Review Article on Innovations and Technology in Surgery

Page 1 of 7

Laser applications in surgery

Beina Azadgoli, Regina Y. Baker

Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, Los Angeles, CA 91011, USA
Contributions: (I) Conception and design: B Azadgoli; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: B Azadgoli; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
Correspondence to: Dr. Regina Y. Baker, MD. Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Department of Surgery,
Keck School of Medicine, 1510 San Pablo St. #415, Los Angeles, CA 90033, USA. Email: Regina.Baker@med.usc.edu.

Abstract: In modern medicine, lasers are increasingly utilized for treatment of a variety of pathologies as interest
in less invasive treatment modalities intensifies. The physics behind lasers allows the same basic principles to be
applied to a multitude of tissue types using slight modifications of the system. Multiple laser systems have been
studied within each field of medicine. The term “laser” was combined with “surgery,” “ablation,” “lithotripsy,”
“cancer treatment,” “tumor ablation,” “dermatology,” “skin rejuvenation,” “lipolysis,” “cardiology,” “atrial
fibrillation (AF),” and “epilepsy” during separate searches in the PubMed database. Original articles that studied the
application of laser energy for these conditions were reviewed and included. A review of laser therapy is presented.
Laser energy can be safely and effectively used for lithotripsy, for the treatment of various types of cancer, for a
multitude of cosmetic and reconstructive procedures, and for the ablation of abnormal conductive pathways. For
each of these conditions, management with lasers is comparable to, and potentially superior to, management with
more traditional methods.

Keywords: Lasers; laser lithotripsy; laser therapy

Submitted Jul 21, 2016. Accepted for publication Nov 23, 2016.
doi: 10.21037/atm.2016.11.51
View this article at: http://dx.doi.org/10.21037/atm.2016.11.51

Introduction Theodore Maiman ultimately created the first “laser”

(light amplification by stimulated emission of radiation)
In 1900, Max Planck discovered that light is released,
by using an electrical source to energize a solid ruby (3).
transferred, and absorbed in specific amounts of energy
Following this bookmark invention, its many possible
called quanta, and that this was related to the frequency
indications in medicine were rapidly recognized. As the CO2
of the radiation and what he discovered to be Planck’s laser was known to emit a concentrated ray of light that was
constant (1). Shortly after, Einstein published his work on easily absorbed by water, it became used to vaporize tissue.
quantum theory, suggesting that most atoms exist in the The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
ground-energy state (E0). These E0 molecules can then be created coagulative necrosis within tissue, and the visible
converted to higher energy levels when energy is added to light lasers were useful for achieving hemostasis (4) (Table 1).
them, and in returning to their ground state, the energy Over time, several different active media have been used to
is released spontaneously as photons or electromagnetic create new lasers, resulting in their utility in a wide range of
(EM) waves. He also discovered that when a photon of the medical subspecialties. The goal of this review is to provide an
same wavelength collides with an excited atom, the two overview of the physics behind laser systems, demonstrating
photons are released concurrently, and therefore have equal how the same basic principles can be applied to various tissue
frequencies. This idea of “stimulated emission” was years types to accomplish the desired effect, and how this has led to
later used in the creation of lasers (2). the wide range of clinical applications of lasers.

© Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(23):452
Page 2 of 7 Azadgoli and Baker. Laser applications in surgery

Table 1 The various lasers commonly used in medicine along with the wavelength at which they operate, their absorption chromophores, and
their clinical applications

Laser Wavelength (nm) Absorption chromophore Application

Ruby 694 Pigment, hemoglobin Dermatology, tattoo removal

Nd:YAG 1,064 Pigment, proteins Wide applications

Er:YAG 2,940 Water Surgery

Diode 630–980 Pigment, water (range) LLLT, PDT, surgery

Argon 350–514 Pigment, hemoglobin Surgery, PDT, ophthalmology, dermatology

CO2 10,600 Water Surgery

Pumped-dye 504–690 Pigment PDT, dermatology

nm, nanometer; LLLT, low level laser therapy; PDT, photodynamic therapy.

Totally reflecting mirror

Excitation power supply The mirrors then reflect these photons and the process of
Partially reflecting mirror
A stimulated emission is amplified. The partially transmitting
mirror then allows a powerful, cohesive beam of photons to
be released as laser light (5) (Figure 1).

B
Laser-tissue interaction

The effect that a laser has on a sample of tissue is dependent

C on both properties of the tissue as well as the laser. The
tissue properties include its structure, water content,
thermal conductivity, heat capacity, density, and its ability to
D absorb, scatter, or reflect the emitted energy. The properties
of the laser that play a role are its power, density, energy
content, and wavelength (6).
Figure 1 Demonstrates a laser medium at ground state (A) followed The main biological targets that are dealt with absorb
by excitation of atoms to higher energy levels (B) and progression light very differently, and their optimum absorption spectra
to stimulated emission (C) with laser beam generation as a final depend on the wavelength of the incident photon energy.
product (D). For the visible light and some near-infrared lasers, the main
target chromophores (any substance that absorbs light)
are hemoglobin and melanin, whereas for CO2 lasers, the
Laser physics only chromophore is water. In order to achieve selective
photothermolysis (using energy at high peak powers and
A simple laser consists of a laser medium (which determines
short pulse widths to destroy the intended target alone)
the wavelength of the system) enclosed between two parallel without damaging the surrounding tissue, the target tissue
mirrors, one of which is partially reflecting and partially must contain chromophores that absorb a specific laser
transmitting. The medium is excited by an electrical source wavelength, and these chromophores should not be found
until the number of atoms in the excited state is greater in the surrounding tissue (7).
than the number in the ground state (population inversion). The CO2, Nd:YAG, and Argon lasers are the lasers most
When the laser medium is activated, it begins to release commonly used in medicine and surgery (Table 1). The
excited photons spontaneously in all directions. However, CO2 laser has carbon dioxide gas as its medium and emits
a small subset of these photons travels along the centerline energy at 10,600 nm. Because its chromophore, water,
of the laser system in a unified fashion between the mirrors. exists everywhere, CO2 lasers cannot be used for selective

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Annals of Translational Medicine, Vol 4, No 23 December 2016 Page 3 of 7

photothermolysis, though they are tissue-selective. All of popular in modern medicine. In addition to their practical
the incident energy is absorbed in the tissue water down to a usefulness in the operating room, lasers have a wide range
specific depth, preventing deeper tissue damage. CO2 lasers of applications in ophthalmology, lithotripsy, the diagnosis
operate in the invisible infrared waveband, thus requiring an and treatment of various cancers, as well as dermatologic
aiming beam for accurate treatment. Focusing the laser on and cosmetic procedures.
the tissue produces extremely high power density resulting
in instant vaporization and ablation of the tissue. As the
Lithotripsy
irradiance of the laser beam is proportional to the inverse
of the square of the diameter of the beam, by defocusing Laser lithotripsy has been a widely accepted technique for
the beam, the surgeon is able to easily change the laser the fragmentation of urinary and biliary stones for the past
from incision mode to bulk vaporization or coagulation. few decades (11). Lasers can accomplish lithotripsy by having
The CO2 laser has a number of beam modes, each of which a photoacoustical/photomechanical effect (laser-induced
reacts differently with the tissue. The simplest mode is shockwave lithotripsy) or a predominantly photothermal
continuous wave (CW), in which the laser beam is emitted, effect. Of the lasers commonly used in lithotripsy, the 1-μsec
operated for a specific time, and then turned off. More pulsed-dye laser is the most popular shockwave laser and has
recent lasers however are quasi-CW (ultrapulsing), meaning been extensively studied (12-14). This device is based on the
they produce short high-peak power pulses with very long excitation of coumarin dye to produce the monochromatic
inter-pulse intervals. This has the advantage of allowing light that fragments the calculi (14). At 504 nm, a green
more precise incisions with minimal heat build-up because light that is absorbed largely by the yellow-colored urinary
each pulse that is delivered is shorter than the time it takes calculi is produced, which allows it to be safely used without
for the target tissue to cool (7). causing much damage to surrounding tissues (13). As the
The active medium of the Nd:YAG laser is a single stone absorbs the energy from the laser, the excited ions that
YAG crystal bar covered with neodymium ions. The are released form a quickly expanding and pulsating cloud
wavelength of light that is produced by of this system, around the stone, creating a shock wave that then breaks the
which is determined by the neodymium ions, is 1,060 nm (5). calculus into fragments (15). Because this laser is ineffective
Because there are no key tissue chromophores at this against the nonabsorbent colorless calculi such as those
wavelength, the Nd:YAG laser-tissue interaction produces composed of cystine, photosensitizers (dye) have successfully
largely a scattering effect (8). Scattering leads to reflection, been used as irrigation fluids and absorbents to initiate the
which prevents the typical narrow, cohesive beam from process of fragmentation (16,17). The Q-switched Nd:YAG
being produced. This decreases the penetrative ability of laser also accomplishes lithotripsy by this mechanism, but it
the laser, resulting in slower heating of the tissue (9). This generates larger-magnitude of shockwaves (18).
property of the Nd:YAG laser makes it ideal for hemostasis The long-pulsed Holium:YAG laser on the other hand, uses
and tumor necrosis, as well as numerous endoscopic a mainly photothermal mechanism to fragment calculi (19)
procedures within various specialties (6,10). (Figure 2A). The laser produces light with a wavelength of
Ion lasers, such as the argon and krypton laser, operate 2,100 nm, which is highly absorbable by water. Thus in the
similarly to gas lasers, except they ionize the active medium. appropriate environment, fluid absorbs the energy and is
This excites ions instead of atoms, using a large power supply. heated as a result. A cloud of vapor is produced, parting the
They can operate at both pulsed and CW modes and can water and allowing the remaining portion of the laser light
produce wavelengths anywhere between 250 and 530 nm, to directly contact the calculus surface, drilling holes into it
with the two most powerful beams being in the blue (488 nm) and leading to its fragmentation (13). A study conducted by
and green (514.5 nm) ranges of the spectrum (6). Cimino et al. demonstrated that Ho:YAG laser lithotripsy is
a more efficacious endoscopic technique for the treatment
of ureteral stones with higher stone fragmentation rates
Clinical applications of lasers
compared to pneumatic lithotripsy, and a review conducted
As minimally invasive techniques are continually being by Teichman concluded that this laser is safe, effective, and
sought out for the treatment of different pathologic works just as well if not better than other modalities, and that
processes, the use of lasers has become increasingly it may also be used for biliary stones (20,21).

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Page 4 of 7 Azadgoli and Baker. Laser applications in surgery

A B reactions induce heating and coagulation, which cause cell

death (26).
To enhance this process and more accurately target the
desired tumor cells, PDT was developed nearly a century
ago and has gained great popularity since. This treatment
modality involves the administration of a photosensitizing
drug followed by the subsequent illumination of the target
area with visible light corresponding to the absorbance
wavelength of the photosensitizing drug (27). The
photosensitizer, which is then activated, initially forms
the excited singlet state and then transitions to the triplet
state, which in the presence of oxygen form reactive
oxygen species that are destructive to neoplastic cells (28).
Selective photothermal therapy, on the other hand, uses
localized light-absorbing dye to enhance the laser-induced
destruction of the tumor cells (29).

Aesthetic and reconstructive surgery

Figure 2 Demonstrates a Ho:YAG lithotripsy laser (A) and an
The unique ability of lasers to target specific structures and
neodymium:yttrium-aluminum-garnet (Nd:YAG) dermatologic
layers of tissue makes them a powerful tool in cosmetic and
laser (B).
reconstructive surgery. Laser resurfacing has been a major
tool used for anti-aging treatment in recent medicine, as
the induction of new collagen formation is known to lessen
Oncology
the effects of photoaging (30). Original skin resurfacing
Lasers are currently being safely used for the treatment of techniques involved using ablative CO2 and Er:YAG laser
cancers arising in various organ systems. In neurosurgery systems to target a specific portion of the dermis. However,
for example, laser interstitial thermal therapy (LITT) because these systems also remove a significant amount of
is a preferred treatment option for patients who are not epidermis, they result in prolonged recovery and increased
ideal surgical candidates (22). Since their introduction to side effects such as infections and erythema. Nonablative
neurosurgery, lasers have become increasingly safe to use lasers, such as the intense pulsed light, Nd:YAG, diode, and
and have been successfully applied for the treatment of Er:glass lasers, which mostly release infrared light, were
unresectable gliomas as well as hard and hemorrhagic tumors subsequently developed to overcome these issues (Figure 2B).
such as meniniomas, tumors of the deep skull base, or tumors The goal of these systems is to target the water in the
deep in the ventricles (10,23). Mucosal ablation techniques dermis, which during the process heats collagen and induces
using lasers are currently being widely and successfully remodeling. Because there is a system that simultaneously
used for the treatment of superficial gastrointestinal cancers cools the epidermis, tissue evaporation does not occur and
including early gastric cancer, superficial esophageal cancer, no external wound is produced. Most recently, fractionated
colorectal adenoma, and high-grade Barrett’s esophagus (24). laser resurfacing has become the basis of skin resurfacing.
Moreover, photodynamic therapy (PDT) using lasers has also Using fractionated lasers, fine beams of high-energy
been shown to be an effective treatment modality for specific light are used to inducing small zones of thermal damage
types of lung cancer lesions (25). (“microscopic thermal zones”) and treating only fractions of
Direct laser ablation has been used for direct destruction skin at a time (31).
of cancer cells through its photochemical, photomechanical, Laser-assisted lipolysis, which uses an optical fiber inserted
and photothermal effects. The photochemical reactions that inside a 1-mm cannula, has also become an increasingly
occur ultimately form toxic radicals that lead to the death of popular procedure in cosmetic surgery. Due to the small
tissues, the photomechanical reactions induce stress on the cannula size, a smaller incision is needed, resulting in less
tissue and lead to its fragmentation and the photothermal bleeding and scar formation. Of all the lasers that are available

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Annals of Translational Medicine, Vol 4, No 23 December 2016 Page 5 of 7

for medical purposes, those with 920 nm wavelengths by deuterium oxide. As a result, it penetrates tissue beyond
have the smallest absorption coefficient in fat tissue, and the endothelium, where it is absorbed by water molecules,
so they penetrate the deeper layers of tissue. Those with resulting in heating and coagulation necrosis. The energy
wavelengths in the 1,320–1,444 nm range have the largest that is delivered can be titrated by changing the power
absorption coefficient in fat, causing smaller penetration (5.5–12 W) in a set of predefined levels (40). The energy
depth and allowing for superficial treatment of such tissues. levels are altered depending on which cardiac wall is being
The Nd:YAG laser (1,064 nm) is the system that is used targeted (41). The Nd:YAG laser is another laser system
most widely in laser lipolysis, as the absorption coefficient that is commonly used for this purpose (42). A multicenter
of fat tissue in this wavelength results in good penetration study conducted by Metzner et al. has shown significant
depth with medium absorption, causing only moderate success rates of PVI using EAS, and has suggested that
temperature elevation and thus less tissue damage (32). the 1-year success rate is comparable to conventional PVI
Further, the coagulation of small blood vessels by the laser techniques (about 63%) (43).
light at this wavelength results in significantly less blood In order to successfully result in a complete conduction
loss during the procedure (33). Abdelaal and Aboelatta were block, a fully transmural lesion must be created in the
able to show a significant decrease in blood loss (54%) with heart. Melby et al. demonstrated that electrical impulses,
laser-assisted liposuction when compared to traditional both paced and AF, could still propagate even through
methods (34). Additionally, a review conducted by Mordon very narrow gaps (≥1 mm) in the ablation line (44). When
and Plot concluded that laser lipolysis produces more even comparing the effects of different energy levels, studies
skin results (35). have shown that the use of higher energy levels results in
Finally, the ability of lasers to selectively target higher rates of PVI with lower AF recurrence rates and no
pathologic vasculature makes them an ideal source for the compromise of the safety profile (45,46).
treatment of vascular defects such as port-wine stains (36). In neurological surgery, MRI-guided laser-induced
Prior to use of lasers, patients did not have many treatment thermal therapy (MRgLITT) is commonly used to treat
options for these types of abnormalities. Currently however, refractory epilepsy, either as a means of ablating the
lasers that are preferentially absorbed by hemoglobin epileptic foci, or as a disconnection tool. MRgLITT
over melanin are used for this purpose, with little trauma combines a diode laser (980-nm) with imaging technology
to the epidermis (37). More recently, lasers with longer to provide intraoperative information that is necessary for
wavelengths, and thus the ability to achieve deeper tissue controlling the amount of energy delivered (47,48).
penetration, have also been introduced (38). A review conducted by Bandt et al. demonstrated the
successful use of laser ablation for the management of
refractory epilepsy of many different focal origins including
Ablation of conductive pathways
mesial temporal lobe epilepsy, cortical dysplasia, post-stroke
After it was discovered that the pulmonary veins (PV) are an neocortical focus, encephalocele, periventricular nodular
important source of ectopic beats that lead to the paroxysms heterotopia, and hypothalamic hamartomas (48). In addition
of atrial fibrillation (AF), the development of catheter to resective techniques for epilepsy management, there
ablation devices was inspired for circumferential PV are disconnective treatment strategies that separate the
isolation (PVI) (39). Today, the laser balloon catheter is one epileptogenic brain from the nonepileptogenic brain by corpus
of the endoscopic ablation systems (EAS) commonly used callosotomy or hemispheretomy. Calistro et al. demonstrated
for the treatment of AF. The device consists of a catheter successful endoscopic disconnection of hypothalamic
with a compliant balloon at its tip that is continuously hamartomas with the use of a robot-assisted thulium-laser and
flushed with deuterium oxide. The catheter is introduced Choudhri et al. successfully demonstrated the use of a carbon
into the left atrium and an endoscope is then inserted dioxide laser for corpus callosotomy in children (49,50).
into the catheter shaft, allowing direct visualization of the
ablation target inside the heart. Ablation is performed with
Discussion
a 980-nm diode laser that is housed in the central lumen,
emitting laser energy perpendicular to the catheter shaft Since their development, the use of lasers in medicine
covering an arc of a 30° angle and allowing circular ablation has become extremely widespread and often imperative.
around each PV. Laser at this wavelength is not absorbed From life-threatening diseases to psychologically stressful

© Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(23):452
Page 6 of 7 Azadgoli and Baker. Laser applications in surgery

cosmetic defects, laser therapy has led to advancements in 2001;15:257-73.

countless pathologies, ultimately benefiting both patients 13. Adams DH. Holmium:YAG laser and pulsed dye laser: a
and physicians. The evolution of laser technology thus far cost comparison. Lasers Surg Med 1997;21:29-31.
has led to the practice of minimally invasive procedures, 14. Grasso M, Bagley D, Sullivan K. Pulsed dye laser
shorter recovery times, and less risk to patient health. As lithotripsy--currently applied to urologic and biliary
laser technology continues to improve in precision and calculi. J Clin Laser Med Surg 1991;9:355-9.
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continue providing safer outcomes, more optimal clearance Surgery. 3rd ed. St. Louis: Mosby, 1994:192.
of disease, and improved patient satisfaction. 16. Ceccheti W, Tasca A, Guazzieri S, et al. Photosensitization
method to improve lithotripsy with dye and alexandrite
lasers. Proc SPIE 1993;1879:160-4.
Acknowledgements
17. Tasca A, Cecchetti W, Zattoni F, et al. Photosensitization
None. of Cystine Stones to Induce Laser Lithotripsy. J Urol
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18. Rink K, Delacretaz G, Salathe RP. Fragmentation
Footnote
process of current laser lithotriptors. Lasers Surg Med
Conflicts of Interest: The authors have no conflicts of interest 1995;16:134-46.
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lithotripsy: a dominant photothermal ablative mechanism
with chemical decomposition of urinary calculi. Lasers
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Cite this article as: Azadgoli B, Baker RY. Laser applications

in surgery. Ann Transl Med 2016;4(23):452. doi: 10.21037/
atm.2016.11.51

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