appropriately sized endo-
scopic retrieval baskets. While there does not seem to
be an absolute size limitation on the use of the Ho:YAG,
operative time relative to simplicity of manual removal
must be appreciated.
­References
Bartges JW. (2017). Urethral diseases. In: Ettinger SJ,
Feldman EC, Cote, E, eds. Textbook of Veterinary
Internal Medicine. Elsevier. pp. 2020–2027.
Berent A. (2015). Cystoscopic guided ablation of ectopic
ureters. In: Berent A and Weisse C ed. Veterinary
Image‐Guided Interventions. Wiley‐Blackwell.
Berent AC. (2016). Diagnosis and management of
nasopharyngeal stenosis. Vet. Clin. Small Anim. Pract.
46(4). pp. 677–689.
Bruhat M, Mage G, Manhes M. (1979). Use of the CO2
laser via laparoscopy. In: Kaplan I, ed. Laser Surgery III,
Proceedings of The Third Congress of International
Society for Laser Surgery. Tel Aviv: International Society
for Laser Surgery. p. 275.
Cerf J, Lindquist EC. (2015). Ultrasound‐guided
endoscopic laser ablation for transitional cell carcinoma
in dogs. In: Weiss C, Berent A, eds. Veterinary Image‐
Guided Interventions. Wiley. pp. 398–409.
Elihali MM, et al. (2017). Use of the moses technology to
improve holmium laser lithotripsy outcomes: a
preclinical study. J. Endourol. 31(6). pp. 598–604.
­Reference ­Reference 237
Figure 17.39 Calculi fragments following Ho:YAG laser lithotripsy.
­Conclusion
The introduction of laser devices via rigid endoscopes
and flexible endoscopic delivery systems has been a great
boon to the small animal endoscopic surgeon. What
were previously purely diagnostic studies have now
become opportunities for intervention and effective
management of a variety of disease conditions. These
two complementary technologies are mutually benefi-
cial, and the clinical synergism afforded is convenient,
cost‐effective, and of clear clinical benefit.
Evans HE, Christensen GC. (1979). The respiratory
apparatus. Miller’s Anatomy of the Dog, 2nd ed. WB
Saunders. p. 513, Figure 8.5.
Gotthelf LN. (2012). Myringotomy and ear disease
management. Clinician’s Brief. Brief Media.
Hotson Moore A, Ragni RA. (2012). Clinical
Manual of Small Animal Endosurgery. Wiley
Blackwell.
Lam N, et al. (2013). Esophageal stenting for treatment
of refractory benign esophageal strictures in dogs.
J. Vet. Internal Med. 27(5). pp. 1064–1070. 10.1111/
jvim.12132.
Lhermette PJ, Sobel DS. (2008). BSAVA Manual of Canine
and Feline Endoscopy and Endosurgery. BSAVA.
Leib M, et al. (2001). Endoscopic balloon dilation of benign
esophageal strictures in dogs and cats. J. Vet. Internal
Med. 15(6). pp. 547–552.
McCarthy TC. (2005). Veterinary Endoscopy for the Small
Animal Practitioner. Elsevier/Saunders.
Ordeix L, Scarampella F. (2008). Rigid endoscopy:
otoendoscopy. Lhermette PJ, Sobel DS, eds. BSAVA
 238 Surgical Lasers in Minimally Invasive and Endoscopic Small Animal Procedures
Manual of Small Animal Endoscopy and Endosurgery.
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BSAVA. pp. 131–141.
Rothaug PG, Tulleners EP. (1999). Neodymium: yttrium‐
aluminum‐garnet laser‐assisted excision of progressive
ethmoid hematomas in horses: 20 cases (1986–1996).
J. Am. Vet. Med. Assoc. 24(7). pp. 1037–1041.
Sea J, et al. (2012). Optimal power settings for Ho:YAG
lithotripsy. J. Urol. 187(3). pp. 914–919.
Sobel DS. (2012). Endoscopy of the upper respiratory tract:
rhinosinusoscopy, pharyngoscopy and tracheoscopy.
Hotson Moore A, Ragni RA, eds. Clinical Manual of
Small Animal Endosurgery. Wiley Blackwell.
pp. 231–254.
Tadir Y, et al. (1989). Tissue effects of a new laparoscopic
carbon dioxide laser probe. Fertil. Sterility. 518.
pp. 1046–1049.
Tams T and Rawlings C. (2010). Small Animal Endoscopy.
Mosby.
Tate LP, et al. (1990). Transendoscopic Nd:YAG laser
surgery for treatment of epiglottal entrapment and
dorsal displacement of the soft palate in the horse.
Vet. Surg. 19(5). pp. 356–363.

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18
Laser Neurosurgical Procedures
Gaemia Tracy
­Introduction
Hansen type I intervertebral disc disease (IVDD) is a con-
dition in which the discs between the vertebrae degenerate.
This disease affects approximately 25% of chondrodys-
trophic breeds (i.e. Dachshund, Beagle, Chihuahua,
Maltese, Shih‐Tzu, French Bulldog, Basset Hound, Corgi,
Pekingese, and Lhasa Apso). IVDD is more prevalent in
chondrodystrophic breeds because the nucleus pulposus
of these breeds begins to degenerate between one and two
years of age. The nucleus pulposus becomes calcified and
puts excessive pressure on the annulus fibrosus, causing
the annulus fibrosus to weaken over time and develop a
bulge that compresses the spinal cord. Any rupture in the
annulus fibrosus allows the nucleus pulposus to escape,
which also results in spinal cord compression within the
vertebral canal. This disease may cause any degree of neu-
rologic dysfunction, from weakness and difficulty walking
to permanent paralysis.
Aside from the possible use of a surgical laser as a cut-
ting implement for approach to the brain or spinal cord,
the use of laser technology in veterinary neurosurgery is a
recent development, and it is still a technology not widely
used. The primary use of a surgical laser in veterinary neu-
rosurgery is to perform a technique known as percutane-
ous laser disc ablation (PLDA). PLDA is a procedure
derived from laser discectomy in humans (Gottlob et al.
1992) and is designed to reduce the risk of recurrence of
disc herniation in patients who have previously experi-
enced a suspected or confirmed episode of IVDD.
­Open Surgical Disc Fenestration vs. PLDA
The traditional method used to decrease IVDD risk is
called disc fenestration. Disc fenestration is an open sur-
gical technique in which the vertebrae are fully exposed,
and muscles are dissected to expose the lateral aspect of
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
239
each intervertebral disc. A small incision is then made in
the lateral aspect of the annulus fibrosus, and a small
probe is used to physically remove as much nucleus
­pulposus material as possible. This procedure decreases
the likelihood of disc herniations from 25% down to
about 10% (Brisson et al. 2004, 2011; Aikawa et al. 2012)
through physically removing a portion of the nucleus
pulposus, creating a path of least resistance for any
remaining nucleus pulposus to herniate laterally into the
muscle instead of dorsally into the vertebral canal. The
surgical approach and fenestration of intervertebral discs
takes about one to two hours to perform. The total
recovery time for this procedure is approximately four to
six weeks before resuming normal activity.
PLDA is a fluoroscopically guided procedure that
achieves the same outcome in a minimally invasive man-
ner (Figure 18.1) (Choy et al. 1992; Dickey et al. 1996).
PLDA uses light from a holmium yttrium aluminum gar-
net (Ho:YAG) laser, delivered through spinal needles
inserted through skin and into thoracolumbar disc
spaces, to slow down the rate of mineralization of the
nucleus pulposus, thus decreasing the likelihood of disc
herniation. The Ho:YAG laser’s wavelength (2100 nm) is
strongly absorbed by water, offering reduced depth of
penetration, which increases the likelihood that it will be
absorbed by the nucleus pulposus, while decreasing the
risk of collateral thermal damage to the annulus fibrosus
and surrounding structures (Piao et al. 2014).
PLDA, similar to open disc fenestration, is also
­successful in lowering the chances of disc herniation
from 25% down to about 10% (Dugat et al. 2016). Unlike
open disc fenestration, PDLA is minimally invasive with
no surgical incisions and with a low frequency of adverse
effects. It takes a fraction of the time compared to disc
fenestration, with a procedure length of approximately
30 minutes. Recovery times are also dramatically
reduced, with a maximum of two weeks before return to
normal activity.
 240 Laser Neurosurgical Procedures
With PLDA, there is a risk of transient ataxia and pain
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that usually resolves within one week. The main techni-
cal risk of the procedure is the inability to insert the nee-
dle into the disc space and ablate the disc (Cvitanic et al.
2000), due to the minimally invasive nature of the proce-
dure and occasional abnormal anatomy encountered in
chondrodystrophic breeds. Eye protection must be worn
by all personnel while using this laser to prevent ocular
trauma (Bartels et al. 2003).
Pain management protocol for PLDA is greatly
reduced compared to that necessary for an open surgi-
cal technique that typically consists of opioid premedi-
cation and intraoperative constant rate infusion of an
opioid, followed by constant rate infusion of opioid
administration postoperatively for 1–2 days and by oral
anti‐inflammatory and pain medication for 7–10 days
postprocedure. Patients are generally hospitalized for
three to five days following such a procedure. In con-
trast, the pain management protocol used for the PLDA
procedure consists of a bolus of intraoperative opioids
and administration of an opioid six hours postprocedure.
Figure 18.1 PLDA is a fluoroscopy‐guided delivery of Ho:YAG laser
light into disc spaces of the thoracic and lumbar spine that decreases
the likelihood of disc herniations in chondrodystrophic breeds.
An anti‐inflammatory and a pain medication are also
administered for two to five days afterward.
Preoperative
Under general anesthesia, the patient is placed in right
lateral recumbence and shaved, followed by sterile prep-
aration from the caudal cervical spine to the l­ umbosacral
junction and extending from dorsal ­midline to halfway
down the left lateral aspect of the body wall. This area is
draped into a sterile field. The anesthetized patient is
covered by the sterile table drape, thus protecting their
eyes from laser light ­during the procedure.
The length of the 320‐μm, low‐OH laser optical fiber is
premeasured by inserting the fiber into the spinal needle
until the tip of the fiber extends just past the tip of the
spinal needle (Figure 18.2). The fiber will be held by hand
at this level during laser light delivery.
Laser settings (Table 18.1) were extrapolated from a
similar procedure used to decrease intervertebral disc
Figure 18.2 Premeasuring the Ho:YAG fiber length with a spinal
needle; the Ho:YAG laser fiber is passed through the needle until it
extends just beyond the needle’s tip.
 ­Open Surgical Disc Fenestration vs. PLD ­Open Surgical Disc Fenestration vs. PLD 241

Table 18.1 PLDA.

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Procedure PLDA

Laser type and Ho:YAG (2100)

wavelength (nm)
Fiber diameter 320‐μm, low‐OH laser optical
fiber
Power (W) 2
Exposure Repeat pulse
Mode Non‐SuperPulse
Frequency (H) 10 Hz, 40 s (5–15 pulses/s)

Figure 18.3 Spinal needles inserted percutaneously into the disc

spaces.

pressure in humans (Choy et al. 1991; Mayhew et al.

2004). The pulsed laser with settings between 5 and Figure 18.4 Orthogonal fluoroscopic projections of the target
15 Hz allows cooling to occur between rapid pulses, disc spaces.
potentially limiting tissue damage through thermal
relaxation time (Buchelt et al. 1995).

PLDA Procedure
Under fluoroscopic guidance, 20‐gauge 2.5‐in. or 3.5‐
in. spinal needles (depending on patient size) are
inserted percutaneously into the middle of each disc
space from T10–T11 to L4–L5 (Figure 18.3).
Orthogonal fluoroscopic images are used to guide and
confirm spinal needle placement (Figures 18.4 and
18.5). An opioid is administered at this time (hydro-
morphone 0.1 mg/kg).
The premeasured length of laser optical fiber from
the Ho:YAG laser is passed through each spinal needle
and held firmly where it enters the hub, and a laser light
of 2‐W power at a 10‐Hz repetition rate is delivered for
40 seconds to each disc space in turn (Figure 18.6).

Postoperative
Figure 18.5 Orthogonal fluoroscopic projections confirming the
The patient is kept under observation overnight and placement of spinal needles in the desired disc spaces prior to
administered an additional opioid (hydromorphone passing the Ho:YAG laser fibers into the disc spaces.
 242 Laser Neurosurgical Procedures
(a)
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Figure 18.6 (a) Inserting the laser fiber through the spinal needle into the nucleus pulposus. (b) Holding the laser fiber in place while the
laser pulses are being delivered.
0.1 mg/kg) for six hours following the procedure. An anti‐
inflammatory (carprofen 2.2 mg/kg BID) and pain medi-
cation (gabapentin 5 mg/kg BID) are administered for
two to five days. Patients are generally discharged from
the hospital the day after the procedure.
Long‐term prognosis of PLDA is good. Typically, two
weeks of restriction from activity are recommended
before return to normal function. Neurologic deficits
(such as ataxia, back pain, and discomfort) are rare and
often transient.
­References
Aikawa T, Fujita H, Shibata M, et al. (2012). Recurrent
thoracolumbar intervertebral disc extrusion after
hemilaminectomy and concomitant prophylactic
fenestration in 662 chondrodystrophic dogs. Vet. Surg.
41. pp. 381–390.
Bartels KE, Higbee RG, Bahr RJ, et al. (2003). Outcome of
and complications associated with prophylactic
percutaneous laser disk ablation in dogs with
(b)
­Conclusion
The PLDA technique using the Ho:YAG laser is an e­ ffective,
minimally invasive approach that provides an option for
owners of chondrodystrophic breeds to p ­ rophylactically
decrease the risk of occurrence of IVDD in their beloved
pet. The technique is performed with short anesthetic
times and a low complication rate. New research continues
to support the use of this procedure to decrease the
likelihood of disc herniations in high‐risk breeds.
thoracolumbar disk disease: 277 cases (1992–2001).
J. Am. Vet. Med. Assoc. 222. pp. 1733–1739.
Brisson BA, Moffatt SL, Swayne SL, et al. (2004).
Recurrence of thoracolumbar intervertebral disk
extrusion in chondrodystrophic dogs after surgical
decompression with or without prophylactic
fenestration: 265 cases (1995–1999). J. Am. Vet. Med.
Assoc. 224. pp. 1808–1814.

Brisson BA, Holmberg DL, Parent J, et al. (2011).
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Comparison of the effect of single‐site and multiple‐site
disk fenestration on the rate of recurrence of
thoracolumbar intervertebral disk herniation in dogs.
J. Am. Vet. Med. Assoc. 238. pp. 1593–1600.
Buchelt M, Schlangmann B, Schmolke S, et al. (1995). High
power Ho:YAG laser ablation of intervertebral discs:
effects on ablation rates and temperature profile. Laser
Surg. Med. 16. pp. 179–183.
Choy DSJ, Altman PA, Case RB, et al. (1991). Laser
radiation at various wavelengths for decompression of
intervertebral disk. Clin. Orthop. Relat. Res. 267.
pp. 245–250.
Choy DS, Ascher PW, Ranu HS, et al. (1992). Percutaneous
laser disc decompression: a new therapeutic modality.
Spine. 17. pp. 949–956.
Cvitanic OA, Schimandle J, Casper GD, et al. (2000).
Subchondral marrow changes after laser discectomy in
the lumbar spine: MR imaging findings and clinical
correlation. AJR 174. pp. 1363–1369.
Dickey DT, Bartels KE, Henry GA, et al. (1996). Use of
the holmium yttrium aluminum garnet laser for
­Reference ­Reference 243
percutaneous thoracolumbar intervertebral disk
ablation in dogs. J. Am. Vet. Med. Assoc. 208.
pp. 1263–1267.
Dugat D, Bartels KE, Payton ME. (2016). Recurrence of
disk herniation following percutaneous laser disc
ablation in dogs with a history of thoracolumbar
intervertebral disk herniation: 303 cases (1994–2011).
J. Am. Vet. Med. Assoc. 249. pp. 1393–1400.
Gottlob C, Kopchok GE, Peng S, et al. (1992).
Holmium:YAG laser ablation of human intervertebral
disc: preliminary evaluation. Laser Surg. Med. 12.
pp. 86–91.
Mayhew PD, McLear RC, Ziemer LS, et al. (2004). Risk
factors for recurrence of clinical signs associated with
thoracolumbar intervertebral disk herniation in dogs:
229 cases (1994–2000). J. Am. Vet. Med. Assoc. 225.
pp. 1231–1236.
Piao D, McKeirnan KL, Sultana N, et al. (2014).
Percutaneous single‐fiber reflectance spectroscopy of
canine intervertebral disc: is there a potential for in situ
probing of mineral degeneration? Laser Surg. Med. 46.
pp. 508–519.
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 245
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Part III

Laser Surgery in Equines

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19
Equine Laser Surgery Procedures
Lloyd P. Tate and Kathryn B. Tate
­Introduction
Lasers were initially introduced to human medicine in
the early 1960s, and veterinary application lagged by
approximately 10 years. The first reported veterinary use
was of a CO2 laser by Steven Carin, DVM from St.
Barnabus Hospital, Livingston, New York in 1972 (Tate
1992; Bartels 2002a, p. xi). He used it to make skin inci­
sions in dogs and cats. Application of the CO2 laser in
large animals was recorded in the early 1980s. Tom
Montgomery, DVM of Lexington, Kentucky used one to
resect cysts, tumors, and perform a neurectomy
(Montgomery 1982; Montgomery and McNaughton
1985). Initially, these machines were large, cumbersome,
and expensive, which limited their usage in the disci­
plines of veterinary medicine. As biomedical laser
­technology merged with military and industrial improve­
ments, size and cost decreased, while dependability
improved. Two limiting factors remained which restricted
CO2 laser application in veterinary surgery: the laser
beam could only be directed to lesions in the line of sight,
and the beam was applied through an articulating arm,
which was cumbersome to use in the operating theater.
The versatility of hollow light waveguides, introduced in
the 1990s for general surgery, significantly increased the
use of CO2 lasers as cutting and hemostatic instruments,
although at the time these machines were of limited
wattage output (12–20 W). There are only a few reports
of using endoscopic waveguides, primarily due to their
expense and transmission of 5–10 W compared to other
laser options for endoscopic application (Tate and Elce
2005). The higher power output (10 W) could be
achieved by using the lighter gas helium, rather than
CO2 or nitrogen to cool the waveguide’s inner reflec­
tive surface. Nevertheless, veterinarians’ clinical and
research use of the CO2 laser has closely paralleled that
of its human counterpart in recent years (Palmer 1996;
Bartels 2002b, pp. 495–515).
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
247
The second type of laser used with broad application
in equine veterinary medicine, the Nd:YAG, also pro­
duced wavelengths that could be applied endoscopically.
In human surgery, it was first used endoscopically to
control gastrointestinal bleeding. With the development
of flexible glass fibers for its delivery, its application
quickly expanded into the fields of endobronchial cancer,
bladder procedures, otorhinolaryngology, gynecology,
and neuro­surgery. The first reports of veterinary endo­
scopic application were reported in 1986 by L.P. Tate,
VMD, in which the Nd:YAG laser was applied to equine
arytenoid cartilage, ablation of the ventricle, sinus drain­
age, and a respiratory tumor (Tate et al. 1986, 1989). The
concept of endoscopic ablation, resection, and vaporiza­
tion of lesions in the standing sedated horse is extremely
appealing to equine veterinarians. This laser was initially
applied to upper respiratory disorders and later applied
to urogenital surgery and laparoscopic abdominal sur­
gery (Palmer 1986, 1993). These early reports describing
laser application, specifically in the standing horse, were
significant in reviving interest in standing surgical proce­
dures. The use of the Nd:YAG laser again paralleled its
human application, first in the noncontact method, and
later in contact delivery of its energy through a sapphire
tip fitted to the glass fiber. The Nd:YAG laser has restric­
tions due to its size, power, and cooling requirements,
which limited its use to hospital situations.
The most significant advance in transendoscopic laser
application was the introduction of the portable diode
laser, providing a means for the clinician to use a laser
outside of a hospital setting. These machines are much
smaller than the Nd:YAG, operate on household current,
and are reasonably priced. Veterinarians traded photo‐
ablation and noncontact application for contact‐cutting
with diode lasers. In turn, specific adjunct instrumenta­
tion was developed that facilitated their use, particularly
in upper respiratory equine surgery. There still remains a
need for noncontact high‐wattage (60–100 W) lasers. A
 248 Equine Laser Surgery Procedures
few expensive diode lasers are available, as well as the
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less‐expensive older Nd:YAG lasers, for this purpose.
This chapter presents and discusses a few equine CO2
laser applications. Commonly treated lesions by transen­
doscopic technique using Nd:YAG and diode lasers will
also be described.
­Equine Carbon Dioxide (CO2) Laser
Surgery
The CO2 laser has become very popular in small animal
and human surgery, for treating cutaneous, oral, ocular,
and urogenital tumors, and other lesions within line of
sight (Holt and Mann 2002, pp. 569–693). In large ani­
mals, clinical use of the CO2 laser is categorized into
three intended purposes: incision, excision, and abla­
tion. Safety procedures apply for eye protection, laser‐
approved endotracheal tubes, and low‐oxygen surgical
environments and evacuating flammable gases when
working in and around hollow organs as described
­earlier in this text (See Chapter 6). Developing experi­
ence as to power settings (W), spot size, and speed in
advancing the beam are extremely important to obtain­
ing a satisfactory outcome, as is gaining experience with
many species with varying skin thickness and water
content. Large animal skin can be quite thick but con­
tains less water than smaller species. Therefore, the sur­
geon will want to use a CO2 laser that produces 20–60 W
output in order to effectively incise, resect, or ablate
cutaneous lesions (Palmer 1991, 2002).
The exception is vaporizing or excising lesions on or
around the eye, such as scleral and corneal squamous cell
carcinoma in which outputs as low as 3–4 W may be
required, in order to not completely penetrate the cornea
(Table 19.1 and Figure 19.1a–c) (Tate 2001).
Equine sarcoid is a common cutaneous tumor that may
be associated with bovine papilloma virus types 1 and 2,
as well as a possible genetic predisposition (Carr 2006).
Table 19.1 Equine cornea, sclera, and eyelid mass removal.
Cornea, sclera, eyelid
Procedure mass removal
Laser type and CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.25, 0.4, 0.8
Power (W) 2–10
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100
They can be singular or multiple and either ­nodular,
fibroblastic, or verrucous in appearance (Figure 19.2a,b).
Many types of therapies are available including immu­
notherapy, cryotherapy, scalpel resection, and CO2 laser
excision or ablation (Figure 19.3; Tables 19.2 and 19.3).
Most frequently, large lesions, especially on or in the ear,
will first require debulking by scalpel or high‐wattage
laser application. The CO2 laser is preferred because of
its hemostatic qualities and its use in defocused mode to
vaporize the base of the tumors.
Large flat nodular or fibroblastic lesions may require
excision in which the skin cannot be closed. The CO2
laser at 30–60 W output can be used to perform such a
procedure. The wound is then left to heal by second
intention (Palmer 2002). It is advisable to submit tissue
samples for histologic conformation.
The CO2 laser has been used to remove other skin
tumors, such as benign equine melanoma, and to create
incisions at various locations. The majority of equine
CO2 laser procedures only require this laser to be set in
the continuous mode even though many machines offer
pulsed or SuperPulse settings. Similarly, the majority of
these veterinary procedures do not require a microman­
ipulator, mechanical scalars, or endoscopic wave guides.
There are reports describing their use, but high cost,
coupled with infrequent use, has not made them a popu­
lar addition.
­Equine Transendoscopic
Laser Surgery
Fiber optic transmission of laser energy, especially
transendoscopic application, has been one of the most
significant advances in large animal veterinary surgery
in the last 30 years. This form of surgery is considered
­minimally invasive and is frequently performed in the
sedated, standing horse. Not requiring general anesthe­
sia and recovery (with its own particular associated
risks and complications) is very appealing to owners.
Third‐party payment is generally not available for elec­
tive procedures and with some insurance policies, addi­
tional cost is incurred when general anesthesia is
required. Thus, owners are always interested in pursu­
ing surgeries that reduce cost and have minimal com­
plications and a shorter recuperation period, all of
which laser surgery offers.
In the 1980s, the primary laser used for large animal
endoscopic procedures was the Nd:YAG, with sporadic
reports of potassium‐titanyl‐phosphate (KTP), Ho:YAG,
and argon‐fluoride also being used in veterinary surgery
(Tate and Glasser 1991; Bartels 2002b, pp. 495–515). The
Nd:YAG was first used in noncontact mode for several
years. The machines were large, heavy, and required
 (a) (b)
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(c)

Figure 19.1 (a) Right eye of a pony with advanced subconjunctival and lid ocular squamous cell carcinoma. (b) Immediately after
receiving the first of three CO2 laser irradiation treatments at 12 W, irradiated through a waveguide with a 1.0 mm tip at one‐week intervals
to reduce the size of the tumor tissue. (c) Two months after receiving laser treatment in which the eyelid is thickened but functional with
no reoccurrence of the cancer.

(a) (b)

Figure 19.2 Two examples of equine sarcoid on the pinna of the ear: (a) is fibroblastic and (b) is nodular. Both require second intention
healing after laser resection due to tissue loss.
 250 Equine Laser Surgery Procedures

Table 19.3 Equine sarcoid or skin mass (ablation).

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Equine sarcoid removal or skin

Procedure mass removal (ablation)

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Spot size (mm) 5–10 (defocused) 1.4
Power (W) 20–30 20
Exposure Continuous Continuous
wave wave
Mode Non‐SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100

they remained nonportable. The sapphire tip, used in

contact mode to incise tissue, reduced collateral latent
thermal necrosis, which was prevalent with high‐output
noncontact application. These units also had a reduced
capacity to vaporize tissue. Therefore, the 100 W
Nd:YAG, or equivalent laser in noncontact application,
still retains a useful place in veterinary laser surgery.
These machines can still be acquired on the used laser
Figure 19.3 A large nodular sarcoid on the pinna of a horse’s ear. market and remain much less expensive than high‐
Traction is being applied and a CO2 laser (25 W) is directed at its output (60–100 W) diode lasers. These machines ­contain
base from dorsal to ventral to resect it from its attachment. This an internal filter that allows a reduced power output of
provides the best visualization in order not to damage the 5–20 W. Laser activation at low‐power outputs should be
underlining cartilage of the ear.
restricted to short time intervals of 15–30 seconds; even
with the filter, it can experience elevated internal heating
that may damage the focusing mechanism. This feature
Table 19.2 Equine sarcoid or skin mass (resection). does allow for contact cutting with a glass fiber that
­generally is used by diode lasers.
Equine sarcoid removal or skin mass In the mid‐1990s, laser manufacturers introduced low‐
Procedure removal (resection)
output 15 W diode lasers and targeted their sales to vet­
Laser type and CO2 (10 600) CO2 (10 600)
erinarians (Orsini 2002). Diode lasers that produced
wavelength (nm) 25–50 W output were also available but more expensive.
Spot size (mm) 0.2–0.5 0.4–0.8
The fiber’s plastic cladding could be easily removed as
needed, providing a fresh 3–5 mm glass cutting surface
Power (W) 20–30 12–20
for surgery. For surgical applications, these lasers
Exposure Continuous wave Continuous are available in two frequencies: 810 and 980 nm.
wave
Performance in respect to cutting between the two
Mode Non‐SuperPulse Non‐SuperPulse ­frequencies was very similar for veterinarians already
Duty cycle (%) 100 100 familiar with contact cutting, and these small light­
weight machines were also very portable. This particular
advance placed an affordable means of performing laser
external water cooling and high voltage, with fragile fiber surgery in the hand of many veterinarians.
alignment, all of which made them nonportable. Many of It is preferable to set the output of these machines
these machines produced 100 W output, which was suf­ between 15 and 18 W for contact cutting; use a laser acti­
ficient to vaporize masses and create an incision. Later, a vation duration of 0.8 seconds on and 0.2 seconds off in a
sapphire tip attached to the fiber became available. This repeat pulse setting (Table 19.4). Often, breakage of the
reduced the size of the machines, now powered by 120 V bare fiber tip can be avoided if power is cycled to allow
AC current (Joffe 1986). The power output was reduced some cooling of the fiber. Avoid buying used diode lasers
because less was required to heat the sapphire tip, but that require a fiber with a priority chip restricting their

Table 19.4 Equine sarcoid or skin mass (incisional removal).
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Equine sarcoid or skin
Procedure mass (incisional removal)
Laser type and Diode laser (810 or 980)
wavelength (nm)
Fiber 600 um contact fiber
Power (W) 15–18
Exposure Repeat pulse
Mode Non‐SuperPulse
Frequency (Hz) 1 The most common of these lesions are abscesses of the
Duty cycle (%) 80
use to one‐time application. When a fiber is cleaved, it is
preferred to first place the distal end against a ­common
tongue depressor and activate the laser for a second. This
blackens the end of the fiber so it quickly heats up when
the laser is activated, allowing for an e­ fficient initial cut
and decreasing the potential for the fiber to stick to tis­
sue. Ancillary equipment includes bronchoesophageal
grasping forceps and laparoscopic instruments 45–60 cm
in length. A handheld stylus that accommodates the laser
fiber within is also useful for general surgery.
Preoperative Considerations
Paralleling advances in laser manufacturing, new phar­
maceuticals allowed for more sophisticated administra­
tion of sedation and better analgesia than had been
previously available. This enabled standing endoscopic
laser procedures to be conducted. The first drug combi­
nation to be used was xylazine and butorphanol. Xylazine
is administered IV at 1.25 mg/kg body weight, and after
its sedative effect is present, it is followed by 0.025 mg/kg
of butorphanol IV (Tate 1991; Hubbell 2009). This com­
bination provides sedation for approximately 20 minutes,
which is sufficient for most standing laser procedures.
Detomidine, at a dose of 0.01–0.02 mg/kg, can be substi­
tuted for xylazine, and a lower dose is recommended
when used in conjunction with butorphanol (Tate 1991;
Hubbell 2009). To avoid ataxia as much as possible with
either combination, the sedative should be administered
first, followed by butorphanol after five minutes has
elapsed. Periodically, if both are given in rapid succession
head tremors may occur, which will make laser irradia­
tion ­difficult. A third approach to s­ edation is to use deto­
midine and then apply a local anesthetic through
polyethylene tubing passed through the biopsy channel
of the endoscope to bathe the area to be irradiated. All
laser safety precautions should be ­followed, similar to
that recommended for the operating room earlier in
­Laser Procedures of the Nasal Passages and Paranasal Sinuse 251
this text (see Chapter 6), except standing stocks are
­substituted for the operating table to assist in control of
the horse.
L­ aser Procedures of the Nasal
Passages and Paranasal Sinuses
In older horses, several lesions may occur that, histori­
cally, were approached surgically by a sinus flap and inci­
sion continued through the floor of the paranasal sinuses.
nasal mucosa, nasal cysts, and fungal granulomas. The
horse presents with respiratory stertor and decreased air
flow from the involved nasal passage. Head radiographs
are useful in determining location, size, number, and
potential origin. Endoscopic examination is of value in
determining what type of lesion is present. Cysts are soft
and can be depressed with touch, whereas granulomas
and tumors appear as firm, solid masses that hemor­
rhage easily when disturbed (Figure 19.4a–c).
Most solid masses can be biopsied by holding a por­
tion with long forceps and incising with the diode laser.
This laser can also be used to incise the capsule of an
abscess and encourage drainage. Laser treatment of cysts
requires higher output than what is readily available
from most portable diode lasers. It is advisable to use
50 W power output to paint the outer visible surface of
the cyst (Table 19.5). This increases the temperature of
the fluid component and destroys the secretory mem­
brane. The laser can then be set at a higher power to drill
through the capsule and drain the cyst (Tate 2004). This
is one example of how the older Nd:YAG out‐performs
the diode laser. In contact application, the diode laser
can incise the cyst capsule but may not destroy the secre­
tory membrane; there could be reoccurrence once the
capsule incision heals.
Performing endoscopy of the paranasal sinuses by pass­
ing an endoscope through the normal drainage course is
very difficult. Postsinus flap surgery, in which a portion of
the ventral floor of the sinus has been removed, provides
easier access. When there has not been a previous surgery,
the easiest way to visually explore the sinus cavities endo­
scopically is through a small trephination hole (Tate 1991).
Trephination can be easily performed in the standing,
sedated horse with a local anesthetic. Under endoscopic
guidance, lesions can be biopsied through this approach
and small lesions vaporized using laser irradiation.
Nasal Neoplasia and Sinusitis
Two frequently encountered benign lesions of the horse
are sinus cysts and progressive ethmoid hematoma.
There are several types of cancer that can arise within
 252 Equine Laser Surgery Procedures
(a)
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(c)
Figure 19.4 Endoscopic view of a nasal cyst (a), and arrow directed at a solid nasal mass (b). A noncontact fiber is emitting Nd:YAG
irradiation set at 100 W output at the nasal cyst (c).
the paranasal sinuses that may appear similar to a pro­
gressive ethmoid hematoma. Adenocarcinoma is the
most common, followed by lymphosarcoma and squa­
mous cell carcinoma. In our experience, the incidence is
higher in older horses (17 years of age and greater) (Tate
and Little 1996). Along with a histologic diagnosis, can­
cer should be suspected when prominent osteolytic
lesions or extensive periosteal proliferation is seen on
radiographs or computed tomography. Progressive
ethmoid hematomas and sinus cysts are benign but
(b)
­emonstrate displacement of sinus structures on
d
­imaging. Sinusitis associated with tooth root infection
frequently produces an unpleasant odor which is noticed
upon physical exam, and multiple fluid lines can be seen
on diagnostic images.
Committing to laser treatment in the nasal passages,
paranasal sinus and remainder of the respiratory tract
requires a confident diagnosis, a laser with sufficient
power output and delivery system suitable to perform
surgery, and serial follow‐up with periodic assessments.

Table 19.5 Dorsal pharyngeal, subepiglottic, intrauterine,
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sinus cysts.
Dorsal pharyngeal, subepiglottic,
Procedure intrauterine, sinus cysts
Laser type and Diode laser (810 or Nd:YAG (1064)
wavelength (nm) 980)
Fiber 600 um contact fiber 600 um noncontact
fiber
Power (W) 15–18 50 (blanch skin)
100 (incise)
Exposure Continuous wave Continuous wave
Mode Non‐SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
L­ aser Procedures of the Pharynx
and Larynx
Lesions located in the equine pharynx are ideal for
transendoscopic laser surgery because there is sufficient
room to manipulate an endoscope in several directions.
Direct viewing is easily possible as is passing an endo­
scope past the lesion and retroflexing to observe and
irradiate the caudal aspects of a lesion (Tate 2004).
Lesions that frequently occupy the pharynx are dorsal
pharyngeal cysts, fungal granulomas, lymphoid polyps,
pharyngeal cicatrix, and squamous cell carcinoma (Tate
and Glasser 1991; Tate and Little 1996; Tate 2004).
Dorsal Pharyngeal Cysts
A dorsal pharyngeal cyst appears endoscopically as a
large soft mass just caudal to the dorsal pharyngeal recess
above the arytenoids (Figure 19.5a) and is often diag­
nosed in horses under two years of age. The primary pre­
senting complaints are stertorous breathing, coughing,
and difficulty swallowing. Radiographic imaging usually
reveals that there is a significant lesion extending above
the arytenoids (Koch and Tate 1978). Contact fiber inci­
sion, to promote drainage, may result in reoccurrence
because the secretory lining has not been destroyed. The
ideal technique is to free‐fiber irradiate the visible sur­
face with medium wattage (40–60 W) until the tissue
blanches (Figure 19.5b), indicting vascular coagulation.
This is followed by capsular incision and drainage
(Figure 19.5c) that can be accomplished by high‐power
(100 W) noncontact irradiation or contact incision
(Table 19.5) (Blikslager et al. 1993; Tate 1997). The fluid
that drains is clear and viscous. The noncontact laser
fiber can then be aimed up and into the cyst cavity and
the secretory membrane irradiated at medium power.
­Laser Procedures of the Pharynx and Laryn 253
Endoscopy at three weeks postlaser surgery should dem­
onstrate complete healing with the presence of a small
scar (Figure 19.5d).
Subepiglottic Cysts
Subepiglottic cysts present with similar signs as dorsal
pharyngeal cysts and can be demonstrated with radio­
graphic imaging (Koch and Tate 1978). They appear on
endoscopy as round masses that lie under the epiglottis
(Figure 19.6). The epiglottis may appear elevated into the
airway obscuring the arytenoid cartilages. Occasionally,
they will lie under the soft palate and are only periodi­
cally observed in the pharynx when swallowing is
induced. The same laser technique as that utilized for
dorsal pharyngeal cysts may be applied here (Tate 1991,
1997). Bronchoesophageal grasping forceps passed up
the opposite nasal passage allows the surgeon to hold the
cyst and prevent it from dropping below the soft palate.
The fluid drained here is often more viscus and opaque
in color compared to dorsal pharyngeal cyst fluid. Other
than reoccurrence, excessive scar tissue formation has
been reported, which can interfere with epiglottic
excursion.
Progressive Ethmoid Hematoma
The etiology of progressive ethmoid hematoma is not
known. They are characterized by a thick mucosa cap­
sule containing an expanding clotted core. Both sinus
cyst and progressive ethmoid hematoma that originate
in the sinuses often exert sufficient pressure on the ven­
tral floor of the maxillary sinus to break through and
expand into the nasal passage and pharynx. Respiratory
stertor is associated with both lesions, but capsular hem­
orrhage is often present with progressive ethmoid hema­
toma and can be visualized endoscopically (Bell et al.
1993; Tate and Blikslager 2002). Progressive ethmoid
hematomas that originate in the sinuses, and any portion
viewed endoscopically in the nasal pharynx obscuring
visualization of the middle ethmoid conchae, should
be surgically removed through a sinus bone flap
(Figure 19.7).
The remaining hole in the ventral maxillary sinus
opening to the nasopharynx can provide endoscopic
access to the internal sinus structures in order to assess
any recurrence. A recurrence presents as a dark red,
raised mass, but care should be taken not to confuse
buds of granulation tissue or dark staining of the mucosa
as a recurrence. Recurrences can be observed from as
early as three months to up to a year postsurgery.
Therefore, it is recommended to perform sinus endos­
copy at three‐month intervals and treat recurrence with
laser irradiation (Table 19.6). A small mass may only
 254 Equine Laser Surgery Procedures

(a) (b)
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(c) (d)

Figure 19.5 Endoscopic image of a dorsal pharyngeal cyst (a) with the arrow pointing to the cyst. An Nd:YAG laser is utilized in a
noncontact application to first blanch the surface of the cyst (b), before incising to permit drainage (c). Three weeks following laser
irradiation, the dorsal pharynx is visualized with only a small scar present (d).

need one application of irradiation. Larger masses
(1–2 cm in diameter or larger) will require multiple
applications of laser energy (Tate and Blikslager 2002).
This should occur in an every‐other‐day regimen until
the entire lesion appears to be destroyed. Spacing the
therapy sessions far apart often results in regrowth and is
not advisable. On initial endoscopy, a progressive
ethmoid hematoma appearing to arise below the middle
ethmoid conchae indicates its origin is from one of two
locations. It may be originating from the sphenopalatine
sinus and has eroded into the ventral ethmoid turbinate,
or it originated solely within the ventral ethmoid turbi­
nate (Figure 19.8). Radiographs or computed tomogra­
phy can determine if the sphenopalatine sinus is involved.
Sinus flap surgery is the appropriate approach.
Sphenopalatine sinus origination has the highest reoc­
currence rate. At time of surgery, I recommend that a
hole be created in the ventral maxillary sinus so future
endoscopy of the surgery area can be performed. When
the progressive ethmoid hematoma has its origin in the
ventral turbinate, it can often be obliterated with laser
energy. In cases where the mass is large (greater than
2 cm in diameter), it is advisable to first inject it endo­
scopically with 10% formalin and start irradiating the
remaining lesion two weeks postinjection (Schumacher
et al. 1998). The remaining mass should be irradiated on
an every‐other‐day cycle until all of the remaining mass
appears to be ready to slough.
 ­Laser Procedures of the Pharynx and Laryn 255
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Figure 19.6 The arrow indicates location of a subepiglottic cyst Figure 19.7 Progressive ethmoid hematoma originating in the
elevating the epiglottis in a dorsal direction. maxillary sinus and protruding into the nasopharynx, obstructing
endoscopy of the middle nasal ethmoid concha. Capsular
hemorrhage is present at several locations resulting in mild
The first recheck at two to four weeks post‐surgery is serosanguinous epistaxis.
recommended, then at two months, three months, six
months, and one year. Table 19.6 Ablation of progressive ethmoid hematoma
and benign masses.
Pharyngeal Masses
Progressive ethmoid hematoma
The majority of pharyngeal solid masses are singular Procedure and benign mass ablation
except for fungal granulomas that may be multiple and
diffusely spread over the upper respiratory tract. Often, Laser type and Diode laser Nd:YAG (1064)
a sizeable piece can be obtained for histologic identifi­ wavelength (nm) (810 or 980)
cation or culture using endoscopic contact laser inci­ Fiber 600 um contact 600 um
sion followed by snare removal. Small masses of a fiber noncontact fiber
centimeter or less can be vaporized. A technique we Power (W) 15–18 100
prefer to remove large masses, cancers, and polyps is to Energy (J) — 10 000 J/dose
score the base of the mass close to its mucosal attach­ Exposure Continuous wave Continuous wave
ment with a noncontact fiber or contact fiber (Tate and Mode Non‐SuperPulse Non‐SuperPulse
Little 1996). This allows the endoscopic snare to seat
Duty cycle (%) 100 100
securely at the base in order cut through it. Removed
sections of a lesion should be submitted for histologic
analysis. The remaining base can then be irradiated.
Fungal lesions may require appropriate systemic anti‐ soft palate are recognized: permanent displacement and
fungal agents. Not very good results have been obtained intermittent displacement. Etiology can be the result of
using topical agents or endoscopic injections around hyperplastic epiglottis, nerve damage possibly related to
the base of these lesions. a previous respiratory infection, or idiopathic. Standard
surgical correction techniques include staphylectomy,
sternothyroideus myotenectomy, and tying the larynx in
Dorsal Displacement of the Soft Palate
a forward elevated position (Davidson 2015).
Dorsal displacement of the soft palate interferes with air Staphylectomy (notching the soft palate with intent to
flow and produces an inspiratory and expiratory noise improve epiglottal excursion) can be performed with the
(Figure 19.9). Two forms of dorsal displacement of the contact laser fiber endoscopically. It is difficult to
 256 Equine Laser Surgery Procedures

Table 19.7 Palatoplasty (dorsal displacement of the soft palate).

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Palatoplasty (dorsal displacement

Procedure of the soft palate)

Laser type and Diode laser (810 Nd:YAG (1064)

wavelength (nm) or 980)
Fiber 600 um contact 600 um contact fiber
fiber
Power (W) 15–18 15–18
Exposure Continuous wave Continuous wave
Mode Non‐SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
Application 2–3 s per location 2–3 s per location
15–25 locations 15–25 locations

­ osition the endoscope such that the laser fiber is per­

Figure 19.8 A small progressive ethmoid hematoma (arrow)
arising from the ventral ethmoid turbinate. The middle nasal
concha is distinctly visible above the progressive ethmoid
hematoma, indicating it does not have a maxillary sinus
component.
p
pendicular to the caudal edge of the soft palate (Tate
et al. 1990; Tate 1991). A bronchoesophageal grasper can
be used to pull the caudal edge rostrally, which in turn
elevates the caudal edge to the vertical position. Even
under heavy sedation this is a difficult procedure to
perform.
When intermittent dorsal displacement is diagnosed,
some horses have responded to contact spot laser
­irradiation (Palatoplasty) of the caudal edge at multiple
locations (Hogan et al. 2002; Davidson 2015). The diode
laser set at 12–15 W output in a continuous exposure is
preferred (Table 19.7).
The laser will be activated for two to four seconds at
15–25 locations with the fiber applying slight pressure
on the mucosa along the caudal border of the soft pallet.
Diode lasers in a noncontact‐fiber technique and CO2
endoscopic hollow waveguide have also been used to
irradiate the soft palate in the same pattern (Figure 19.10).
The theory is that the induced inflammation results in a
thickening of the caudal border, reducing the ease by
which the epiglottis slips below the soft palate. Owners
are often willing to try this because it is performed with
the horse standing. The recuperation period is short, and
no major complications have been reported.

Entrapment of the Epiglottis

Entrapment of the epiglottis is characterized by the arye­
piglottic fold and subepiglottic tissue covering the dorsal
surface and lateral margins of the epiglottis. On
­endoscopy, the outline of the epiglottis is visible, but the
serrated edges and dorsal epiglottic vessels are not
Figure 19.9 Endoscopy of the pharynx demonstrating dorsal
displacement of the soft palate. The epiglottis is not visible, and
(Figure 19.11) (Tate et al. 1990; Tate 1991).
the soft palate’s caudal border is partially obstructing the Rima Prior to the advent of transendoscopic laser surgery,
glottidis. epiglottic release was performed under general a­ nesthesia
 ­Laser Procedures of the Pharynx and Laryn 257
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Figure 19.10 Palatoplasty for intermittent displacement, Figure 19.11 Endoscopy of entrapment of the epiglottis by the
performed underneath the epiglottis on the caudal border of the aryepiglottic fold. The outline of the epiglottis under the
soft palate, using an endoscopic CO2 laser wave guide entrapment can be distinguished, but the scalloped edges and
transmitting 7 W of power. dorsal vessel of the epiglottis are not.

Table 19.8 Entrapment of the epiglottis.

Procedure Entrapment of the epiglottis

Laser type and Diode laser (810 or Nd:YAG (1064) Nd:YAG (1064)
wavelength (nm) 980)
Fiber 600 um contact fiber 600 um contact fiber 600 um noncontact fiber
Power (W) 15–18 15–18 100
Exposure Repeat pulse Continuous wave Continuous wave
Mode Non‐SuperPulse Non‐SuperPulse Non‐SuperPulse
Frequency (Hz) 1 — —
Duty cycle (%) 80 100 100

through a laryngotomy incision. The tissue was grasped
with forceps and resected using scissors. The first stand­
ing innovation involved a long hook knife applied under
endoscopic guidance to axially divide the entrapping
aryepiglottic fold. There were several incidences of inad­
vertent movement of the horse’s head resulting in divi­
sion of the soft palate. This instrument is still used blindly,
but with a manually guided oral approach with the horse
recumbent under short acting anesthetic.
The first reported laser release was performed with
noncontact Nd:YAG laser irradiation using 100 W out­
put (Table 19.8) (Tate et al. 1990). The releasing inci­
sion was made in a caudal‐to‐rostral direction until the
e­ piglottis was freed. Later, when the chisel‐shaped sap­
phire tip became available, contact release was reported
using a rostral‐to‐caudal incision by pushing the tip
through the tissue (Tulleners 1990). Currently, diode
lasers are used to release the entrapments by dragging
the contact fiber in a caudal‐to‐rostral direction
(Table 19.8) (Parente 2002). The end appearance, at two
to three weeks postrelease, is essentially the same.
Initially, the noncontact Nd:YAG at 100 W output pro­
duced more immediate swelling of the incised edges of
the aryepiglottic fold. This was due to a broad area of
tissue being heated by the laser beam as more scatter
irradiation was absorbed than with the contact
 258 Equine Laser Surgery Procedures

(a) (b)
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Figure 19.12 Two examples of transendoscopic laser axial division of the aryepiglottic fold entrapping the epiglottis. The edges are
thicker (a, arrow) when the non‐contact Nd:YAG laser was used compared with the release of the edges depicted (b, arrow) through the
use of a diode laser with a contact fiber.

t­echnique (Figure 19.12a,b). There is a tendency to Laser Vocal Fold Resection

inadvertently make superficial cuts into the epiglottis
Left laryngeal hemiplegia is a common disease of horses
because the depth of the fiber’s penetration into tissue
and can occur at any age. It is characterized by an inspira­
is difficult to judge. These usually heal by the time the
tory noise or roaring, exercise intolerance and failure of
horse is ready to return to exercise in approximately
abduction of the corniculate process of the arytenoid on
two weeks and are thus not considered a real complica­
endoscopy. There are three etiologies: genetic, idiopathic,
tion. There are several modifications of this technique
and iatrogenic. Most horse owners understand and accept
to reduce epiglottic damage. Creation of a horizontal
the first two. Lack of knowledge as to the course and loca­
incision just under the tip of the epiglottis may speed
tion of the left recurrent nerve, in close proximity to the
the release by allowing additional widening of the axial
jugular vein, is the reason there is a lack of understanding
incision. Other surgeons like to grasp the caudal edge
of the third. Many aspects of horsemanship are per­
of the entrapment with bronchoesophageal forceps.
formed from the left side, including intravenous medica­
This allows the surgeon to elevate and divide the
tion administration. Inadvertent perivascular injection of
entrapment with less of a chance of striking the dorsal
irritating medications can be responsible for damage to
surface of the epiglottis. Entrapment of the epiglottis
the nerve and paralysis of the laryngeal abductor muscles.
can occur concurrently with dorsal displacement of the
The right recurrent laryngeal nerve has a short course
soft palate. Inflammation at the caudal edge of the soft
from the cranium to the larynx and is thus less likely to be
palate or ulceration of the entrapment in the area of the
damaged. The high incidence of this disease is believed to
tip of the epiglottis is suggestive of both conditions
have a genetic component.
being present. Release of epiglottic entrapment in the
The first reported corrective procedure was in 1936,
standing, sedated horse is probably one of the most
describing a standing ventriculectomy in which a bur
common procedures performed using a diode laser.
was inserted through a laryngotomy incision and used to
Failure to obtain complete release or partial re‐entrap­
evert the mucosa of the ventricle. This was followed by
ment is rare, as is restriction of epiglottic excursion due
scissors, which were used blindly to resect the attached
to excessive scar formation.
 ­Laser Procedures of the Pharynx and Laryn 259

Table 19.9 Ventricle ablation.

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Procedure Ventricle ablation

Laser type and Nd:YAG (1064)

wavelength (nm)
Fiber 600 um noncontact fiber
Power (W) 100
Energy (J) ≤ 3500
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100

Table 19.10 Ventriculocordectomy.

Procedure Ventriculocordectomy

Laser type and wavelength (nm) Diode laser (810 or 980)

Fiber 600 um contact fiber

Figure 19.13 Endoscopy of the equine larynx postlaryngoplasty
surgery with the left arytenoid well‐abducted. The left ventricle
was ablated using noncontact laser irradiation (arrow).
mucosa (Hobday 1936). The ventricle and laryngotomy
were left to heal by second intention. This remained the
standard until it was combined with a laryngoplasty per­
formed under general anesthesia, first described in 1970
(Marks et al. 1970).
No further advances were reported until we described
using Nd:YAG laser transendoscopic ablation of the ven­
tricle of a horse in 1986 (Figure 19.13) (Tate et al. 1986).
This replaced the need of a laryngotomy incision and
could be performed prior to or after the laryngoplasty
procedure. In these authors’ opinion, it was more aesthet­
ically pleasing to horse owners, and by eliminating the
laryngotomy incision (which usually became infected),
the potential for infection of the laryngoplasty itself was
reduced. We reported on a large series of ventricular
ablations in which only two horses developed mucoceles
that were corrected successfully by applying laser irradia­
tion (Bristol et al. 1995). These authors have not experi­
enced mucocele formation after restricting the Joules to
3500 or less in performing ventricle ablation (Table 19.9).
In order to use the smaller, less powerful diode laser
(Table 19.10), practitioners modified the procedure.
Bronchoesophageal grasping forceps or a long surgical
bur introduced nasally was used to evert the mucosa of
the ventricle. This was followed by contact laser fiber
resection of the mucosa. Currently this method has also
been modified, in that the contact resection includes the
vocal fold and medial wall of the ventricle and is referred
Power (W) 8–10
Exposure Repeat pulse
Mode Non‐SuperPulse
Frequency (Hz) 1
Duty cycle (%) 80
to as a ventriculocordectomy (Robinson et al. 2006;
Hawkins 2015).
The grasping forceps are centered on the vocal cord, and
the initial incision is made with the laser fiber on the dorsal
aspect. This allows the section being resected to be lifted
dorsally, facilitating continued tissue resection. Vessels that
may hemorrhage are usually located in the ventral section
of the vocal cord. This sequencing of the surgery allows for
the most unobstructed viewing of the area. Laser resection
of the vocal fold is now one of the two procedures for which
the diode laser is most often used. Whether employing
transendoscopic ablation or resection, both have improved
the outcome of surgical correction of left laryngeal hemi­
plegia. Currently, these procedures can be successfully per­
formed on the standing, sedated horse, which reduces cost
and a number of potential anesthetic and recovery related
complications.
Arytenoid Chondritis
Nodules of granulation tissue and fistulas into the aryte­
noid cartilage are associated with arytenoid chondritis.
The nodules are often very dense and require contact
laser fiber incision at their base followed by endoscopic
snare to accomplish removal (Tate 1991). Noncontact
 260 Equine Laser Surgery Procedures

photo‐ablation has also been used successfully but

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requires a laser with high wattage output. These lesions

can be approached through a standing laryngotomy inci­
sion and the laser fiber can be driven into a fistula in
combination with curettage using a small bone curette
(Sullins 2002). Long‐term systemic antimicrobial ther­
apy is also necessary.

Laser Surgery for Guttural Pouch Granuloma

The equine species and close relatives have a unique
upper respiratory hollow space called the guttural pouch.
These are paired diverticula of the eustachian tube, each
further separated into a medial and lateral compartment
by the stylohyoid bone. In the adult, each is approxi­
mately 500 cm3 in volume. There is a pharyngeal opening
large enough to accept passage of an endoscope. The
opening appears as a slit in the dorsal pharyngeal wall,
caudal and ventral to the ethmoid turbinate. A unique
feature is that a number of nerves and vessels traverse
the dorsal and caudal walls just under the semitranspar­
ent mucosa. Any infection or inflammation within the
guttural pouches can produce neurologic signs such as
Horner’s syndrome, facial paralysis, dysphagia, and ves­
tibular disorders. In addition to causing neurologic signs,
large mycotic granulomas may erode a branch of the
external or internal carotid artery resulting in profuse
epistaxis. The horse is unique in that it has a large verte­
bral artery and can survive with the loss of either com­
mon carotid or its branches. The usual treatment for
epistaxis arising from the guttural pouch is vascular
occlusion of the involved vessel, performed under gen­
eral anesthesia and assisted by radiographic imaging
(Freeman 1980). Through an unknown mechanism, the
mycotic granuloma will dissipate over time once the vas­
cular supply has been occluded. Occasionally (weeks to
months postvascular occlusion) the granuloma remains.
These have been successfully dissolved over several
weeks with noncontact, low‐power laser irradiation. We
prefer to irradiate the lesion with 10–15 W of energy for
30 seconds weekly (Figure 19.14) until the lesion resolves
(Tate et al. 1998). The laser is used to only irradiate the
lesion in a sweeping pattern. Whenever a laser is used
within the guttural pouch, application time should be
kept to a minimum. Elevation of temperature within the
pouch could damage the mucosa and traversing nerves.
Flow of carbon dioxide or nitrogen gas, used to cool the
tip of a noncontact fiber, is beneficial in reducing
­temperature and dissipating any smoke that accumu­
lates. When a contact fiber is used, cooling gas can be
provided intermittently through the biopsy channel of
the endoscope or through tubing separately placed in
the guttural pouch.
Figure 19.14 Noncontact fiber (black arrow) within the guttural
pouch aimed at a mycotic lesion that has not dissipated after
arterial occlusion. The mycotic lesion has eroded through the
median septum. The sympathetic branch of the Vagus nerve is
visible in the background (white arrow).
Laser Surgery for Guttural Pouch Tympanites
A condition in young horses that is characterized by a
large accumulation of air trapped in the guttural pouch is
referred to as guttural pouch tympanites. Unilateral
involvement is most common. The etiology is probably
genetic. The condition is characterized by a large
­tympanic swelling caudal to the ramus of the mandible
(Figure 19.15).
Radiographic imaging demonstrates the air‐filled
­guttural pouch displacing the trachea. There may also be
a fluid line within the pouch (often milk). These horses
have stertorous breathing due to the dorsal pharynx
obscuring the arytenoids. Additionally, significant aspi­
ration pneumonia is often present, increasing the anes­
thetic mortality rate (Tate 1991; Tate and Blikslager
1995). Before endoscopic laser surgery was introduced,
treatment for unilateral tympanites was performed
under general anesthesia and consisted of resection of
the median septum between the two pouches. This
would allow the remaining, functionally normal pharyn­
geal opening to exchange air for both guttural pouches.
In cases of bilateral involvement, partial resection of the
cartilage portion of the pharyngeal opening would be
included. Over‐distention of the guttural pouch makes
identification of the traversing nerves difficult, adding
additional risk factors to a general surgical procedure.

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Figure 19.15 Foal with guttural pouch tympany with distension
protruding behind the ramus of the mandible. Source: Courtesy of
Professor Emeritus Derek C Knottenbelt OBE, BVM&S, DVM&S,
DipECEIM, DACVIM, MRCVS. Director, Equine Medical Solutions
Ltd., Stirling, UK.
Similar to the general surgical procedure, the first
standing transendoscopic laser correction was directed
at removal of a segment of the median septum separating
the two guttural pouches (Tate and Blikslager 1995). A
metal catheter (with its end bent at 15°–25°) was intro­
duced into one guttural pouch and rotated to tent the
mucosa of the septum. The endoscope carrying the laser
fiber was introduced in the opposite guttural pouch. The
metal catheter tented the tissue and was used both as a
reference point and a backstop to prevent laser irradia­
tion from being directed at vessels and nerves. This
could be a tedious procedure to perform in a foal regard­
ing cooling and smoke dispersal. A less‐invasive proce­
dure was quickly developed in which a Chambers
catheter, which has a ball‐shaped end, was introduced
into the guttural pouch. The catheter is rotated and
retracted so that the pharyngeal mucosa (medial and
dorsal to the pharyngeal opening) is tented. The endo­
scope containing either the noncontact or contact laser
fiber is introduced through the opposite nasal passage
into the pharynx. The tented mucosa is irradiated until
the ball end of the catheter is clearly visible (Tate and
Blikslager 1995). The Chambers catheter is removed and
a 23–26 French Foley catheter is introduced through the
newly created fistula into the guttural pouch
(Figure 19.16). The bulb of the catheter is expanded with
5–7cm3 of water and secured externally by suture. In
order for a permanent salpingopharyngeal fistula to
­Other Laser Applications in Equine 261
Figure 19.16 Endoscopic view of the dorsal pharynx with a Foley
catheter being introduced into a laser‐formed fistula (heavy
arrow). The two thin arrows denote the dorsal and ventral limits of
the opposite pharyngeal opening to the guttural pouch.
form, the catheter must remain in place for three weeks.
After this, the horse should be checked every other week
for potential closure, which would require replacement
of the Foley catheter for an additional one to two weeks.
There have been several studies performed to try to
determine if pharyngeal fistulation into the guttural
pouch has a long‐lasting detrimental effect on horses. To
date, none have been described of any significance, and
the procedure has been adapted to facilitate guttural
pouch drainage in cases of chronic bacterial infection or
empyema. The procedure has also been used with some
success to prevent or reduce dorsal collapse of the phar­
ynx and obstructive breathing.
­Other Laser Applications in Equines
There are other rarely seen lesions of the upper and
lower respiratory tract that can be treated by transendo­
scopic laser surgery. Pharyngeal cicatrix is an example
that presents as a thin web of tissue circumferentially
restricting air flow. Masses of the trachea and bronchi
are other examples. These often require periodic reap­
plication of laser energy as total resolution may not be
obtainable. Mid‐tracheal squamous cell carcinoma
(determined by biopsy) should not be laser‐irradiated.
This lesion originates in the thorax and erodes through
 262 Equine Laser Surgery Procedures
and into the trachea. Irradiation could thus produce
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severe hemorrhage or pneumothorax.
Laser irradiation is a popular means of treating intrau­
terine cysts, similar to the description for the treatment
of dorsal pharyngeal cyst (Blikslager et al. 1993). Web
obstructions in the urethra can be corrected with laser
irradiation followed by bougienage. There are reported
abdominal laparoscopy procedures in which laser irra­
diation was used to incise tissue and coagulate vessels.
­Conclusion
Specifically designed laparoscopic bipolar electrocautery
instruments have become the favorite of equine surgeons
over laser abdominal instrumentation. Cost, availability,
and instrument design are important considerations
when choosing equipment for performing surgery. As
seen with many of the applications in this chapter, the
question often is not whether a technology is superior in
obtaining results but also how often it can be applied and
at what cost. The multiple ways that the portable diode
laser with contact fiber can be applied exemplifies inno­
vation and successful development in veterinary surgery.
Veterinary medicine has been a great contributor to
introducing lasers into human surgery. Small animal
laser applications are described for every specialty and
mirror human application. The CO2 laser, photodynamic
therapy (PDT), and endoscopic hollow waveguides are a
few examples that were first introduced using animal
­References
Bartels KE. (2002a). Crane SW. Forward, Lasers in
medicine and surgery. Vet. Clin. North Am. Small Anim.
Pract. 32. p. xi.
Bartels KE. (2002b). Lasers in veterinary medicine: where
have we been, and where are we going. Vet. Clin. North
Am. Small Anim. Pract. 32. pp. 495–515.
Bell BTL, Baker GJ, Foreman JH. (1993). Progressive
ethmoid hematoma: characteristics, cause, and treatment.
Compend. Contin. Educ. Pract. Vet. 15. pp. 1391–1397.
Blikslager AT, Tate LP, Weinstock D. (1993). Effects of
neodymium:yttrium aluminum garnet laser irradiation
on endometrium and on endometrial cysts in six horses.
Vet. Surg. 22. pp. 351–356.
Bristol DG, Palmer SE, Tate LP, et al. (1995). Complications
of Nd:YAG laser ventriculectomy in horse: a review of
106 consecutive cases. J. Clin. Laser Med. Surg. 13.
pp. 377–381.
Carr EA. (2006). Skin conditions amenable to surgery. In:
Auer JA and Stick J, eds. Auer and Stick Equine Surgery,
3rd ed. pp. 309–313.
models. The field of veterinary medicine has long been a
testing ground, with appropriate humane considera­
tions, for all aspects of new medical technology and
introduction of new devices and medications.
As to the upper respiratory tract of the horse, the flex­
ible endoscope represents the greatest advance in diag­
nostic imaging of the twentieth century. The ability to
apply laser energy to lesions in the standing horse through
an endoscope represents, in my opinion, the most signifi­
cant advance in treatment modality of that century. In
human medicine, you have pioneers such as Leon
Goldman and Isaac Kaplan who pioneered the applica­
tion of the CO2 laser. Early in my career, both encouraged
my clinical and research endeavors into laser application.
In 1983 Steve Crain, DVM and Hy Newman, DVM, a vis­
iting Israeli veterinarian, asked if I wanted to go to a laser
conference. At that time, other than comic book images, I
had little knowledge of what a laser was. At the confer­
ence and later, Stephen Joffe MD, spent some time teach­
ing how to apply laser energy to tissue. He offered a
Nd:YAG laser with the understanding we would publish
one paper in the next two years. Six were published or
presented on respiratory disorders of the horse and
clients came from all over the United States. What made
the technology flourish was not just acquiring the
machine but also the training to successfully apply it. This
is the message to all who are considering introducing any
new technology: one must understand the science, tissue
response, and be comfortable and confident in its
application.
Davidson E. (2015). Dorsal displacement of the soft palate:
standing and dynamic endoscopic examination. In:
Hawkins J, ed. Advances in Equine Respiratory Surgery,
Section II. Wiley Blackwell. pp. 97–139.
Freeman DE. (1980). Diagnosis and treatment of diseases
of the guttural pouch (part 1). Compend. Contin. Educ.
Vet. 2. pp. S3–S11.
Hawkins J. (2015). Laser ventriculocordectomy. In:
Hawkins J, ed. Advances in Equine Upper Respiratory
Surgery. Wiley Blackwell. pp. 21–27.
Hobday F. (1936). The surgical treatment of roaring in the
horse. North Am. Vet. 17. pp. 17–21.
Hogan PM, Palmer SE, Congelosi M. (2002).
Transendoscopic laser cauterization of the soft palate as
a treatment for dorsal displacement of the soft palate. In:
Proceedings of the 48th American Association of Equine
Practioners. AAEP. pp. 228–230.
Holt TL and Mann FA. (2002). Soft tissue application of
lasers. Vet. Clin. North Am. Small Anim. Pract. 32.
569–693

Hubbell JAE. (2009). Practical standing chemical restraint
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of the horse. Anesthesia and pain management. In:
Proceedings of the 55th American Association of Equine
Practitioners. AAEP. pp. 2–9.
Joffe SN. (1986). Contact neodyminum:YAG laser surgery
in gastroenterology: a preliminary report. Lasers Surg.
Med. 6. pp. 155–157.
Koch DB, Tate LP. (1978). Pharyngeal cysts in horses.
J. Am. Vet. Med. Assoc. 173. pp. 860–862.
Marks D, MacKay‐Smith MP, Cushing LS, Leslie JA.
(1970). Use of a prosthetic device for surgical correction
of laryngeal hemiplegia in horses. J. Am. Vet. Med. Assoc.
157. pp. 157–163.
Montgomery TC. (1982). Laser medicine and surgery. In:
Proceedings of the 28th American Association of Equine
Practitioners. AAEP. pp. 215–216.
Montgomery TC, McNaughton SD. (1985). Investigating
the CO2 laser for plantar digital neurectomy in the
horse. Lasers Surg. Med. 5. pp. 515–517.
Orsini JA. (2002). Chronicle of laser usage in equine
surgery. Clin. Tech. Equine Pract. 1. pp. 3–8.
Palmer SE. (1986). Clinical use of the carbon dioxide
laser in an equine general surgery practice. In:
Proceedings Lasers on Veterinary Medicine AccuVet
Lasers. AAEP. p. 35.
Palmer SE. (1991). Standing laser surgery of the head
and neck. Vet. Clin. North Am. Equine Pract. 7.
pp. 549–569.
Palmer SE. (1993). Standing laparoscopic laser technique
for ovariectomy in five mares. J. Am. Vet. Med. Assoc.
203. pp. 279–283.
Palmer SE. (1996), Instrumentation and techniques for
carbon dioxide lasers in equine general surgery. Vet.
Clin. North Am. Equine Pract. 12. pp. 397–414.
Palmer SE. (2002). Treatment of common cutaneous
tumors using the carbon dioxide laser. Clin. Tech. Equine
Pract. 1. pp. 43–50.
Parente EJ. (2002). Transendoscopic axial division of the
epiglottic entrapment. Clin. Tech. Equine Pract. 1.
pp. 9–12.
Robinson P, Derksen FJ, Stick JA, et al. (2006). Effects of
unilateral laser‐assisted ventriculocordectomy in horses
with laryngeal hemiplegia. Equine Vet. J. 38.
pp. 491–496.
Schumacher J, Yarbough T, Pascoe J. (1998).
Transendoscopic chemical ablation of progressive
ethmoid hematomas in standing horses. Vet. Surg. 27.
pp. 175–188.
Sullins KE. (2002). Minimally invasive laser treatment of
arytenoid chondritis in horses. Clin. Tech. Equine Pract.
1. pp. 13–16.
Tate LP. (1991). Application of lasers in equine upper
respiratory surgery. Vet. Clin. North Am. Equine Pract. 7.
pp. 165–195.
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Tate LP. (1992). Lasers in veterinary surgery. In: Auer JA
and Stick J, eds. Auer Equine Surgery. WB Saunders.
pp. 177–185.
Tate LP. (1997). Transendoscopic Nd:YAG ablation of
cystic lesions in 27 large animals: 1985–1995. Proc. Int.
Soc. Opt. Eng. 2970. pp. 215–221.
Tate LP. (2001). Carbon dioxide, diode and Nd:YAG laser
application in large animals. In: Proceedings of the 2001
Veterinary Surgical Laser Society. Washington, DC:
AAEP. pp. 57–65.
Tate LP. (2004). Transendoscopic laser ablation of upper
respiratory cysts in twelve horses 1993–2003. Progress
in biomedical optics and imaging. Int. Soc. Opt. Eng.
5312. pp. 354–358.
Tate LP, Blikslager AT. (1995). Transendoscopic Nd:YAG
treatment of guttural pouch tympanites in eight foals.
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diagnosis and treatment of progressive ethmoid
hematomas. In: Proceedings of the 48th Annual
American Association of Equine Practitioners. AAEP.
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Tate LP, Elce YA. (2005). Transendoscopic application of
CO2 laser irradiation using the Omniguide fiber. Proc.
Int. Soc. Opt. Eng. 5686. pp. 612–619.
Tate LP, Glasser M. (1991). Six years of transendoscopic
Nd:YAG application in large animals. Proc. Soc. Photo‐
Opt. Eng. 1424. pp. 209–217.
Tate LP, Little EDE. (1996). A review of treatment of upper
airway obstruction caused by various processes both
malignant and nonmalignant in the horse using
transendoscopic Nd:YAG laser applications. Proc. Int.
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Tate LP, Newman HC, Sweeny CL, et al. (1986). An
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Transendoscopic neodymium:yttrium aluminum garnet
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780–791.
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Transendoscopic Nd:YAG laser surgery for treatment of
dorsal displacement of the soft palate and entrapment of
the epiglottis: in the horse. Vet. Surg. 19. pp. 356–363.
Tate LO, Tudor RA, Little ED. (1998). Nd:YAG
photovaporization of residual equine guttural pouch
mycotic lesions after internal carotid occlusion. Proc.
Int. Soc. Opt. Eng. 3245. pp. 417–421.
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Part IV

Laser Surgery in Exotics Species

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20
Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles,
and Avians)
Eva Hadzima, Maros Pazej, and Katherine Weston
­Introduction
A variety of surgical procedures are often done daily in
an exotic practice. The surgeon should have the option
of tools with which to incise. Surgical lasers have many
benefits compared to the scalpel blade and radiosur­
gery in exotic patients. Laser incisions permit delicate
and precise dissection with reduced tissue damage and
less postoperative inflammation. CO2 lasers offer
superior accuracy and reduced collateral thermal dam­
age to radiosurgery. The same benefits of CO2 laser use
in other animals are amplified in exotics. The laser
sealing of small vessels resulting in reduced blood loss
is of great benefit because many exotic species have
small blood volume. The laser sealing of nerve endings
may also decrease self‐induced trauma after surgery
and lessen postsurgical fear and anxiety. The laser pro­
vides for safer surgery with reduced anesthesia time
and a quicker recovery period. Ablation of cutaneous
masses is simplified, with minimal loss of blood.
A surgical laser is ideal for making incisions in skin for
general celiotomy procedures, such as splenectomy,
exploratory laparotomy, hepatic biopsy, cesarean deliv­
ery, gastrotomy, or enterotomy procedures. As with
other species, the linea alba is tented and incised using a
perpendicular beam through tented tissue so that laser
energy is directed away from coelomic and abdominal
structures. An instrument (such as a groove director) is
inserted in the coelom or abdomen, and the incision in
the linea alba is extended with the laser using the instru­
ment as a backstop for beam (Figure 20.5).
In the coelom of exotic animals with air sacs, the air
purge that flows through laser handpieces can inflate
membranes, making surgery more difficult and possi­
bly risking embolism. This air flow can be disconnected
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
267
for these procedures for short periods without harming
the laser.
In cases where margin evaluation is critical (e.g. tumor
resection), the use of the scalpel to collect biopsy sam­
ples may still be preferred, as there will always be a
degree of coagulative artifact with laser use that may hin­
der histopathological evaluation at the biopsy margins. If
sending samples for histopathology let the pathologist
know the tissue or mass was removed via laser to prevent
false or misleading results.
Perioperative and postoperative thermal support and
analgesia are extremely important for all exotic species.
The following procedures were performed at Dewin­
ton Pet Hospital (DPH) using a Class IV CO2 laser,
10 600–11 100 nm, CW Max 40 W, Pulsed Max 300 W,
with articulated arm and 3 and 9 mm handpieces
(Figures 20.1–20.7). For those with a different model
laser with adjustable spot sizes, a starting spot size of 0.25
or 0.4 mm is suggested as per the hand speed and comfort
level of the surgeon. Magnification is beneficial when
working with small exotics. Excellent magnifying head
loupes are available and should be used when working in
the abdomen or coelom of small exotics (Figure 20.1).
­Rabbit Laser Surgery Procedures
Anesthesia
Apply an intravenous (IV) or intraosseous (IO) catheter
and hydrate with IV or IO fluids during the whole proce­
dure. Use midazolam and butorphanol to achieve mod­
erate sedation. Intubate the animal with an uncuffed
endotracheal (ET) tube if possible, then induce and
maintain anesthesia on isoflurane. The incision area may
be given an optional local block of lidocaine.
 268 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)
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Figure 20.1 Laser surgeons demonstrating proper protective

eyewear and surgical masks, magnification loupes, and additional
lighting via headlamps.

Figure 20.3 CO2 surgical laser smoke evacuator system with stand
and foot pedal. Source: Authors, edited by Milan Janicek.

Figure 20.2 A 15 W CO2 surgical laser with articulated arm

delivery system. Source: Authors, edited by Milan Janicek.

Orchiectomy
Preoperative
Figure 20.4 The 3 and 9 mm surgical laser handpieces. Source:
The prescrotal and scrotal areas are prepped and draped Authors, edited by Milan Janicek.
for aseptic surgery in dorsal recumbence.
A 1–1.5 cm incision is made with the laser on the
Procedure ­ rescrotal midline (Table 20.1 and Figure 20.8). One tes­
p
An open prescrotal incision is the preferred technique in ticle is gently pushed at the scrotum, with the surgeon
rabbits to prevent postop infection. visualizing the movement of the tunic within the incision

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Figure 20.5 The handpieces with distance guides and back stops
such as a groove director. Source: Authors, edited by Milan Janicek.
Figure 20.6 CO2 laser control panel, set for 6 W continuous wave
SuperPulse.
Figure 20.7 A veterinary operating room set up for laser surgery
on exotic species.
­Rabbit Laser Surgery Procedure 269
Table 20.1 Rabbit orchiectomy.
Procedure Rabbit orchiectomy
Laser type and CO2 (10 600)
wavelength (nm)
Handpiece (mm) 3
Power (W) 6
Exposure Continuous wave
Mode SuperPulse or non‐SuperPulse
Duty cycle (%) 100
Figure 20.8 Orchiectomy of a rabbit (Oryctolagus cuniculus).
site. Rabbits can withdraw their testicles into the abdo­
men, so care must be taken to avoid this during manipu­
lation. If the testicle is withdrawn, gentle pressure applied
to the abdomen will return the testicle to its normal posi­
tion. The tunic is clamped with a pair of hemostats and
pulled toward the incision site. The tunic is fairly well‐
attached to the scrotum, so a second set of hemostats is
clamped caudally, closer to the attachment with the scro­
tum, and gently pulled to free more tunic. The first
hemostat is unclamped and reclamped caudally to the
second one. This procedure is repeated until the whole
testicular tunic is separated from the inner part of the
scrotum. At that time, the scrotum will be positioned
inside out, so the tip of a closed hemostat is inserted to
place the scrotum into a normal position. The same
approach of exposing the testicle can be done manually
as well.
The tunic is then incised with the laser to expose the
testicle. The vascular cord and vas deferens are visual­
ized and ligated together with two individual circumfer­
ential sutures. The vas deferens and vascular cord are
 270 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

clamped above the second (distal) knot and transected The uterus is positioned very superficially just cranial
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with the laser. The remaining stump is pushed inside the
tunic. The tunic is encircled with a transfixion suture,
clamped, and resected with the laser against saline‐
soaked gauze. The stump is observed for hemorrhage.
The inguinal ring should be closed to prevent prolapse of
abdominal organs. The second testicle is excised in the
same manner. The subcutaneous tissue is closed with
simple continuous 4‐0 absorbable suture, and the skin
with 4‐0 absorbable suture in an intradermal pattern.
Postoperative
Nonsteroidal anti‐inflammatory drugs (NSAIDs) (e.g.
Meloxicam) may be given postoperatively for discom­
fort. Cisapride and metoclopramide may also be added
to prevent Rabbit Gastro‐Intestinal Stasis (RGIS) if not
eating or defecating within two to four hours postopera­
tively. Monitor the incision site daily. At the time of
­discharge, the animal should have normal mobility and
the incision should appear clean and undisturbed. It is
recommended to keep the male separate from females
for three months, as there is still a chance of pregnancy
for this period of time.
Ovariohysterectomy
Preoperative
The ventral midline area is prepped and draped for asep­
tic surgery in dorsal recumbence.
to the bladder and is usually easily visualized after enter­
ing the abdominal cavity. The uterine horn is gently exte­
riorized and cautiously manipulated due to very friable
fat tissue attached along the whole of its length. A “bulge”
of extra adipose tissue is located cranially to the ovary
and should be included in the incision site. The blood
vessels of the ovary are ligated with two circumferential
sutures of 4‐0 absorbable suture or hemostatic clips. To
protect the abdominal organs, saline‐soaked gauze is
always placed behind tissue to be excised. Ligated vessels
are clamped with a pair of hemostats and resected with
the laser (Figure 20.9). Resection of the broad ligament is
proceeded caudally in the same manner. The abdominal
wall and subcutaneous tissue are closed with a simple
continuous pattern, and the skin closed with an intrader­
mal pattern, using 4‐0 absorbable suture.
Postoperative
In order to prevent RGIS, it may be required to give
Metoclopramide and force‐feed the rabbit two to four
hours postoperatively. Administer a NSAID (e.g.
Meloxicam) for the next five days for postoperative dis­
comfort and monitor the incision site daily. At the time
of discharge, the animal should have normal mobility,
and the incision should appear clean and undisturbed.
Use paper‐based litter to prevent adhesions to the
incision.

Procedure
A ventral midline incision of approximately 3 cm is made
with the laser extending caudally to the umbilicus
(Table 20.2). A rabbit’s linea alba is very thin, so addi­
tional caution is necessary when entering the abdominal
cavity. It is preferable to use a number 15 scalpel blade
for such an entry. In case the laser is used, the linea alba
should be lifted and tented, and an instrument such as a
groove director be placed under the linea to prevent
laser trauma to internal organs.

Table 20.2 Rabbit ovariohysterectomy.

Procedure Rabbit OHE

Laser type and CO2 (10 600)

wavelength (nm)
Handpiece (mm) 3
Power (W) 6
Exposure Continuous wave
Mode SuperPulse or non‐SuperPulse
Duty cycle (%) 100
Figure 20.9 Ovariohysterectomy of a rabbit (Oryctolagus cuniculus).
 ­Rabbit Laser Surgery Procedure 271

Abscesses and Cysts Cutaneous, Abdominal, and Mammary Gland

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Most cutaneous abscesses in rabbits are encapsulated
and very thick. The laser can be used to vaporize the
abscess wall. Facial abscesses may arise from an infected
tooth root. Dental X‐rays should be done prior to every
surgical procedure in these species. Dental abscesses
may recur if the underlying diseased tooth is not
removed. All abscesses should be sampled periopera­
tively for culture.
Procedure
Use repeat pulse for ablation of the abscess capsule
(Table 20.3). The abscess’ whole capsule is excised if
possible with marsupialization (the surgical technique
of cutting an abscess or cyst and suturing the edges of
the opening to form a continuous surface from exterior
to interior). Suture with 4‐0 absorbable suture material
so that the site remains open and can drain freely. This
technique is used to treat an abscess or cyst when a
­single draining would not be effective and complete
removal of the surrounding structure would not be
desirable.
Postoperative
Following abscess ablation, the surgical site is filled
with a slow‐release preparation of an antibiotic of
choice while awaiting culture results. On discharge
home, continue with antibiotic therapy as previously
prescribed or use an alternative according to culture
results. Appropriate pain medication is strongly
­recommended. Consider RGIS medication and food
supplementation if needed. The incision site should be
monitored daily. Use paper‐based litter to prevent
adhesions to the incision.
Mass Removals
Preoperative
The ventral midline area is prepped and draped for asep­
tic surgery in dorsal recumbence, with an optional local
block of lidocaine or another local anesthetic to help
control self‐induced trauma.
Procedure
An elliptical incision is made with the laser in the skin
surrounding the mass (Table 20.4). The mass is dissected
from the surrounding tissue with laser settings depend­
ing on the thickness of the tissue. The laser will cauterize
most vessels as the tissue is dissected. The surrounding
tissue is ablated using a defocused beam on repeat pulse.
Subcutaneous tissues are closed with a 4‐0 or 5‐0 absorb­
able suture. The skin is closed with a 4‐0 or 5‐0 absorb­
able suture in an intradermal pattern. All sutures should
be buried, because exposed suture is easily chewed
(Rupley and Parrott‐Nenezian 2002).
Cystotomy
Cystotomy in rabbits may be performed to remove cys­
toliths. X‐rays should always be performed peri‐ or post­
operatively to be certain that all stones were removed.
Preoperative
The ventral midline area is prepped and draped for asep­
tic surgery in dorsal recumbence.
Procedure
The initial skin incision is made in the caudal abdomen
with the laser in SuperPulse mode (Table 20.5). The
abdominal cavity is entered at the linea alba with a stab
incision using a number 15 scalpel. An instrument is
inserted in the abdomen, and the incision in the linea

Table 20.4 Rabbit mass removal.

Table 20.3 Rabbit abscess.
Procedure Rabbit mass removal
Procedure Rabbit abscess
Laser type and CO2 (10 600) CO2 (10 600)
Laser type and CO2 (10 600) CO2 (10 600) wavelength (nm)
wavelength (nm)
Handpiece (mm) 3 3
Handpiece (mm) 3 or 9 3 or 9 Power (W) 4–8 4
Power (W) 4–6 4 Exposure Continuous wave Repeat pulse
Exposure Continuous wave Repeat pulse Mode SuperPulse or Non‐SuperPulse
Mode Non‐SuperPulse Non‐SuperPulse non‐SuperPulse
Frequency (Hz) — 5 Frequency (Hz) — 5
Duty cycle (%) 100 40 Duty cycle (%) 100 40
 272 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)
Table 20.5 Rabbit cystotomy.
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Procedure Rabbit cystotomy
Laser type and CO2 (10 600)
wavelength (nm)
Handpiece (mm) 3 Orchiectomy
Power (W) 6 The testicles of rodents are readily retracted into the
Exposure Continuous wave
Mode SuperPulse or non‐SuperPulse
Duty cycle (%) 100
alba is extended with the laser using the instrument as a
backstop for the laser beam. The urinary bladder is exte­
riorized within the incision site and packed with mois­
tened gauze. The bladder is palpated to localize any
cystoliths. The bladder wall is opened with a small stab
incision on the dorsal aspect of the bladder, to a length
appropriate to the size of cystoliths. The cystoliths are
removed and the bladder examined to insure nothing
else remains. The bladder wall is closed with 5‐0 absorb­
able monofilament suture in two layers, a simple contin­
uous pattern followed by a Cushing pattern. Linea alba
and subcutaneous tissue are closed separately with a
simple continuous pattern. The skin is closed with an
intradermal pattern using 4‐0 absorbable monofilament
suture (Rupley and Parrott‐Nenezian 2002).
Postoperative
Analgesics of some type should always be given. NSAIDs
(e.g. Meloxicam) may be given if renal values are
­unaltered. Consider starting RGIS protocol and food
supplementation. Submit cystoliths for analysis and
urine for culture.
­ odent Procedures (Guinea pigs,
R inal cavity is carefully entered at the linea alba with a scal­
Chinchillas, Degus, Gerbils,
Hamsters, Rats, and Mice)
The procedure for orchiectomy of rodents is similar to
rabbits; however, the inguinal canals must be closed
after removing the testes. This is accomplished by
closure of the tunics by simple interrupted suture
­ Procedure
­pattern with a 4‐0 absorbable suture. The skin incision
may be closed with a drop of tissue glue (Rupley and
Parrott‐Nenezian 2002).
Anesthesia
Apply an IV or IO catheter and hydrate with IV or IO fluids
during the whole procedure. Use butorphanol and mida­
zolam to achieve moderate sedation, and ­glycopyrrolate
may also be added in guinea pig cases. Intubate the animal
with an uncuffed ET tube if possible, then induce and
maintain anesthesia on isoflurane. The incision area may
be given an optional local block of lidocaine.
abdomen. They can be pushed back into the scrotum
with gentle pressure on the caudal abdomen.
Preoperative
The ventral midline area is prepped and draped for asep­
tic surgery in dorsal recumbence.
Procedure (Scrotal, Closed)
An incision is made over the caudal portion of the testicle
(Table 20.6). After incision is made through the skin and
the underlying fascia, lobulated fat may be exteriorized.
When the testicle is isolated, the ligament of the testicle is
gently torn from the tunic. Due to the presence of an open
inguinal ring, ideally the castration should be closed, leav­
ing the tunic intact to prevent herniation. The tunic (con­
taining vas deferens and vascular cord) is clamped with
hemostats, double‐ligated with absorbable suture, and
resected with the laser. The remaining tunic is carefully
replaced into the abdominal cavity and observed for hem­
orrhage. The inguinal fat is returned to the inguinal ring
to minimize herniation. Fascia is closed with either simple
interrupted or short simple continuous pattern, following
with intradermal pattern for skin. Another testicle is pro­
ceeded in the same manner (Lightfoot and Bartlett 2002).
Procedure (Prescrotal, Open)
This method is preferred to the closed technique due to a
lower infection rate. A midline abdominal ­incision is
made with the laser cranially to the prepuce. The abdom­
pel blade. One testicle is pushed into abdominal cavity
and exteriorized through the incision site. The spermatic
Table 20.6 Rodent orchiectomy.
Rodent orchiectomy
Laser type and wavelength (nm) CO2 (10 600)
Handpiece (mm) 3
Power (W) 6
Exposure Continuous wave
Mode SuperPulse or
non‐SuperPulse
Duty cycle (%) 100

(a)
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Figure 20.10 (a,b) Orchiectomy of a guinea pig (Cavia porcellus) (prescrotal technique).
and vascular cord are ligated with two circumferential
sutures. Any vessels connected to the testicle through the
adjacent fat are ligated with a simple interrupted pattern.
The second testicle is exteriorized in the same manner.
Both testicles are excised with the laser and observed for
hemorrhage (Figure 20.10a,b). The linea alba and subcu­
taneous tissue are closed with 4‐0 absorbable suture in a
simple continuous pattern. The skin is closed with 4‐0
absorbable suture in an intradermal pattern.
Postoperative
The animal is placed on flow‐by oxygen postsurgery and
observed closely during recovery until walking on its
own. NSAIDs (e.g. Meloxicam), tramadol, and the sur­
geon’s choice of antibiotics are typical discharge medica­
tions. Monitor the incision site daily. At discharge time,
the animal should have normal mobility, and the incision
should look clean and undisturbed. Keep the male sepa­
rate from females for three months as there is still a
chance of pregnancy for that period of time.
Ovariohysterectomy
Ovariohysterectomy (OHE) of rodent species is similar
to that of rabbits. However, the ovaries are more tightly
adhered and cannot be lifted easily through the abdomi­
nal incision, so a relatively longer incision is required to
­Rodent Procedures (Guinea pigs, Chinchillas, Degus, Gerbils, Hamsters, Rats, and Mice 273
(b)
permit observation and ligation of the ovarian vessels
(Parrott 2000).
Preoperative
The animal is placed in lateral or dorsal recumbence, and
the bilateral areas or the ventral midline area are prepped
and draped for aseptic surgery.
Procedure (Bilateral Flank Approach)
This approach is recommended for OHE in hystrico­
morphic rodents. A skin incision about 2 cm in length is
made with the laser (Table 20.7) midway between the last
rib and the iliac crest, just dorsally from mid‐abdomen to
sub lumbar muscle. Blunt dissection is used to breach
the abdominal musculature and enter the abdominal
cavity. The ovary is typically identified, exteriorized, and
ligated. It is preferred to ligate both the vascular supply
and the proximal oviduct. The muscle defect is closed
with a continuous suture pattern, and the skin is closed
routinely (Murray 2006).
Procedure (Midline Approach)
The patient is placed in dorsal recumbence, and a ventral
midline incision is made with the laser first through skin
and then through the linea alba.
Care must be taken to avoid incising the large cecum,
which is easily visualized after entering the abdominal
 274 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

Table 20.7 Rodent ovariohysterectomy. Table 20.8 Rodent abscess.

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Procedure Rodent OHE Procedure Rodent abscess

Laser type and CO2 (10 600) CO2 (10 600) Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm) wavelength (nm)
Handpiece (mm) 3 3 Handpiece (mm) 3 or 9 3 or 9
Power (W) 5–6 4–6 Power (W) 4–6 4
Exposure Continuous wave Continuous Exposure Continuous wave Repeat pulse
wave Mode Non‐SuperPulse Non‐SuperPulse
Mode SuperPulse Non‐SuperPulse Frequency (Hz) — 5
Duty cycle (%) 100 100 Duty cycle (%) 100 40

Suture with 4‐0 absorbable suture material so that the

cavity. The ovaries lie caudally and laterally to the kid­
neys and are about 6–8 mm long. The abdomen in guinea
pigs is deep, and the ovaries can be difficult to exterior­
ize. Ovarian vessels are short, so care must be taken to
avoid tearing them. Usually, two simple interrupted
sutures are placed on each pedicle.
Once the ovarian pedicle is transected, the corre­
sponding uterine horn is followed caudally. The body of
the uterus is double‐ligated with circumferential sutures,
clamped and resected with the laser. Linea, subcutane­
ous (SC) tissue, and skin are closed in a similar manner
to that used with other mammals (Lightfoot and Bartlett
2002; Mitchell and Tully 2009).
Postoperative
Postoperative antibiotics should be administered, while
NSAIDs (Meloxicam, etc.) and tramadol may be pre­
scribed for discomfort, along with RGIS protocol if
required. The incision site should be monitored daily and
should appear clean and undisturbed at discharge time.
Abscesses and Cysts
Most cutaneous abscesses in rodents are encapsulated
and very thick in consistency. The laser can be used to
vaporize the abscess wall. Facial abscesses may arise
from an infected tooth root. Dental X‐rays should be
done prior to every surgical procedure in these species.
Dental abscesses may recur if the underlying diseased
tooth is not removed. All abscesses should be cultured.
Procedure
Use repeat pulse for ablation of the abscess capsule
(Table 20.8). The entire capsule is excised if possible with
marsupialization (the surgical technique of cutting an
abscess or cyst and suturing the edges of the opening to
form a continuous surface from exterior to interior).
site remains open and can drain freely. This technique is
used to treat an abscess or cyst when a single draining
would not be effective and complete removal of the sur­
rounding structure would not be desirable. Refer to
Video 20.1 for this procedure.
Postoperative
Following abscess ablation, the surgical site is filled with
a slow‐release preparation of antibiotics of surgeon
choice, while awaiting culture results. On discharge
home, continue with antibiotic therapy as previously
prescribed or use an alternative according to antibiotic
culture results. Pain medication is recommended with
the use of an NSAID combination. Consider RGIS
­medication and protocol if needed.
Video 20.1 (This video does not include audio commentary.)
Abscess treatment in a guinea pig.
Cutaneous, Abdominal, and Mammary Gland
Mass Removals of Rodents and Hedgehogs
In guinea pigs there is little redundant tissue in the ingui­
nal area. If a bilateral mastectomy is required, it should
be staged two to four weeks apart, or a rotation or
advancement flap of the caudal abdomen is performed to
facilitate closure of the skin.
Complete mastectomy is not possible in rats and mice
because of the diffuse location of the mammary tissue,
making recurrence common.
Preoperative
The ventral midline area is prepped and draped for
­aseptic surgery in dorsal recumbence, with an optional
local block of lidocaine or another local anesthetic to
help control self‐induced trauma.
 ­Rodent Procedures (Guinea pigs, Chinchillas, Degus, Gerbils, Hamsters, Rats, and Mice 275

Procedure Cystotomy
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An elliptical incision is made with the laser in the skin Cystotomy in guinea pigs may be performed to remove
surrounding the mass (Table 20.9). The mass is dissected cystoliths. X‐rays should always be performed peri‐ and
from the surrounding tissue with the above laser settings postoperatively to be certain that all stones were removed
depending on the thickness of the tissue (Figure 20.11a). (Rupley and Parrott‐Nenezian 2002).
The laser will seal most vessels as the tissue is dissected.
The surrounding tissue is ablated using a defocused Preoperative
beam on repeat pulse. Subcutaneous tissues are closed The ventral midline area is prepped and draped for
with a 4‐0 or 5‐0 absorbable suture. The skin is closed ­aseptic surgery in dorsal recumbence.
with an absorbable suture in an intradermal pattern. All
sutures should be buried, because exposed suture is Procedure
­easily chewed (Rupley and Parrott‐Nenezian 2002). A ventral midline incision is made in the caudal a­ bdomen
with the laser (Table 20.10 and Figure 20.11b). The blad­
der is isolated from the abdomen with sterile moistened
Table 20.9 Rodent and hedgehog mass removal.
gauze. Two stay sutures are placed at the lateral aspect of
the bladder using 4‐0 monofilament absorbable suture.
Procedure Rodent and hedgehog mass removal
A stab incision is made on the mid‐dorsal aspect of the
bladder, then lengthened appropriately to the size of cys­
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm) toliths. The cystoliths are removed, and the bladder exam­
ined to ensure that no remaining cystoliths are present.
Handpiece (mm) 3 3
Any stones located in the urethra may be retropulsed back
Power (W) 4–8 4 into bladder using sterile saline and removed. The bladder
Exposure Continuous wave Repeat pulse wall is closed with 5‐0 absorbable suture in two layers of
Mode SuperPulse or Non‐SuperPulse simple continuous pattern followed by a mattress pattern.
non‐SuperPulse The stay sutures are removed. The abdominal wall and
Frequency (Hz) — 5 the subcutaneous layers are closed separately with a sim­
Duty cycle (%) 100 40 ple continuous pattern. The skin is closed with 4‐0 absorb­
able suture in an intradermal pattern.

(a) (b)

Figure 20.11 (a) Mass removal in a hamster (Phodopus sungorus). (b) Cystotomy in a guinea pig (Cavia porcellus).
 276 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

Table 20.10 Rodent (guinea pig) cystotomy. Table 20.11 Prairie dog orchiectomy.
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Procedure Rodent (guinea pig) cystotomy Procedure Prairie dog orchiectomy

Laser type and CO2 (10 600) CO2 (10 600) Laser type and wavelength (nm) CO2 (10 600)
wavelength (nm) Handpiece (mm) 3
Handpiece (mm) 3 3 Power (W) 6
Power (W) 6–7 4–6 Exposure Continuous wave
Exposure Continuous wave Continuous wave Mode SuperPulse or
Mode SuperPulse Non‐SuperPulse non‐SuperPulse
Duty cycle (%) 100 100 Duty cycle (%) 100

Postoperative the testicles are removed. The site is inspected for

The animal may be hydrated with a bolus of warm SC
fluids. Metoclopramide may be given SC to prevent
RGIS. The animal may be kept on oxygen within an incu­
bator with close monitoring during recovery. The animal
is discharged on RGIS protocol medications, antibiotics,
and pain management of the surgeon’s choice. The inci­
sion should be monitored daily. Submit stones for analy­
sis and urine for culture.
­ rairie Dog Laser Surgery
P technique is used to remove the testicle. The tunic, vas
Procedures
Orchiectomy
Preoperative
In young prairie dogs, the testicles are located in the
abdominal cavity throughout the first year, while in
mature prairie dogs, the testicles may be located in the
scrotum. The animal is placed in dorsal recumbence.
The caudal abdomen is prepped and draped for aseptic
surgery in young animals, while the prescrotal and scro­
tal areas are prepped and draped for aseptic surgery in
adults. A local block of lidocaine is optional.
Procedure (Young Prairie Dogs)
A 1–1.5‐cm midline incision is made with the laser
anterior to the tip of the prepuce (Table 20.11). The
linea alba is lifted and tented and is incised using a
horizontal beam through the tented tissue so that the
laser energy is directed away from abdominal struc­
tures. An instrument (such as a groove director) is
inserted in the abdomen, and the incision in the linea
alba is extended with the laser using the instrument as
a backstop for the laser beam. The testicles are found
in the fat anterior to the bladder. The vessels associ­
ated with the testicles are transected with the laser, and
hemorrhage. The abdomen is closed in a routine fash­
ion with 4‐0 or 5‐0 absorbable suture, and the skin is
closed with an intradermal suture pattern. It is impor­
tant to bury all sutures, as prairie dogs are adept at
removing any exposed suture.
Procedure (Mature Prairie Dogs)
A 1‐cm incision is made through the skin with the
laser over the palpated testicle. The tunic is then
incised with the laser exposing the testicle. A closed
deferens, and vessels are ligated with a small (4‐0 to
5‐0) absorbable suture. The duct, tunic, and vessels
are transected distal to the ligature. The area is
inspected for hemorrhage. The other testicle is
exposed and transected in a similar manner. The skin
is closed with 4‐0 absorbable suture in a subcuticular
pattern. It is important to bury sutures, as prairie dogs
are adept at removing any exposed suture (Rupley and
Parrott‐Nenezian 2002).
Postoperative
The incision can be infiltrated with Bupivacaine to help
control self‐induced trauma.
­Ferret Laser Surgery Procedures
Anesthesia
Apply an IV or IO catheter and hydrate with IV or IO
fluids during the whole procedure. Use midazolam and
butorphanol to achieve moderate sedation. Intubate the
animal with an uncuffed ET tube if possible, then induce
and maintain anesthesia on isoflurane. The incision area
may be given an optional local block of lidocaine.
 ­Ferret Laser Surgery Procedure 277

Orchiectomy Table 20.13 Ferret ovariohysterectomy.

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Preoperative
Procedure Ferret OHE
The prescrotal and scrotal areas are prepped and draped
for aseptic surgery in dorsal recumbence. Laser type and CO2 (10 600)
wavelength (nm)
Procedure Handpiece (mm) 3
A small prescrotal incision is made through the skin with
Power (W) 6
the laser (Table 20.12). The testicles are removed with an
Exposure Continuous wave
open or closed technique. The spermatic cord, vessels,
and tunics are clamped, ligated, and removed. Alternately, Mode SuperPulse or non‐SuperPulse
the spermatic cords can be tied with an overhand knot. Duty cycle (%) 100
The skin is closed with a 4‐0 absorbable suture in a sub­
cuticular pattern.
The testicular vessels in a young ferret can be sealed
incision when the fat is retracted. If the uterus cannot be
with a defocused beam and ligated with the laser (Rupley
visualized after manipulation of the fat, it can be caught
and Parrott‐Nenezian 2002).
with a spay hook similar to the procedure in a cat.
The ovarian vessels can be ligated with a 3‐0 or 4‐0
Postoperative
transfixing absorbable suture or with hemostatic clips.
As with a feline, scrotal incisions are left open to heal by
The broad ligament is transected with the laser, using a
second intention.
saline‐soaked sponge as a backstop.
The uterus is exteriorized, clamped, ligated, and
Ovariohysterectomy excised at the cervix. The abdomen is closed in a routine
fashion, and the skin is closed with an intradermal suture
Preoperative
pattern (Rupley and Parrott‐Nenezian 2002).
The ventral midline area is prepped and draped for asep­
tic surgery in dorsal recumbence, and the bladder is
expressed by gentle palpation. Adrenalectomy
Following approach into the abdomen, the CO2 laser air
Procedure
purge may be disconnected to both assist with incision
A 2–3 cm midline incision is made with the laser starting
and prevent embolism of delicate structures. Left adre­
1–2 cm caudal to the umbilicus (Table 20.13). The linea
nal gland masses can be removed using a 3 mm tip and a
alba is lifted and tented and is incised using a horizontal
power setting of 6–7 W. In most cases, no ligatures are
beam through the tented tissue so that the laser energy is
needed. When transecting the bulk of the mass the set­
directed away from abdominal structures. An instru­
tings listed below can be used as for the left side. An abla­
ment is inserted in the abdomen, and the incision in the
tion tip should be used for any remaining mass next to
linea alba is extended with the laser using the instrument
hemaclips on a 40% pulsed setting. Adrenal tissue can be
as a backstop for the laser beam.
vaporized with a defocused laser beam. However, a por­
The uterus is bicornuate and has a uterine body, as in
tion of the gland should be excised and a sample turned
felines. The uterus can often be found just under the
in for histopathological analysis. All adrenalectomy
patients undergoing surgery should receive IV fluids
with 5% dextrose therapy during the perioperative period
Table 20.12 Ferret orchiectomy.
(Parrott 2000; Rupley and Parrott‐Nenezian 2002).
Procedure Ferret orchiectomy
Procedure
A midline incision is made with the laser from the
Laser type and CO2 (10 600) CO2 (10 600) xiphoid to 2–3 cm cranial to the pubis (Table 20.14). The
wavelength (nm)
linea alba is lifted and tented and is incised using a hori­
Handpiece (mm) 3 3 zontal beam through the tented tissue so that the laser
Power (W) 5 4–5 energy is directed away from abdominal structures. An
Exposure Continuous wave Continuous wave instrument is inserted in the abdomen, and the incision
Mode SuperPulse Non‐SuperPulse in the linea alba is extended with the laser using the
instrument as a backstop for the laser beam. For right
Duty cycle (%) 100 100
adrenalectomies, the approach is the same as for a left
 278 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)
Table 20.14 Ferret adrenalectomy.
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Procedure
Laser type and wavelength (nm) CO2 (10 600)
Handpiece (mm) 3 3
Power (W) 5–7
Exposure Continuous wave
Mode SuperPulse
Frequency (Hz) — —
Duty cycle (%) 100
adrenalectomy, except that the duodenum is elevated,
and the viscera are retracted to the left to expose the liver
and right kidney.
A complete abdominal exploratory is performed,
including inspection of the pancreas for insulinoma nod­
ules. The colon is retracted to the right to expose the left
kidney and adrenal gland.
Right adrenal masses frequently lie beneath the caudate
lobe of the liver, under the descending vena cava. The
hepatorenal ligament is incised with scissors or the laser
to elevate the caudal tip of the liver lobe and expose the
right adrenal gland. The right adrenal gland is closely
associated with the vena cava and may extend dorsal to it.
Avoid lacerating the vena cava during extraction of the
gland. The vena cava is flipped over using sterile applica­
tors and an ophthalmic curved hemostat. Any visceral
attachments to the liver are gently teased away and the
capsule opened to expose the adrenal gland. The perito­
neum over the gland may be incised with the laser.
Continue dissecting around the gland with iris or micro­
surgical scissors or cotton‐tipped applicators. The gland
is teased away from the attachment of the vena cava.
Apply hemostatic clips or ligatures when the gland has
been dissected, revealing the vessels that enter the gland.
Glandular tissue adhered close to the vena cava is excised
with scissors or laser with a pulse pattern. Seal vessels
with a defocused laser beam. Absorbable gelatin sponge
(Gelfoam) or oxidized regenerated cellulose (Surgicel)
can also control minor hemorrhage. If a mass is invading
the vena cava, hemaclips are placed into the vena cava
before transecting. Up to 70% of the flow can be inter­
rupted without significant morbidity. If the vena cava is
lacerated, it is temporarily occluded with nontraumatic
clamps. A 7‐0 to 8‐0 suture material on a small atraumatic
needle is passed and tension is applied while it is sutured.
The left adrenal gland is medial and cranial to the left
kidney. A retractor is applied to increase exposure.
Dissect the gland on the medial side with cotton‐tipped
Ferret adrenalectomy
CO2 (10 600) CO2 (10 600)
3
5 5–6
Continuous wave Repeat pulse
Non‐SuperPulse Non‐SuperPulse
5
100 40
applicator and the laser. Gently elevate the gland as it is
dissected free from the fat and small blood vessels. The
adrenolumbar vein is identified and ligated as it runs lat­
eral and caudal on the ventral surface of the gland.
Ligation of the adrenolumbar vein can be performed
with hemostatic clips or small suture or it can be sealed
with a defocused laser beam if very small. If both adrenal
glands appear abnormal on inspection or palpation,
remove the entire right adrenal gland and all of the
affected left adrenal gland. Closure is routine (Rupley
and Parrott‐Nenezian 2002).
Postoperative
If both glands are totally removed, dexamethasone
sodium phosphate and temporary supplementation with
prednisone orally may be given. Ferrets rarely require
supplementation with fludrocortisone acetate.
Insulinoma Removal
Preoperative
Blood glucose levels should be checked prior to prepara­
tion for surgery. Preoperative fasting is limited to two to
three hours. The ventral midline area is prepped and
draped for aseptic surgery in dorsal recumbence.
Procedure
A midline incision is made with the laser from the xiphoid
to halfway between the umbilicus and the pubis
(Table 20.15). The linea alba is lifted and tented and is
incised using a horizontal beam through the tented tissue
so that the laser energy is directed away from abdominal
structures. An instrument is inserted in the abdomen, and
the incision in the linea alba is extended with the laser
using the instrument as a backstop for the laser beam.
A complete abdominal exploratory is performed,
including inspection of both adrenal glands. Often, the
masses are felt as firm structures within the pancreas.
 ­Sugar Glider Laser Surgery Procedure 279

Nodules are sometimes raised and lighter or pinker than SuperPulse or 8 W continuous wave (Table 20.16). The
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the normal surrounding tissue. Inspect and gently pal­
pate the entire pancreas. Place a saline‐soaked sponge
behind the tissue while excising to protect other struc­
tures from the laser beam. The nodules are gently lifted
with atraumatic forceps and excised with the laser. The
tissue surrounding the excision site is gently wiped with
saline‐soaked cotton tipped swabs. Closure is routine. A
sample of tissue should be submitted for histopathology
(Rupley and Parrott‐Nenezian 2002).
Postoperative
Postoperative pancreatitis does not appear to occur.
Supportive care is continued as indicated.
subcutaneous tissue is bluntly dissected with scissors
and the laser until the facial plane around the sac is iden­
tified. Dissection of this plane is continued with the laser
at 6 W continuous wave. Remove the anal sac intact. If
rupture occurs, then lavage the site with sterile saline.
The duct is transected at the opening on the anus. The
incision is closed with surgical glue or a single suture
(Rupley and Parrott‐Nenezian 2002).
Postoperative
Remove the purse string suture and cotton ball from the
rectum prior to recovery.

Anal Sacculectomy ­ ugar Glider Laser Surgery

The animal is placed in dorsal recumbence. A betadine‐
soaked cotton ball and a purse string suture is placed in
the rectum to prevent ignition of intestinal gas by the
laser. Take care to not damage the anal sphincter during
surgery.
Procedure
The ducts are identified at the mucocutaneous junction
of the anus at the 4 and 8 o’clock positions. One duct is
cannulated with a tomcat urethral catheter. The skin
over the tip of the catheter is incised with the laser at 6 W
Table 20.15 Ferret insulinoma removal.
Procedure Ferret insulinoma removal
S
Procedures
Anesthesia
Prior to sedation, hydrate with a 2.5% Dextrose and
Lactated Ringers Solution (LRS) subcutaneously. Use
midazolam and butorphanol to achieve moderate seda­
tion. Then induce and maintain anesthesia on isoflurane.
A local block of lidocaine to the incision site is strongly
recommended to prevent chewing after recovery.
Orchiectomy
Preoperative
The prescrotal and scrotal areas are prepped and draped
for aseptic surgery.

Laser type and wavelength (nm) CO2 (10 600) Procedure

Handpiece (mm) 3 A local anesthetic is administered at the base of the scro­
Power (W) 6 tum stalk. The scrotum stalk is clamped with hemostats
just above the abdomen for two to three minutes to crush
Exposure Continuous wave
the spermatic and vascular cords. Saline‐soaked gauze is
Mode Non‐SuperPulse placed under the stalk, which is then completely resected
Duty cycle (%) 100 with the laser (Table 20.17 and Figure 20.12). The

Table 20.16 Ferret anal sacculectomy.

Procedure Ferret anal sacculectomy

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Handpiece (mm) 3 3 3
Power (W) 6 8 6
Exposure Continuous wave Continuous wave Continuous wave
Mode SuperPulse Non‐SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100 100
 280 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

clamped hemostats should be kept in place for an addi­ Procedure

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tional two to three minutes.
Postoperative
The animal should be monitored very closely for chew­
ing at the incision site. After the sugar glider awakens,
pieces of a favored food, such as mealworms or fruit, may
serve as a distraction from this. A NSAID (e.g.
Meloxicam) is given as an anti‐inflammatory once the
swallow reflex is present.
Abscesses and Cysts
Most cutaneous abscesses in sugar gliders are encapsu­
lated and very thick. The laser can be used to vaporize
the abscess wall. Facial abscesses may arise from an
infected tooth root. Dental X‐rays should be done prior
to every surgical procedure in these species. Dental
abscesses may recur if the underlying diseased tooth is
not removed. All abscesses should be cultured.
Use repeat pulse for ablation of the abscess capsule
(Table 20.18). The abscess’ whole capsule is excised if
possible with marsupialization (the surgical technique of
cutting an abscess or cyst and suturing the edges of the
opening to form a continuous surface from exterior to
interior). Suture with 4‐0 absorbable suture material so
that the site remains open and can drain freely. This
technique is used to treat an abscess or cyst when a sin­
gle draining would not be effective and complete removal
of the surrounding structure would not be desirable.
Postoperative
Following abscess ablation, the surgical site is filled with
the surgeon’s choice of a slow‐release preparation of
antibiotics while awaiting culture results. On discharge
home, continue with antibiotic therapy as previously
prescribed or use an alternative according to antibiotic
culture results. A NSAID (Meloxicam, etc.) and trama­
dol should be prescribed as pain medication. Consider
RGIS medication if needed.

Cutaneous, Abdominal, and Mammary Gland

Mass Removals
Table 20.17 Sugar glider orchiectomy.
Preoperative
Procedure Sugar glider orchiectomy
The ventral midline area is prepped and draped for aseptic
surgery in dorsal recumbence, with an optional local
Laser type and CO2 (10 600) CO2 (10 600) block of lidocaine or another local anesthetic to help
wavelength (nm) control self‐induced trauma.
Handpiece (mm) 3 3
Procedure
Power (W) 5 4 An elliptical incision is made with the laser in the skin
Exposure Continuous wave Continuous wave surrounding the mass. The mass is dissected from the
Mode SuperPulse Non‐SuperPulse surrounding tissue with the above laser settings
Duty cycle (%) 100 100 ­depending on the thickness of the tissue. The laser will
seal most vessels as the tissue is dissected. The surround­
ing tissue is ablated using a defocused beam on repeat
pulse (Table 20.19). Subcutaneous tissues are closed with
a 4‐0 or 5‐0 absorbable suture. The skin is closed with

Table 20.18 Sugar glider abscess.

Procedure Sugar glider abscess

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Handpiece (mm) 3 or 9 3 or 9
Power (W) 4–6 4
Exposure Continuous wave Repeat pulse
Mode Non‐SuperPulse Non‐SuperPulse
Frequency (Hz) — 5
Duty cycle (%) 100 40
Figure 20.12 Orchiectomy of a sugar glider (Petaurus breviceps).
 ­Potbellied Pig Laser Surgery Procedure 281

Table 20.19 Sugar glider mass removal. Table 20.20 Pot‐bellied pig orchiectomy.
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Procedure Sugar glider mass Procedure Potbellied pig orchiectomy

Laser type and CO2 (10 600) CO2 (10 600) Laser type and wavelength (nm) CO2 (10 600)
wavelength (nm) Handpiece (mm) 3 or 9
Handpiece (mm) 3 3 Power (W) 8
Power (W) 4–8 4 Exposure Continuous wave
Exposure Continuous wave Repeat pulse Mode SuperPulse
Mode SuperPulse or Non‐SuperPulse Duty cycle (%) 100
non‐SuperPulse
Frequency (Hz) — 5
Duty cycle (%) 100 40
continuous pattern, and the skin is closed with an intra­
dermal pattern.
absorbable suture in an intradermal pattern. All sutures
should be buried, because exposed suture is easily Postoperative
chewed (Rupley and Parrott‐Nenezian 2002). Postoperative antibiotics are strongly recommended,
and NSAID (Meloxicam, etc.) suspension issued for
postoperative discomfort. Consider adding Cerenia to
­ otbellied Pig Laser Surgery
P prevent vomiting, which is common in pigs after any sur­
gery. Skin sutures may be removed in 10–14 days.
Procedures
Anesthesia Ovariohysterectomy
Apply an IV catheter and hydrate with IV fluids during The ideal age for an OHE in potbellied pigs is about four to
the whole procedure. Use butorphanol, medetomidine, six months due to their size. Older female potbellied pigs
and midazolam to achieve moderate sedation. Intubate generally display irritable behavior for 2–3 days of estrus
the animal with a cuffed ET tube if possible, then induce out of every 21 days of the estrous cycle (Lawhorn 2018). A
and maintain on isoflurane. The incision area may be right or left flank approach may be used in extremely obese
given an optional local block of lidocaine. potbellied pigs, or as an alternative approach for this pro­
cedure. Please see this chapter’s entry on guinea pig OHE
for description of a lateral approach.
Orchiectomy
Preoperative Preoperative
The prescrotal and scrotal areas are prepped and draped The ventral midline area is prepped and draped for asep­
for aseptic surgery in dorsal recumbence. tic surgery in dorsal recumbence.

Procedure
A prescrotal incision is made with the laser (Table 20.20).
One testicle is exteriorized into the incision site and its
tunic incised with the laser to expose the testicle with its
spermatic and vascular cord. The vascular cord and vas
deferens are ligated together with two individual circum­
ferential 3‐0 absorbable sutures. The vas deferens and
vascular cord are clamped distal to the knot and incised
with the laser. The remaining stump is pushed inside the
tunic. The cremaster muscle and tunic are encircled with
transfixion ligature, clamped, and resected with the laser
against saline‐soaked gauze. The stump is observed for
hemorrhage. The second testicle is handled in the same
manner. Absorbable 3‐0 suture material is used for all
closures. The subcutaneous tissue is closed with a simple
Procedure
Approach is via a ventral midline incision (Table 20.21).
After six months of age, the uterus is quite large and freely
mobile. The removal of the ovaries and uterus is similar to
that of the dog or cat. However, note that there is a large
uterine middle blood vessel that also requires separate liga­
tion (Figure 20.13a–c). The uterine horns fold back on
themselves and are located beside the body of the uterus
with the ovaries. Penetration of the cervix by sutures
should be avoided when ligating the uterine stump to pre­
vent intermittent postsurgical hemorrhage from the vulva.
Absorbable 3‐0 suture material is used for all closures. The
subcutaneous tissue is closed with a simple continuous
pattern, and the skin with an intradermal pattern (Lawhorn
2018). Refer to Video 20.2a–c for this procedure.
 282 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

Postoperative Video 20.2a (This video does not include audio commentary.)
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Postoperative antibiotics are strongly recommended. Ovariohysterectomy of a potbellied pig, demonstrating skin
incision.
NSAIDs (Meloxicam, etc.) are issued for postoperative dis­
comfort, tramadol for pain control, and Cerenia to prevent
vomiting. Skin sutures may be removed in 10–14 days. Video 20.2b (This video does not include audio commentary.)
Ovariohysterectomy of a potbellied pig, demonstrating laser
ovarian incision.
Table 20.21 Potbellied pig OHE.
Video 20.2c (This video does not include audio commentary.)
Procedure Potbellied pig OHE Ovariohysterectomy of a potbellied pig, demonstrating uterine
incision.
Laser type and wavelength (nm) CO2 (10 600)
Handpiece (mm) 3 or 9 ­Reptile Laser Surgery Procedures
Power (W) 6–8
Exposure Continuous wave The reptile epidermis contains less water than mamma­
Mode SuperPulse lian skin. The skin on the reptile thus quickly builds up
Duty cycle (%) 100
char, which must be wiped away often with damp gauze
between laser passes (Parrott 2000).

(a) (b)

(c)

Figure 20.13 (a) Ovariohysterectomy of a potbellied pig (Sus scrofa domesticus), demonstrating laser ovarian incision. (b)
Ovariohysterectomy of a potbellied pig, demonstrating uterine incision. (c) Ovariohysterectomy of a potbellied pig, demonstrating
postsurgical ovaries and uterus with minimal bleeding.

Anesthesia
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Apply an IV or IO catheter and hydrate with IV or IO
fluids during the whole procedure. Use butorphanol (or
hydromorphone) and midazolam to achieve moderate
sedation. Alfaloxone IV in a tail vein will achieve moder­
ate‐to‐high sedation or induction, and Ketamine may be
added for deeper induction. Intubate with an uncuffed
ET tube or soft red‐rubber catheter (depending on the
species) if possible and maintain on isoflurane. An
optional local block of lidocaine may be applied to the
incision site.
Orchiectomy (Iguanas and Other Large
Lizards)
Male green iguanas can become very aggressive during
the reproductive period, which can result in serious
injury to pet owners who may not expect such behavior.
Early clinical evidence suggests that removal of the testi­
cles from these animals may improve behavior during
this reproductive period. One should note that neutering
does not subdue aggressive behaviors immediately after
surgery. In almost all cases, a change in temperament is
not seen until the animal’s subsequent breeding season.
The client should be informed of this before the proce­
dure is performed to avoid disappointment. When per­
forming this neuter procedure, it is important to note
that the right testicle is very close anatomically to the
vena cava, and the left gonad is attached to the adrenal
gland (Mader 2005).
Preoperative
The animal is placed in dorsal recumbence, and the mid­
line area is prepped and draped for aseptic surgery.
Procedure
An incision is made approximately halfway between the
sternum and pubis, extending approximately half of this
length (Table 20.22). A midline or paramedian approach
is made by tenting the skin with forceps and incising with
the tip of a scalpel blade or scissors on the midline, or
with the laser in a paramedian approach.
The large ventral abdominal vein is suspended along
the ventral midline by a short mesovarium. Careful dis­
section is necessary to avoid damage to this vessel if a
midline approach is used. If this vessel is damaged, it
should be ligated.
When using a paramedian approach, the muscle of the
body wall must be incised after the skin incision. The
muscle is thin, and hemorrhage is minimal with the laser.
The muscle is tented and incised using a horizontal beam
through the tented tissue so that the laser energy is
directed away from coelomic structures. An instrument
­Reptile Laser Surgery Procedure 283
Table 20.22 Reptile orchiectomy.
Procedure Reptile orchiectomy
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Handpiece (mm) 3 (small reptiles) 9 (large reptiles)
Power (W) 4–12 6–10
Exposure Continuous wave Continuous wave
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
is inserted in the coelom, and the incision in the muscle
is extended with the laser using the instrument as a back­
stop for the laser beam.
The incision is carefully extended with scissors or the
laser, with continued use of an instrument used as a
backstop here to prevent damaging the internal organs.
Decreased power settings are required as one approaches
closer to the vessels of the testicle and kidney.
The right testicle is closely associated with the caudal
vena cava along the dorsal body wall, while the adrenal
gland is interposed between the left testicle and the cau­
dal vena cava along the dorsal body wall. The testicles are
visualized by retracting the viscera to the side.
The testicular capsule is gently manipulated to prevent
rupture. The right testicle is gently elevated at one pole,
and a hemostatic clip is applied between the testicle and
the caudal vena cava. The laser is used to transect the
tissue distal to the clip. After the testicle is further ele­
vated, another hemostatic clip is applied to further ligate
the vascular mesorchium. This process is repeated until
the right testicle is removed. If the caudal vena cava is
damaged, the defect can be closed with hemostatic clips
longitudinally along and parallel to the wall of the caudal
vena cava, or with small sutures on an atraumatic needle.
The left testicle is removed after applying hemostatic
clips between the testicle and the adrenal gland.
The celiotomy incision is closed in two layers with 3‐0
to 5‐0 absorbable suture. The body wall is closed using a
simple continuous pattern. The muscle is thin and friable
and must be handled gently. The skin is closed in an
everting pattern such as horizontal mattress sutures, or
with skin staples.
Postoperative
Water should be offered in a small drinking bowl to pre­
vent soaking and contamination of the coelom from the
incision. The sutures or staples are left in place for six
weeks or until the next shed (Parrott 2000). Antibiotics
may be administered, and NSAIDs (Meloxicam, etc.) and
tramadol given for pain relief. Keep lizards away from
 284 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

water for a minimum of one month to prevent contami­ Turtles: Plastron Osteotomy Approach
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nation of the delicate incision and recheck the incision This approach is used in many chelonians for access to
weekly for three to four weeks. Most lizards will shed the coelomic cavity, with a trapezoidal incision made with
skin sutures and staples after healing is done, so removal an osteotome through the femoral and abdominal shields
is usually not required. to prevent injury to the pelvic bones (Mader 2005).

Turtles: Prefemoral Approach

Ovariosalpingectomy
Always remove the ovaries whenever attempting to steri­
lize a female reptile patient. Removal of only the oviducts
with the ovaries left intact is not acceptable due to future
complications (Mader 2005).
Preoperative
The animal is placed in dorsal or lateral recumbence
depending on the species and procedure. The midline
or lateral area is prepped and draped for aseptic
surgery.
The wide variety of differing anatomies of pet lizards,
snakes, and chelonians (turtles) makes multiple descrip­
tions of approaches (midline, paramedian, prefemoral,
or lateral) necessary depending on species and surgical
procedure being performed:
Lizards: Midline Approach
The incision is made approximately halfway between the
sternum and pubis and extends approximately half of
this length. The large ventral abdominal vein and bilat­
eral pelvic veins caudally are suspended along the ventral
midline by a short mesovarium. Careful dissection is
used to avoid damage to this vessel if a midline approach
is utilized. If damaged, this vessel should be ligated
(Parrott 2000; Mader 2005).
This approach is more widely used in the present day in
chelonians than the plastron osteotomy approach and is
the preferred approach due to less trauma subjected to
the plastron and the benefit of laser use throughout the
surgical procedure (Figure 20.14).
Snakes: Right Lateral Approach
Following measurement and confirmation by X‐rays to
check the location of the ovaries, an incision is made
between the two most ventral rows of scales lateral to the
large ventral scutes to approach the coelomic cavity from
the left side (Figure 20.15a–c).
Chameleons: Left Lateral Approach
The surgical incision is made laterally between the last
two‐third of ribs to approach the coelomic cavity from
the left side, while the patient is in right lateral recum­
bence (Figure 20.16a–c).
Reptile Ovariosalpingectomy Procedure
The technique for removing the reproductive organs is
similar in gravid and nongravid reptiles (Figure 20.17).
However, in gravid reptiles, the oviduct is much larger
and the blood supply is much greater. The right ovary is
closely associated with the caudal vena cava along the
dorsal body wall, and the left adrenal gland is interposed
between the left ovary and the caudal vena cava along the

Lizards: Paramedian Approach

This procedure is similar to the midline approach but
avoids the large ventral abdominal vein when cutting
skin and tissue underneath. It can be performed to the
right or left side of the midline. The muscle of the body
wall must be incised after the skin incision. The muscle
is thin, and hemorrhage is minimal with laser use. The
muscle is lifted and tented and is incised using a horizon­
tal beam through the tented tissue so that the laser
energy is directed away from coelomic structures. An
instrument is inserted in the coelom, and the incision in
the muscle is extended with the laser using the instru­
ment as a backstop. Using a 3 mm tip for smaller and
juvenile reptiles and a 9 mm tip for adult and larger rep­
tiles, the incision is carefully extended with the laser or
scissors, with continued use of an instrument as a back­ Figure 20.14 Prefemoral approach to ovariosalpingectomy in a
stop here to prevent damaging the internal organs red ear slider (Trachemys scripta elegans), demonstrating laser
(Parrott 2000; Mader 2005). incision of reptilian (turtle) skin.

(a)
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(c)
Figure 20.15 (a–c) Ovariosalpingectomy in a corn snake (Pantherophis guttatus), demonstrating laser incision of reptilian skin.
dorsal body wall. The ovary is identified and elevated. In
nonactive ovaries, the right ovary is grasped with atrau­
matic forceps by its ligamentous attachment. Hemostatic
clips are placed between the ovary and the caudal vena
cava, and the ligament is then transected via laser
(Table 20.23) on the ovarian side of the clips. The ovary
is then removed. To remove the left ovary, the clips are
applied between the left adrenal gland and the ovary to
avoid damaging the adrenal gland.
In gravid and reproductively active reptiles, the large
vessels of the ovary are doubly ligated with hemostatic
clips or ligatures and transected between. The liga­
ment is transected with the laser, and the ovary is
removed.
After the oviducts are identified, the vessels of the ovi­
ducts and shell glands are ligated with hemostatic clips
or sealed with a defocused beam and transected.
Hemostatic clips or ligatures are applied at the base of
­Reptile Laser Surgery Procedure 285
(b)
each shell gland at the junction of the oviduct and the
cloaca, and the oviduct is transected.
In reptiles with postovulatory egg binding, the ovi­
ducts are enlarged and filled with eggs. The oviducts are
exteriorized, allowing visualization of the large vessels of
the oviducts. Beginning at the infundibulum, the vessels
are isolated and doubly ligated with hemostatic clips or
ligatures and transected between the ligatures. The ovi­
duct is ligated at the cloaca and transected. The ovaries
are identified and removed after removal of the oviducts.
The same process is repeated on both ovaries and
oviducts.
The celiotomy incision is closed in two layers using 3‐0
to 5‐0 absorbable suture. The body wall is closed using a
simple continuous pattern. Because it is thin and friable,
the muscle must be handled gently. The skin is closed in
an everting pattern such as horizontal mattress, or with
skin staples. Refer to Video 20.3a,b for this procedure.
 286 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

(a) (b)
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(c)

Figure 20.16 (a–c) Ovariosalpingectomy in a chameleon (Chamaeleo dilepis and Chamaeleo calyptratus).

Table 20.23 Reptile ovariosalpingectomy.

Procedure Reptile OVS

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Handpiece (mm) 3 or 9 3 or 9
Power (W) 4–12 12
Exposure Continuous wave Continuous wave
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100

Figure 20.17 Ovariosalpingectomy in a red ear slider (Trachemys

scripta elegans) (prefemoral approach).

Postoperative
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Water should be offered in a small drinking bowl to pre­
vent soaking and contamination of the coelom from the
incision. The sutures or staples are left in place for six
weeks or until the next shed (Parrott 2000). Postoperative
antibiotic therapy is per surgeon’s choice, and a NSAID
(Meloxicam, etc.) and tramadol are administered for
pain relief. In herbivore species consider adding gastro­
intestinal (GI) medications to prevent GI stasis. Keep
lizards and aquatic reptiles away from water for a mini­
mum of one month to prevent contamination of the deli­
cate incision and recheck the incision weekly for three to
four weeks. Most reptiles will shed sutures and staples
away, so their removal may not be necessary.
Video 20.3a (This video does not include audio commentary.)
Ovariosalpingectomy in a red ear slider, demonstrating a
prefemoral approach and laser incision of reptilian skin.
Video 20.3b (This video does not include audio commentary.)
Ovariosalpingectomy in a red ear slider (Trachemys scripta
elegans) (prefemoral approach).
Ear Abscess
Abscesses of the middle ear are common in chelonians
and some lizards. They are often caused by multiple fac­
tors related to inadequate husbandry or occur secondary
to masses. Treatment must correct the underlying causes
and should involve broad‐spectrum antibiotics depend­
ing on culture. Supportive care should be provided
before surgery in debilitated patients.
Preoperative
The animal is placed in sternal or lateral recumbence
and depends on species and procedure. The tympanum
and surrounding skin is prepped and draped for aseptic
surgery, with an optional local block of lidocaine.
Table 20.24 Reptile ear abscess.
Procedure Reptile ear abscess
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Handpiece (mm) 3 3
Power (W) 4–6 3–5
Exposure Continuous wave Continuous wave
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
­Reptile Laser Surgery Procedure 287
Procedure
The ventral half of the tympanum is excised with the laser
(Table 20.24) by making a semicircular incision along its
ventral border and incising across the tympanum’s center.
The exudate is then removed with small ear loops or
curettes, with samples being obtained for culture. The
cavity and eustachian tube are gently flushed with saline
to completely remove all of the debris. If the animal is not
intubated, tracheal aspiration is prevented by placement
of cotton swabs in the caudal oropharynx, which should
be removed prior to recovery. The incision is left open,
and the cavity can be subsequently flushed with diluted
betadine (Rupley and Parrott‐Nenezian 2002).
Postoperative
Following abscess evacuation, the surgical site is filled with
a slow‐release preparation of antibiotics (determined by
the surgeon) while awaiting culture results. A sample
should be tested for parasites by wet‐mouth‐check with
warm saline in‐house, adding appropriate deworming
therapy if needed. Histopathology of suspicious tissue
should also be performed. Pain medications are prescribed
according to species and procedure. On discharge home,
continue with antibiotic therapy as previously prescribed
or use an alternative according to antibiotic culture results.
Cystotomy
Cystotomy may be performed on chelonians and some
lizards with urinary bladders to remove stones (Frye
1972; Mangone & Johnson 1998; Mader et al. 1999).
In many chelonians, access to the coelomic cavity is via
a plastron osteotomy with an osteotome, making a trap­
ezoidal incision through the femoral and abdominal
shields to prevent injury to the pelvic bones. Alternatively,
a prefemoral approach may be made with the laser
(Table 20.25). The urinary bladder is normally bilobed.
The right sac of the urinary bladder is covered by the
right lobe of the liver, thus preventing large stones from
remaining within the right sac. Most stones are therefore
Table 20.25 Reptile cystotomy.
Procedure Reptile cystotomy
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Handpiece (mm) 3 or 9 3 or 9
Power (W) 4–10 4–8
Exposure Continuous wave Continuous wave
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
 288 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

found in the left sac, though smaller stones can be found Table 20.26 Reptile oral mass removal.
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in either (Mader 2005). In larger chelonians with a single

small stone, cystotomy could be done through a prefem­ Procedure Reptile oral mass removal
oral approach as described above in chelonian ovariosal­
pingectomy (OVS). Laser type and wavelength (nm) CO2 (10 600)
In lizards, approach should be made by the standard Handpiece (mm) 3
midline or paramedian coeliotomy approaches previously Power (W) 5–7
described, with the incision made more caudally. Small Exposure Continuous wave
calculi can be removed from a left flank incision as well.
Mode SuperPulse
Duty cycle (%) 100
Preoperative
The animal is placed in dorsal or lateral recumbence
depending on the species and procedure. The midline or
lateral prefemoral area are prepped and draped for asep­
tic surgery, with an optional local block of lidocaine.

Procedure
Following approach to the bladder, the urinary bladder is
generally easily elevated out of the coelomic cavity. The
bladder should be isolated with moistened laparotomy
sponges or gauze. A standard cystotomy is performed as
in mammals. In normal reptile bladders, the wall is thin.
However, in the presence of a stone, cystitis may be present
and therefore the bladder wall could be very thickened.
Very large stones may be reduced to a manageable size
by chipping at them with the jaws of forceps prior to
removal from the bladder to avoid a large cystotomy inci­
sion. Once the stones have been removed, flush the blad­
der thoroughly with saline solution. The urinary bladder is Figure 20.18 Oral mass removal in a Chinese water dragon
then closed with 4‐0 monofilament absorbable suture in a (Physignathus cocincinus).
double layered closure, rinsed once more, and then placed
back into the body cavity. The coelomic cavity should be
copiously irrigated with warmed, sterile saline solution Abdominal and Cutaneous Mass Removals
prior to routine closure. Skin closure is routine. Masses need to be assessed with respect to size and tissue
components before selecting a laser exposure, power, and
Postoperative
spot size to use. Due to the decreased water content of rep­
X‐rays should always be performed peri‐ or postoperatively
tilian skin, increased power settings are needed to ablate or
to be certain that all stones were removed. Antibiotics should
remove masses such as papillomas and caseated abscesses.
be sent home according to urine culture results and surgeon
Accurate assessment of the tissue before attempting to
choice. Pain is treated with NSAIDs (e.g. Meloxicam) and
remove it is vital. Large liver and renal masses should be
tramadol. Monitor the incision site daily. Submit stones for
bluntly dissected away from other structures and ligated
analysis and urine for culture. In herbivore species, consider
if large vessels are present. Smaller masses can be ablated
adding GI medications to prevent GI stasis.
in the abdomen instead of excising, though a sample of
tissue should be taken for histopathology before ablation
Oral Mass Removals
commences.
Procedure
Gingival and lip incisions are made at the base of the Procedure
mass with the laser (Table 20.26 and Figure 20.18). Both A power setting of 10 W will remove most masses of this
may be closed with 5‐0 absorbable suture in a simple nature (Table 20.27). Between laser passes, frequently
interrupted pattern following mass excision. remove char and re‐evaluate the mass before proceeding.
As the mass becomes smaller, a decreased power setting
Postoperative of 7–8 W and a pulsed mode of 40% will protect the sur­
Hydrate as necessary with SC or IO fluids. Sutures do rounding skin from thermal damage.
not need to be removed. Monitor closely for the next Using 6 W, most small masses can be excised for histo­
24 hours and keep warm. pathology before ablating the rest. Small dermal masses
 ­Reptile Laser Surgery Procedure 289

Table 20.27 Reptile abdominal and cutaneous mass removal.

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Procedure Reptile abdominal and cutaneous mass removal

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Handpiece (mm) 9 9 3
Power (W) 10 7–8 6–7
Exposure Continuous wave Repeat pulse Continuous wave
Mode Non‐SuperPulse Non‐SuperPulse Non‐SuperPulse
Frequency (Hz) — 5 —
Duty cycle (%) 100 40 100

Table 20.28 Reptile limb and tail amputation and repair.

Procedure Reptile limb and tail amputation

Laser type and CO2 (10 600)

wavelength (nm)
Handpiece (mm) 3 (smaller species) or 9 (larger species)
Power (W) 6–12
Exposure Continuous wave
Mode SuperPulse
Duty cycle (%) 100

are removed at power settings of 6–7 W continuous

wave. Larger masses can be removed at this same setting
or ablated at 10 W as above. Figure 20.19 Fracture repair of a caiman lizard (Dracaena
Abdominal masses need to be assessed as to their guianensis).
vascularity and organ involvement. For example, renal
masses can be removed after ligation with hemaclips if
the vessels are over 0.5 mm in diameter. If the animal’s
mass is small, an ablation tip with a power setting of 10 W
continuous wave can vaporize the tissue layer by layer,
with char being removed with a moistened sterile swab or
ophthalmic applicator in between passes (Parrott 2000).

Limb and Tail Amputation and Repair

Procedure
Laser settings for reptilian limb and tail surgery will vary
from 6 to 12 W SuperPulse depending on species and size
of the animal (Table 20.28 and Figures 20.19–20.21).
For tail amputation (Figure 20.20), an elliptical skin
incision is made slightly distal to the area of concern
where healthy tissue is presented. The skin on the tail is
pulled cranially, exposing the coccygeal vertebrae, and
the distal tail is disarticulated with the laser within the
intercoccygeal space. The skin is retracted to the nor­
mal position, and the subcutaneous layer is closed with
a simple continuous pattern. The skin is closed with Figure 20.20 Tail amputation of a bearded dragon (Pogona
intradermal and simple interrupted pattern, usually vitticeps).
 290 Laser Surgery Procedures in Small Exotic Animals (Small Mammals, Reptiles, and Avians)

Table 20.29 Avian orchiectomy.

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Procedure Avian orchiectomy

Laser type and CO2 (10 600) CO2 (10 600)

wavelength (nm)
Handpiece (mm) 3 3
Power (W) 6–8 6
Exposure Continuous wave Repeat pulse
Mode Non‐SuperPulse Non‐SuperPulse
Frequency (Hz) — 5
Duty cycle (%) 100 40

Table 20.30 Avian ovariosalpingectomy.

Procedure Avian OVS

Laser type and wavelength (nm) CO2 (10 600)

Figure 20.21 Limb amputation of a leopard gecko (Eublepharis
macularius).
with 4‐0 absorbable suture. Stapling rather than sutur­
ing the skin may increase chances of proper healing
(Rupley and Parrott‐Nenezian 2002).
Postoperative
Antibiotics depend on blood or tissue culture, while
NSAIDs (e.g. Meloxicam) and tramadol may be adminis­
tered for pain control, depending on the species and
severity of the surgery. Follow up is within 7 days with
suture or staple removal within 21 days or longer depend­
ing on the species.
­Avian Laser Surgery Procedures
Orchiectomy
Small birds and birds under 200 g can have testicular tis­
sue ablated using a 3 mm tip with a power setting of
6–8 W (Table 20.29). The beginning ablation begins on a
continuous mode. However, as the tissue is vaporized
closer to the underlying vessels of the kidneys, a repeat
pulse mode of 40% with a reduced power setting of 6 W
is used (Parrott 2000).
Ovariosalpingectomy
The reproductive tract of young birds and birds weighing
under 300 g can be removed using a 3 mm tip and a laser
Handpiece (mm) 3
Power (W) 3–7
Exposure Continuous wave
Mode Non‐SuperPulse
Duty cycle (%) 100
power setting of 7 W continuous wave. Usually no liga­
tion is required for the small vessels of the oviduct at this
setting.
Mature birds weighing over 300 g may require pre­
placement of ligation clips due to the increased vessel
size. Mature birds with large ova are in danger of having
peritonitis if the ova are left in the abdomen. The ova are
manipulated with moistened ophthalmic applicators and
the vascular stalk exposed and transected using a 3 mm
tip at 3–4 W.
Preoperative
Use appropriate premedication followed with isoflurane
for induction and maintenance of anesthesia. The bird is
placed in right lateral recumbence, and its left leg is
retracted caudally and rotated externally to expose the
left body wall. The left body wall is prepped and draped
for aseptic surgery. A left lateral approach with or with­
out a flap is performed.
Procedure
The skin is incised from the proximal end of the pubic
bone to the sixth rib dorsal to the uncinate process
(Table 20.30). The incision is made as far dorsally as
­possible. Retract the left leg further. Identify the branch of
the femoral artery on the surface of the body wall that

extends perpendicular and medial to the coxofemoral
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joint. This artery is sealed with a defocused beam before
transection. Incise through the midlateral celomic
musculature parallel and dorsal to the skin incision.
­ with small hemostatic clips. The oviduct is ­doubly ligated
Elevate the musculature from the underlying coelomic
structures. The muscle is incised using a horizontal beam
through the tented tissue so that the laser energy is
directed away from coelomic structures. An instrument
is inserted in the coelom, and the incision in the muscle is
extended with the laser using the instrument as a back­
stop to protect the underlying structures. The incision is
continued through the seventh and eighth rib with scis­
sors. A defocused beam can be used to control hemor­
rhage. Lung tissue can be reflected if needed. If greater
exposure is needed, the incision is extended medially
anterior to the pubis and the rib. Place a retractor to pro­
vide exposure. Retract the proventriculus laterally and
ventrally and tease away the ventral suspensory ligament
of the proventriculus to visualize the ovary and cranial
oviduct. Examine the oviduct before beginning the sal­
pingectomy. The ventral suspensory ligament is bluntly
dissected to straighten the bends and folds of the oviduct.
Any air flush system to the laser handpiece should be dis-
connected at this point before dissection is made in the
­References
Frye F. (1972). Surgical removal of a cystic calculus from
a desert tortoise. J. Am. Vet. Med. Assoc. 161(six).
pp. 600–602.
Lawhorn B. (2018). Reproduction of potbellied pigs. http://
www.merckvetmanual.com/exotic‐and‐laboratory‐
animals/potbellied‐pigs/reproduction‐of‐potbellied‐pigs
(accessed 04 March 2018).
Lightfoot T, Bartlett L. (2002). The Exotic Guidebook:
Exotic Companion Animal Procedures. Lake Worth, FL:
Zoological Education Network.
Mader D, Ling G, Ruby A. (1999). Cystic calculi in the
California desert tortoise (Gopherus agassizii):
evaluation of 100 cases. In: Proceeding of the Association
of Reptilian and Amphibian Veterinarians, ARAV Sixth
Annual Conference (5–9 October 1999). pp. 81–82.
Mader DR. (2005). Reptile Medicine and Surgery, 2nd ed.
St. Louis, Missouri: Saunders Elsevier.
Mangone B, Johnson JD. (1998). Surgical removal of a
cystic calculi via the inguinal fossa and other
­Reference 291
coelom. Dissect the caudal infundibulum from the ovary
with the laser. Ligate the cranial ovariooviductal artery
and cranial oviductal vein at the base of the infundibulum
with hemostatic clips at the oviduct sphincter. The ovi­
duct is transected between the clips, and the dorsal liga­
ment is then carefully dissected with the laser, ligating
larger vessels with hemostatic clips and sealing smaller
vessels with a defocused laser beam before transection.
The anterior coelom is closed from the body wall to
the ribs with 4‐0 or 5‐0 absorbable suture material. The
rest of the musculature and skin are closed with 5‐0 or
6‐0 absorbable suture in a routine fashion (Parrott 2000;
Rupley and Parrott‐Nenezian 2002).
­Conclusion
There are many benefits of the CO2 laser in exotic animal
practice. Their use is limited only by your imagination.
The techniques presented here are to be used as guide­
lines only (Rupley and Parrott‐Nenezian 2002). Never
give up and enjoy!
techniques applicable to the approach in the Desert
tortoise, Gopherus agzzizii. In: Proceeding of the
Association of Reptilian and Amphibian
Veterinarians, ARAV Fifth Annual Conference,
Kansas City, Missouri (26–29 September 1998).
pp. 87–88.
Mitchell MA, Tully TN. (2009). Manual of Exotic Pet
Practice. St. Louis, Missouri: Saunders Elsevier.
Murray MJ. (2006). Spays and neuters in small mammals.
Proceedings of the North American Veterinary
Conference, Orlando, FL (7–11 January 2006).
Parrott T. (2000). Laser use in avian and exotic animal
medicine: advanced characterization, therapeutics, and
systems X. BiOS 2000 The International Symposium on
Biomedical Optics 2000, San Jose, CA, USA (17 May
2000).
Rupley AE, Parrott‐Nenezian T. (2002). The use of surgical
lasers in exotic and avian practice. Vet. Clin. North Am.
Small Anim. Pract. 32(3). pp. 703–721.
 292
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21
Laser Surgery in Aquatic Animals (Sea Turtles)
Brooke M. Burkhalter and Terry M. Norton
­Introduction
Flexible‐fiber hollow waveguide carbon dioxide (CO2)
lasers have been used for a variety of procedures in many
exotic species throughout veterinary fields, including
small mammals, reptiles, fish, dolphins, sea turtles, and
other aquatic species. Procedures most commonly per-
formed in aquatic animals include dermal mass excisions
or ablations, abscess debridement, laser‐assisted ampu-
tations, and other dermal incisions. In sea turtles, the
CO2 laser is used to assist in flipper amputations, enu-
cleations, and esophagostomies, and is most commonly
used for fibropapilloma (FP) tumor excisions.
­ ea Turtle Fibropapilloma Surgical
S and ocular conjunctiva, but can also be found on the flip-
Excision Procedure
Overview
Fibropapillomatosis (FP) is a debilitating infectious neo-
plastic disease that affects sea turtles of all species, but
most commonly juvenile green sea turtles (Chelonia
mydas). Originally isolated to equatorial regions and
warmer climates, the disease is spreading and is now con-
sidered a global threat. The exact etiology of the disease is
multifactorial, and not yet completely understood. It is
known to be associated with chelonid fibropapilloma‐
associated herpesvirus (CRPHV or ChHV5). However,
the disease expression and tumor formation are variable
and are suspected to be influenced by environmental
stressors and overall immune status (Aguirre and Lutz
2004; Herbst et al. 2008; Page‐Karjian et al. 2012; Alfaro‐
Nunez et al. 2014). The disease is often self‐limiting and
has been documented to spontaneously regress (Hirama
and Ehrhart 2007; Page‐Karjian et al. 2014). However,
although the tumors are locally aggressive and benign, the
disease is often fatal due to physical debilitations created
by their presence. The tumors block vision, prevent appro-
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
priate feeding and foraging behaviors, limit swimming and
diving abilities and predator evasion, cause increased
entanglement risk, and cause overall immunosuppression
leading to other secondary illnesses (Herbst 1994).
FP is usually easy to recognize on physical exam, char-
acterized by the presence of external cutaneous prolif-
erative masses (papillomas) that vary greatly in number,
size, and physical characteristics (Figure 21.1).
Earlier stages can be more plaque‐like, resembling
other diseases. Diagnosis can be confirmed histologi-
cally. Turtles diagnosed with FP are given a tumor score
of 1–3 based on the size and number of tumors
(Table 21.1) (Work and Balazs 1999).
External tumors most commonly occur on the skin (the
inguinal and axillary regions being the most prevalent)
pers, other cutaneous regions, cornea, face, carapace,
plastron, and cloaca. Internal tumors are most commonly
associated not only with lungs and kidneys but also have
been reported throughout the gastrointestinal (GI) tract,
liver, heart, bone, and other organs (Herbst 1994). Overall,
case management and treatment options cannot be based
exclusively on external tumor scores (Page‐Karjian et al.
2014). Each turtle must be assessed individually based on
FP tumor score, size, location, characteristics, turtle’s
body condition, other injuries, secondary illnesses, overall
health, and facility/staff resources available. Currently,
there are no effective treatments for internal tumors and
animals thus afflicted have a poor prognosis. Humane
euthanasia is recommended for these cases.
Many FP tumors, particularly larger tumors, are highly
vascular. Intraoperative hemostasis is essential for
patient safety, decreased postoperative morbidity, and
surgeon visualization. The bloodless surgical field pro-
vided by the use of a CO2 laser enables the surgeon to
more accurately follow clean surgical margins around
the tumor and navigate tissue planes more precisely.
Another benefit of CO2 laser surgery over conventional
scalpel is the prevention of surgical site contamination

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Figure 21.1 Juvenile green sea turtle (Chelonia mydas) with
fibropapillomatosis.
Table 21.1 Sea turtle fibropapilloma tumor scoring system: green
sea turtles afflicted with fibropapillomatosis are assigned tumor
scores based on the size and number of external tumors (Work
and Balazs 1999).
Tumor size (cm) 0 1 2 3
<1 0 1–5 >5
1–4 0 1–5 >5
4–10 0 0 1–3
>10 0 0 0 >1
and infection through vaporization of infectious agents
and neoplastic cells at the surgical site. Furthermore,
since FP surgeries typically involve multiple excisions,
the noncontact incision of the laser prevents accidental
bacterial and neoplastic contamination of consecutive
surgical sites. The local thermal effects combined with
decreased tissue manipulation have been shown to
decrease the chances of tumor seeding and recurrence
(Lanzafame et al. 1988a,b).
There are some disadvantages of using the CO2 laser
that must be considered during FP excision. Since many
tumors grow on or near boney tissue of the carapace,
plastron, skull, or digits, the surgeon must adjust for these
locations to prevent complications. The power necessary
to penetrate the epithelium and dense soft t­ issue closely
associated with the bone to effectively ablate neoplastic
­Sea Turtle Fibropapilloma Surgical Excision Procedur ­Sea Turtle Fibropapilloma Surgical Excision Procedur 293
cells, can also cause collateral thermal damage to
underlying bone, leading to abscess formation. Also,
hemostasis with the laser is only effective for vessels less
than 0.5 mm in diameter. As many FP tumors have ­vessels
larger in size, additional means of hemostasis are often
required, such as ligatures or radio‐cautery. Another lim-
itation of surgical lasers in sea turtles results from the
highly viscous tear film produced by the salt glands. The
thick tear film makes laser usage and visualization more
challenging for ocular and periocular procedures.
Preoperative
Prior to surgery, sea turtles with FP should undergo a
thorough diagnostic work up to assess their overall
health and screen for the presence of internal visceral
tumors. The ideal database prior to surgery includes a
complete physical exam, complete blood cell count
(CBC) with differential, plasma chemistry panel, radio-
graphs, computed tomography (CT), GI endoscopic
exam, and laparoscopic exam of the coelomic cavity.
While none of these diagnostics are definitive, they are
the most comprehensive tools available at this time.
Radiography and ultrasonography have very limited
sensitivity for internal tumor identification. Larger
­
tumors, especially pulmonary, are often visible on
radiographs (Figure 21.2).
CT studies are more sensitive for smaller pulmonary
lesions, but tumors can still be overlooked (Figure 21.3).
Renal tumors and other coelomic visceral tumors are
rarely visualized on CT. These tumors are sometimes
identified with endoscopic and laparoscopic exams
(Figure 21.4).
>5 However, tumors on the dorsal aspect of lungs or
>5 ­kidneys, and within organ parenchyma, will not be visi-
>4 ble (Mader 2006). Magnetic resonance imaging (MRI)
can be more sensitive for smaller visceral tumors.
However, MRI requires heavy sedation and is often not
readily available or is cost‐prohibitive (Croft et al. 2004).
Turtles affected with FP are commonly found to be ema-
ciated, anemic, and have pneumonia or other infections
and injuries. These conditions often require stabiliza-
tion and treatment prior to surgery. For anesthetic safety
and decreased postoperative morbidity, a general rule of
thumb is that the animal should be determined to be
healthy enough overall for general anesthesia and have
an albumin >1.0 g/dl and a PCV (packed cell volume)
>20%, depending on the size and number of tumors
being excised. Periocular tumors typically have less
bleeding and less exposed surface area, and therefore
can be done with lower values. Turtles with small tumor
burdens often do not require general anesthesia and
have less risk of hemorrhage, and surgery can be per-
formed during more debilitated conditions using local
anesthesia.
 294 Laser Surgery in Aquatic Animals (Sea Turtles)
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(a) (b)

Figure 21.2 (a–b) Radiographs of juvenile green sea turtle (Chelonia mydas) with pulmonary fibropapillomatosis. (a) Dorsoventral view
showing numerous soft tissue nodules of various size throughout the pulmonary fields (several are highlighted with arrows). (b) Left
lateral view showing multiple soft tissue nodules of various size within the pulmonary parenchyma (some lesions are highlighted with
arrows).

Figure 21.3 Images of three‐view computed tomography (CT) scan of a juvenile green sea turtle (Chelonia mydas) with a visible
pulmonary mass (highlighted with arrows) consistent with fibropapillomatosis.

Turtles undergoing surgery for excision of FP tumors
often require general anesthesia for the procedure. A
variety of sedation protocols are acceptable (Norton
et al. 2017). At our rehabilitation facilities, a common
sedation protocol includes a combination of intravenous
dexmedetomidine 50 μg/kg, ketamine 1.0–1.5 mg/kg,
and butorphanol 0.4 mg/kg. Isoflurane or sevoflurane
are recommended for anesthetic induction and mainte-
nance. Local anesthesia is also used in conjunction with
general anesthesia for additional intraoperative and
post‐operative analgesia, which lowers necessary gas
concentrations (Figure 21.5). Lidocaine 2% or lidocaine
1% + epinephrine is administered up to 6 mg/kg total
dose as local subcutaneous (SC) ring blocks or SC splash
blocks around the tumors. The lidocaine can be diluted
with sodium bicarbonate or saline to increase volume for
larger tumor burdens. Lidocaine 2% (preservative free)
can also be administered intrathecally for regional

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(a)
(c)
Figure 21.4 (a–d) Images of fibropapilloma tumors identified on laparoscopic exam of the coelomic cavity of a juvenile green sea turtle
(Chelonia mydas). (a, b) Renal tumors. (c) Hepatic tumor. (d) Pulmonary tumors.
anesthesia for inguinal procedures (Mans 2014). Often
times, local anesthesia (with or without sedation) is ade-
quate for animals with a small number of minor tumors
or posterior quadrant procedures.
FP tumor burdens are quite variable, and frequently
very extensive. To formulate surgical planning, all factors
of intraoperative and postoperative patient morbidity
must be considered, including hemorrhage, protein loss,
anesthesia time, pain, and infection. In an effort to mini-
mize anesthetic complications, a general rule of thumb is
to limit anesthesia time to one hour. Tumors are prior-
itized based on size, location, and detriment to the
patient. Periocular tumors that block vision, large tumors
limiting swimming or resting behaviors, and necrotic
and infected tumors are removed first. For extensive
tumor burdens, surgical procedures are often divided
into anatomical regions or quadrants (for example, all
tumors from right inguinal region) (Figure 21.6).
­Sea Turtle Fibropapilloma Surgical Excision Procedur ­Sea Turtle Fibropapilloma Surgical Excision Procedur 295
(b)
(d)
The turtle should be prepped for surgery using standard
aseptic surgical prep techniques, using either chlorhexidine
or betadine scrub and alcohol. Povidone‐iodine 5% and
saline are recommended for periocular procedures.
Alcohol is highly flammable, and therefore a thorough
final rinse is performed with saline to prevent ignition
with the surgical laser. Efforts should be taken throughout
surgery to maintain sterility and prevent cross‐contami-
nation of surgery sites.
Procedure
To begin, a circumferential incision is made through the
dermis surrounding the tumor with an additional 1–2 cm
margin of clean skin where anatomically possible
(Figure 21.7a). Hand movements should be slow and
steady using the maximum wattage with which the sur-
geon is comfortable (Table 21.2). The wattage must be
powerful enough to cut full thickness in a single sweep
 296 Laser Surgery in Aquatic Animals (Sea Turtles)
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Figure 21.5 Lidocaine is administered intrathecally for regional
anesthesia. Using sterile technique, Lidocaine 2% (preservative‐
free) up to 4 mg/kg is administered into the subdural space
between coccygeal vertebrae using a 25 or 27 g needle at a 45°
angle (Mans 2014). Frequently, 2 mg/kg is effective, leaving
additional lidocaine dosing for other SC local blocks.
Figure 21.6 Turtles with stage 2–3 FP tumor burdens will
undergo multiple procedures for surgical excision to minimize
complications and post‐operative morbidity. Surgeries are
commonly divided into quadrants based on anatomic regions as
shown.
(Video 21.1). If the wattage is too low, charring and
repetitive cutting motions will cause increased collateral
thermal tissue damage. If the wattage is too high, the
laser will penetrate unintended deeper tissue layers. The
thickness and toughness of sea turtle skin varies based
on species, size, and anatomic location. The skin over the
flippers is toughest, but extreme care must still be taken
to protect underlying muscle, tendons, nerves, vascula-
ture, and bone, as there is minimal SC tissue (Video
21.2). Irrigating the incision with sterile saline while cut-
ting and allowing brief periods of tissue rest between
incisions can help decrease thermal damage. SuperPulse
mode can also be used for this purpose. In the inguinal
region, care must be taken to avoid carapace or plastron
marginal bone and coelomic lining that is fairly superfi-
cial in certain areas, especially in thin turtles. For dermal
incisions, 0.4 mm spot size at 14–18 W continuous wave
non‐SuperPulse is commonly recommended. After the
dermal incision is completed, the power setting is often
decreased to 12–16 W continuous wave non‐SuperPulse
for SC dissection underneath the tumor. The tumor and
dermal margin are retracted upward, and the laser used
to cut through SC tissue to dissect and peel away neo-
plastic tissue, maintaining perpendicular orientation to
the cutting surface throughout (Figure 21.7b–c and
Video 21.3). As the end of excision is approached, saline‐
soaked gauze is placed behind the cutting surface as a
backstop to prevent trauma of underlying tissue or
drapes (Figure 21.7d). Most dermal FP tumors are super-
ficial and do not extend beyond the dermis (Video 21.4).
However, some tumors (especially inguinal and shoulder
tumors) can invade deeper tissues, requiring more exten-
sive dissection. Most hemostasis is achieved with the
laser, though larger more vascular tumors may require
additional measures. Supplemental hemostasis can be
achieved with radiocautery and ligatures. Studies have
shown that poliglycaprone 25 (monocryl) and polyglyco-
nate (maxon) sutures cause the least tissue reaction in
sea turtle skin (Govett et al. 2004). Hemostasis with the
CO2 laser is effective for vessels less than 0.5 mm diam-
eter and in parallel orientation. Since some vessels
originate from deeper tissues, they may initially be per-
pendicular and require tissue manipulation to reorient
for effective hemostasis. Increasing the distance of the
hand piece to 1–3 cm from tissue helps defocus the beam
and increase coagulation. Once the tumor has been com-
pletely excised, the power is decreased to 10–12 W con-
tinuous wave, non‐SuperPulse mode and a 1.4 mm spot
size used with a defocused beam (1–3 cm from tissue
surface) for tissue contraction and additional hemosta-
sis. The use of an adjustable handpiece simplifies the
adjustment of spot size enormously, further reducing
anesthesia time. The defocused beam is used in a spiral
or painting motion, beginning centrally and working
outward toward margins (Figure 21.7e). This helps to
shrink the size of incision to facilitate healing, reduce
infection, and seal off nerve endings, lymphatics and
blood vessels. Incisions are left open to heal via second
intention. Previous methods of suturing and grafting
proved unsuccessful. Incisions are covered with a topical
 ­Sea Turtle Fibropapilloma Surgical Excision Procedur ­Sea Turtle Fibropapilloma Surgical Excision Procedur 297
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(a) (b)

(c) (d)

(e)

Figure 21.7 (a–e) Surgical excision of fibropapilloma tumor from the ventral front flipper of a juvenile green sea turtle (Chelonia mydas).
(a) Circumferential incision through the dermis including tumor and additional 1–2 cm margin of normal skin. (b, c) The laser beam is
oriented perpendicular to the cutting surface while the tissue margin is retracted upward for SC dissection underneath the tumor. (d)
Saline‐soaked gauze is placed behind the tumor to protect underlying tissue and drapes during excision. This is particularly necessary for
tumors along flipper margins, and during the final stages of any excision. (e) After excision, a defocused beam with Wide Ablation tip is
used in a spiral motion for hemostasis and contraction of the incision.
 298 Laser Surgery in Aquatic Animals (Sea Turtles)
Table 21.2 General laser settings for fibropapillomatosis tumors.
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Procedure
Laser type and wavelength (nm) CO2 (10 600)
Spot size (mm) 0.4
Power (W) 14–18
Exposure Continuous wave
Mode Non‐Superpulse
Duty cycle (%) 100
hydrogel or collagen product for moistening and protec-
tion during recovery. The incisions are either bandaged
or left open, depending on size, location, and hemor-
rhage (Figure 21.8). Incisions with continued concerns
for hemorrhage are bandaged with a hemostatic agent
for 12–48 hours as needed to control bleeding. Pressure
bandages are placed using Vetwrap, Elasticon, or action‐
bandages (Figure 21.9).
Video 21.1 Dermal incision using CO2 laser for fibropapilloma
tumor excision from juvenile green sea turtle (Chelonia
mydas) (This video does not include audio commentary.). A
dermal incision is made using a 0.4 mm focal spot size at 16 W
continuous wave exposure in non‐SuperPulse mode. The
power is set such that a full thickness incision is made
through the dermis in a single sweep, using slow and steady
linear hand movements while maintaining traction along the
incision.
Video 21.2 CO2 laser excision of fibropapilloma tumor from the
dorsal aspect of a front flipper of a juvenile green sea turtle
(Chelonia mydas). (This video does not include audio commentary.)
Prior to the start of this video, a circumferential full thickness
dermal incision was made around the FP tumor and the adjacent
1 cm of normal skin using a 0.4 mm focal spot size and 12 W
continuous wave exposure in SuperPulse mode. The video begins
at the start of SC dissection. The laser is used to dissect through
the tissue planes underneath the tumor and associated dermis.
The focal spot is redirected to maintain a perpendicular
orientation to the cutting surface. Traction is maintained on
excised tissue to facilitate visualization and depth of tissue plane,
and maintain control of the depth of the incision. There is minimal
SC tissue in this location, so extreme care must be taken to avoid
cutting underlying musculature, nerves, tendons, and bones
unless associated with the tumor.
Video 21.3 CO2 laser SC dissection during excision of a large
cluster of fibropapilloma tumors in the inguinal fossa and from a
proximal rear flipper of a juvenile green sea turtle (Chelonia
mydas) (This video does not include audio commentary.). Prior to the
start of the video, a circumferential full thickness dermal incision
was made around the region of FP tumors to be excised (depicted
in Video 21.1). SC dissection is performed using a 0.4 mm focal
spot size at 14 W continuous wave exposure in non‐SuperPulse
mode. The laser orientation is adjusted throughout surgery to
maintain perpendicular orientation to the cutting surface. Traction
is maintained on tissue to allow visualization and accurate control
General FP surgery
CO2 (10 600) CO2 (10600)
0.25–0.4 1.4
12–16 10–12
Continuous wave Continuous wave (defocused)
Non‐Superpulse Non‐Superpulse
100 100
of tissue depth. The surgery is performed from superficial areas to
deeper regions, constantly moving around the tumor pedicle to
ensure maintenance of the desired tissue plane. If the surgeon
continues in same region without equalizing the depth in other
regions, they will inadvertently remove viable deeper layers of
tissue. There is some hemorrhage noted from the transection of a
deeper vessel in the SC adipose tissue. Not shown in the video is
hemostasis provided with hemostats and ligature placement.
Shortly thereafter, a small vessel was transected, and the laser
beam was defocused and directed parallel to the surface of the
vessel for hemostasis. Throughout the video, you can see the
separation of SC adipose tissue and fascial planes from the deeper
musculature during the careful dissection around the flipper.
Maintaining this control of depth is crucial throughout the
procedure.
Video 21.4 CO2 laser excision of a large cluster of fibropapilloma
tumors from the left ventral shoulder region of a juvenile green
sea turtle (Chelonia mydas) (This video does not include audio
commentary.). Highlights of a surgical excision of a large cluster
of FP tumors from the left ventral shoulder region of a juvenile
Green Sea Turtle. Dermal incisions, SC dissection, and
maintaining adequate depth control are all depicted.
Considerations for Periocular FP Tumors
The effects of the CO2 laser on deeper structures of the
eyes of turtles has not been well studied. Therefore, it is
unknown if there are negative impacts from laser use on
and around periocular structures in sea turtles, including
the scleral ossicles. Many surgeons find the laser more
challenging and less precise for ocular procedures due to
the viscous tear film production. However, some sur-
geons do utilize the laser in these regions. A water‐based
ophthalmic lubricant should be utilized to protect the
cornea during these procedures, as petroleum‐based
lubricants may ignite under the laser.
Procedure: Scleral Tumors
The technique for excision of scleral tumors is similar
to that of dermal tumors, with some minor adjust-
ments. The cornea should be protected with saline‐
soaked gauze or ophthalmic ointment to prevent
collateral damage. Using a 0.25 mm spot size, 7–8 W, a
repeat pulse exposure in SuperPulse mode, pulsing
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(a) (b)

(c) (d)

(e)

Figure 21.8 (a–e) Examples of surgical sites immediately following excision of fibropapilloma tumors from a juvenile green sea turtle
(Chelonia mydas). (a, b) Small excision sites without concerns of hemorrhage that do not require bandaging. (c–e) Larger excision sites
with concerns for hemorrhage; these should be bandaged for 24–72 hours postoperatively.
 300 Laser Surgery in Aquatic Animals (Sea Turtles)

10 ms at 20 Hz, 20% power (Table 21.3), the tumor is (Figure 21.10). Care is taken to maintain a perpendicular
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dissected off the surface of the globe using lateral
retraction in a “peeling motion” (Video 21.5). Rather
than making a circumferential incision, the incision is
started at one end of the tumor (usually the ventral
aspect) and dissection is then continued circumferen-
tially, gradually working around all margins of the
tumor while carefully maintaining appropriate depth
orientation of the laser tip to the cutting surface during
dissection. Extreme caution must be used when incis-
ing the anterior portion of the tumor, as it is often
along the corneal margin. If tumors involve the cornea
(Figure 21.11), a scalpel blade is used to perform a par-
tial keratectomy in that region. If the tumor involves a
full‐thickness penetration of the corneal tissue, an
enucleation is performed. After excision, a 0.25–
0.4 mm spot size at 2–4 W continuous wave SuperPulse
defocused beam can be used for focal ablation and
hemostasis as necessary (Figure 21.10e). The conjunc-
tival defect is left open to heal by second intention.
Some surgeons still prefer using a conventional blade
and iris scissors for the excision of scleral tumors
(Video 21.6).

Video 21.5 Surgical excision of scleral fibropapilloma tumor

from a juvenile green sea turtle (Chelonia mydas) using CO2
laser (This video does not include audio commentary.) The eyelids
are retracted open by an ophthalmic speculum to aid in
visualization during the procedure. Using a 0.25 mm focal spot
size and 7 W repeat pulse exposure in SuperPulse mode
(pulsing at 10 ms, 20 Hz, 20% power), the tumor is dissected off
(a) the surface of the sclera using lateral retraction in a peeling
motion. The incision is started along the ventral aspect of
tumor and continued in a lateral direction circumferentially
around the tumor, maintaining appropriate depth along the
surface of the globe. Note how the surface of the cornea and
the deeper structures of the eye are protected with saline
soaked gauze. Ophthalmic ointment can also be used. Once
the tumor has been completely excised, the focusing tip is
distanced from the cutting surface to defocus the laser beam
for surface ablation and hemostasis.

(b) Video 21.6 Surgical excision of scleral fibropapilloma tumor from

Figure 21.9 (a, b) Examples of bandages placed to protect
incisions and control hemorrhage post‐operatively for larger
incisions in inguinal, shoulder, and flipper regions. Bandage layers
most commonly consist of: hemostatic agent, hydrogel,
nonadherent pad, gauze pads, and Vetwrap.
a juvenile green sea turtle (Chelonia mydas) using steel
instruments (This video does not include audio commentary.). An
incision is made through the conjunctiva along the lateral aspect
of the scleral tumor using iris scissors. Dissection continues along
the surface of the globe circumferentially around the tumor using
iris scissors and a beaver scalpel blade.

Table 21.3 Laser settings for periocular fibropapillomatosis tumors.

Procedure Periocular FP tumors

Laser type and wavelength (nm) CO2 (10 600) CO2 (10 600) CO2 (10 600)
Spot size (mm) 0.25 0.4 0.25
Power (W) 7–8 2–4 10
Exposure Repeat pulse Continuous wave (defocused) Continuous wave
Mode Superpulse Non‐Superpulse Non‐Superpulse
Frequency (Hz) 20 Hz, 10 ms — —
Duty cycle (%) 20 100 100
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(a) (b)

(c) (d)

(e)

Figure 21.10 (a–e) Excision of a scleral tumor from the left eye of a juvenile green sea turtle (Chelonia mydas) using a CO2 laser.
(a) Common appearance of scleral and conjunctival/nictitating membrane fibropapilloma tumors. (b–d) The cornea is protected using
saline‐soaked gauze. An incision is made through the conjunctiva along the ventral aspect of the tumor, including 3–5 mm of healthy
conjunctiva for margins. The tumor is retracted laterally and dissection is continued around and underneath the tumor, carefully following
the surface of the globe to control depth. (e) After excision, the tip is distanced from the cutting surface to defocus the beam for ablation
and hemostasis of the globe surface and remaining conjunctiva.
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(a)

Figure 21.11 Juvenile green sea turtle (Chelonia mydas) with

corneal fibropapilloma, requiring partial keratectomy.

Procedure: Eyelid and Conjunctival Tumors

For eyelid tumors, care is taken to preserve as much
of the dermal eyelid margin as possible. Most of the
time, the tumors originate from the conjunctival sur-
face, and do not actively infiltrate the margin
(Figure 21.12a). However, tumors that originate from
or infiltrate the dermal aspect of the eyelids require
resection of that region (Figure 21.13). The cornea is
covered in ophthalmic ointment for protection.
(b)
Saline‐soaked gauze is placed over the ointment to
create a safe cutting surface. The tumor and associ-
ated eyelid or conjunctiva are retracted over the
saline‐soaked gauze. A 0.25 mm focal spot size at
10 W continuous wave SuperPulse mode is used to
make a linear, full thickness incision 1–3 mm proxi-
mal to the tumor base for excision (Figure 21.14a–b
and Video 21.7). For conjunctival tumors on the
medial eyelids, the same settings are used to dissect
the conjunctiva from the dermal layer of the eyelid for
excision. The conjunctival defect is left open to heal
by second intention (Figure 21.14c). Some surgeons
still prefer using a conventional scalpel blade and iris
scissors for excision of conjunctival tumors
(Figures 21.12b,c and 21.15a–c). If upper eyelid con-
junctival tumors are removed in conjunction with (c)
scleral tumors, there is a risk of adhesions forming
that may restrict the movement of upper eyelid, Figure 21.12 (a) Juvenile green sea turtle (Chelonia mydas) with
inhibiting closure over the cornea after healing. To common scleral and conjunctival fibropapilloma tumors. (b, c)
Excision of scleral tumors using conventional scalpel blade. The
facilitate healing in a more functional manner, a tem- tumor is retracted laterally. A full thickness conjunctival incision is
porary tarsorrhaphy is often necessary for the first made along the limbus and continued along the surface of the
7–10 days postop. globe, peeling away the tumor.
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(a)

Figure 21.13 A juvenile green sea turtle (Chelonia mydas) with

fibropapilloma tumors originating from sclera and dermal surface
of the ventral eyelid.

Video 21.7 Surgical excision of fibropapilloma tumor from

corner of eyelids of a juvenile green sea turtle (Chelonia
mydas) using CO 2 laser (This video does not include audio
commentary.). Saline soaked gauze is used to protect the
cornea and nearby tissues from the surgical laser. A 0.25 mm
focal spot size at 10 W continuous wave SuperPulse mode
setting is used. The tumor is retracted, allowing an incision to
be made full thickness through the dermis and conjunctiva
immediately adjacent to the tumor. Saline soaked gauze is
placed underneath the tumor to provide a safe cutting
surface for the final transection of medial tissue. The tip is (b)
then distanced from the cutting surface for ablation and
hemostasis.

Considerations for Tumors Near Bone

In many other species and their anatomical regions,
the density and depth of soft tissues is such that the
power of the laser can be precisely controlled to mini-
mize collateral thermal damage beyond a few cell lay-
ers. Sea turtle anatomy differs, however, and there are
several regions where the very thick epidermal tissue
of these animals is directly associated with underlying
bone. The power required to cut through the tissue
generates collateral thermal energy that is transferred
into the surrounding bone. This thermal energy has
been demonstrated to vary in severity based on power (c)
and exposure time. The damage to outermost bone is
Figure 21.14 (a, b) Surgical excision of a small fibropapilloma
mild, showing carbonized tissue. However, as laser
tumor from the margin of the nictitating membrane (third eyelid)
surgery continues to approach this contact region, of a juvenile Green sea turtle (Chelonia mydas) using CO2 laser. The
the tissue exhibits more pronounced zones of thermal cornea is protected with saline soaked gauze. The nictitating
necrosis and damage. These effects have caused focal membrane is retracted over the saline soaked gauze. A full
thickness incision is made through the third eyelid 3 mm proximal
to the tumor margin for excision. (c) Postoperative photo
following excision of the tumor from the margin of nictitating
membrane. A tumor was also removed from the sclera (see
Figure 21.10) exposing the scleral ossicle.
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(a)
(b)
(c)
Figure 21.15 (a–c) Excision of upper eyelid conjunctival
fibropapilloma tumors from a juvenile green sea turtle (Chelonia
mydas) using conventional steel instruments. (a) The tumor and
conjunctiva are retracted laterally. (b) The incision is started along
the dermal margin of the eyelid, preserving as much of the eyelid
margin as possible. The excision is extended along the
conjunctival surface until only normal conjunctival tissue is
present, denoting complete excision. (c) Photo of conjunctival
incision site after complete excision.
Table 21.4 Laser settings for FP tumors near bone.
Procedure FP tumors near bone
Laser type and CO2 (10 600) CO2 (10 600)
wavelength (nm)
Spot size (mm) 0.25–0.4 0.4–0.8
Power (W) 12–14 10–12
Exposure Continuous wave Continuous wave
(defocused)
Mode SuperPulse Non‐SuperPulse
Duty cycle (%) 100 100
infarcts and abscesses within the underlying bone
(Rayan et al. 1992; Krause et al. 1997). Therefore, the
laser can be used cautiously for the initial approach to
tumor resection around bone, but then conventional
blade and steel instruments are used to complete the
procedure (Table 21.4).
Procedure
Radiographs with or without CT are performed prior
to surgery to identify and evaluate the extent of boney
involvement for surgical planning. Small tumors in
earlier stages of growth can be hidden underneath the
keratin and are not easily identified on physical exam
alone. However, bone destruction is visible on CT
(Figure 21.16). For tumors on the plastron, carapace,
or face, the CO2 laser is used initially to cut through
keratin and superficial epithelial tissue. A circumfer-
ential incision is made around the tumor including
1 cm margins beyond lytic area of bone as anatomi-
cally able, using a 0.25–0.4 mm spot size and 12–14 W
continuous wave in SuperPulse mode (Figure 21.17a).
From there, a #11 scalpel blade is used to deepen the
incision to the level of bone. The scalpel blade or a
sharp periosteal elevator is used to continue sharp
dissection around and underneath the tumor for exci-
sion (Figure 21.17b). Once the tumor and surround-
ing epithelial tissue has been removed, the affected
bone margins are excised using curettes, rongeurs, or
bone saw as needed. Care must be taken to avoid
damaging the coelomic lining. A defocused laser
beam, at 0.4–0.8 mm spot size and 10–12 W continu-
ous wave in non‐SuperPulse mode can be used for
hemostasis as needed at the end of the procedure,
although this will not be effective for cortical bleed-
ing (Figure 21.17c). These areas are then packed with
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(a) (b)

(c) (d)

Figure 21.16 (a–d) CT scans are utilized to identify bony involvement of FP tumors on the carapace and plastron. Margins of the affected
bone must be debrided during tumor excision to prevent recurrence. (b, d) Image of 3D reconstruction of CT demonstrating lysis of bony
carapace deep to external fibropapilloma tumors. There was previous trauma to the left posterior bridge of the carapace. There are two FP
tumors on the right anterior bridge of the carapace also demonstrating associated bone lysis, not adequately visible on this image. (a, c)
Photo of carapace of the same turtle showing gross appearance of the lytic lesions identified on CT. Note that the anterior lesion does not
have a visible external tumor. There is only a discoloration of keratin. The tumor was visible after keratin was removed from that area.
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(a)

(a)

(b)

(b)

(c)

Figure 21.17 (a–c) Excision of FP tumors in regions with

underlying bone (carapace, plastron, skull) require a combination
of laser for initial approach and a conventional blade to prevent
excessive collateral thermal damage and abscessation of the
surrounding bone. (a) The laser is used to make a circumferential
incision through keratin and epithelium. (b) #11 scalpel blade
being used to sharply dissect the tumor and associated soft tissue
from underlying bone. (c) A defocused laser beam and wide
ablation tip is used along the margins of the incision and soft
tissues for hemostasis.
(c)
Figure 21.18 (a) Postoperative excision site of a fibropapilloma
tumor removal on the plastron of a juvenile Green sea turtle
(Chelonia mydas). (b) Incision packed with hemostatic agent to
control hemorrhage postoperatively. (c) The incision covered in
bone cement for protection during initial stages of healing.

hemostatic agents and pressure bandaged. Incisions
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that are completely surrounded by bone can be packed
with honeycomb, dental wax, or may covered in bone
cement to help create pressure within the incision
(Figure 21.18).
Postoperative Care
Recovery times allotted between surgical procedures
vary based on the individual animal but are typically
about two to four weeks. Postoperative care is simi-
lar to that of most species but also quite unique
when caring for sea turtles due to the aquatic environ-
ment and stress. Primary factors that must be addressed
include controlling hemorrhage, controlling pain, pre-
venting infection, minimizing stress, and encouraging
healing. In debilitated patients, this also includes man-
aging other comorbidities such as anemia, emaciation,
pneumonia, and other conditions. Postoperative hem-
orrhage is most critical during the initial 24‐hour
period following ­surgery. Although hemorrhage can be
well controlled intraoperatively, it may increase during
recovery as blood pressure normalizes and the turtle
becomes active, sometimes traumatizing the area. If
bleeding is severe, additional radiocautery or ligature
placement may be necessary. Most of the time, pres-
sure bandages with hemostatic agents are effective, but
these may need to be changed every few hours until
controlled. Once the hemorrhage has stopped, a clean
nonadherent bandage is left in place for 24–48 hours to
prevent recurrence.
Turtles are returned to the water as soon as possi-
ble based on recovery (Figure 21.19). Average times
range from 3 to 24 hours postop, depending upon
anesthetic recovery and postoperative bleeding.
Bandages can remain in place while in water, as long
as they do not prohibit swimming and surfacing. The
water depth is adjusted to accommodate the turtle’s
strength, pain, and abilities postop.
Analgesics, most commonly meloxicam and trama-
dol, are administered for one to four weeks, depend-
ing upon the size and location of incisions (Norton
et al. 2017).
Infection risk is high after FP tumor excision due to
open incisions and the aquatic environment. Good
water quality is imperative during wound healing.
Broad spectrum antibiotics are administered during
healing for prophylaxis. Wound cleaning and topical
wound care is provided during the initial 24–48 hours
postop, then continued every 72 hours for the first two
to three weeks, then once weekly until healed. Wounds
are cleaned with dilute betadine or chlorhexidine and
­Prognosis and Conclusio ­Prognosis and Conclusio 307
saline, and loose caseous scab material is gently
debrided once granulation has begun. Topical colloidal
silver or zinc spray followed by hydrogel or collagen
spray is applied. Topical antibiotic ointments are dis-
couraged unless infection is present due to the risk of
antibiotic resistance. The exception is for ocular inci-
sions; triple antibiotic ophthalmic ointment is applied
for three to seven days postop. Wound healing occurs
quickly over several weeks (Figure 21.20).
At our sea turtle rehabilitation facilities, therapeutic
laser treatments (Class IV 12 W) are performed during
the initial postop period to help control pain and
inflammation (Figure 21.21).
While overall healing time may not be altered
(Kurach et al. 2015), decreased redness, swelling, and
pain have been consistently observed during the acute
healing phase. Laser therapy is performed every
72 hours with prescribed wound care during the initial
two to three weeks postop. Beneficial effects of the
laser are present with treatments as frequent as every
24–36 hours, but they are not significant enough to
warrant the stress of additional animal handling for
sea turtles.
­Prognosis and Conclusion
Sea turtles heal quickly from dermal FP excisions, and
once tumors are completely removed, they can success-
fully be released under the guidance of regulatory
authorities. However, recurrence of FP tumors is com-
mon. Up to 60% of tumors regrow postoperatively (Page‐
Karjian et al. 2014). Animals need to be monitored
closely postop for development of new tumors and
regrowth (Figure 21.22). When regrowth occurs, it is
typically noted within 36 days of surgery (Page‐Karjian
et al. 2014).
The risk factors of regrowth, as with initial tumor
development, are multifactorial and not completely
known. As with all herpesviruses, stress and immuno-
suppression are likely critical factors. It is also dependent
upon surgical margins, tumor stages, tumor aggression,
internal tumors, and other unknown factors. Recurrent
tumors are excised with the same techniques as previ-
ously described. If animals have extensive regrowth,
additional or repeat diagnostics should be performed to
screen for internal FP tumors.
Recent genomic studies indicate that FP tumors
share molecular characteristics with human basal cell
carcinoma (Duffy et al. 2018). There are a number of
effective therapies for treating basal cell carcinoma,
including the topical application of fluorouracil (5‐FU)
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(a) (b)

(c)

(d)

(e)

Figure 21.19 (a–e) Juvenile green sea turtles (Chelonia mydas) in various depths of water with multiple types of bandages in place during
the initial 4–36‐hour postoperative period following excision of fibropapilloma tumors.
 ­Prognosis and Conclusio ­Prognosis and Conclusio 309
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(a) (c)

(c)

(b) (d)

Figure 21.20 (a–h) A series of photographs taken of a juvenile green sea turtle (Chelonia mydas) following the progression of healing after
fibropapilloma tumor excisions. (a) Preoperative tumors present in the left inguinal fossa and peri‐cloaca. (b) Immediate postoperative
excision from the left inguinal quadrant: exposed muscle and SC tissue present. No closure performed. (c) Two weeks postoperative:
caseous scab material is completely covering all incisions, beginning to thicken as a protective layer while granulation tissue begins to
form. (d) Four weeks postoperative: thick, healthy caseous scab material tightly adhered to underlying granulation bed. The margins are
loosening and beginning to peel away as epithelialization begins. The smaller, more superficial anterior incision is fully epithelialized at
this stage. (e) Six weeks postoperative: caseous scab material continues to loosen and peel away as epithelialization progresses. (f ) Eight
weeks postoperative: the remaining granulation bed and caseous scab material are very superficial, with continued wound contraction
and epithelialization. (g) Ten weeks postoperative: remaining caseous scab material ready to slough to allow epithelialization of remaining
central area. (h) Incisional scar tissue fully healed prior to release.
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(e) (f)

(g) (h)

Figure 21.20 (Continued)

Figure 21.22 A juvenile green sea turtle (Chelonia mydas) with

fibropapilloma tumor regrowth noted within scar tissue of a
previous surgical excision site on the left inguinal quadrant. A
Figure 21.21 A juvenile Green sea turtle (Chelonia mydas) receiving
large cluster of FP tumors is visible adjacent to the right inguinal
laser therapy on incisions following fibropapilloma tumor excisions.
quadrant.
Treatments are performed immediately postop, then repeated every
72 hours for two–three weeks to help control pain and inflammation.

onto affected skin regions (Duffy et al. 2018). A 5‐FU
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treatment has been used experimentally as 1% oph-
thalmic solution, applied topically twice daily for six to
eight weeks into the eyes (with a 15 minute “dry dock”
time for the turtle to allow for sufficient contact).
Initial studies have shown a decrease in recurrence of
up to 50% with this treatment (Duffy et al. 2018). It has
also been used topically on areas of skin of early
regrowth or boney regions postop to prevent recur-
rence. There is some evidence that it is effective in
treatment or prevention, and further research is cur-
rently being done to find other chemotherapeutics for
FP tumors. Until more advancements are made in the
understanding of the disease and treatment options,
surgical excision with CO2 laser remains the treatment
of choice for fibropapillomatosis.
­References
Aguirre AA, Lutz PL. (2004). Marine turtles as sentinels of
ecosystem health: is fibropapillomatosis an indicator?
Ecohealth. 1. pp. 275–283.
Alfaro‐Nunez A, Bertelsen MF, Bojesen AM, et al.
(2014). Global distribution of chelonid
fibropapilloma‐associated herpesvirus among
clinically healthy sea turtles. BMC Evol. Biol. 14.
pp. 206–217.
Croft LA, Graham JP, Schaf SA, et al. (2004). Evaluation of
magnetic resonance imaging for detection of internal
tumors in green turtles with cutaneous
fibropapillomatosis. J. Am. Vet. Med. Assoc. 225(9).
pp. 1428–1435.
Duffy DJ, Schnitzler C, Karpinski L, et al. (2018). Sea turtle
fibropapilloma tumors share genomic drivers and
therapeutic vulnerabilities with human cancers.
Commun. Biol. 1(1). p. 63.
Govett P, Harms CA, Linder KE, et al. (2004). Effect of four
different suture materials on the surgical wound healing
of loggerhead sea turtles (Caretta caretta). J. Herpetol.
Med. Surg. 14(4). pp. 6–11.
Herbst LH. (1994). Fibropapillomatosis of marine turtles.
Annu. Rev. Fish Dis. 4. pp. 389–425.
Herbst LH, Lemaire S, Ene AR, et al. (2008). Use of
baculovirus‐expressed glycoprotein H in an enzyme
linked immunosorbent assay developed to assess
exposure to chelonid fibropapillomatosis‐associated
herpesvirus and its relationship to the prevalence of
fibropapillomatosis in sea turtles. Clin. Vaccine
Immunol. 15. pp. 843–851.
Hirama S, Ehrhart LM. (2007). Description, prevalence,
and severity of green turtle fibropapillomatosis in three
­Reference ­Reference 311
The CO2 laser has many other applications in sea
turtles and other aquatic animal species. It is com-
monly used to assist in flipper amputations. Similar
settings for such procedures are used as described
above for dermal FP excision procedures. Vessels larger
than 0.5 mm diameter require ligation. The bone is dis-
articulated at the joint, or cut with giggly wire or ron-
geurs, depending on the location of the amputation.
Surgical lasers are also commonly used for esophagos-
tomies for fish hook removals and esophagostomy tube
placement. They can also be used for enucleations,
abscess lancing, and other soft tissue surgeries. Based
upon the surgeon’s comfort and skill level, CO2 lasers
have a wide variety of practicalities for soft tissue
­surgeries in aquatic species.
developmental habitats on the east coast of Florida.
Fla. Sci. 70. pp. 435–448.
Krause LS, Cobb CM, Rapley JW, et al. (1997).
Laser irradiation of bone. I. An in vitro study
concerning the effects of the CO 2 laser on oral
mucosa and subjacent bone. J. Periodontal. 68(9).
pp. 872–880.
Kurach LM, Stanley BJ, Gazzola KM, et al. (2015).
The effect of low‐level laser therapy on the healing
of open wounds in dogs. Vet. Surg. 44(8).
pp. 988–996.
Lanzafame RJ, McCormack CJ, Rogers DW, et al. (1988a).
Mechanisms of reduction of tumor recurrence with
carbon dioxide laser in experimental mammary tumors.
Surg. Gynecol. Obstet. 167(6). pp. 493–496.
Lanzafame RJ, Qiu K, Rogers DW, et al. (1988b).
Comparison of local tumor recurrence following
excision with the CO2 laser, Nd:YAG laser, and Argon
Beam Coagulator. Lasers Surg. Med. 8(5).
pp. 515–520.
Mader DR. (2006). Medical care of sea turtles: medicine
and surgery. In: Mader DR, ed. Reptile Medicine and
Surgery, 2nd ed. St. Louis, MO: Saunders, Elsevier.
pp. 997–1000.
Mans C. (2014). Intrathecal drug administration in turtles
and tortoises. J. Exotic Pet Med. 23(1). pp. 67–70
Norton TM, Mosley CI, Sladky KK, et al. (2017). Analgesia
and anesthesia. In: Manire CA, Norton TM, Stacy BA,
et al. Sea Turtle Health & Rehabilitation. Plantation, FL:
J. Ross Publishing. pp. 527–550.
Page‐Karjian A, Torres F, Zhang J, et al. (2012). Presence of
chelonid fibropapilloma‐associated herpesvirus in
 312 Laser Surgery in Aquatic Animals (Sea Turtles)
tumored and non‐tumored green turtles, as detected by
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polymerase chain reaction, in endemic and non‐endemic
aggregations, Puerto Rico. Springer Plus. 1. p. 35.
Page‐Karjian A, Norton TM, Krimer P, et al. (2014).
Factors influencing survivorship of rehabilitating green
sea turtles (Chelonia mydas) with fibropapillomatosis.
J. Zoo Wildl. Med. 45(3). pp. 507–519.
Rayan GM, Stanfield DT, Cahill S, et al. (1992). Effects of
rapid pulsed CO2 laser beam on cortical bone in vivo.
Lasers Surg. Med. 12(6). pp. 615–620.
Work TM, Balazs GH. (1999). Relating tumor score to
hematology in green turtles with fibropapillomatosis.
J. Wildl. Dis. 35. pp. 804–807.
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Part V

Integrating Surgical Lasers in Your Veterinary Practice


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22
Tips and Tricks for Veterinary Laser Surgeons
Les “Laser Les” Lattin
­Introduction
I was actively involved in wet labs where many tissue
models and techniques were discussed and developed,
and I have had the opportunity to observe thousands of
carbon dioxide (CO2) laser surgeries performed by many
veterinary specialties over the past 28 years. In this chap-
ter is information I have learned in that time from some
of the most skilled CO2 laser surgeons in veterinary
medicine.
­Intraoperative Recommendations
Operating the Laser While
Maintaining Sterility
To maintain sterility when changing the settings on the
panel of the laser, autoclave several syringe plungers and
keep them in each of your sterile packs (Figure 22.1). The
rubberized end can push buttons on the laser panel with-
out damage. Keep the top of the plunger sterile by put-
ting the plunger in a designated receptacle on the side of
the laser (Figure 22.2).
A 6″–12″ long piece of 1″ diameter polyvinyl chloride
(PVC) pipe (purchased at any hardware store) can also
be autoclaved in your pack (Figure 22.3). The surgeon
can place this PVC pipe over the smoke evacuator nozzle
(Figure 22.4) usually held by a stand or assistant
(Figure 22.5). Now, if the pipe touches the surgeon, there
is no contamination, and it can be adjusted by the sur-
geon to obtain maximum removal of any plume that is
produced.
Preventing Air Embolism
In a CO2 laser, air is flushed through the delivery system
to keep any surgical smoke plume from entering. This air
runs for about two seconds after the laser stops. This is
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
315
an important consideration with delicate surgeries (e.g.
thyroidectomies, vaginal surgery, cherry eye, and entro-
pion) where the tissue is thin, and air movement could
enter the tissue to cause embolism. For such procedures,
reducing or disconnecting this airflow will prevent such
an occurrence.
Regarding Char
Char is a normal by‐product of laser use. Char remains
following photovaporization, and its removal is extremely
important, unless otherwise specifically directed in a
given procedure in this text. If you attempt to cut through
char, the laser beam will hit the char instead of your
­target, creating heat in the adjacent tissue, which could
result in swelling and thermal injury. If the heat is exces-
sive, dehiscence could occur.
Remove char by using sterile moistened nonwoven
gauze sponges to gently wipe while using slight downward
pressure with a slight twist. A sterile‐moistened cotton‐
tipped applicator will also remove char in this instance.
Char can be beneficial for distichia surgery. Leaving
char in place permits the surgeon to hit the char in single
pulse exposure and create lateral heat, which assists in
ablating the hair follicle. The hair should not be inserted
into the tip of the handpiece during the procedure
because ablation of hair within the tip can cause deposi-
tion of char on the interior reflective surface, compro-
mising power density and distribution of the laser beam.
It is also generally recommended not to remove char
from the site of soft palate resection to reduce risk of
hemorrhage.
Backstops
A sterile‐moistened gauze sponge can be used when per-
forming laser surgery to act as a barrier against the laser
beam. Place this sterile saline‐ or water‐soaked nonwo-
ven gauze sponge behind tissue that you are lasing. Once
 316 Tips and Tricks for Veterinary Laser Surgeons
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Figure 22.3 A 12″ section of autoclaved PVC pipe.

Figure 22.1 Plunger and receptacle.

Figure 22.4 Smoke evacuator hose with mess before PVC pipe
added.

Figure 22.2 Receptacle mounted on laser with sterile plunger. Figure 22.5 Smoke evacuator after PVC added.

the beam cuts through this tissue, the soaked sponge will
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absorb the beam, preventing reflection and collateral
damage. A laser directed on moistened gauze may not
yield any initial result because the moisture absorbs the
laser energy. A little smoke as the moisture is vaporized
is a good visual cue to either move the beam away from
that spot or deactivate the laser and remoisten the gauze.
A nonwoven gauze sponge is recommended with laser
use because there are no gaps in the weave of the sponge,
leaving no opening for the laser beam to pass through.
A well‐moistened nonwoven gauze sponge works well
in the oral cavity to protect endotracheal tubes from
inadvertent direct or indirect laser beam contact, help-
ing to prevent damage to the tube and catastrophic com-
bustion of anesthetic gases. In soft‐palate surgery, the
same sponge can protect tissues behind the soft palate.
Another use of the moistened nonwoven gauze sponge
is for growth removal. Fold the gauze over to cut a fenes-
tration in the center, then open and drape it to surround
the growth (Figure 22.6). The gauze should stay in place
as tension is placed on the growth using forceps in any
direction, to ablate the growth while protecting sur-
rounding healthy tissue.
A groove director (Figure 22.7) is very useful for
approach to the ventral midline. Use it to raise up the
linea, applying tension so that the CO2 laser beam can be
directed toward the groove director, cutting efficiently
while protecting underlying tissue. Angle the groove
director to keep the beam from reflecting upward toward
the surgeon or other operating personnel.
Figure 22.6 Fenestration in nonwoven gauze sponge.
­Maintenance Recommendation 317
Figure 22.7 Groove director.
Petrolatum‐based lubes are flammable. When per-
forming laser surgery around the eyes, only aqueous
water‐soluble lube should be used as a moistening agent.
When working in the oral cavity, use lubricating water‐
soluble jelly on the teeth to provide an immediate barrier
of protection from an inadvertent laser pass. Be sure to
reapply as often as needed.
When working in the ear canal, water or saline can be
added below growths targeted for removal in the canal,
to protect structures behind the growth.
Visualization
Accurate removal of diseased tissue is highly dependent
on your ability to see what you are doing. Magnification
loupes add greatly to your visualization of your surgical
site and may make all the difference in spotting details
important to your procedure. A light on the loupe will
also add further detail where the overhead theater lights
may not be able to reach.
­Maintenance Recommendations
Laser Delivery System Calibration and Care
Different delivery systems and handpieces may vary in
their delivery of power to tissue from that shown on
the laser panel. For consistent results, the surgeon
should test each to ensure every surgery would have
adequate power to achieve the goal of the procedure,
including testing midprocedure during the changing
of handpieces.
For the hollow waveguide (HWG) delivery system of
the CO2 laser, a routine calibration before each proce-
dure will check the percent transmission of the laser
beam through the waveguide. Following calibration, the
surgeon can adjust the laser’s software to deliver the
desired wattage accurately based on the HWG transmis-
sion being used for surgery.
An HWG should not be bent or kinked and should
have a gentle curve not to exceed the two ends being par-
allel to each other. To facilitate this shape, the laser
should be positioned at the surgeon’s side or close by
across the table. If the laser is too far away, the surgeon
may tend to bend the fiber close to the handpiece, ­putting
excessive stress on the end of the HWG. Repeated
 318 Tips and Tricks for Veterinary Laser Surgeons

e­xcessive stress of this kind will otherwise cause the

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waveguide to develop memory and result in a decrease in

power transmission over time. Too sharp a bend or kink
will result in inadequate or zero transmission of the laser
beam through the HWG and require replacement.
Care should be taken with articulated arm delivery sys-
tems that they are not jarred, knocked around, or
dropped during and between procedures. The mirrors
within the arm may be knocked out of alignment in such
instances, requiring return to the manufacturer for
maintenance and realignment. If the targeting beam of
an articulated arm system does not match the laser beam
itself, then the unit should be removed from use immedi-
ately for expert maintenance.
A dramatic decrease in power could be due to a loss of
carbon dioxide gas in the resonator. Over time, the O‐
rings that contain the gas in the resonator could begin to
shrink, resulting in CO2 leakage and loss of power. This
is rare, but such instances would require maintenance by
the manufacturer. Some CO2 laser models may have a
Figure 22.8 Repurposed needle container before tips inserted.
SELF TEST feature to help diagnose a resonator leakage,
and inquiry should be made to the manufacturer on how
to do so.

Laser Tips and Handpieces

Following the surgery, handpieces and tips can be
cleaned with enzymatic or ultrasonic cleaner. The inte-
rior of the tip should not be scratched, or the integrity of
the beam may be affected. A soft product like Ethilon or
braided suture material can be used to clean the inner
surface.
When using a CO2 laser that uses ceramic tips, direct
contact between the tissue and the tip can occlude the tip.
The outer portion of the tip may appear dark due to cel-
lular residue. To remove this residue, use wet–dry sand-
paper of 200 grit or finer. Cut a small 1″‐square from the
sheet. Fold this small piece of sandpaper and place the
ceramic tip inside this folded square. Gently twist the tip
in the sandpaper, and it will remove any char on the tip. Figure 22.9 Repurposed needle container after tips inserted,
If the surgeon should see a glow at the distal end of the ready for autoclave.
tip during surgery, the tip should be replaced.
Ceramic tips should never be cold soaked as ceramic burst, 100 ms. Hold the tip about 1 mm off and perpen-
can retain moisture; such tips could crack from the laser’s dicular to the tongue depressor to produce a charred cir-
heat. To prevent this, steam autoclave tips prior to sur- cle. If there is an area within the charred circle that
gery to remove moisture. appears untouched, this may indicate debris inside the
Because ceramic tips are small and hard to handle, a tip, requiring a replacement tip and recalibration. Repeat
strainer basket, such as that used for tea leaves, can con- the test with each new tip. A half‐circle on the char may
tain tips before placing the basket in the ultrasonic be indicative of a kinked HWG.
cleaner. This is a quick and easy way to clean them with- Small laser tips can be autoclaved in repurposed ­needle
out misplacing them. containers (Figure 22.8). A color code system can be used so
A can of compressed air can be used to help unclog that a certain spot‐size tip is matched to a needle container
debris from inside tips and handpieces. of a specific color. Put the cleaned tip in the container, and
To test tips for occlusion prior to surgery, the laser use autoclave tape around the cap. Autoclave with your
should be fired at a tongue depressor at 10 W, single packs or separately (Figure 22.9).

Most CO2 laser handpieces can be cleaned like any
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surgical instrument. Enzymatic or ultrasonic cleaner can
be used on stainless units without a lens prior to
autoclaving.
The lens portion of a CO2 surgical laser must never be
autoclaved to avoid damaging the lens. Contact your
laser manufacturer for information on keeping the lens
of your laser clean.
­Practice
Items such as tongue depressors, raw chicken, and eggs
may be used to practice technique. Tongue depressors
help to give excellent examples of different exposure and
mode settings (continuous wave (CW), repeat pulse
(RP), single pulse, and SuperPulse) of your CO2 laser and
also assist in checking the integrity of ceramic tips.
Practice on tongue depressors at different power set-
tings, exposures, modes, and hand speeds to produce
different effects on these objects and observe the results
you would like to obtain in your procedures.
­Practic 319
A tomato is also ideal for practice on organic material, as
its water content can simulate skin. The use of the 0.8‐mm
spot size allows better visualization of the results. Applying
laser energy to a tomato stem will demonstrate sparking
prior to a procedure. The lack of water here is comparable
to hitting char or hard tissue such as teeth and bone.
At 10 W, CW, an incision at slow speed will produce
sparking because of the beam’s striking char. Increase the
hand speed to reduce or eliminate this. A fast hand speed
may produce little effect on the tomato’s surface due to
inadequate time of exposure.
A focused beam applied close to a tomato or tongue
depressor produces a small spot and good depth. Backing
the handpiece away from the tomato will increase the
spot size with an exponential decrease in power.
Observing these techniques helps to demonstrate the
discussions of power density and fluence discussed in
previous chapters, and with practice and observation,
technique will improve.
I hope some of these ideas learned from other laser
surgeons can make your laser use more efficient and
enjoyable.
 320
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23
Pain Management in Laser Surgery Procedures1
Noel Berger
­Introduction
Consumers of veterinary medical and surgical services
continue growing the strength of the human–animal
bond. It is not unusual at all to have companion animals
accompany their owners in restaurants, hotels, libraries,
office buildings, medical doctors’ offices, and schools.
We are increasingly reminded that pet owners are
referred to as persons in need of animal therapy services
or even pet parents. Animal owners are more aware than
ever of potential for presurgical and postsurgical dis-
comfort, and they want assurances that any pain is con-
trolled or alleviated.
Major pharmaceutical companies spend significant
marketing dollars on increasingly creative media tar-
geted to address public perception of pain and pain man-
agement. These same companies also invest heavily in
positioning pain management as an important consid-
eration for the veterinary community.
The current practice of veterinary medicine requires a
comprehensive pain management program that mini-
mizes and alleviates pain and its perception in our
patients. Treatment protocols will vary widely among
veterinary hospitals and among veterinary practitioners
alike. However, it is clear that daily implementation of
surgical pain management benefits both the patient and
the veterinary–client relationship. Reducing anxiety and
fear associated with pain is equally important, and astute
veterinary practitioners are consistently using several
modes of pain management to improve their patients’
quality of care. Pain‐reduction techniques enhance the
perception of value of the cost of veterinary services for
1 Portions of this chapter were adapted from: Berger and Eeg (2006).
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
clients, and veterinarians benefit from the improved
team approach to pet care.
­Pain
What is pain? It is described as an unpleasant sensory or
emotional experience associated with actual or potential
tissue damage, as defined by the International Association
for the Study of Pain (IASP). The primary goal of pain
management is to maximize absence of pain sensation
and create analgesia.
Physiologic pain is a protective mechanism by the body
to warn of continuing contact with potentially tissue‐
damaging stimuli. It is produced by stimulation of
primary nociceptors innervated by high threshold A‐
delta and unmyelinated C fibers. This type of pain
teaches the body to avoid these types of noxious stimuli.
This mechanism is managed by a complex interaction of
nociceptors; first‐, second‐, and third‐order neurons
ascending to the brain; and sensory and descending
inhibitory neurons from the midbrain. They all combine
to initiate, identify, and modify clinical pain response in
our patients.
Nociceptors have the important job of recognizing
mechanical, chemical, or thermal energy. The affected
nociceptors then modify this recognition to an electri-
cal impulse that is carried up from the primary afferent
fibers to the dorsal horn in the gray matter of the spinal
tract and brainstem. Ultimately, these impulses travel
through the thalamus to the cerebral cortex where
realization, identification, and response are generated.

Pain can further be broken down into subsections of
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peripheral pain. These include visceral pain and
somatic pain. Visceral pain is a poorly localized pain
often described in human medicine to be a dull or
gnawing type of feeling. This type of pain is typically
felt in the thoracic and abdominal viscera. Somatic
pain is a localized pain event, identified in human
medicine as a stabbing, aching, or throbbing feeling.
Somatic pain includes the response noted after soft
tissue surgery. It can be cutaneous and superficial or
musculoskeletal and related to joint, muscle, perios-
teum, or bone.
Neuropathic pain is often poorly responsive to treat-
ment. This type of pain is a response to direct damage to
peripheral nerves or the spinal cord. It can lead to mala-
daptive compensation by the cerebral cortex thereby
perpetuating an inappropriate response to stimuli or lack
thereof.
For our discussion, clinical pain is the most important
consideration before, during, and after laser surgery.
Clinical pain is an ongoing activation of nociceptors due
to peripheral tissue injury or deeper injury to the nerv-
ous system. Nociception is the physiologic process that,
when reaching a completed pathway transmission to the
cortex, results in conscious perception of pain.
The ultimate goal of the laser surgeon is to modify,
reduce, or eliminate the three distinct physiologic
processes (transduction, transmission, and modula-
tion) involved in nociception by pharmacological,
mechanical, and thermal means. CO2 lasers, and to
some extent diode lasers, provide the technological
means for reducing tissue interaction and therefore
reducing pain.
­Patient Pain Recognition
Because animals are unable to talk, it is critical that clini-
cians have a complete understanding of potential physi-
ologic and behavioral signs of pain. Once the clinician
understands these pain indicators, they can formulate
interventions for their patient.
Physiologic alterations due to acute pain include
increased blood pressure, heart rate, and peripheral
vasoconstriction. Increased respiratory rate and muscle
twitching or contraction may also occur. A stress leuko-
gram is often noted in the presence of acute and inter-
mediate pain. Weight loss due to reduced water and food
intake may also be noted.
Behavioral changes are unique to each patient. It is
usually the animal’s owner who notes these changes or
lack of normal behavioral signals postoperatively.
­The Benefits of Pain Management Using Lasers in Surger ­The Benefits of Pain Management Using Lasers in Surger 321
Animals typically become less active during painful
stimuli, but more restless. The level of relaxation
decreases significantly. They become variably aggressive
and submissive during pain recognition. Postural
changes are often seen in patients that have poor postop-
erative pain management. Animals generally demon-
strate guarding behaviors over surgical sites. This can
manifest in a variety of ways such as biting, scratching,
licking, chewing, or pawing at the painful area. Cats’
purrs may be mistaken for signs of comfort, when in
actuality they are an indication of a behavioral response
to pain.
When there is a likelihood of experiencing pain from
surgical or therapeutic procedures, analgesics must be
used regardless of the animals’ outward behavior. It is
incumbent upon us, as the patients’ advocates, to use
pain management and help the client understand that
the benefits of analgesic drug administration far exceed
the risks associated with pharmacologic administration
to the patient.
­ he Benefits of Pain Management
T
Using Lasers in Surgery
One of the greatest advantages of laser surgery, spe-
cifically procedures that use CO2 laser energy, is
diminished postoperative pain. There is a preponder-
ance of ­convincing evidence in the medical literature
describing ex vivo studies of nerve conduction and
reduction following CO2 laser transection. The dem-
onstration of reduced horseradish peroxidase (HRPO)
uptake has been the standard proof of reduced nerve
conduction. In the veterinary literature, Mison et al.
(2002) showed in a clinical study that there was immediate
postoperative reduced pain for CO2 laser declawed
cats. The authors showed that in the immediate post-
operative period, cats having the CO2 laser surgery
technique used for this procedure were able to bear
significantly more weight, as measured by peak vertical
force on a pressure platform, than cats undergoing
traditional scalpel surgery. There was no significant
difference in weight bearing at seven days after s­ urgery
in cats that had scalpel dissection vs. CO2 laser dissec-
tion. In this study, it was concluded that the benefit of
using CO2 laser was realized in the immediate postop-
erative period when it is most important to have
­comfort. A similar study was conducted five years
later by an independent group (Robinson 2007) that
showed improved limb function may result from
decreased pain during the first 48 hours following
laser onychectomy.
 322 Pain Management in Laser Surgery Procedures
Other papers have described that the reduced pain
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veterinary patients may experience following elongated
soft palate resection, anal sacculectomy, ablation of blad-
der transitional cell carcinoma, aural hematoma repair,
meibomian adenoma excision, and a variety of benign
skin lesions. Most of these studies focused on the reduc-
tion in hemorrhage or postoperative swelling. It is rea-
sonable to further hypothesize from experience that
reduced swelling will provide pain relief due to dimin-
ished activation of pressure nociceptors.
Recently, it has been shown (Carreira et al. 2017) that
skin incisions made with a CO2 laser caused a lower
increase in arterial blood pressure compared to incisions
made with a scalpel blade. This parameter is recognized
by the American College of Veterinary Internal Medicine
as a reliable indicator of the pain response in anesthetized
patients. An increase in arterial blood pressure correlates
well with more painful stimuli. Therefore, a significantly
reduced measured arterial blood pressure would indicate
a reduction in painful stimuli. The authors developed
their thesis further by showing that patients undergoing
CO2 laser surgery required less anesthesia compared to
their counterparts undergoing scalpel surgery for the
same procedure. Similar results have been shown in
reports from human dentistry and oral surgery.
Anecdotally, the perceived pain reduction following
CO2 laser surgery continues long after the initial proce-
dure. This has led to a general acceptance in the veteri-
nary community that the use of CO2 lasers in veterinary
surgery results in a more comfortable postoperative
recovery. Although the transection of nerves, cutting
tissue, ablating lesions, and surgery in general is painful
and requires anesthesia, it is the intent of conscientious
laser surgeons and anesthetists alike to minimize pain.
Using a CO2 laser in surgery is one technique to arrive at
these goals.
­ ain Management Strategies
P
for the Laser Surgery Patient
It is important to embrace both preemptive analgesia
and multimodal analgesia for maximum pain relief ben-
efit to the patient. Preemptive analgesia is the adminis-
tration or application of analgesics prior to surgery. The
great advantages of this protocol are decreased duration
and intensity of postoperative pain and elimination of a
recurrent pain state.
A partial list of preemptive analgesic techniques includes
anesthetic premedications such as opioids, alpha‐2 ago-
nists, nonsteroidal anti‐inflammatory drugs (NSAIDs),
and presurgical epidural, with or without local anesthesia
blocks to the skin or target tissue. Preemptive analgesia
has been shown to be an effective and less costly way to
provide for postoperative pain reduction and return to
normal function following laser surgery.
Multimodal analgesia simultaneously combines or
administers in close order two or more analgesic drug
classes and analgesic techniques. This maximizes the
reduction in transduction, transmission, and modulation
of the afferent pain response at different points in the
pain perception pathway. Combining a number of drug
classes (as previously stated) and techniques can pro-
duce a synergistic analgesia to reduce or eliminate pain
perception. The main advantages are inhibition of sur-
gery‐induced peripheral nociceptor stimulation associ-
ated with inflammation and transduction, stopping
increased neuronal sensitivity within the spinal cord
known as “wind up,” transmission, and prevention of
resistance to postoperatively administered analgesics
due to tachyphylaxis.
There is an abundance of nontraditional methods for
postoperative pain reduction using a variety of tech-
niques and resources. Our interest is in the use of photo-
biomodulation. This is the use of near‐infrared laser
wavelengths delivered at low‐power density to reduce
the initiation and transmission of pain signals. The
reader should refer to Chapter 5 for further information
on this adjunctive laser treatment modality to surgical
laser applications.
The ultimate goal of modern anesthetic protocols is
better postoperative quality of life. This can be measured
by reduced short‐ and long‐term recovery, improved
overall tissue healing, increased mobility, and return to
normal family interaction. The combination of both
preemptive and multimodal analgesia can be applied
easily with little additional time or cost. The results are
great benefits to the patient and client in the perioperative
and postoperative period.
­Conclusion
Current anesthetic and analgesic techniques work syner-
gistically with the use of laser energy during surgery to
enhance control of pain. It is beyond the scope of this
chapter to include any specific anesthetic or analgesic
protocols. It is important that veterinarians and other
medical professionals arm themselves and their staff
with the best pain management information and surgical
techniques to provide for superior pain control for their
patients. Using lasers in surgery is one important tool to
serve that purpose.­

Reference
VetBooks.ir
Berger, N.A. and Eeg, P.H. (2006). Pain management
considerations for laser surgery procedures. Veterinary
­Further Reading
Mison MB, Bohart GH, Walshaw R, et al. (2002). Use of
carbon dioxide laser for onychectomy in cats. J. Am.
Vet. Med. Assoc. 221(5). pp. 651–653.
Robinson DA. (2007). Evaluation of short‐term limb
function following unilateral carbon dioxide laser or
scalpel onychectomy in cats. J. Am. Vet. Med. Assoc.
230(3). pp. 353–358.
­Further Readin ­Further Readin 323
Laser Surgery: A Practical Guide. Chapter 8, 101–108.
Hoboken, NJ: Wiley‐Blackwell.
Carreira ML, Ramalho R, Nielsen S, et al. (2017).
Comparison of the hemodynamic response in
general anesthesia between patients submitted to
skin incision with scalpel and CO2 laser using dogs as
an animal model. A preliminary study. ARC J.
Anesthesiology. 2(1). pp. 24–30.
 324
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24
Laser Surgery in the Mobile Practice
Janine S. Dismukes
­Introduction
Mobile and house call veterinary practice is the original
“Fear Free” paradigm in veterinary medicine. With the
new push for “Fear Free” veterinary visits, more veteri-
narians should consider integrating house calls into their
practice. Mobile veterinarians minimize the majority
of the pet’s anxiety by allowing them to be in the com-
fort of their own homes. Many surgeries are perfect fits
for mobile veterinary practice, as the pet falls asleep
and wakes up in their own home. The only limitation
would be those surgeries that require continuous rate
infusion (CRI) medications and overnight monitoring
postoperatively.
A CO2 laser can be used for many types of procedures,
including routine spays, neuters, mass removals, meibo-
mian gland adenoma resections, cystotomies, soft palate
resections, tonsillectomies, and amputations. This chap-
ter will discuss how and why mobile veterinary services
can (and should) include CO2 surgical lasers.
­Advantages
There are many advantages of using a CO2 laser instead
of a scalpel during mobile practice. First and foremost is
the amazing control of bleeding. The laser also seals the
lymph vessels. Minimal bleeding and lymphatic drainage
thus minimizes bruising and swelling around the inci-
sion. This has all been demonstrated in discussion and
the pictures throughout this text. However, in mobile
practice, the appearance of the incision is particularly
important because you are handing the pet directly to the
client after a surgery; the laser helps to prevent a
­dramatically bloody, bruised, or swollen appearance to
the surgical site. Additionally, the decreased swelling at
the incision reduces the need for skin sutures to ensure
closure, and the absence of sutures is esthetically ­pleasing
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
for clients. For most of my surgeries, only subcuticular
sutures and skin glue are used. The lack of itchy skin
sutures also greatly reduces a pet’s draw to their incision,
precluding the need for Elizabethan collars.
A mobile veterinary practice that offers CO2 laser sur-
geries is also considered innovative and appreciated by
its clientele (Figure 24.1).
­Equipment
A mobile veterinary vehicle that contains a surgery
suite is required. The surgery suite must have wall
brackets to secure oxygen tanks, blankets for warmth,
an anesthesia vaporizer, and anesthesia monitors.
Choose a mobile unit floor plan that allows the CO2
laser to be secured in transit as well as during surgery.
If you have the laser prior to design of your mobile unit,
custom fit a bracket onto the wall so that the laser can
be secured during transit. As a practical matter, make
sure there is enough electricity available in your mobile
unit for the laser to work simultaneously with hot water
blankets, heart and blood pressure monitors, lighting,
and other equipment. Have the additional equipment
needed for plugging into the client’s house for your
power needs, should the mobile unit’s electrical require-
ments be inadequate or fail at the time of the
procedure.
I prefer the upright CO2 lasers with hollow waveguide
and adjustable handpiece. Here is a picture of the bracket
that I had installed (Figure 24.2), and a picture of the
laser within the bracket for travel (Figure 24.3).
I have a small sorting container nearby to hold laser
goggles, laser handpieces, laser tips, suture material, and
skin glue. The evacuation system is tucked under the sur-
gery table to help remove the laser plume from the suite.
With this setup, I can perform any surgery that I could in
a standard “brick and mortar” practice.

Figure 24.1 A mobile veterinary practice
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vehicle equipped for laser surgery.
Figure 24.2 Wall‐mounted custom bracket installed for
transporting a laser surgical unit.
­Logistics
The logistics of the mobile laser surgery experience
begins with the client calling to schedule the procedure
at their home. The receptionist gives the client preopera-
tive instructions and schedules a technician visit to draw
preoperative labs if bloodwork has not been acquired
recently. On the morning of surgery, the mobile surgical
unit parks in the client’s driveway, and a source of power
is procured, by either plugging into an outlet on the cli-
ent’s house or starting a mobile generator. The veterinar-
ian or technician obtains the client’s signature on the
­Logistic ­Logistic 325
Figure 24.3 The surgical laser within its bracket for transport.
procedure consent form and informs the client of what
will happen, step‐by‐step. We ask that cats are placed in
a small bathroom (i.e. no chasing or places to hide) prior
to our arrival, as a means of minimizing the cat’s fear and
anxiety. We ask that dogs are securely leashed. The vet-
erinarian goes inside the home, obtains baseline vitals,
and administers a sedative premedication. Cats can be
held in the bathroom by their owners until they fall
asleep, then brought into the surgical unit in a carrier.
Dog owners are asked to take their pet for a short walk to
evacuate bowels and bladder and, when the patient is
groggy, walk them into the surgical unit.
 326 Laser Surgery in the Mobile Practice
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Figure 24.4 Laser surgical procedures may be conducted in a
mobile practice much the same as in a fixed clinic setting.
Owners are invited to stay in the surgical unit while an
intravenous catheter is placed, induction medications
are administered, the pet is intubated, and cardiopulmo-
nary monitors are attached. Owners are usually content
to leave their pet at that time.
Surgical sites are clipped and prepped as usual, and the
pet is transferred into the surgery suite. The CO2 laser
procedure is performed as it would be in a fixed clinic
setting (Figure 24.4).
At time of extubation, the client is asked to put two
towels in the dryer for 5–10 minutes. The warm towels
are used to tightly swaddle the small dogs and cats, so the
owners can hold them on their own couches as the pet
wakes up. The large dogs are carried inside the home
with a stretcher. Most of the time, owners want to sit
with the dog while waking up; therefore, a dog bed is
placed on the floor in front of the couch. One warm
towel is placed on the dog’s bed, then the dog on top of
that, and then the other warm towel is placed on top of
the dog. The owner sits on the floor holding the dog’s
head in their lap to keep their heads from flopping as
they wake from anesthesia. If the owner prefers or the
veterinarian recommends, the bed and warm towels are
placed in a crate or kennel, and the dog is carried directly
to it from the surgical unit.
It is this author’s observation that animals that wake up
smelling their own home and hearing their owner’s voice
recover from anesthesia much calmer and smoother
than animals who are put in a stainless steel cage in a
hospital setting.
If the pet was anxious at the time of premedication,
then adrenaline is still present when they wake up post-
operatively. In extending the “Fear Free” paradigm, have
a sedative (half of a Dexdomitor® premedication dose)
ready when they are extubated to diminish or even elimi-
nate the dysphoric thrashing or howling. Remind the
owner that any vocalizing is not pain but that the pet is
not understanding why there are “purple elephants flying
around the room.” Recommend that the owner hugs the
pet and talks to them in soothing tones to make them feel
more secure.
­Conclusion
Mobile and house call practice is not only for euthanasia
but both pets and owners will also be pleasantly sur-
prised at how smooth and easy a laser surgery experience
can be.

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25
Economic Considerations for Laser Surgery
John C. Godbold, Jr
­Introduction
For at least three decades diplomate and general practi-
tioner surgeons have embraced surgical lasers as valua-
ble tools – tools that enhance surgical capabilities,
increase surgical precision, facilitate new procedures,
and improve the quality of patient care. If those attrib-
utes were the only consideration, laser technology would
be used in every veterinary practice. Yet, for some, the
illusion remains that laser technology is too expensive
for veterinary medicine. Do surgical lasers give a positive
return on the investment required for their purchase? Is
investment in a surgical laser a good idea?
Evidence in this and previous publications confirms
laser technology can be a valuable addition to the sur-
gery suite (Bartels 2002; Berger and Eeg 2006; Brown
2017). Decades of use and successful practitioner experi-
ence also have demonstrated that surgical lasers generate
healthy revenue.
Prior to investing in a surgical laser, practices should
perform a return on investment (ROI) calculation, estab-
lish appropriate fees, and develop a plan for training staff
and marketing the technology. With appropriate pre‐
purchase analysis and planning, a surgical laser can be
economically successful.
­Valuable Technology. Affordable
Technology?
Veterinary clients have become increasingly demanding
of high‐quality veterinary care. Clients expect care will
include the most advanced technology available and per-
ceive lasers to be part of that advanced technology.
Because of the pervasive use of lasers in the human
medical field, veterinary practices incorporating lasers as
part of their technology are viewed by clients as being
more progressive. Practice image defines what spectrum
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
327
of the veterinary clientele a practice attracts. Practices
that clients perceive to be advanced, progressive, and
cutting edge attract clients willing to pay for high‐quality
care (Figure 25.1) (Irwin 2002).
Regardless of the wavelength or specific laser device
used for the procedures outlined in this textbook, the
purchase of a surgical laser requires a significant invest-
ment. When this book was published prices ranged from
several to tens of thousands of dollars (US$).
Any practice investment should be preceded by a ROI
assessment (Buy With Confidence 2010; Jergler 2017).
Many easy‐to‐use ROI calculators are available on the
Internet, including those that are specific for veterinary
surgical lasers (Veterinary Surgical Laser ROI 2018). All
ROI calculators include consideration of the cost of the
equipment, cost of its use, and revenue generated from
its use.
Cost includes the actual equipment cost (purchased or
leased), equipment supplies, maintenance, and staff
costs associated with the equipment. Revenues include
laser‐specific fees and fees from increased number and
diversity of procedures performed. Additional nonspe-
cific revenue will be realized from enhancement of the
practice image following the introduction of laser
technology.
Calculating Cost
Accurately estimate cost when calculating potential ROI
of a surgical laser. In determining the actual equipment
cost, consider whether a lease, lease purchase, financed
purchase, or direct purchase is most advantageous. Since
tax savings from depreciation or deduction may vary
with different types of purchases, consult with the prac-
tice accountant for guidance.
Estimate operating costs, which include laser expend-
able supplies, parts that require replacement over time,
maintenance, and service plans. Most surgical lasers
 328 Economic Considerations for Laser Surgery
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require replacement of the delivery system every few
years. Plume evacuation systems require filter replace-
ment. If a prepaid service plan is not maintained, then a
monthly amount should be budgeted for future
maintenance.
Overall cost of the surgical laser also includes the
direct and indirect cost of staff. Time for training and
safety certification should be factored in, as well as the
day‐to‐day cost of staff time to set up the laser for sur-
gery, assist with the laser during surgery, and set down
the laser after surgery.
­Calculating Revenue
Initial ROI calculation must include an estimate of
­revenue. One early decision must be how fees will be
assigned, adjusted, or included for use of the laser
device. Practices may use multilevel, tiered laser‐use
fees added to various procedures, adjust total procedure
fees when the laser is used, or increase all surgery fees
(Textboxes 25.1 and 25.2).
Regardless of the approach, an estimate of the average
increase in procedure fees is multiplied times the num-
ber of procedures currently being performed to estimate
laser revenue.
The initial revenue calculation will be conservative; it
will not include the increase in revenue from the a­ ddition
of new clients attracted to a practice doing laser surgery
and from the laser facilitating procedures the practice
did not previously perform.
Figure 25.1 Veterinary clients have
become increasingly demanding of
high‐quality veterinary care. Confident
recommendation of laser surgery by the
veterinarian helps clients understand that
laser surgery is part of high‐quality care.
Source: Christopher Winkler.
Textbox 25.1 Surgical Laser Revenue Projection Using
Modest Laser Fees and Infrequent Use
Average fee: US$50
Two laser surgery procedures a day
Per day – US$100
Per week – US$500
Per month – US$2150
Per year – US$25 800
Textbox 25.2 Surgical Laser Revenue Projection Using
Average Laser Fees and More Frequent Use
Average fee: US$75
Three laser surgery procedures a day
Per day – US$225
Per week – US$1125
Per month – US$4838
Per year – US$58 050
­Laser Fees
Practices investing in a surgical laser should not hesitate
to charge for using the device. Everything the practice
does should reflect value in the technology. Clients
expect cutting‐edge technology and accept the value of
the technology modeled by the practice. Modeling the
value of laser surgery begins with emphasis of patient
benefit and continues with fees that reflect the worth of
that benefit.

Obviously, fees must be within a range that clients are
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willing to pay. Fees for laser use must also be acceptable
to staff members. If fees are so high that staff members
are not comfortable prescribing laser surgery, then the
device will not be used.
Tiered Fee Structure
An early approach to surgical laser fees, still in use in
many practices, relies on a tier of laser add‐on or use fees
(Textbox 25.3). The tier includes fees ranging from a
modest amount for quick outpatient procedures or elec-
tive surgeries, to much higher fees for procedures requir-
ing prolonged laser use or greater expertise. The tier may
include a “zero” laser fee when the addition of the tech-
nology is pro bono.
A rationale for this way of assigning fees is that it makes
the laser’s use (and the practice’s value of its use) very
transparent. Since there is an invoice line item for the
laser’s use, the owner is reminded of the laser value with
each invoice.
Bundled Fee Structure
Another approach is to bundle fees (Strategies for
Pricing Part 3 2014) for procedures in which the laser
is used. This requires increasing the overall fee for pro-
cedures by a flat or tiered rate rather than invoicing a
specific laser use fee. An argument for this approach is
that it eliminates the laser as an estimate item that cli-
ents might potentially decline since use of the laser is
part of the overall procedure. Practices that use this
method frequently promote that all of their procedures
are performed with a laser since they are a “laser sur-
gery practice.”
Textbox 25.3 Example of a Tier of Laser Use Fees
Assigned as an Invoice Line Item in Addition to All
Other Fees for a Procedure
Tiered Laser Use Fees
Level 0 – Pro‐bono procedures US$0
Level I – Outpatient procedures US$5 per min
US$50 minimum
Level II – Elective procedures US$40
Level III – Minor nonelective US$80
Level IV – Routine nonelective US$120
Level V – Extended nonelective US$220
­Plan for Economic Succes ­Plan for Economic Succes 329
­ ea or Nay? Should Laser
Y
Be an Option?
Many practices agonize over whether to make laser use
an option that clients can choose or reject. Too many
veterinarians, afraid of client reaction to higher fees
when technology is included, have adopted the “a la
carte” approach, and offer laser use as an option in
procedures.
If that has been your approach, outline for several rou-
tine surgical procedures the protocols that you know are
the safest, the most effective, the most humane, and the
most client‐friendly, regardless of cost. Experienced CO2
laser users would include laser use in almost every proto-
col. Next, ask yourself why you do not offer those proto-
cols as the standard of care in your practice. Why offer
less, if you know it is not the best?
What will happen if you offer only the best? A few
clients will drift away and join the phone shoppers at
the local veterinary discount outlet, but the good news
is that your fiscal health does not have to be tied to
marginal clients. Your financial success can be tied to
those clients who seek your care regardless of cost
because they know you offer the best care available
(Godbold 2002).
­Plan for Economic Success
Establishing your practice as a laser surgery practice and
making the addition of the laser an economic success
requires more than calculating a ROI, establishing fees
for its use, and making the commitment to have the laser
be one of your standards of care. Staff must be trained
and prepared, a core laser message adopted, and an
appropriate marketing effort begun and maintained.
Training and Staff Preparation
Everyone in the practice must be trained with basic
information about the value of laser surgery. A surgical
laser is not a sit‐in‐the‐corner, rarely used technology. It
is a game changing, practice changing, quality of care‐
changing technology, and all in the practice must know
about it. All must know something about it and some
must know everything about it.
In every practice, there should be a person who is
responsible for the laser, ensures everyone is properly
trained, and maintains all the information about laser
surgery in one place. This important role is usually filled
by a veterinary nurse or technician. At least one staff
member should undergo laser safety training and be cer-
tified as a laser safety officer (LSO). An online LSO
 330 Economic Considerations for Laser Surgery
course with certification is available at www.aimla.org.
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The LSO will frequently be the head laser nurse or
technician.
Core Message
Each practice should have a core message about laser
surgery that all on the staff can paraphrase in his or her
words (Figure 25.2). The core message may be simple:
“Yes, we use a laser in all of our surgery procedures. It
reduces bleeding and swelling and reduces pain after-
wards. Patients are much more comfortable after the
procedures. We love it and know you will be pleased.”
A consistent core message, repeated in every conversa-
tion about surgical procedures, helps establish for staff
members and clients that the technology is one of your
standards of care. Having laser surgery become part of
the practice’s identity has been very successful for many
practices.
Marketing Laser Surgery
A generation ago, marketing in veterinary medicine was
limited to yellow page ads and printed, mailed communi-
cations. Today, yellow pages ads are a distant memory (or
should be!) and mailed communications are of little to no
value.
The digital revolution, driven by the Internet, laptops,
tablets, and smart phones, has changed the way clients
interact with practices. Clients no longer rely on a prac-
tice as their sole source of information. Clients are more
informed and client‐to‐client dialogue is common.
Information is a click away and opinions are shared in
exponential numbers (Fletcher 2016). Digital images and
video have replaced detailed written information, and
when written information is used, bullet points that grab
(and keep) attention are required (Bruce 2012).
Communication in the digital age changes rapidly and
good marketing requires understanding digital trends
and moving quickly into new digital venues.
In‐office Displays, Pictures, and Videos
The lobby, reception, or waiting area and outpatient con-
sultation rooms should be a marketing venue
(Figure 25.3). Display pictures of recent laser surgery
patients along with their engaged owners. Use a digital
picture frame or display monitor to show appropriate
videos of laser surgeries along with images of patients
before and after surgery. Feature a laser surgery case of
the week, both in the practice and on the Internet. Do
obtain owner permission before using patient images.
Equip initial phone contact and front office staff to
identify potential laser surgery patients. Those staff
members can begin educating owners about laser sur-
gery and its advantages (the core message) before they
reach the consultation room. Practice specific literature,
tablet video (Figure 25.4), or a QR code (two‐dimensional
barcode) directing the client to online content promoting
laser surgery, can be in the owner’s hands while in the
lobby and consultation room.
Website
An eye catching, current, and search engine optimized
website has become critical for effective marketing. Few
Figure 25.2 Each practice should have a
core message about laser surgery that all
on the staff can paraphrase in his or her
words. Staff members can begin
educating owners about laser surgery and
its advantages (the core message) before
they reach the consultation room.
Source: Christopher Winkler.
 ­Plan for Economic Succes ­Plan for Economic Succes 331

Figure 25.3 Educational displays about

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laser surgery can be placed in the lobby or

reception area and serve as entertaining
and educational ways of demonstrating
the benefits of the advanced technology.
Source: Christopher Winkler.

Figure 25.4 Videos of laser surgery

patients, before and after surgery, can be
shown by staff members to clients in the
exam room. Digital tablets allow easy
access to videos and pictures for client
education. Source: Christopher Winkler.

practices have the internal resources to develop, main-
tain, and search engine optimize a website, so marketing
dollars that used to be spent on yellow page ads and post-
age now must be directed toward professionals that can
make your website an extension of your practice.
Devote several pages of your website to laser surgery
(Figures 25.5 and 25.6). Use the pages to emphasize the
practice’s core message about why laser is a standard of
your care and the benefits of laser surgery in specific
procedures. Include the same images, video, and case of
the week that are components of in‐office marketing.
Supply links to additional authoritative sources of infor-
mation so clients receive positive reinforcement and
support of your approach to the technology.
 332 Economic Considerations for Laser Surgery
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Figure 25.5 Devote an entire page of the practice’s website to laser surgery. Use that page to emphasize the practice’s core message
about why laser is a standard of your care. Source: Christopher Winkler.

Figure 25.6 Use additional website pages to detail the benefits of laser surgery when used in specific surgical procedures.
Source: Christopher Winkler.

Figure 25.7 Social media, in multiple
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forms, is a marketing necessity for
today’s practice. Frequent posts about
laser surgery cases and their outcomes
are popular and generate client
interest. Source: Christopher Winkler.
Social Media
A website is used to display information that is more
static, whereas social media is used to disseminate rap-
idly changing information and to establish practice‐to‐
client and client‐to‐client relationships. Social media, in
multiple forms, is a marketing necessity for today’s prac-
tice. Facebook, Instagram, Pinterest, Twitter, and new
platforms that will emerge are the single most effective
way to reach clients. Clients’ appetites for still image and
video content are now paired with easier methods of
making and posting social media updates.
To use social media sites effectively the practice needs to
make additions, updates, and postings on a regular basis,
preferably daily. Since social media content should
include images or video, updates most often must be
generated from within the practice rather than outsourced
(Figure 25.7). Assign the task of keeping social media posts
updated to a conscientious, technologically capable staff
member who will also monitor for any negative comments.
Community Marketing
Kennel clubs, feline clubs, civic groups, and schools all
offer opportunities for a practice member to serve as a pre-
senter. Develop a short, simple presentation about laser
­Conclusio ­Conclusio 333
surgery for event opportunities. Include images and ­videos,
and several laser surgery patient stories. Make a practice
member with good communication skills available to
attend organizations’ events. Always have a generous sup-
ply of practice specific information for attendees including
printed information with the practice’s website, social
media presence, and a QR code with contact information.
­Conclusion
The economic considerations required for a practice to
incorporate laser surgery are no more complex than for
any other technology. Practices must do an appropriate
pre‐purchase analysis of the potential ROI. A proposed
fee structure must be established to help determine if
incorporating a surgical laser is economically sound. If
the potential ROI supports acquiring a surgical laser,
then a plan for integrating the technology should be
detailed. Staff training and preparation should be initi-
ated and a comprehensive marketing plan developed.
Using these logical and organized steps, practices can
make a conscientious decision about laser surgery tech-
nology and implement it in a way that will be successful.
 334 Economic Considerations for Laser Surgery
­References
VetBooks.ir
Bartels KE. (2002). Lasers in medicine and surgery.
Vet. Clin. North Am. Small Anim. Pract. 32(3). pp.
497–745.
Berger NA, Eeg PH. (2006). Economic consideration for
use of laser energy. In: Veterinary Laser Surgery: A
Practical Guide. Hoboken, NJ: Wiley‐Blackwell.
Brown J. (2017). A look at veterinary lasers. https://www.
veterinarypracticenews.com/a‐look‐at‐veterinary‐lasers
(accessed 20 January 2018).
Bruce R. (2012). 8 quick tips for writing bullet points
people actually want to read. https://www.copyblogger.
com/writing‐bullet‐points (accessed 20 January 2018).
Buy With Confidence. (2010). Buy with confidence. https://
www.veterinarypracticenews.com/buy‐with‐confidence
(accessed 20 January 2018).
Fletcher D. (2016). How the digital revolution is changing
consumer behavior. https://www.linkedin.com/pulse/
how‐digital‐revolution‐changing‐consumer‐behaviour‐
dee‐anne‐slade (accessed 20 January 2018).
Godbold JC. (2002). If it is the best, why offer less?
Laserpoints. 4. p. 8.
Irwin JR. (2002). The economics of surgical laser
technology in veterinary practice. Vet. Clin. North Am.
Small Anim. Pract. 32(3). pp. 549–567.
Jergler D. (2017). Many happy returns. https://www.
veterinarypracticenews.com/many‐happy‐returns
(accessed 20 January 2018).
Strategies for Pricing, Part 3. (2014). Strategies for pricing,
Part 3. https://www.avma.org/PracticeManagement/
BusinessIssues/economics/Pages/Strategies-for-Pricing-
Part-3.aspx (accessed 20 January 2018).
Veterinary Surgical Laser ROI. (2018). Veterinary surgical
laser ROI. https://www.aesculight.com/why‐aesculight/
roi (accessed 20 January 2018).
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Part VI

The Future of Lasers in Veterinary Medicine and Surgery

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26
The Future of Lasers in Veterinary Medicine and Surgery
Christopher J. Winkler
­Introduction
The past two decades have seen incredible progress in
the development of laser technologies for the veterinary
profession, and there is every indication this will con-
tinue. In keeping with the general consensus of today’s
veterinary laser practitioners that higher power equates
to improved results in surgical outcomes, the latest gen-
eration of surgical lasers have been developed with
power outputs of up to 45 W at continuous wave, and up
to 30 W at SuperPulse. With such units, laser surgery
may now be conducted at the same hand speed as that
performed with a scalpel blade, with the added benefits
of no hemorrhaging, with reduced collateral thermal
injury, and with sealed nerve endings and lymphatics.
Such an innovation is an extraordinarily useful tool to
possess for soft tissue surgery. Let us consider how lasers
in veterinary medicine and surgery may continue to be
developed and utilized even further.
­Laser Surgical Innovations
Laser‐Tissue Welding
Today’s surgical lasers are extremely efficient at creating
incisions; can we also someday use them for closure of
surgical incisions, as this author’s clients so often per-
ceive or request? There is progress being made in this
area to reduce or eliminate the need for sutures and
­staples. In studies to improve repair of surgical anasto-
moses of colorectal cancer patients, near‐infrared wave-
lengths of laser light have been used photothermally on
exogenous nanocomposite chromophores (a protein
“tissue patch” of polypeptides or collagen matrices laced
with gold nanorods) to seal ruptured ex vivo porcine
intestines, demonstrating immediate liquid‐tight seals
and enhanced bursting pressure against leakage and per-
itoneal infection. The laser can be tuned to match the
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
337
maximum absorbance of a particular type of patch. The
adaptation of this technology to other tissue types may
be looked forward to with great anticipation, perhaps
one day even replacing linear and circular cutting and
stapling devices with dual laser wavelength devices that
provide fluid‐tight seals and transect tissue without leav-
ing staples within the patient (Huang et al. 2013; Urie
et al. 2015; Mushaben et al. 2018).
Smaller Handheld Laser Units
Today’s surgical lasers are large and bulky; it is the
delivery system that makes it wieldy to the surgeon, and
such delivery systems and handpieces have made great
leaps forward over the past decade. But many surgeons
yearn for entirely handheld units. Such units would be
smaller, lighter and less bulky, allowing mobile and
traveling surgeons to carry them with ease between
practices, particularly in disaster relief. How would we
move toward this goal?
The relatively large size of surgical lasers is due to the
requirements of the optical resonator, which must be of
a certain length in order to function. As mentioned in
Chapter 1, weak gain lasers require an active medium of
relatively long length. Decreasing this length may be
possible if the active media are placed under higher
pressure. 3‐D printing using carbon‐fiber nanotubes
may make it possible someday to produce an optical
resonator small enough for a hand‐held unit while safely
containing the pressure of the lasing medium. As we’ve
seen in our everyday phones and portable electronics,
circuitry is becoming adequately smaller to make a
hand‐held surgical laser feasible. Paper‐based batteries
may also one day carry enough charge to provide ade-
quate power output for an entire surgery. Once these
hurdles are all surmounted, two particular problems
remain: smoke evacuation and heat dissipation. Smoke
evacuation may always be a separate system where
hand‐held lasers are concerned, but such units are still
 338 The Future of Lasers in Veterinary Medicine and Surgery
relatively small and quite portable compared to present‐
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day lasers themselves. A heat dissipation technique
would have to be developed, then, to allow for the safe
operation of a hand‐held unit for the patient, surgeon,
and the unit itself (Nystrom et al. 2009; Chang 2014;
Huang et al. 2014).
In the meantime, strides may continue to be made
toward developing more flexible and yet more rugged
and efficient beam delivery systems. A hollow waveguide
just as small and yet just as flexible as an optical fiber
would continue to advance the way endoscopic proce-
dures may be integrated with CO2 lasers, further increas-
ing the number of minimally invasive procedures that
can be performed. The continued development of spe-
cialty handpieces for specific procedures is also a direc-
tion of interest. A handpiece feature to strongly consider
would be a feedback mechanism detecting tissue absorp-
tion spectra and temperature, adjusting the laser’s power
density automatically in response to efficiently achieve
the desired surgical effect.
­Laser Surgical Integrations
The integration of laser surgery with other technologies
will continue to further innovate how veterinary surgery
is conducted.
Even if a hand‐held surgical laser unit presently
remains unworkable, the miniaturization of optical reso-
nators would still allow for the production of even
smaller lighter surgical laser units than those presently
available. Smaller CO2 resonators would make room for
the integration of other near‐infrared laser wavelengths
within the same housing. Coupling such a unit with mul-
tiple flexible delivery systems would allow the surgeon
the option of selection from WYSIWYG to WYDSCHY
to SYCUTE surgical wavelengths and even therapeutic
laser wavelengths in a single procedure, all delivered
through a single hand piece. Smaller smoke evacuation
units might also be integrated within the laser’s housing
and hand piece. Cooperation between a variety of ven-
dors may see the integration of video endoscopes into
such a laser unit, providing the veterinary surgeon with a
single minimally invasive endoscopic device delivering a
multitude of laser wavelengths for enhanced versatility
of procedures.
Although push‐button consoles are now the norm,
voice‐activation and Bluetooth may become mainstream
in a sterile operating environment to assist the surgeon
in system activation and safety. Voice‐activation may be
integrated into today’s lasers to allow the surgeon to pro-
gram power, exposure, operating mode, frequency, and
duty cycle, and switch the unit from STANDBY to
READY and back, all without the need for contact with
the console. A Bluetooth earpiece could also be equipped
to vibrate when the laser is activated, creating an addi-
tional safety feature for veterinarians with hearing
impairment.
Heads‐up displays developed for aerospace are seeing
use in modern motorcycle helmets, while wearable tele-
visions and virtual reality systems are also now available
to the public. With the integration of voice‐activated sys-
tems to eliminate direct contact with the laser, the addi-
tional step could be taken to provide a display in the laser
surgeon’s protective eyewear to show the laser’s present
display of power and settings (BioOptics World 2014;
Cision PR Web 2018).
As the use of therapy lasers becomes more prevalent in
the operating theater, multiple optical density (OD) val-
ues in laser safety eyewear would eliminate the need for
multiple lenses for different laser wavelengths and
changing them on sterile personnel as they switch to dif-
ferent lasers during a procedure. An alternative would be
to create laser safety eyewear with lenses capable of
polarizing to different OD levels for different laser wave-
lengths, which may also be voice‐activated.
Combining voice‐activation, displays which provide
the surgeon valuable information at just a glance, and
elimination of multiple safety lenses, would reduce the
time of the operation even further, and therefore the
patient’s time under anesthesia.
Human trans‐oral robotic surgery (TORS) using CO2
lasers is already a reality. Such integration has demon-
strated combining the superior dexterity of the robotic
arm with the enhanced surgical aspects of the CO2 laser
over steel scalpels or electrocautery, to precisely remove
tumors with minimal invasiveness while improving post‐
surgical chemotherapy and radiation therapy options.
The surgeon is not even required to scrub in for such a
procedure and may even perform the surgery remotely.
It is not difficult to imagine such equipment being devel-
oped for veterinary use as it becomes more widely avail-
able (UTHealth 2014; Mount Sinai 2018). Indeed, a
report from the Oklahoma City Zoo and Botanical
Garden has demonstrated that veterinary robotic sur-
gery has already been used successfully during a gorilla’s
umbilical hernia repair procedure to minimize trauma
(KFOR‐TV and Querry 2018).
­Laser Education
Veterinary School Curriculums
The technologies and techniques we have discussed in
this textbook are well‐established, and there is every
indication that they will remain and continue to be devel-
oped, becoming an integral part of veterinary medicine
and surgery of today and tomorrow. Colleges of
Veterinary Medicine should consider taking steps to

incorporate coursework on laser physics, laser–tissue
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interaction, and laser safety into their curriculums to
prepare their students and graduates for the technolo-
gies becoming so readily available in today’s practices.
Such education would make tomorrow’s veterinarians
valuable to their employers, improve levels of safety in
veterinary facilities, and increase confidence and alacrity
in veterinarians’ familiarity with laser equipment and
techniques, all while continuing to improve the quality of
patient care and meeting public expectations for the best
and most advanced services available to their pets.
Acceptance of Laser Medicine and Surgery
as a Board Certification Specialty
The precedent exists in radiology for a board certifica-
tion based on a technology and how it interacts with
living tissue in order to improve patient care.
­ lasers, and possibly refer cases for diagnostic
Compartmentalizing components of a laser education
within an existing specialty (such as surgery, internal
medicine, or rehabilitation) potentially isolates the stu-
dent from a complete understanding of how lasers work
and fundamentally interact with living tissue, as the dif-
ferent lasers used in surgical applications, photodynamic
therapy, and photobiomodulation all share the same
roots in physics, tissue interaction, and safety, making a
broad study of the subject invaluable to the understand-
ing of practitioners wishing to implement these technol-
ogies in an integrated effort with utmost effectiveness.
Governing bodies of veterinary medicine should there-
fore consider the establishment and recognition of laser
medicine and surgery as a separate board certification.
I­ n Their Own Words: The Authors
on the Future of Lasers
My vision is of an un‐tethered laser surgical hand‐
piece, with laser emission activated and deacti-
vatedbythesurgeon’sfingerpressure.Thehand‐piece
will monitor tissue temperature and adjust power
density for best tissue effect.
John C. Godbold, Jr., DVM
I have seen many advances in the use of Lasers
over the past 28 years for both human and animal
uses. I hope new applications continue to develop
and that more surgeons take advantage of this
amazing technology.
Les “Laser Les” Lattin
Laser surgical procedures offer the option to
p erform traditional surgical procedures with
­ glues, and even allografts.
decreased morbidity, decreased surgical time,
­In Their Own Words: The Authors on the Future of Laser 339
and decreased recovery time. The future of laser
surgery also offers the opportunity to perform
procedures that a scalpel and blade previously
could not reach.
Gaemia Tracy DVM
When I was a student in the mid 1980s, ultra-
sound imaging was becoming available, and we
thought it would be utilized by specialists only.
At this time, more than 30 years later, it is
extremely common for general practitioners to
have these devices in their hospitals for everyday
use. My belief is that in the near future, every
practitioner will have a laser in their hospital as
well. The benefits are so obvious for the patient,
client, and veterinarian alike. All veterinarians
someday will be using surgical lasers, therapeutic
imaging using lasers for optical coherence
tomography.
Noel Berger, DVM, MS, DABLS
The future of CO2 lasers in veterinary surgery will
revolve around minimally invasive robotic sur-
gery. Human surgeons have embraced this new
and exciting technology in the treatment of head
and neck cancer, urogenital disease in women
such as myomyectomy for uterine fibroids and
prostatectomy in men. These robotic devices con-
sist of a small flexible fiber‐based laser delivery
system with a 360° mobile laser tip. They are
equipped with cameras that can provide 3‐D
images. They can be used by themselves or
­combined with a magnifying device such as an
operating microscope. The mobility of the laser
tips exceeds that of the human wrist allowing the
surgeon unparalleled access to the target tissue.
These devices incorporate and enhance the
­advantages of the CO2 laser: precise dissection,
hemorrhage control and minimal collateral tissue
damage. Procedures using minimally invasive
robotic devices help achieve the goals of surgery:
diminished patient morbidity, shorter anesthesia
and hospitalization times and earlier return to
function.
Daniel M. Core, DVM
There is much interest in performing direct tissue
apposition … to directly “weld” vessels, bone,
nerves, and possibly other soft tissues. This would
reduce the morbidity and delay in healing associ-
ated with using artificial substances such as suture,
David S. Bradley, DVM, FASLMS
 340 The Future of Lasers in Veterinary Medicine and Surgery
­References
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BioOptics World. (2014). Ophthalmology/image‐guided
surgery: ‛heads‐up’ 3D‐enabled retinal surgery broadcast
live. https://www.bioopticsworld.com/articles/print/
volume‐7/issue‐3/departments/news‐notes/
ophthalmology‐image‐guided‐surgery‐heads‐up‐3d‐
enabled‐retinal‐surgery‐broadcast‐live.html (accessed
24 June 2018).
Chang A. (2014). New 3D printer by MarkForged can print
with carbon fiber. https://www.popularmechanics.com/
technology/gadgets/a10025/new‐3d‐printer‐by‐
markforged‐can‐print‐with‐carbon‐
fiber‐16428727/?click=pm_latest (accessed 24 June
2018).
Cision PR Web. (2018). The Los Angeles Minimally
Invasive Spine Institute reports the first use in the
United States of a Novel Sony Heads‐Up Display for
spinal surgery. http://www.prweb.com/releases/2016/06/
prweb13517248.htm (accessed 24 June 2018).
Huang K, Seo M, Sarmiento T. et al. (2014). Electrically
driven subwavelength optical nanocircuits. Nat.
Photonics 8, 244–249.
Huang H, Walker C, Nanda A. et al. (2013). Laser welding
of ruptured intestinal tissue using plasmonic
polypeptide nanocomposite solders. ACS Nano. 7(4). pp
2988–2998.
KFOR‐TV and Querry K. (2018). Oklahoma City gorilla
undergoes first robotic surgery to repair hernia. https://
kfor.com/2018/09/24/oklahoma‐city‐gorilla‐undergoes‐
first‐robotic‐surgery‐to‐repair‐hernia (accessed 25
September 2018).
Mount Sinai. Skull Base Surgery Center. (2018) TransOral
Robotic Surgery (TORS) program. https://www.
mountsinai.org/locations/skull‐base‐surgery‐center/
treatment/transoral‐robotic‐surgery‐tors (accessed 24
June 2018).
Mushaben M, Urie R, Flake T, et al. (2018).
Spatiotemporal modeling of laser tissue soldering
using photothermal nanocomposites. Lasers Surg.
Med. 50(2). pp. 143–152.
Nystrom G, Razaq A, Strømme M, et al. (2009). Ultrafast
all‐polymer paper‐based batteries. Nano Lett. 9(10). pp.
3635–3639.
Urie R, Quraishi S, Jaffe M, et al. (2015). Gold nanorod‐
collagen nanocomposites as photothermal nanosolders
for laser welding of ruptured porcine intestines. ACS
Biomater. Sci. Eng. 1(9). pp. 805–815.
UTHealth. (2014). TORS‐L: transoral robotic surgery
with CO2 laser offers greater precision for surgeons
and de‐intensification of adjuvant therapies for
patients. https://med.uth.edu/orl/2014/08/25/tors‐l‐
transoral‐robotic‐surgery‐with‐co2‐laser‐offers‐
greater‐precision‐for‐surgeons‐and‐de‐
intensification‐of‐adjuvant‐therapies‐for‐patients
(accessed 24 June 2018).

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Appendix A
Glossary
Ablation The process of removal of tissue by cutting or
vaporization. Typically achieved in laser surgery
when fluence exceeds 3 J/cm2.
Absorption The conversion of light to other forms of
energy when it passes through material media.
Active medium A material selected for containment
within a given optical cavity to undergo stimulated
emission for the production of radiant energy
(photons). The specific medium used within the
optical cavity of a laser resonator determines the
specific wavelength of laser light produced by that
resonator.
Articulated arm A delivery system consisting of an
apparatus of tubes and seven 360°‐swiveling elbow
joints, each joint containing a mirror of high
reflectance.
Atom The smallest unit having all the unique physical
and chemical properties of any one of the elements,
of which there are 108 varieties presently known. An
atom consists of a nucleus containing neutrons
(uncharged particles) and protons (positively charged
particles), around which smaller, negatively charged
particles known as electrons rotate in orbits that can
be elliptic or circular and are constrained to have only
certain sizes and distances from the nucleus. In a
normal (neutral) atom, the number of electrons is
equal to the number of protons.
Attenuation The progressive weakening of a light ray as
it penetrates deeper into a material medium. In
general, it is caused by both absorption and scattering.
In homogeneous, isotropic materials, it is exponential
in nature: the ray loses a constant fraction of its
intensity in every unit distance of forward travel.
Average power An expression (in W) of the total amount
of laser energy delivered divided by the duration of the
laser exposure. For a pulsed laser, the product of the
energy per pulse (J) and the pulse frequency (Hz).
Beam of light A bundle of rays of light traveling in the
same general direction with an included solid angle
that is less than 90°. May be divergent, convergent, or
collimated.
Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.
© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
341
Chromophore A substance, molecule, or tissue type
exhibiting selective light‐absorbing qualities (often to
specific wavelengths), facilitating its conversion to
other forms of energy. Also known as a
photoacceptor.
Coagulation A process of denaturing living tissue by
heating it to temperatures between 45 and 70 °C for
sufficient periods of time. Typically, occurs in laser
surgery at a fluence of 3 J/cm2 or less.
Coherence A unique characteristic of laser radiation,
manifested in two ways: spatial and temporal. Spatial
coherence is the coincidence of the crests and valleys
of the electrical waves of light rays in a beam, along
surfaces that are everywhere perpendicular to the
rays. Temporal coherence is the constancy of speed
of propagation, frequency, and wavelength of the
light waves.
Collimation The property of a beam of light in which
all the rays are parallel to one another; the beam has
no divergence, and its included solid angle is 0°. A
characteristic of laser radiation.
Contact technique A laser technique in which the
delivery system of the laser comes into direct contact
with the target tissue, such as the direct contact
utilization of a charred hot glass tip of a diode or
Nd:YAG laser.
Continuous wave A type of exposure where laser light
is continuously emitted as long as the activation
switch is depressed. By definition, a continuous wave
always possesses a duty cycle of 100%.
Delivery system A means of delivery of laser light
from a resonator to a patient. Its distal end is
typically fitted with either a handpiece or other
piece of equipment (a microscope or endoscope)
for the refinement of laser light delivery to the
patient.
Drug‐to‐light interval The period of time between the
administration of a photosensitizer and its activation
by light.
Duty cycle The percentage of a given single cyclical
period of time in which laser light is being emitted, or
 342 Appendix A Appendix A
“on.” For example, in a period of 1 second, if the laser
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were on for 0.8 seconds and off for 0.2 seconds, the
laser’s duty cycle would be 80%.
Electron The small, negatively charged particle that
orbits the nucleus of an atom.
Energy The ability to do work, such as lifting a mass
against the force of gravity. The product of power
(W) and duration (seconds). 1 J = 1 W × 1 second.
Energy density A synonymous term with fluence (see
fluence).
Excimer A diatomic molecule consisting of a halogen
atom (Cl or F) and an atom of noble gas (argon,
dkrypton, or xenon), which exists only in the excited
state of one or both atoms, and dissociates after
emitting radiation in the ultraviolet portion of the
spectrum.
Excitation The process by which an atom or molecule
or ion increases its energy above the normal, or
ground, level. It requires absorption of a quantum of
energy from outside having exactly the value
corresponding to the difference between the ground
level and some permitted higher level.
Exposure The synonymous term used in this textbook
for a temporal mode.
Fluence The energy delivered by a laser beam to a
target, divided by the irradiated area of that target.
The basic unit is 1 J/cm2.
Frequency The number of cycles per second of a
sinusoidal wave of light passing a fixed point in space;
or the number of pulses per second in the output
power of a pulsed laser.
Gaussian The name given to a laser beam that has the
most fundamental transverse electromagnetic mode
(TEM00), or bell‐shaped distribution of power density
across the beam.
Hand piece That part of a laser’s delivery system held
in the hand of a surgeon for delivery of laser light to
the patient. Handpieces come in a variety of designs,
some with the means to adjust spot size in order to
further manipulate control of fluence and power
density during a surgical procedure. They are typically
made of autoclavable materials to facilitate sterility.
Hertz The basic unit of frequency in the International
System (SI) of units, measured in cycles per second.
Hollow waveguide A delivery system consisting of a
flexible hollow metal tube, the inner surface of which
carries high reflectance.
Index of refraction The ratio of the speed of light in
free space to its speed in a material medium. The
refractive index of every material medium is greater
than unity, except near wavelengths where the
medium exhibits significant absorption.
Intensity Synonymous with irradiance and power
density of a ray or beam of light (see power density).
Ion An atom in which the number of orbiting electrons
is not equal to the number of protons on the nucleus.
It has a net electric charge that is either positive or
negative, but not zero.
Irradiance Synonymous with Intensity and power
density of a ray or beam of light (see power density).
Joule (J) The basic unit of energy or work in the
International System (SI) of units, equal to an
exposure of 1 W of power for one second.
Kilogram (kg) The basic unit of mass in the
International System (SI) of units, equal to 1000 g.
Laser An apparatus for the purpose of generating
coherent, collimated, monochromatic
electromagnetic radiation. The acronym LASER
stands for Light Amplification by Stimulated
Emission of Radiation.
Laser light The spectrum of electromagnetic radiation
producible by a laser apparatus, ranging from 100 to
20 000 nm, and consisting of sinusoidal waves of
orthogonal electric and magnetic fields that are both
perpendicular to its axis of propagation.
Characteristics particular to laser light include
coherence, collimation, and monochromaticity.
Longitudinal modes Those discrete wavelengths of
standing waves of light reflected back and forth between
the mirrors of an optical cavity in such a way that the
forward and backward waves reinforce each other.
Mass The essential property of matter. Mass is
convertible into energy according to the equation
E = mc2, where E is energy, m is mass, and c is the
velocity of light in free space.
Matter The fundamental substance of which all
materials in the universe are composed. Its most
important property is mass. Its basic unit is the atom.
Meter The basic unit of length in the International
System (SI) of units.
Molecule A collection of atoms bound together by
forces associated with the outermost electrons.
Inorganic molecules are usually smaller than organic,
the most complex of which can contain thousands of
atoms.
Monochromaticity The property of having just one
wavelength. A characteristic of laser radiation.
Micrometer (μm) One millionth (10−6) of a meter. Also
known as a micron.
Microsecond (μs) One millionth (10−6) of a second.
Mie scattering A type of scattering caused by particles
greater than or equal to the wavelength of the laser
light being scattered, predominantly occurring in a
forward direction of propagation.
Millisecond (ms) One thousandth (10−3) of a second.
Mode For the purpose of this textbook, the state in
which the laser is operating with Superpulse either
on or off.

Nanometer (nm) One billionth (10−9) of a meter. In
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this textbook, the basic unit of a wavelength of laser
light.
Nanosecond One billionth (10−9) of a second.
Non‐contact technique A laser technique in which the
delivery system does not touch the target tissue, such
as the beam of a CO2 laser. Light radiation may be
focused or defocused depending on operator’s
technique and procedure.
Optical cavity A chamber or volume of space coaxial
with and located between two mirrors whose
geometry is such that a paraxial ray of light traveling
back and forth between the mirrors will always
remain within the cavity.
Optical fiber A delivery system consisting of a solid
slender filament of optically transparent material
(quartz, glass, or polymethylmethacrylate) having a
diameter between 0.1 and 1.0 mm and an index of
refraction significantly greater than unity. It is usually
clad with a thin coating of another material having a
lower index of refraction. It transmits light by total
internal reflection, even around bends of short
radius.
Peak power The highest power in a laser pulse.
Photobiomodulation In medicine, the utilization of
light energy to achieve physiological and biochemical
changes within tissues in order to obtain a beneficial
therapeutic outcome.
Photochemolysis Breakdown of living tissue or
inorganic polymers by rupture of interatomic bonds
caused by energetic photons at wavelengths shorter
than 319 nm. This process occurs at average power
densities below 1 W/cm2.
Photodynamic therapy The selective removal of
unwanted cells and tissues through the release of
reactive (singlet) oxygen by a chemical substance
(photosensitizer) following that substance’s activation
by light.
Photon A massless quantum of radiant energy,
transmitted through free space and material media in
straight‐lines at the speed of light. It is equivalent to a
wavelet, and its energy is proportional to the
frequency of this equivalent wavelet.
Photoplasmolysis The ionization of atoms in
molecules by the strong electric fields of light waves
at power densities above 10 billion W/cm2, to form a
plasma at very high temperatures.
Photopyrolysis The conversion of light into heat
within tissue, causing the elevation of its temperature
to levels and for time intervals such that the tissue is
destroyed (but not vaporized) by thermal breakdown
and the denaturation of proteins, at temperatures
between 50 and 100 °C. This process occurs in soft
tissue at power densities between 1 and 100 W/cm2.
Appendix A 343
Photosensitizer A chemical substance applied
topically or systemically with selective uptake by cells
that, when activated by light, releases reactive
(singlet) oxygen to cause local cell death.
Photothermolysis The conversion of light into heat
within tissue and the subsequent destruction of that
tissue either by thermal breakdown or by
vaporization of the histologic water. Includes both
photopyrolysis and photovaporolysis. The primary
process by which most laser surgery is conducted.
Photovaporolysis The conversion of light into heat
within tissue, causing subsequent destruction of that
tissue through rapid boiling of the water within and
between cells to form steam, which expansively
ruptures the cells and destroys the histologic
architecture, at temperatures between 100 and
300 °C. This process occurs in soft tissue at power
densities between 100 and 1 000 000 W/cm2.
Picosecond One trillionth (10−12) of a second.
Planck’s constant The proportionality factor (h) in the
equation relating photonic energy to the frequency of
the equivalent wavelet: Ep = hf. This factor is named
after Max Planck, and its value is 6.626 × 10−34 J s.
Plume The smoke produced from aerosolization of
by‐products due to laser–tissue interaction. It is
composed primarily of water vapor, with cellular
debris, particulate matter, carbonaceous and
inorganic materials, and potentially biohazardous
products.
Population inversion A condition of having more
atoms or molecules of a medium in an excited state
within a laser resonator than in unexcited or less‐
excited states.
Power The amount of work performed in a unit of
time, such as the time‐rate of transfer of energy from
one place to another, or transformation of energy
from one form to another. The basic unit of power is
the watt (W). 1 W = 1 J/1 second.
Power density The power transmitted by a laser
beam per unit area of cross‐section of that beam,
or the power falling upon the target of a laser
beam per unit area of the irradiated surface of
that target, also known as intensity and
irradiance. The basic unit of power density in
laser surgery is 1 W/cm2.
Pulse duration A measurement of the total amount of
time that a pulse is emitted; also known as pulse
width.
Pumping The process of adding energy to a laser
medium in such a way that its atoms or molecules are
excited, creating a population inversion.
Radiation The transport of energy through space from
one point to another, with or without the need for an
intervening material medium. It occurs in straight‐lines
 344 Appendix A Appendix A
and at constant speed in a homogeneous, isotropic
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medium.
Radical A group of connected atoms or ions that
passes unchanged through a chemical reaction, and
may form an important constituent of a molecule.
Randomly diffused radiant flux Light within tissue
having such strong scattering that the probability of
photon travel is equal in all possible directions. The
exact opposite of collimated, coherent radiation such
as laser light. When dealing with randomly diffused
radiant flux, power density is the number of photons
per unit time passing through a small sphere, divided
by the equatorial cross‐section of that sphere.
Ray of light The axis of a light wave.
Rayleigh scattering A type of scattering caused by
particles less than the wavelength of the laser light
being scattered. Unlike Mie scattering, Rayleigh
scattering is strongly dependent on the wavelength of
laser light and may occur in any direction.
Reflection The redirection of a ray of light from its
impact point on the boundary surface between two
different media back into the hemisphere of space,
centered at the impact point, from which that ray
originated, in such a way that the angle of incidence
is equal to the angle of reflection (both measured
from the perpendicular to the reflecting surface in
the plane defined by the incident and reflected
rays). In general, some of the intensity of the ray
will be lost by penetration into the reflecting
medium, so that the reflected ray is relatively
weaker than the incident ray.
Refraction The change in direction of a ray of light
upon striking the interface between two media of
different refractive indices, in such a way that the
angle of incidence is always less in the medium of
higher index. In general, refraction is accompanied by
reflection of some of the intensity of the incident ray,
except where the angle of incidence is greater than
the critical angle for total reflection in dense‐to‐rare
crossing of the interface.
Repeat pulse A type of exposure where the laser light
is emitted intermittently in short bursts as long as the
trigger is depressed.
Repetition rate Number of pulses per second, also
known as the pulse rate, usually expressed in hertz.
Resonator That part of a laser apparatus consisting of
the optical cavity and the active medium contained
therein.
Scattering The change in direction of a ray of light in a
material medium or living tissue without a change of
wavelength; the result is the dispersal of the ray of
light throughout tissue.
Second (s) The basic unit of time in the International
System (SI) of units.
Single pulse A type of exposure where laser light is
emitted in only a single timed burst with depression
of the trigger.
Singlet oxygen The lowest excited state of the O2
molecule. Highly cytotoxic in its reaction with
surrounding organic compounds.
Spectrum A continuous range of wavelengths or
frequencies of electromagnetic radiation. The whole
electromagnetic spectrum spans more than 20 orders
of magnitude, from long radio waves to ultra‐short
cosmic rays.
Speed of propagation The distance traveled per unit
time by a light wave or photon, without regard to
direction. In free space, it is 2.998 × 108 m/s.
Spontaneous emission The emission of a photon of
light by an excited atom or molecule as it returns to a
lower level of energy without an external influence.
The source of all light in nature.
Spot Size In focused laser beam systems, the diameter
(in mm) of the circular pattern that laser light
produces on its target tissue that contains 86% of the
total power of the laser beam, or the diameter of the
aperture of a handpiece to create just such a circular
pattern when held at optimal focal distance from the
target tissue. Spot size is inversely proportional to
power density.
Stimulated emission The triggering of an excited
atom or molecule by an incident photon to emit an
identical photon, parallel to and synchronized with
the incident photon, but without absorption of the
incident photon.
Superpulse A mode of laser light delivery
characterized by extremely short pulses of high peak
power, in which the pulse durations are shorter than
thermal relaxation time, while the spacing between
pulses is greater than thermal relaxation time. Such
intense pulses of high power exceed the power of a
continuous wave exposure and help to facilitate
efficient ablation, while the interval between pulses
minimize collateral thermal trauma. Superpulse may
be available in different forms of exposure.
Temporal mode The pattern of time‐variation of
output power from a laser apparatus. In this
textbook, temporal mode is synonymous with
Exposure. Usually, available in three pre‐programmed
forms: continuous wave, repeat pulse, or single pulse.
Thermal relaxation time The rate at which an
irradiated tissue diffuses heat; it is dependent on a
particular tissue’s wavelength‐dependent absorption
coefficient.
Transmission The passage of laser light directly
through tissue without any tissue effects, due to lack
of an appropriate absorptive or scattering medium
relative to the laser’s wavelength.

Transverse electromagnetic mode The distribution of
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power density across a laser beam as a function of
angular position and radial distance from the axis. It
is usually abbreviated as TEMmn, where m and n are
integers equal to the number of troughs of power
density in the x‐direction and y‐direction,
respectively, of a three‐dimensional plot of the
intensity profile of the beam in which the z‐direction
is the beam axis of propagation.
Vaporization The conversion of liquid water into vapor.
Appendix A 345
Velocity (of a photon or wave) The vector whose
direction is the direction of travel at the point or
moment in question, and whose magnitude is the
speed of the wave or photon at that point and
moment.
Watt (W) The basic unit of power in the International
System (SI) of units. 1 W equals 1 J/s.
Wavelength The distance between any two successive
crests of the electric wave of a ray of light. In this
book, measured in nanometers.
 346
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Appendix B

Certifying and Academic Laser Organizations

American Board of Laser Surgery (ABLS) Laser Institute of America (LIA)

Administrative Office 13501 Ingenuity Drive, Suite 128
55 Corporate Drive, 3rd Floor Orlando, FL 32826, USA
Trumbull, CT 06611, USA Phone: 1‐800‐345‐2737
Phone: 203‐332‐2507 www.lia.org
www.americanboardoflasersurgery.org https://www.lia.org/contact
lasers1060@gmail.com
International Academy for Laser Medicine
American Institute of Medical Laser Applications
and Surgery (IALMS)
(AIMLA)
Borgo Pinti 57
18070 Raymond Rd
50121, Florence, Italy
Marysville, OH 43040, USA
Phone: (+39) 055.234.2330
Phone: 937‐642‐9813
http://ialms.international
www.aimla.org
secretary@ialms.international
ron.riegel@aimla.org
sarah.crouse@aimla.org North American Association
for PhotobiomoduLation Therapy (NAALT)
American Laser Medicine College and Board
3700 Koppers Street, Suite 100
(ALMCB)
Baltimore, MD 21227, USA
(Advanced level training and certification in laser ­surgery
Phone: 410‐592‐9889
and laser dentistry)
www.naalt.org
Peter Vitruk, PhD
www.naalt.org/contact
Peter@americanlaserstudyclub.org
American Laser Study Club (ALSC)
www.americanlaserstudyclub.org
ALSC@americanlaserstudyclub.org
American Society for Laser Medicine and Surgery
(ASLMS)
2100 Stewart Avenue, Suite 240
Wausau, WI 54401, USA
Phone: 715‐845‐9283/877‐258‐6028
www.aslms.org
information@aslms.org

Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.

© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
 347
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Appendix C

Tables of Laser Settings

Table C.1 Chapter 7: Canine and feline elective laser surgery procedures.

Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Onychectomy, feline CO2 0.25–0.4 6–12 Continuous wave SuperPulse — 100

10 600 nm
Orchiectomy, canine CO2 0.25–0.4 8–15 Continuous wave SuperPulse — 100
10 600 nm
Orchiectomy, feline CO2 0.25 6 Continuous wave SuperPulse — 100
10 600 nm
Ovariohysterectomy, CO2 0.25–0.4 10–20 Continuous wave SuperPulse — 100
canine 10 600 nm
Ovariohysterectomy, CO2 0.25 7–10 Continuous wave SuperPulse — 100
feline 10 600 nm

Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.

© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
 348 Appendix C

Table C.2 Chapter 8: Canine and feline oral laser surgery procedures.
VetBooks.ir

Laser type Spot size/fiber

Procedure wavelength diameter (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Contact mucositis and CO2 0.8, or 2.5 × 0.4 3–6 Continuous wave Non‐SuperPulse — 100
mucosal ulceration 10 600 nm
Frenectomy CO2 0.4 4–6 Continuous wave Non‐SuperPulse — 100
10 600 nm
Gingivectomy CO2 0.25 or 0.3 4–8 Continuous wave Non‐SuperPulse — 100
10 600 nm 0.8 10–15
Gingivoplasty CO2 0.8 (defocused) 8–10 Continuous wave Non‐SuperPulse — 100
10 600 nm
Gum Chewer’s lesions CO2 0.8 (defocused) 4 Continuous wave Non‐SuperPulse — 100
10 600 nm
Operculectomy CO2 0.25 or 0.3 10 Continuous wave Non‐SuperPulse — 100
10 600 nm
Diode laser 0.3 4 Continuous wave Non‐SuperPulse — 100
810 nm
Oral mass excision CO2 0.25 or 0.3 5 Continuous wave Non‐SuperPulse — 100
10 600 nm
Periodontal pocket CO2 4 (defocused) 2 Continuous wave Non‐SuperPulse — 100
surgery 10 600 nm
Diode laser 0.3 0.8–1.5 Repeat pulse Pulsed 15–17 50
810 nm 30 s 33 ms
Stomatitis, feline CO2 0.8 6 Continuous wave Non‐SuperPulse — 100
10 600 nm
Tongue surface surgery CO2 0.4 10 Continuous wave Non‐SuperPulse — 100
10 600 nm

Table C.3 Chapter 9: Canine and feline laser surgery procedures of the nose and throat.

Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency Duty cycle (%)

Elongated soft palate CO2 0.4 6–8 Repeat pulse Non‐SuperPulse 10 Hz, 10 ms 10
(marking)
Elongated soft palate 10 600 nm 15–30 Continuous — 100
(excision) wave
Everted laryngeal CO2 0.4 3–4 Continuous SuperPulse — 100
saccules 10 600 nm wave

Stenotic nares (marking) CO2 0.4 4 Repeat pulse Non‐SuperPulse 2–5 Hz, 10 ms 2–5
Stenotic nares (alar fold 10 600 nm 0.8 10–20 Continuous SuperPulse or — 100
ablation) wave non‐SuperPulse
Stenotic nares (alar fold 0.4 8–10
excision)
Tonsillectomy CO2 0.4 3–4 Continuous Non‐SuperPulse — 100
10 600 nm wave
 Table C.4 Chapter 10: Canine and feline laser surgery procedures of the ear.

Laser type Duty

Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency cycle (%)
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Apocrine cysts CO2 0.8 3–4 Repeat Non‐SuperPulse 2 Hz, 200 ms 40

pulse
10 600 nm 6 Continuous — 100
wave
Aural hematoma CO2 1.4 10–15 Continuous Non‐SuperPulse — 100
10 600 nm wave

Cerumen glands CO2 0.8 3–4 Repeat Non‐SuperPulse 2 Hz, 200 ms 40

120–180 WG pulse

10 600 nm 0.25 Continuous SuperPulse — 100

wave
Myringotomy CO2 0.8 4–6 Single pulse, Non‐SuperPulse — —
200–500 ms
10 600 nm 120–180 WG 4 Repeat pulse 2 Hz, 200 ms 40
Nasopharyngeal CO2 0.8 10–15 Continuous Non‐SuperPulse — 100
polyps 10 600 nm 120–180 WG wave

Stenotic ear CO2 0.8 6–7 Continuous Non‐SuperPulse — 100

canals 10 600 nm 120–180 WG wave

Table C.5 Chapter 11: Canine and feline periorbital and eyelid laser surgery procedures.

Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency Duty cycle (%)

Cherry eye CO2 0.25 3–4 Continuous SuperPulse — 100

10 600 nm wave

Distichiasis CO2 0.25–0.4 3–5 Continuous SuperPulse — 100

wave
10 600 nm Single pulse, Non‐SuperPulse — —
200–500 ms
Entropion CO2 0.25 or 0.4 10–15 Continuous SuperPulse — 100
(incisional) 10 600 nm wave

Entropion CO2 0.4 8–10 Continuous Non‐SuperPulse — 100

(non‐incisional) 10 600 nm wave

Eyelid neoplasia CO2 0.25 or 0.4 3–5 Continuous SuperPulse — 100

10 600 nm 0.4 8–12 wave

Lagophthalmos CO2 0.25 3–4 Continuous SuperPulse — 100

10 600 nm wave

Nasal facial fold CO2 0.4 15–20 Continuous SuperPulse — 100

trichiasis 10 600 nm wave

Table C.6 Chapter 12: Ophthalmic lasers for the treatment of glaucoma.

Laser type Duty

Procedure wavelength Delivery system Sites (°) Power (mW) Exposure Duration (ms) Energy (J) cycle (%)

ECP Diode laser 1 mm × 30 mm 90–360 250 (100–1000) Continuous To effect — 100

810 nm Endoscope wave

mTSCP Diode laser MP3 probe 320–340 2000 Micropulse 18 000 12 33

810 nm
TSCP Diode laser 600 μm 24–55 1000–1500/site Continuous 1500–4000/site 2.5–4/site 100
810 nm Glaucoma wave
(“G”) probe
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Table C.7 Chapter 13: Canine and feline dermatologic laser surgery procedures.

Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Actinic keratosis CO2 Wide ablation tip 8 Repeat pulse SuperPulse 20 40

10 600 nm 0.8 mm 4 10 20
5 40
Bowenoid in situ CO2 Wide ablation tip 25 Repeat pulse SuperPulse 20 73
carcinoma 12 20
10 600 nm 0.8 mm 12 20–40
Ceruminous (apocrine) CO2 Wide ablation tip 12–25 Repeat pulse SuperPulse 29 73
cystomatosis 10 600 nm or 0.8 mm 8 Non‐SuperPulse 10–20 20–40
External ear CO2 Wide ablation tip 12–25 Repeat pulse SuperPulse 29 73
hyperplasia 10 600 nm or 0.8 mm 8 Non‐SuperPulse 10–20 20–40
Follicular cyst, CO2 Wide ablation tip 30–35 Continuous wave Non‐SuperPulse — 100
interdigital 10 600 nm 25–12 Repeat pulse SuperPulse 29 73
12 10–20 30–50
Follicular cyst, elbow CO2 Wide ablation tip 25–12 Repeat pulse SuperPulse 29 73
10 600 nm 8 10–20 40
Follicular tumors CO2 0.25 mm 25 Repeat pulse SuperPulse 29 73
10 600 nm 12 20 40
Hamartomas CO2 0.25 mm 35 Repeat pulse SuperPulse 29 73
12 20 73
10 600 nm Wide ablation tip 20 29 73
12 20 40
Pigmented viral CO2 Wide ablation tip 30 Repeat pulse SuperPulse 29 73
plaques 15 20 60
10 600 nm 0.8 mm 12 10–20 20–60
Sebaceous gland CO2 Wide ablation tip 30–35 Repeat pulse SuperPulse 29 73
tumors 10 600 nm 25–12 Non‐SuperPulse 20 40
Squamous cell CO2 0.25 mm 25 Repeat pulse SuperPulse 29 73
carcinoma 10 600 nm 12 20 40

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 Appendix C 351

Table C.8 Chapter 14: Canine and feline urogenital and perianal laser surgery procedures.
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Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency Duty cycle (%)

Anal gland excision CO2 0.25 10–15 Continuous SuperPulse — 100

10 600 nm 3–5 wave

Cystotomy CO2 0.25 10 Continuous SuperPulse — 100

10 600 nm wave
Orchiectomy, CO2 0.25 10–15 Continuous SuperPulse — 100
cryptorchid 10 600 nm wave

Paraphimosis CO2 0.25 10–15 Continuous Non‐SuperPulse — 100

10 600 nm 5–8 wave

Perineal urethrostomy, CO2 0.25 15 Continuous SuperPulse — 100

canine 10 600 nm 10 wave Non‐SuperPulse
Perineal urethrostomy, CO2 0.25 15 Continuous SuperPulse — 100
feline 10 600 nm 10 wave Non‐SuperPulse
Prolapse, urethral CO2 0.25 10 Continuous Non‐SuperPulse — 100
10 600 nm wave

Prolapse, vaginal CO2 0.25 15–20 Continuous SuperPulse — 100

10 600 nm 15 wave

Vasectomy, canine CO2 0.25 15 Continuous SuperPulse — 100

10 600 nm wave

Vulvoplasty, canine CO2 0.25 15 Continuous SuperPulse — 100

10 600 nm Wide ablation tip wave Non‐SuperPulse

Table C.9 Chapter 15: Canine and feline oncological laser surgery procedures.

Laser type
Procedure wavelength Spot size Power (W) Exposure Mode Frequency Duty cycle (%)

Cutaneous CO2 0.8–1.4 mm 10 or more Continuous Non‐SuperPulse — 100

neoplasms 10 600 nm 3 mm wide wave
(ablation) ablation tip
Cutaneous CO2 0.25–1.4 mm 10–15 Continuous SuperPulse or — 100
neoplasms 10 600 nm (0.4 mm) wave non‐SuperPulse
(excision)
Oral tumor CO2 0.4 mm 10–15 Continuous Non‐SuperPulse — 100
(ablation) defocused wave
10 600 nm 3 mm wide
ablation tip
Oral tumor CO2 0.25–1.4 mm 10–15 Continuous SuperPulse or — 100
(excision) 10 600 nm (0.4 mm) wave non‐SuperPulse

Subcutaneous CO2 0.25–1.4 mm 10–15 Continuous SuperPulse or — 100

neoplasms (lipoma, 10 600 nm (0.4 mm) wave non‐SuperPulse
AGASACA)
Thyroidectomy CO2 0.25–1.4 mm 10–15 Continuous SuperPulse or — 100
10 600 nm (0.4 mm) wave non‐SuperPulse
 352 Appendix C

Table C.10 Chapter 16: Canine and feline laser photodynamic therapy procedures.
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Laser type Drug‐to‐light Treatment

Procedure wavelength Fiber diameter Photosensitizer interval Power (mW) Dose (J/cm2) frequency

Antimicrobial PDT Diode 400–600 μm Methylene– 5 min 500 10–100 1 wk−1

(810 nm) microlens violet–blue

PDT of neoplasms Diode 400–600 μm mTHPC 6h 500 10–30 (non‐contact) 1 mo−1

(652 nm) microlens 30 (contact)

Table C.11 Chapter 17: Surgical lasers in minimally invasive and endoscopic small animal procedures.a

Laser type Power Contact

Procedure wavelength Fiber diameter (W) Frequency Energy (J) technique

a
Aural mass resection Diode Dependent on 10–12 Continuous wave Contact
and ablation 810 or 980 nm otoscope

Ectopic ureter Diode 325 μm sculpted, Up to 10 Short cycle 0.5–0.8 Contact

correction pointed tip
810 or 980 nm Right‐angled firing
fiber
a
Ho:YAG Dependent on 8–10 Hz 1.2 Contact
2100 nm endoscope
a
Endobronchial mass Diode Dependent on 12–15 5000–2000 Hz Contact
resection 810 or 980 nm endoscope
a
Ho:YAG 4–10 Hz 0.8–1.7 Non‐contact
2100 nm
a a
Esophageal mass Diode Dependent on 10–12 Long cycle
debulking 810 or 980 nm endoscope
a
Ho:YAG 550 μm Up to 18 Long cycle 1.2
2100 nm
a
Esophageal stricture Ho:YAG 325 μm 8–12 15 Hz 0.5–0.8
resection 2100 nm
a
Everted laryngeal Diode Dependent on Up to 12 Up to 20 000 Hz Contact
Saccule resection 810 or 980 nm endoscope
a
Gastric mass debulking Diode Maximum allowed 15 Short cycle Contact and
810 nm by endoscope non‐contact
a a a
Gastric mass resection Diode Maximum allowed 8–10
810 or 980 nm by endoscope
a
Lithotripsy Ho:YAG 325–550 μm 8–15 Hz 1.2–2 Contact or
2100 nm non‐contact
a
Myringotomy Diode 325 μm or less <8 Continuous wave Contact
810 or 980 nm
 Appendix C 353

Table C.11 (Continued)

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Laser type Power Contact

Procedure wavelength Fiber diameter (W) Frequency Energy (J) technique
a
Persistent mesonephric Diode Maximum allowed 12–14 15 Hz Contact
remnant resection 810 or 980 nm by endoscope
a
Ho:YAG 8–10 Hz 1.2
2100 nm
a
Rhinoscopic laser Diode Dependent on 6–12 Continuous wave Contact
intervention 810 or 980 nm endoscope or up to 20 Hz
a
Ho:YAG 6–10 Hz 0.8–1.7 Contact and
2100 nm non‐contact
a
Transurethral resection Diode Maximum allowed 10–15 Long cycle Contact
of neoplasia (TURN) 810 or 980 nm by endoscope
a
Transurethral resection Ho:YAG 525 μm 8–15 Hz 1.2–1.7 Contact
of prostate (TURP) 2100 nm
a
Certain fields of Table C.11 will depend on the reader’s own equipment selection and the individual surgical case.

Table C.12 Chapter 18: Canine laser neurosurgical procedures.

Laser type
Procedure wavelength Fiber diameter Power (W) Exposure Mode Frequency

Percutaneous laser Ho:YAG 320‐μm, low‐OH 2 Repeat pulse Non‐SuperPulse 10 Hz, 40 s

disc ablation (PLDA) 2100 nm laser optical fiber (5–15 pulses/s)

Table C.13 Chapter 19: Equine laser surgery procedures.

Laser type Spot size/fiber Frequency Duty

Procedure wavelength diameter Power Exposure Mode (Hz) cycle (%)

Cysts (dorsal Diode 600 um 15–18 W Continuous Non‐SuperPulse — 100

pharyngeal, sinus, 810/980 nm Contact fiber wave
subepiglottic,
intrauterine) Nd:YAG 600 um 50 W (blanch) 100
1064 nm Non‐contact fiber 100 W (incise)
Entrapment of the Diode 600 um 15–18 W Repeat pulse Non‐SuperPulse 1 80
epiglottis 810/980 nm Contact fiber
Nd:YAG 600 um 15–18 W Continuous Non‐SuperPulse — 100
Contact fiber wave

1064 nm 600 um 100 W

Non‐contact fiber
Mass removal (cornea, CO2 0.25, 0.4, or 0.8 mm 2–10 W Continuous Non‐SuperPulse — 100
sclera, eyelid) 10 600 nm wave

(Continued )
 354 Appendix C

Table C.13 (Continued)

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Laser type Spot size/fiber Frequency Duty

Procedure wavelength diameter Power Exposure Mode (Hz) cycle (%)

Mass removal Diode 600 um 15–18 W Continuous Non‐SuperPulse — 100

(Progressive ethmoid 810/980 nm Contact fiber wave
hematoma and benign
mass ablation) Nd:YAG 600 um 100 W 100
1064 nm Non‐contact fiber
Mass removal (sarcoid CO2 5–10 mm defocused 20–30 W Continuous Non‐SuperPulse — 100
or skin mass, ablation) 10 600 nm 1.4 mm 20 W wave

Mass removal (Sarcoid Diode 600 um 15–18 W Repeat pulse Non‐SuperPulse 1 80

or skin mass, incisional 810/980 nm Contact fiber
removal)
Mass removal (sarcoid CO2 0.2–0.5 mm 20–30 W Continuous Non‐SuperPulse — 100
or skin mass, resection) 10 600 nm 0.4–0.8 mm 12–20 W wave

Palatoplasty (dorsal Diode 600 um 15–18 W Continuous Non‐SuperPulse — 100

displacement of the 810/980 nm 2–3 s/location wave
soft palate) 15–25 locations
Nd:YAG Contact fiber 100
1064 nm
Ventricle ablation Nd:YAG 600 um 100 W (≤3500J) Continuous Non‐SuperPulse — 100
1064 nm Non‐contact fiber wave

Ventriculocordectomy Diode 600 um 8–10 W Repeat pulse Non‐SuperPulse 1 80

810/980 nm Contact fiber
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Table C.14 Chapter 20: Laser surgery procedures in exotic small animals.

Procedure Laser type wavelength Spot size (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Abscess, rabbit CO2 3 or 9 4–6 Continuous wave Non‐SuperPulse — 100

10 600 nm (0.25–1.4) 4 Repeat pulse 5 40
Abscess, reptile (ear) CO2 3 4–6 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4) 3–5 Non‐SuperPulse
Abscess, rodent CO2 3 or 9 4–6 Continuous wave Non‐SuperPulse — 100
10 600 nm (0.25–1.4) 4 Repeat pulse 5 40
Abscess, sugar glider CO2 3 or 9 4–6 Continuous wave Non‐SuperPulse — 100
10 600 nm (0.25–1.4) 4 Repeat pulse 5 40
Adrenalectomy, ferret CO2 3 5–7 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4) 5 Non‐SuperPulse
5–6 Repeat pulse Non‐SuperPulse 5 40
Amputation, reptile (limb and tail) CO2 3 (small) 6–12 Continuous wave SuperPulse — 100
10 600 nm (0.25–0.4)
9 (large)
(0.8–1.4)
Anal sacculectomy, ferret CO2 3 6 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4) 8 Non‐SuperPulse
6
Cystotomy, rabbit CO2 3 6 Continuous wave SuperPulse or — 100
10 600 nm (0.25 or 0.4) non‐SuperPulse

Cystotomy, reptile CO2 3 or 9 4–10 Continuous wave SuperPulse — 100

10 600 nm (0.25–1.4) 4–8 Non‐SuperPulse
Cystotomy, rodent (guinea pig) CO2 3 6–7 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4) 4–6 Non‐SuperPulse
Insulinoma, ferret CO2 3 6 Continuous wave Non‐SuperPulse — 100
10 600 nm (0.25 or 0.4)
Mass removal, rabbit CO2 3 4–8 Continuous wave SuperPulse or — 100
non‐SuperPulse
10 600 nm (0.25 or 0.4) 4 Repeat pulse Non‐SuperPulse 5 40

(Continued )

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Table C.14 (Continued)

Procedure Laser type wavelength Spot size (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Mass removal, reptile (abdominal CO2 9 (large) 10 Continuous wave Non‐SuperPulse — 100
and cutaneous) (0.8–1.4) 7–8 Repeat pulse 5 40
10 600 nm 3 6–7 Continuous wave — 100
(0.25 or 0.4)
Mass removal, reptile (oral) CO2 3 5–7 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4)
Mass removal, rodent and CO2 3 4–8 Continuous wave SuperPulse or — 100
hedgehog 10 600 nm (0.25 or 0.4) non‐SuperPulse
4 Repeat pulse Non‐SuperPulse 5 40
Mass removal, sugar glider CO2 3 4–8 Continuous wave SuperPulse or — 100
non‐SuperPulse
10 600 nm (0.25 or 0.4) 4 Repeat pulse Non‐SuperPulse 5 40
Orchiectomy, avian CO2 3 6–8 Continuous wave Non‐SuperPulse — 100
10 600 nm (0.25 or 0.4) 6 Repeat pulse 5 40
Orchiectomy, ferret CO2 3 5 Continuous wave SuperPulse — 100
10 600 nm (0.25 or 0.4) 4–5 Non‐SuperPulse
Orchiectomy, pot‐bellied pig CO2 3 or 9 8 Continuous wave SuperPulse — 100
10 600 nm (0.25–1.4)
Orchiectomy, prairie dog CO2 3 6 Continuous wave SuperPulse or — 100
10 600 nm (0.25 or 0.4) non‐SuperPulse

Orchiectomy, rabbit CO2 3 6 Continuous wave SuperPulse or — 100

10 600 nm (0.25 or 0.4) non‐SuperPulse

Orchiectomy, reptile CO2 3 (small) 4–12 Continuous wave SuperPulse — 100

(0.25 or 0.4)
10 600 nm 9 (large) 6–10 Non‐SuperPulse
(0.8–1.4)
Orchiectomy, rodent CO2 3 6 Continuous wave SuperPulse or — 100
10 600 nm (0.25 or 0.4) non‐SuperPulse

Orchiectomy, sugar glider CO2 3 5 Continuous wave SuperPulse — 100

10 600 nm (0.25 or 0.4) 4 Non‐SuperPulse

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VetBooks.ir

Procedure Laser type wavelength Spot size (mm) Power (W) Exposure Mode Frequency (Hz) Duty cycle (%)

Ovariohysterectomy, ferret CO2 3 6 Continuous wave SuperPulse or — 100

10 600 nm (0.25 or 0.4) non‐SuperPulse

Ovariohysterectomy, pot‐bellied CO2 3 or 9 6–8 Continuous wave SuperPulse — 100

pig 10 600 nm (0.25–1.4)
Ovariohysterectomy, rabbit CO2 3 6 Continuous wave SuperPulse or — 100
10 600 nm (0.25 or 0.4) non‐SuperPulse

Ovariohysterectomy, rodent CO2 3 5–6 Continuous wave SuperPulse — 100

10 600 nm (0.25 or 0.4) 4–6 Non‐SuperPulse
Ovariosalpingectomy, avian CO2 3 3–7 Continuous wave Non‐SuperPulse — 100
10 600 nm (0.25 or 0.4)
Ovariosalpingectomy, reptile CO2 3 or 9 4–12 Continuous wave SuperPulse — 100
10 600 nm (0.25–1.4) 12 Non‐SuperPulse

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 358 Appendix C

Table C.15 Chapter 21: Laser surgery procedures of aquatic animals (sea turtle fibropapillomatosis).
VetBooks.ir

Laser type
Procedure wavelength Spot size (mm) Power (W) Exposure Mode Frequency Duty cycle (%)

Fibropapillomatosis CO2 0.4 14–18 Continuous wave Non‐SuperPulse — 100

surgery, general 10 600 nm 0.25–0.4 12–16
1.4 10–12 Continuous wave
(defocused)
Fibropapillomatosis CO2 0.25 7–8 Repeat pulse SuperPulse 20 Hz, 10 ms 20
surgery, periocular 10 600 nm 0.4 2–4 Continuous wave Non‐SuperPulse — 100
(defocused)
0.25 10 Continuous wave
Fibropapillomatosis CO2 0.25–0.4 12–14 Continuous wave SuperPulse — 100
surgery, tumors 10 600 nm 0.4–0.8 10–12 Continuous wave Non‐SuperPulse
near bone (defocused)
 359
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Index

Page locators in bold indicate tables. Page locators in italics indicate figures. This index uses letter‐by‐letter
alphabetization

a sugar glider laser surgery ALSC see American Laser Study Club
abdominal laser surgery procedures procedures 280, 280 ALT see argon laser trabeculoplasty
canine cystotomy for urolithiasis urogenital and perianal laser ameloblastic fibro‐odontoma 210
194–196, 195–196, 195 surgery procedures 175 American Board of Laser Surgery
rabbit laser surgery ABLS see American Board of Laser (ABLS) xiii, 346
procedures 271, 271 Surgery American Institute of Medical Laser
reptile laser surgery procedures abscess Applications (AIMLA) xiii,
288–289, 289 absorption 53, 346
rodent laser surgery procedures ideal laser scalpel 32–35, American Laser Medicine College
274–275, 275, 275 33–35, 40 and Board (ALMCB) 346
sugar glider laser surgery laser physics and equipment American Laser Study Club (ALSC)
procedures 280, 280 3–4, 4 xiii, 346
ablation laser–tissue interaction 23–25, American National Standards
dermatologic laser surgery 23–24, 25, 29 Institute (ANSI) 45, 52–55
procedures 141, 142, 142, photobiomodulation 44, 47 American Society for Laser Medicine
154–163 accidental trauma 57, 57 and Surgery (ASLMS)
ear laser surgery procedures 106 actinic keratosis 141, 142, 142 xiii, 346
equine laser surgery active medium 4 analgesia see pain management
procedures 248, 250, adenocarcinoma 202–203, 223, anal gland excision 177–180,
253–255, 259–260 224, 252 178–181, 178
ideal laser scalpel 32–33, 35–38, adenosine triphosphate (ATP) anal sacculectomy 279, 279
36–37, 40–41 42, 44 anesthesia
laser–tissue interaction 26, 27–28 adrenalectomy 277–278, 278 ear laser surgery procedures 108
minimally invasive and endoscopic AGASACA see apocrine gland anal ferret laser surgery procedures 276
small animal procedures sac adenocarcinoma mobile practice 326
226, 226–227, 227 AIMLA see American Institute of oral laser surgery procedures
nose and throat laser surgery Medical Laser Applications 84–85
procedures 103 air embolism 315 periorbital and eyelid laser surgery
oncological laser surgery alimentary tract laser endoscopic procedures 121, 125
procedures 199–200 surgery 227–230 pot‐bellied pig laser surgery
rabbit laser surgery procedures bowel masses 229–230, 230 procedures 281
271, 271 esophageal masses 228, 229 rabbit laser surgery procedures 267
reptile laser surgery procedures gastric masses 229, 229–230, 229 reptile laser surgery procedures 283
288–289, 289 strictures 227–228, 228, 228 rodent laser surgery procedures 272
rodent laser surgery procedures ALMCB see American Laser Medicine sea turtle laser surgery procedures
274, 274 College and Board 294–295, 296

Laser Surgery in Veterinary Medicine, First Edition. Edited by Christopher J. Winkler.

© 2019 John Wiley & Sons, Inc. Published 2019 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/winkler/laser
 360 Index
anesthesia (cont’d )
VetBooks.ir
sugar glider laser surgery
procedures 279
urogenital and perianal laser
surgery procedures 164
ANSI see American National
Standards Institute
antimicrobial photodynamic therapy
(A‐PDT) 209–213, 214, 215
apocrine cystomatosis 159–161,
160–161, 160
apocrine cysts 109, 109, 109
apocrine duct adenoma 199
apocrine gland anal sac
adenocarcinoma (AGASACA)
202–203
aquatic animals see sea turtle laser
surgery procedures; turtles
argon lasers 213
argon laser trabeculoplasty (ALT) 131
articulated arm delivery 7, 9
arytenoid chondritis 259–260
ATP see adenosine triphosphate
aural hematoma 49, 113–115,
113–115, 114
aural masses 226, 226–227, 227
autoclavable handpieces 9, 10
avian laser surgery procedures
290–291
orchiectomy 290, 290
ovariosalpingectomy 290–291, 290
b 3–9, 6–10, 267, 267–268,
backstops 315–317, 317
basal cell carcinoma (BCC) 206, 208
BAS/BAOS see brachycephalic airway
syndrome
BCC see basal cell carcinoma
beam delivery technology 7–9,
8–10
bearded dragon 289
bladder incision postcystotomy 49
bowel masses 229–230, 230
Bowenoid in situ carcinoma
141–144, 143–144, 143
brachycephalic airway syndrome
(BAS/BOAS) 99, 104–105,
225–226
c photobiomodulation 46
caiman lizard 289
canine laser surgery procedures see
individual procedures
CBC see complete blood cell count
Center for Devices and Radiological
Health (CDRH) 52
cerumen glands 107–109, 108, 108
ceruminous cystomatosis 159–161,
160–161, 160
chameleons 284, 286
char removal
ear laser surgery procedures
107, 108
elective feline/canine surgeries
63, 64, 68
nose and throat laser surgery
procedures 103
oral laser surgery procedures 86
practice recommendations 315
cherry eye 122–124, 122–124, 123
Chinese water dragon 288
chondrosarcoma 224
chromophores
ideal laser scalpel 32, 33
laser–tissue interaction 23
photobiomodulation 44, 45
CO2 lasers
dermatologic laser surgery
procedures 141–163
ear laser surgery procedures
106–107
elective feline/canine surgeries 63
equine laser surgery procedures
247–248, 248, 249, 250, 256
ideal laser scalpel 39, 40–41
laser physics and equipment
277–278
laser surgical integrations 338
laser–tissue interaction 27–28
minimally invasive and endoscopic
small animal procedures 217
mobile practice 324
nose and throat laser surgery
procedures 99, 103–105
oncological laser surgery
procedures 198–204
oral laser surgery procedures 84,
85, 86–90, 92–94, 97
pain management 321–322
periorbital and eyelid laser surgery
procedures 117–121,
123–127
power density 16, 18, 20
practice recommendations
315–319
safety issues 56, 56, 58
sea turtle laser surgery procedures
292–293, 296–297, 311
urogenital and perianal laser
surgery procedures 164, 173
coagulation
ear laser surgery procedures 106
ideal laser scalpel 32–33,
38–41, 39
laser–tissue interaction 26, 28, 30
oncological laser surgery
procedures 204
ophthalmic lasers for glaucoma
treatment 131–139
power density 21
coagulation necrosis 131, 132
coherence 5–6
collagen 43
collagenous hamartomas 151–153,
152, 152
collimation 5–6, 17
comminuted fracture 50
community marketing 333
complete blood cell count
(CBC) 293
computed tomography (CT)
minimally invasive and endoscopic
small animal procedures
221, 222
sea turtle laser surgery
procedures 293, 294,
304, 305
conjunctival tumors 302, 302–304
connective tissue 34, 35
contact mucositis/contact mucosal
ulceration 88–89, 88, 89
continuous wave exposure
ear laser surgery procedures
108–110, 112
laser physics and equipment 9, 10
nose and throat laser surgery
procedures 100–104
oncological laser surgery
procedures 200
periorbital and eyelid laser surgery
procedures 117, 125–126
photobiomodulation 45–46
power density 19–20
sea turtle laser surgery procedures
296, 304
urogenital and perianal laser
surgery procedures 169,
174, 177–178, 185–187,
190, 194
corn snake 285

CPC see cyclophotocoagulation
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cryptorchid orchiectomy 165–169,
166–169, 167
CT see computed tomography
cutaneous neoplasia 199–202,
200–202, 200
cyclophotocoagulation (CPC)
comparison of mTSCP and
TSCP 135
endoscopic cyclophotocoagulation
132–133, 135–139, 136,
138, 138
micropulse transscleral
cyclophotocoagulation
132–135, 134, 135–136,
138–139
ophthalmic lasers for glaucoma
treatment 131–133, 132
preoperative treatments for TSCP,
mTSCP, and ECP 133,
134, 137
success rates of TSCP, mTSCP, and
ECP 138–139
transscleral cyclophotocoagulation
132–134, 133, 133, 138–139
cystadenomas 109, 109, 109
cystotomy
for canine urolithiasis 194–196,
195–196, 195
rabbit laser surgery procedures
271–272, 272
reptile laser surgery procedures
287–288, 287
rodent laser surgery procedures
275, 275, 276
urolithiasis 194–196,
195–196, 195
cytoscopy 231–232, 231
d comparison of diode and CO2
dermatologic laser surgery
procedures 141–163
actinic keratosis 141, 142, 142
Bowenoid in situ carcinoma
141–144, 143–144, 143
ceruminous (apocrine)
cystomatosis 159–161,
160–161, 160
elbow callus follicular cysts
156–157, 156–158, 157
equine laser surgery
procedures 248, 250, 251
external ear hyperplasia 161–163,
161–163, 162
follicular tumors 149–151,
149–151, 150
hamartomas 151–153,
151–153, 152
interdigital follicular cysts
153–156, 154–156, 155
introduction 141
pigmented viral plaques 144–145,
144–146, 146
rabbit laser surgery procedures
271, 271
reptile laser surgery procedures
288–289, 289
rodent laser surgery procedures
274–275, 275, 275
sebaceous gland tumors 157–159,
158–159, 159
squamous cell carcinoma 144,
144, 146–149, 146–149, 148
sugar glider laser surgery
procedures 280, 280
diode lasers see near‐infrared diode
lasers
distichiasis 116–118, 117, 118
dorsal displacement of the soft
palate (equine) 255–256,
256–257, 256
dorsal pharyngeal cysts 253,
253, 254
e elongated soft palate (resection
ear laser surgery procedures
106–115
apocrine cysts 109, 109, 109
cerumen glands 107–109,
108, 108
ceruminous (apocrine)
cystomatosis 159–161,
160–161, 160
lasers 106–107
equine laser surgery procedures
248, 249–250
external ear hyperplasia 161–163,
161–163, 162
introduction 106
myringotomy 111–112,
111–112, 112
nasopharyngeal polyps in cats
and kittens 110–111,
110, 110
opening stenotic ear canals
112–113, 112, 113
otoscope 107, 108
Index 361
procedures of the pinna 113–115,
113–115, 114, 145, 147, 248,
249–250
reptile laser surgery procedures
287, 287
economic considerations 327–334
calculating cost 327–328
calculating revenue 328
core message 330, 330
introduction 327
laser fees 328–329
marketing laser surgery 330–331,
331–333
planning for economic
success 329–333
providing high‐quality care 327,
328, 329
tiered/bundled fee structures 329
training and staff preparation
329–330
ECP see endoscopic
cyclophotocoagulation
ectopic ureter 234–235, 234–235,
235
educational materials 330, 331
elbow callus follicular cysts
156–157, 156–158, 157
elective laser surgery procedures see
individual procedures
electrical hazards 57–58
of ) 99–102, 100–101, 100
endobronchial masses 224–225,
225, 225
endoscopic cyclophotocoagulation
(ECP) 132–133, 135–139,
136, 138, 138
endotracheal tubes
minimally invasive and endoscopic
small animal procedures
221–222
nose and throat laser surgery
procedures 100, 104
safety issues 56–57
energy density (fluence) 36, 45
entrapment of the epiglottis
256–258, 257–258, 257
entropion 118–120, 118–120, 119
incisional laser entropion
surgery 119–120, 119, 120
nonincisional laser entropion
surgery 118–119, 119, 119
episiotomy 185–189, 186–190
epithelium 33–34
 362 Index
equine laser surgery procedures
VetBooks.ir
247–263
arytenoid chondritis 259–260
CO2 lasers 247–248, 248,
249, 250
dorsal displacement of the soft
palate 255–256,
256–257, 256
dorsal pharyngeal cysts 253,
253, 254
entrapment of the epiglottis
256–258, 257–258, 257
guttural pouch granuloma
260, 260
guttural pouch tympanites
260–261, 261
introduction 247–248
nasal passages and paranasal
sinuses 251–252, 252, 253
other laser applications 261–262
pharyngeal masses 255
pharynx and larynx 253–261
progressive ethmoid hematoma
251–255, 253, 255–256, 255
subepiglottic cysts 253, 253, 255
transendoscopic laser surgery
247–262, 251, 252, 254–261
vocal fold resection 258–259,
259, 259
equipment malfunction 57–58
Er:YAG lasers
ideal laser scalpel 39–40, 39
laser physics and equipment
10–11
laser–tissue interaction 28
safety issues 58
Er:YSGG lasers 10–11
esophageal masses 228, 229
esophageal strictures 227–228,
228, 228
everted laryngeal saccules 104, 104,
225–226, 225
external ear hyperplasia 161–163,
161–163, 162
eyelid surgery see periorbital and
eyelid laser surgery
procedures
eye protection 54–55, 54–55
f laser‐tissue welding 337
facial abscess (SEE ABSCESS) 215
FDA see Food and Drug
Administration
fee structures 328–329
feline laser surgery procedures see
individual procedures
ferret laser surgery
procedures 276–279
adrenalectomy 277–278, 278
anal sacculectomy 279, 279
anesthesia 276
insulinoma removal 278–279,
279
orchiectomy 277, 277
ovariohysterectomy 277, 277
fiber‐optic telescope 107
fibro‐adnexal hamartomas
151–153, 151–153, 152
fibropapillomatosis (FP)
anesthesia 294–295, 296
general laser settings 298
introduction 292–293, 293
laparoscopy 293, 295
periocular FP tumors 298–302,
300, 301–304
postoperative care 307, 308–310
preoperative 293–295, 294–296
procedure 295–298, 297,
299–300
prognosis and conclusion
307–311, 310
radiographic and CT imaging
293, 294, 304, 305
sea turtle laser surgery procedures
292–311
tumor scoring system 293
tumors near bone 303–307, 304
fire hazards 56–57
fluence see energy density
fluoroscopy 239, 241
follicular cysts see elbow callus
follicular cysts; interdigital
follicular cysts
follicular tumors 149–151,
149–151, 150
Food and Drug Administration (FDA)
6–7, 52
FP see fibropapillomatosis
future of lasers
acceptance as a board certification
speciality 339
authors’ comments 339
laser surgical integrations 338
miniaturization of handheld laser
units 337–338
veterinary school curriculums
338–339
g
gallium‐aluminum‐arsenide diode
lasers 210
gastric masses 229, 229–230, 229
gastrointestinal methane 56
Gaussian geometry 15, 15, 18
gauze sponge 317, 317
gingivectomy 89, 91, 91
gingivoplasty 89, 90, 91
glaucoma see ophthalmic lasers for
glaucoma treatment
green sea turtles see sea turtle laser
surgery procedures
groove director/plunger 57, 57,
317, 317
guinea pig 275, 275, 276
gum chewer’s lesions 89–90,
94, 95
guttural pouch granuloma
260, 260
guttural pouch tympanites
260–261, 261
h
hamartomas 151–153,
151–153, 152
hamsters 274–275, 275, 275
hand speed
ideal laser scalpel 38
laser–tissue interaction 30
power density 20, 21
Hansen type I intervertebral disc
disease (IVDD) 239–242
Harlens–Jenson technique 121
hedgehog 274–275, 275
helium‐neon lasers 210
hemorrhage
minimally invasive and endoscopic
small animal procedures
222–223
nose and throat laser surgery
procedures 101–103
urogenital and perianal laser
surgery procedures 194
hemostasis
ideal laser scalpel 39, 39
laser–tissue interaction 26,
28–30
nose and throat laser surgery
procedures 101, 103, 103
oncological laser surgery
procedures 201, 201
sea turtle laser surgery
procedures 296

hollow waveguide delivery
VetBooks.ir
equine laser surgery
procedures 256
laser physics and equipment 7–9,
8–10
nose and throat laser surgery
procedures 105
power density 17
practice recommendations
317–318
hot fiber tips 11–12, 11–12
Hotz–Celsus technique 119–120,
119, 120
house calls see mobile practice
Ho:YAG lasers
laser physics and equipment
10–11
laser–tissue interaction 30
minimally invasive and endoscopic
small animal procedures
217–219, 218–219, 223–224,
223, 227–237, 229–230,
232–233, 236–237
neurosurgical laser procedures
239, 240
hyperplasia of the third eyelid gland
122–124, 122–124, 123
hypocalcemia 204–205
i active medium and excitation
iguanas 283–284, 283
incision/excision
ear laser surgery procedures 106
ideal laser scalpel 35,
37–38, 38
laser physics and equipment
6–7, 28, 31
laser–tissue interaction
22–23, 26
periorbital and eyelid laser
surgery procedures
119–120, 119, 120
photobiomodulation 46–48,
48–49
power density 16, 20–21,
37–38, 38
safety issues 55–57
see also individual procedures
inflammation 42–43, 46
inflammatory polyps
221–224
insulinoma 278–279, 279
interdigital follicular cysts 153–156,
154–156, 155
International Academy for Laser
Medicine and Surgery 346
intraocular pressure (IOP) 129–135,
138–139
inverse population 4–5
IOP see intraocular pressure
IVDD see Hansen type I
intervertebral disc disease
k light absorption and scattering in
keratoconjunctivitis sicca 121
l subepithelium connective
lagophthalmos 120–121, 121
laparoscopy 293, 295
laser‐assisted in situ keratomileusis
(LASIK) 28
Laser Institute of America (LIA)
53, 346
laser lithotripsy 235–237,
236–237, 236
laser otoendoscopy 226–227
aural masses 226, 226–227, 227
myringotomy 227, 227
laser peripheral iridotomy (LPI) 131
laser physics and equipment 3–13
absorption, spontaneous emission,
and stimulated emission
3–4, 4
(pumping) mechanism 4
beam delivery technology 7–9,
8–10
creating laser light 3–6
future of lasers 337–340
introduction 3
inverse population and light
amplification 4–5
laser tube technology 6–7, 7
minimally invasive and endoscopic
small animal procedures
217–221
mobile practice 324, 325
monochromacity, coherence, and
collimation 5–6, 5
Nd:YAG, Ho:YAG, Er:YAG, and
Er:YSGG lasers 10–11
near‐infrared diode lasers and hot
fiber tips 11–12, 11–12
optical resonator 3–4, 4–5
photons and waves 3
power control exposures 9, 10
power control modes 10
practical surgical lasers 6–12, 6
Index 363
practice recommendations
315–319, 316–318
small exotic animal laser surgery
procedures 267, 267–268
laser safety officer (LSO) 53–55, 58
laser scalpel 32–41
introduction 32
laser light absorption by biological
tissues 32–35, 33–35, 40
epithelium 33–34
light absorption and scattering in
tissue 34, 35
photothermal laser–tissue
interaction 32–33, 34
power density and incision
depth 37–38, 38
soft tissue ablation 32–33, 35–38,
36–37, 40–41
soft tissue coagulation 32–33,
38–41, 39
spatial accuracy of
photovaporolysis 37, 37
summary 40–41, 40
thermal relaxation time
34–35, 36
laser therapy see photobiomodulation
laser–tissue interaction (LTI) 22–31
absorption and scattering
coefficients 23–25, 24, 25
basic principles 22–25, 23
ideal laser scalpel 32–41
introduction 22
laser selection 26–30, 26
methods of laser–tissue
disruption 25–26, 25
photobiomodulation 46
photochemolysis 25
photoplasmolysis 25
photothermolysis 26
power density 14, 16–17, 22,
26, 30
randomly diffused radiant flux 23
surgical lasers and proper
technique 30, 31
SYCUTE lasers 29–30
WYDSCHY lasers 28–29, 29
WYSIWYG lasers 26–28, 27
laser‐tissue welding 337
laser tube technology 6–7, 7
laser turbinectomy 221–224
LASIK see laser‐assisted in situ
keratomileusis
 364 Index
leather punch technique 114, 114
VetBooks.ir
LIA see Laser Institute of America
light amplification 4–5
limb amputation and repair
289–290, 289–290, 289
lipomas 202–203
lithotripsy see laser lithotripsy
lizards 284, 289
loupes 317
lower urinary tract laser endoscopy
231–237
congenital anomalies 233–235,
234–235, 234, 235
cytoscopy and general anatomic
considerations
231–232, 231
laser lithotripsy 235–237,
236–237, 236
transitional cell carcinoma
and TURN 232–233,
232–233, 232
transitional cell carcinoma and
TURP 233, 233, 233
LPI see laser peripheral iridotomy
LSO see laser safety officer
LTI see laser–tissue interaction
lymphosarcoma 252
m cytoscopy and general anatomic
magnetic resonance imaging (MRI)
221, 222, 293
magnification loupes 317
mammary gland laser surgery
procedures
rabbit laser surgery procedures
271, 271
rodent laser surgery procedures
274–275, 275, 275
sugar glider laser surgery
procedures 280, 280
mast cell tumors 201
mastocytoma 200
maximum permissible exposure
(MPE) 53–58
meibomian gland adenoma
126–127
micropulse transscleral
cyclophotocoagulation
(mTSCP) 132–135, 134,
135–136, 138–139
Mie scattering, laser–tissue
interaction 23
miniaturization of handheld laser
units 337–338
minimally invasive and endoscopic
small animal procedures
217–238
alimentary tract laser endoscopic
surgery 227–230
bowel masses 229–230, 230
esophageal masses 228, 229
gastric masses 229,
229–230, 229
strictures 227–228, 228, 228
endoscopic cyclophotocoagulation
132–133, 135–139, 136,
138, 138
endoscopy equipment 219–221,
220–221
equipment and general principles
217–221
introduction 217
laser equipment 217–219,
218–219
laser otoendoscopy 226–227
aural masses 226,
226–227, 227
myringotomy 227, 227
lower urinary tract laser endoscopy
231–237
congenital anomalies 233–235,
234–235, 234, 235
considerations 231–232, 231
laser lithotripsy 235–237,
236–237, 236
transitional cell carcinoma
and TURN 232–233,
232–233, 232
transitional cell carcinoma and
TURP 233, 233, 233
respiratory tract laser endosurgery
221–226
endobronchial masses
224–225, 225, 225
everted laryngeal saccules
225–226, 225
nasal neoplasia, inflammatory
polyps, and laser
turbinectomy 221–224,
221, 222, 223
mobile practice 324–326
advantages 324
equipment 324, 325
introduction 324
logistics 325–326, 326
modified Morgan Pocket
technique 123
monochromacity 5–6, 23
Moses effect 218
MPE see maximum permissible
exposure
MRI see magnetic resonance imaging
mTSCP see micropulse transscleral
cyclophotocoagulation
myringotomy 111–112, 111–112,
112, 227, 227
n
NAALT see North American
Association for
PhotobiomoduLation Therapy
nasal adenocarcinoma 223, 224
nasal facial fold trichiasis 121–122,
121–122, 122
nasal lymphosarcoma 224
nasal neoplasia 221–224, 223,
251–252
nasogastric tubes 222
nasopharyngeal polyps 110–111,
110, 110, 223
Nd:YAG lasers
equine laser surgery procedures
247–251, 251, 252, 257–259
laser physics and equipment
10–11
laser–tissue interaction 29
minimally invasive and endoscopic
small animal procedures 217
ophthalmic lasers for glaucoma
treatment 129, 131
near‐infrared diode lasers
ear laser surgery procedures
106–107
equine laser surgery procedures
247–251, 251, 252, 256–259
ideal laser scalpel 34, 35–36, 37,
39, 40
laser physics and equipment
11–12, 11–12
minimally invasive and endoscopic
small animal procedures
217–219, 218, 223, 223, 226,
227–235, 230, 235
oncological laser surgery
procedures 198
ophthalmic lasers for glaucoma
treatment 129–140
oral laser surgery procedures 84,
85, 93, 95–97
photodynamic therapy 209,
210–213

neoplasia of the eyelid 124–127,
VetBooks.ir
125–127, 126
neurosurgical laser procedures
239–243
introduction 239
open surgical disc fenestration
versus PLDA 239–240, 240
PLDA procedure 241, 241–242
postoperative 241–242
preoperative 240–241, 241
NHZ see nominal hazard zone
nictitating membrane 122–124,
122–124, 123, 303
nodular sebaceous gland
tumors 157–159,
158–159, 159
nominal hazard zone (NHZ) 53–58
non‐SuperPulse mode
ideal laser scalpel 41
laser physics and equipment 10
sea turtle laser surgery
procedures 296, 304
North American Association for
PhotobiomoduLation Therapy
(NAALT) 346
nose and throat laser surgery
procedures 99–105
brachycephalic airway syndrome
99, 104–105
dermatologic laser surgery
procedures 146–148
equine laser surgery procedures
251–261, 252, 253, 254–261,
255–257, 259
everted laryngeal saccules
104, 104
introduction 99
preoperative considerations 99
soft palate resection 99–102,
100–101, 100
stenotic nares 102–104,
102–103, 102
summary 104–105
tonsillectomy 104, 104
o contact mucositis and contact
oncological laser surgery
procedures 198–205
advantages over traditional scalpel
blade excision 198–199
cutaneous neoplasia 199–202,
200–202, 200
introduction 198–199
oral tumors 203–204, 203, 203
photodynamic therapy 206,
207–209, 209, 210–214
subcutaneous neoplasia 199,
202–203, 202
thyroidectomy 204–205, 204, 204
see also dermatologic laser surgery
procedures; individual tumor
types
onychectomy 77–83, 79–83
operculectomy 89, 92, 92
ophthalmic lasers for glaucoma
treatment 129–140
anatomy of the canine eye 130
comparison of mTSCP and
TSCP 135
cyclophotocoagulation
131–133, 132
diode lasers for glaucoma
treatment 129–139
endoscopic cyclophotocoagulation
132–133, 135–139, 136,
138, 138
introduction 129
light absorption by human pigment
epithelium 130
micropulse transscleral
cyclophotocoagulation
132–135, 134, 135–136,
138–139
open‐angle and closed‐angle
glaucomas 130–131, 131
penetrance of light by
wavelength 129, 130
preoperative treatments for
TSCP, mTSCP, and ECP 133,
134, 137
success rates of TSCP, mTSCP, and
ECP 138–139
transscleral cyclophotocoagulation
132–134, 133, 133, 138–139
optical fibers 57
optical pumping 4
optical resonator 3–4, 4–5
oral laser surgery procedures 84–98
anesthesia 84–85
mucosal ulceration 88–89,
88, 89
feline oropharyngeal inflammation ‐
stomatitis 85–88,
86–87, 88
frenectomy 92–93, 96, 97
gingivectomy 89, 91, 91
gingivoplasty 89, 90, 91
Index 365
gum chewer’s lesions 89–90, 94, 95
introduction 84–85
laser types 84, 85
operculectomy 89, 92, 92
oral mass excision 90–92, 95, 96
periodontal pocket surgery
94–97, 97, 97
photobiomodulation 84, 85, 88
reptile laser surgery procedures
288, 288, 288
safety issues 84
tongue surface surgery 89, 93, 93
oral mass excision 90–92, 95, 96
oral tumors 203–204, 203, 203
orchiectomy
avian laser surgery procedures
290, 290
canine 63–72, 64–73, 64
canine unilateral cryptorchid
orchiectomy 165–169,
166–169, 167
cryptorchid orchiectomy
165–169, 166–169, 167
feline 76, 76
ferret laser surgery procedures
277, 277
pot‐bellied pig laser surgery
procedures 281, 281
prairie dog laser surgery
procedures 276, 276
rabbit laser surgery procedures
268–270, 269, 269
reptile laser surgery procedures
283–284, 283
rodent laser surgery procedures
272–273, 272, 273
sugar glider laser surgery
procedures 279–280, 280
oropharyngeal inflammation 85–88,
86–87, 88
osteosarcoma 224
otitis externa 215
otitis media 111–112, 111–112, 112
otoendoscopy see laser otoendoscopy
otoscope 107, 108
ovariohysterectomy
canine 72–76, 71–73, 73
feline 76–77, 74–78, 78
ferret laser surgery procedures
277, 277
photobiomodulation 48
pot‐bellied pig laser surgery
procedures 281–282,
282, 282
 366 Index
ovariohysterectomy (cont’d )
VetBooks.ir
rabbit laser surgery procedures
270, 270, 270
rodent laser surgery procedures
273–274, 274
urogenital and perianal laser
surgery procedures 185
ovariosalpingectomy
avian laser surgery procedures
290–291, 290
reptile laser surgery procedures
284–287, 284–286, 286
p nasal facial fold trichiasis
pain management 320–323
benefits of laser surgery procedures
321–322
classification of pain 320–321
introduction 320
photobiomodulation 42, 46
recognizing patient pain 321
strategies for the laser surgery
patient 322
palatoplasty 255–256, 256–257, 256
papillary carcinoma 211
paranasal sinuses 251–252,
252, 253
paraphimosis 169–172,
170–173, 170
PDT see photodynamic therapy
PEG see percutaneous endoscopic
gastrostomy
penile urethrostomy 193–194, 194
percutaneous endoscopic gastrostomy
(PEG) tubes 228
percutaneous laser disc ablation
(PLDA) 239–243
introduction 239
open surgical disc fenestration
versus PLDA 239–240, 240
PLDA procedure 241, 241–242
postoperative 241–242
preoperative 240–241, 241
perianal adenoma 201, 202
perianal procedures see urogenital
and perianal laser surgery
procedures
perineal urethrostomy 189–190
canine penile urethrostomy
193–194, 194
feline perineal urethrostomy
190–193, 190, 191–193
periodontal pocket surgery 94–97,
97, 97
periorbital and eyelid laser surgery
procedures 116–128
anatomy 116
distichiasis 116–118, 117, 118
entropion 118–120,
118–120, 119
equine laser surgery procedures
248, 249
hyperplasia or prolapsed third
eyelid gland 122–124,
122–124, 123
introduction 116
lagophthalmos 120–121, 121
121–122, 121–122, 122
neoplasia of the eyelid 124–127,
125–127, 126
sea turtle 298–302, 300, 301–304
perivulvar dermatitis 173–174, 176
persistent mesonephric remnants
233–234, 234
pharyngeal cicatrix 261
pharyngeal masses 255
photobiomodulation 42–51
elective surgeries and simple
incisions and excisions
48, 48
general guidelines 47
introduction 42
optimal parameters 43–46
delivery methods and
time 45–46
power 44–45
wavelength 43–44, 44
oral laser surgery procedures 84,
85, 88
safety issues 47
science and physiology of laser
therapy 42–43
soft tissue trauma and
reconstructive surgery 48,
49–50
targeted photobiomodulation
44, 45
treatment techniques and
recommendations 47–48
photochemolysis 25
photodynamic therapy (PDT)
206–216
antibacterial treatment 209–213,
214, 215
basic principles 206–207
cancer/neoplasm treatment 206,
207–209, 209, 210–214
contraindications 208
drug‐to‐light interval 207
introduction 206
light activation method 207
light delivery, exposure, and
activation 207
photosensitizers 206–207, 210–213
posttreatment management
208–209
safety issues 208–209
photons 3
photoplasmolysis, laser–tissue
interaction 25
photopyrolysis see coagulation
photothermolysis
ideal laser scalpel 32–33, 35–41
laser–tissue interaction 26,
27–28
see also ablation; coagulation
photovaporolysis see ablation
pigmentation 47
pigmented viral plaques 144–145,
144–146, 146
pinna procedures
canine and feline laser surgery
procedures 113–115,
113–115, 114, 145, 147
equine laser surgery procedures
248, 249–250
plasma cell pododermatitis 43
PLDA see percutaneous laser disc
ablation
pododermatitis 153–156,
154–156, 155
polypoid bladder masses 231
pot‐bellied pig laser surgery
procedures 281–282
anesthesia 281
orchiectomy 281, 281
ovariohysterectomy 281–282,
282, 282
power density 14–21
altering power density 17–20
power 17
spot size: angle of incidence
19, 19
spot size: distance and diameter
17–19, 18
time: hand speed 20, 21
time: laser delivery exposures
and modes 19–20
ideal laser scalpel 37–38, 38
illustration of concepts 14–15
introduction 14

laser beam geometry 15, 15, 18
VetBooks.ir
laser–tissue interaction 14,
16–17, 22, 26, 30
photobiomodulation 44–45
summary 20–21
practice recommendations 315–319
backstops 315–317, 317
char 315
delivery system calibration and
care 317–318
intraoperative recommendations
315–317
introduction 315
laser tips and handpieces
318–319, 318
maintaining sterility 315, 316
maintenance recommendations
317–319
practicing technique 319
preventing air embolism 315
visualization 317
prairie dogs 276, 276
priapism 169
progressive ethmoid hematoma
251–255, 253, 255–256, 255
prolapsed third eyelid gland
122–124, 122–124, 123
prostaglandins 43
r cutaneous, abdominal, and
rabbit laser surgery procedures
267–272
abscesses and cysts 271, 271
anesthesia 267
cutaneous, abdominal, and
mammary gland mass
removal 271, 271
cystotomy 271–272, 272
orchiectomy 268–270, 269, 269
ovariohysterectomy 270, 270, 270
radiography 293, 294, 304, 305
randomly diffused radiant flux
(RDRF) 23
reconstructive surgery 48, 49–50
record‐keeping 58
red ear slider 286
reflection 22, 23
refraction 23
repeat pulse exposure
ear laser surgery procedures
108, 111
laser physics and equipment 9, 10
photobiomodulation 45–46
power density 19–20
reptile laser surgery procedures
282–290
abdominal and cutaneous mass
removals 288–289, 289
anesthesia 283
cystotomy 287–288, 287
ear abscess 287, 287
limb and tail amputation and
repair 289–290,
289–290, 289
oral mass removal 288, 288, 288
orchiectomy 283–284, 283
ovariosalpingectomy 284–287,
284–286, 286
respiratory tract laser endosurgery
221–226, 221
endobronchial masses 224–225,
225, 225
everted laryngeal saccules
225–226, 225
nasal neoplasia, inflammatory
polyps, and laser
turbinectomy 221–224,
221, 222, 223
retinal detachment 132
rodent laser surgery procedures
272–276
abscesses and cysts 274, 274
anesthesia 272
mammary gland mass
removal 274–275, 275, 275
cystotomy 275, 275, 276
orchiectomy 272–273, 272, 273
ovariohysterectomy
273–274, 274
s tumor scoring system 293
safety issues 52–59
accidental trauma 57, 57
cancer 57
electrical hazards and equipment
malfunction 57–58
eye safety and eye wear 54–55,
54–55
fire hazards 56–57
government regulation and ANSI
standards 52–53
inappropriate and unskilled use 58
introduction 52
laser safety officer 53–55, 58
maximum permissible exposure
and safeguarding the nominal
hazard zone 53–58
Index 367
oral laser surgery procedures 84
photobiomodulation 47
photodynamic therapy
208–209
record‐keeping 58
signage 54, 54
skin safety 55–56, 55
smoke and smoke evacuators
56, 56
sapphire tips 28
sarcoid removal 248, 250, 251
scattering
ideal laser scalpel 33–34
laser–tissue interaction 23–25,
23–24, 28
SCC see squamous cell carcinoma
scleral tumors 298–299, 301–303
sea turtle laser surgery procedures
292–312
anesthesia 294–295, 296
fibropapilloma excision
292–311
general laser settings 298
introduction 292–293, 293
laparoscopy 293, 295
periocular FP tumors 298–302,
300, 301–304
postoperative care 307,
308–310
preoperative 293–295,
294–296
procedure 295–298, 297,
299–300
prognosis and conclusion
307–311, 310
radiographic and CT imaging
293, 294, 304, 305
tumors near bone 303–307, 304
sebaceous gland tumors 157–159,
158–159, 159
sessile polyps 224
signage 54, 54
single pulse exposure 9, 10, 111
sinus cysts 251–252, 253
sinusitis 251–252
skin protection 55–56, 55
smoke evacuators
ear laser surgery procedures 107
practice recommendations
315, 316
safety issues 56, 56
small exotic animal laser surgery
procedures 267
 368 Index
snakes 284, 285
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Snook hook 167, 168
social media 333, 333
soft palate resection 99–102,
100–101, 100
soft tissue sarcomas 201
soft tissue trauma 48, 49–50
solar‐induced actinic keratosis 141,
142, 142
solid core fibers 7
spontaneous emission 3–4, 4
spot size
angle of incidence 19, 19
distance and diameter
17–19, 18
ideal laser scalpel 38
laser–tissue interaction 30
squamous cell carcinoma (SCC)
canine and feline laser surgery
procedures 144, 144,
146–149, 146–149, 148
equine laser surgery procedures
248, 249, 252, 261–262
minimally invasive and
endoscopic small animal
procedures 224
photodynamic therapy 206,
207–209, 212–214
staff training and preparation
329–330
stenotic ear canals 112–113,
112, 113
stenotic nares 102–104,
102–103, 102
sterility 315, 316
stimulated emission 3–4, 4
stomatitis 85–88, 86–87, 88
strictures 227–228, 228, 228
subcutaneous neoplasia 199,
202–203, 202
subepiglottic cysts 253,
253, 255
subepithelium 34, 35
sublingual granuloma 89, 93
sugar glider laser surgery
procedures 279–281
abscesses and cysts
280, 280
anesthesia 279
cutaneous, abdominal, and
mammary gland
mass removal
280–281, 281
orchiectomy 279–280, 280
SuperPulse mode
ear laser surgery procedures
108–109
ideal laser scalpel 35, 36, 38,
38, 41
laser physics and equipment 10
nose and throat laser surgery
procedures 102–104
oncological laser surgery
procedures 200, 204
periorbital and eyelid laser surgery
procedures 117, 125–126
photobiomodulation 45–46
power density 20
sea turtle laser surgery procedures
296, 304
urogenital and perianal laser
surgery procedures 169,
177–178, 185–187, 190, 194
SYCUTE lasers 29–30
t TURN see transurethral resection of
tail amputation and repair 289–290,
289–290, 289
TCC see transitional cell
carcinoma
TEM see transverse electromagnetic
mode
thermal burning 129, 131, 132
thermal relaxation time 34–35, 36
thermal trauma
laser–tissue interaction
28, 30, 31
ophthalmic lasers for glaucoma
treatment 131–132, 134
power density 20, 21
throat procedures see nose and
throat laser surgery
procedures
thyroidectomy 204–205, 204, 204
tissue necrosis
equine laser surgery
procedures 250
laser–tissue interaction 28, 31
oncological laser surgery
procedures 200
power density 21
tongue surface surgery
89, 93, 93
TORS see trans‐oral robotic
surgery
tracheal masses 225
transendoscopic laser surgery
247–262, 251, 252, 254–261
transitional cell carcinoma
(TCC) 232–233, 232–233,
232, 233
transmission 22–23, 23, 28
trans‐oral robotic surgery
(TORS) 338
transscleral cyclophotocoagulation
(TSCP) 132–134, 133, 133,
138–139
transurethral resection of neoplasia
(TURN) 232–233,
232–233, 232
transurethral resection of the
prostate (TURP) 233,
233, 233
transverse electromagnetic mode
(TEM) 15, 15, 18
TSCP see transscleral
cyclophotocoagulation
turbinectomy see laser
turbinectomy
neoplasia
TURP see transurethral resection of
the prostate
turtles 284, 284, 286
u
ulcerated fibroma 125
urethral prolapse 180–185,
181–185, 182
urinary tract calculi 235–237,
236–237, 236
urogenital and perianal laser
surgery procedures
164–197
anal gland excision 177–180,
178–181, 178
canine unilateral cryptorchid
orchiectomy 165–169,
166–169, 167
canine vasectomy 164–165,
164–166, 165
cystotomy for urolithiasis
194–196, 195–196, 195
introduction 164
paraphimosis 169–172,
170–173, 170
perineal urethrostomy
189–190
canine penile urethrostomy
193–194, 194
feline perineal urethrostomy
190–193, 190, 191–193
 Index 369

summary 196–197 v V‐plasty 125–127, 126–127

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urethral prolapse 180–185, vaginal prolapse 185–189, vulvoplasty 173–176,

181–185, 182 185–190, 185 173–177, 174
vaginal prolapse 185–189, vasectomy 164–165, 164–166, 165
185–190, 185 ventriculocordectomy 258–259, w
vulvoplasty 173–176, 259, 259 websites 330–331, 332
173–177, 174 video otoscope 107, 108 white blood cells 42–43
urolithiasis 194–196, vocal fold resection 258–259, WYDSCHY lasers 28–29, 29
195–196, 195 259, 259 WYSIWYG lasers 26–28, 27