Nd:YAG surgical lasers are in general use, particularly in gastroenterology, urology, gynecology, and general surgical applications, to photocoagulate,

cut, or vaporize tissue. Nd:YAG laser energy penetrates more deeply into tissue than energy emitted by CO2, potassium titanyl phosphate (KTP/532, also called frequency-doubled Nd:YAG), or argon lasers and affects a larger volume of tissue. With their wide ranges of both power and spot size, Nd:YAG lasers can photocoagulate blood vessels at low power densities (e.g., for treatment of vascular tumors and anomalies) and vaporize tumors at high power densities (e.g., for treatment of solid tumors such as esophageal squamous carcinoma). In addition, Nd:YAG surgical laser energy (1,064 nm wavelength) can be delivered through flexible silica fibers and can pass through clear fluids, unpigmented tissue, and the top layer of the skin, making Nd:YAG lasers more effective than other types of lasers in treating certain medical conditions. For example, Nd:YAG surgical lasers are used to control excessive uterine bleeding and bleeding gastrointestinal ulcers; to relieve the intensity of painful symptoms caused by otherwise inoperable highly vascular tumors of the respiratory tract, stomach, and brain; and to destroy prostate, rectal, and bladder tumors. There are two types of Nd:YAG lasersgeneral surgical and ophthalmicand each has a specific application. The Nd:YAG ophthalmic laser produces a very shortpulsed, low-energy photodisruptive effect (measured innanoseconds and millijoules), while the Nd:YAG surgical laser usually uses a continuous wave or pulsed continuous wave and delivers greater amounts of energy (measured in seconds and joules), producing a photoablative effect. The Product Comparison chart also includes a non-ablative Nd:YAG laser designed for laser skin rejuventation, wrinkle reduction, acne, and acne scar treatments. The laser energy penetrates the upper to deep tissue layers to stimulate collagen production or to shrink sebaceous glands. Frequency-doubled Nd:YAG lasers pass Nd:YAG laser energy through a KTP or other special crystal, doubling the frequency and halving the wavelength to 532 nm. This wavelength is visible (green) and is absorbed primarily by pigmented tissue to a depth of 1 to 2 mm. It is used largely in otolaryngology, gynecology, and dermatology and in general surgical procedures such as laparoscopic cholecystectomy. Physicians have also begun using high-powered (e.g. 80 W) KTP lasers to treat benign prostate hyperplasia (BPH) because the wavelength is

excellent for hemostatis and transmits through water. One manufacturer now offers a frequency doubled double-pulse Nd:YAG (FREDDY) laser for lithotripsy treatments which simultaneously emits two pulses with 532 nm and 1032 nm and wavelengths. Combining an Nd:YAG laser with a CO2 laser adds a beam that can vaporize surface tissue with little thermal effect on nearby healthy tissue structures. CO 2 lasers emit invisible infrared beams of 10,600 nm wavelength that effectively vaporize water and are efficient cutting tools. Low-powered Nd:YAG lasers are also available for dental procedures. Principles of operation Lasers are designated by their active medium, which emits light of a single predominant wavelength. Input energy from a light (or other energy) source interacts with the medium within the laser tube to cause the emission of a narrow beam, or pencil, of high-energy light. In Nd:YAG lasers, the medium consists of neodymium (Nd), a rare-earth element, dispersed or doped in a solid crystal of yttrium-aluminum-garnet (YAG). This laser emits a single wavelength (1,064 nm) of near-infrared light, which is in the invisible portion of the electromagnetic spectrum. This wavelength is minimally absorbed in tissue, with maximal penetration. It is absorbed primarily by tissue chromophores, is less well absorbed by blood, and is minimally absorbed by water. The Nd:YAG laser penetrates tissue up to 10 mm and is highly scattered so that it is converted into heat, producing a photothermal destructive effect. Like most laser systems, Nd:YAG systems consist of a lasing medium (i.e., an Nd:YAG doped crystal rod), a laser pump or energy source, and an optical resonating cavity containing mirrors. Other components may include cooling systems and aiming beams. The reflective ellipsoidal laser cavity contains the solid Nd:YAG rod and flash lamp (pump) at the ellipses foci. The laser pump, which is typically an incoherent visible optical light source, supplies energy to the rod in the form of photons. When electrons in the medium (Nd:YAG) absorb these photons, they become excited and move to a higher, less stable energy level. This creates a state called a population inversion, in which more of the atoms in the medium are in the excited state than in the ground state. The instability of this state culminates in a certain moment when some atoms release their photons. These newly released photons stimulate the excited electrons to decay back to their original energy levels with the emission of identical photons. Because the original photons and the emitted photons have identical wavelengths, they leave the atoms in phase. This process initiates a reaction called stimulated emission, in

which a cascading wave of reactions causes a great number of identical photons to be released at the same moment. The light produced by stimulated emission is coherent and monochromatic. A collimated beam is created when this light is reflected in a resonator chamber between two mirrors, one of which is partially reflective and allows the parallel waves to exit the optical cavity. Directing the invisible beam of the Nd:YAG or CO2 laser to the target tissue requires an aiming beama second, low-power laser that produces a visible beam of light, allowing the surgeon to verify the area to be treated before activating the laser. This can be either a helium-neon (He-Ne) laser, producing a red, orange, or yellow guiding light, or a filtered xenon lamp, producing a red, blue, or white light. Integrated optics align the aiming beam with the invisible therapeutic beam to ensure that both travel the same path. In some laser systems, the aiming beams brightness and/or color can be adjusted. A separate aiming beam is not needed for the KTP laser; however, a nontherapeutic low-power KTP beam is used to highlight the area to be treated. Because Nd:YAG surgical lasers convert electrical energy to light energy inefficiently, a cooling system is needed to prevent heat damage to the laser. Most laser cooling systems use a self-contained internal radiator and fan assembly to circulate cooling water through the laser head; earlier cooling systems required external plumbing. Nd:YAG surgical laser energy is focused into small, flexible, silica fibers that connect to the laser aperture, usually found on the side of the laser unit. These fibers can be passed through flexible or rigid endoscopes to apply laser energy within body cavities or closed anatomic spaces, such as the stomach, uterus, bladder, and respiratory passages. Some fibers have specially shaped crystal contact tips and require cooling by the passage of a nonflammable gas or liquid through the fiber to prevent overheating of the tip. Laser energy heats the contact tip, and the heat is used to treat the tissue. Delivery of the Nd:YAG laser energy to tissue can be achieved in one of several ways. Catheters can be used to deliver the optical fibers through blood vessels. Bare fibers are suitable for introduction into confined cavities through endoscopes because of their narrow diameter. Since the laser light leaves the fiber typically with a divergence of 20 to 30 degrees, the diverging beam may be used for superficial treatment of large areas. If a small spot is required for a high-precision application, a focusing lens can be placed in front of the fiber tip. For contact cutting or vascular recanalization, a fiber tip allows contact-mode operation so that the tip is in physical contact with the tissue. Contact-mode lasing may be used to apply energy locally for precise tissue destruction with minimal lateral damage. Endoscopes with multiple channels allow the surgeon to perform other procedures (e.g., suctioning). In addition, micromanipulators and handpieces can

be used for applications in which the laser beam energy must be focused on a specific area or when fine control of beam movement is necessary. The KTP/532 laser can be used with handpieces, micromanipulators, and endoscopes. CO2 delivery systems consist of a hollow articulated arm with mirrors set in articulating joints so that the beam can be aimed in any direction. The end of the arm has an accessory attachment (e.g., handpiece, laparoscope) with a focusing lens to control the spot size and focal length of the beam, enabling the surgeon to vary the power density and the effect of the laser energy on the tissue. (For a more detailed description of CO2 laser delivery systems, see the Product Comparison titled Lasers, Carbon Dioxide, Surgical/Dermatologic.) Early Nd:YAG laser surgeries were performed with a free-beam technique; that is, the laser fiber remained several millimeters away from the tissue during lasing. Limitations of the free-beam method included deep tissue penetration, lack of tactile sensation for the surgeon, and an inability to focus the laser beam. Some manufacturers provide wavelength conversion contact tips for Nd:YAG lasers, which attach to the end of the laser fiber. This allows surgeons to cut and coagulate tissue by direct contact, with minimal effect on nearby tissue. The contact tips are shaped crystals of synthetic sapphire or ceramic that are screwed into a metal ferrule on the end of the laser fiber. Laser energy is concentrated at the end of the contact tip, where it is converted mostly to heat energy so that the laser works like a hot knife and enables precise tissue destruction. Other manufacturers provide silica tips of various shapes to deliver laser energy by direct contact with tissue. Contact tips provide the surgeon with tactile feedback; the tissue effect depends on the tips shape and coating (e.g., frosted tips emit a small amount of laser energy and provide greater hemostasis) and the energy output. Contact tips can be used for 8 to 10procedures, depending on the surgeons skill. Some manufacturers provide disposable contact fibers with integral shaped tips. Adhering tissue can cause silica fibers to absorb laser energy, raising them to very high temperatures. As a result, the fibers can burn, melt, or chip and become unable to deliver laser energy uniformly. To prevent this from occurring, some silica fiber systems need a supply of cooling gas (e.g., air, CO2, nitrogen) or cooling liquid flowing around the fiber to protect the tip. Pressurized gas can be supplied from the hospitals piped medical gas system, an external tank, or an integral system, and gravity or a pump can provide liquid flow; either can be increased during laser operation and decreased when not needed. It should be noted that gas cooling of Nd:YAG fiber tips has been associated with a risk of fatal gas embolism. This issue is described in detail in the Reported Problems section below. KTP and Nd:YAG surgical lasers can be used in a continuous-wave mode or a pulsed mode. In the continuous-wave mode, the laser delivers energy continuously as long as the footswitch is depressed. In the pulsed mode, the laser fires repetitive short pulses at a selected exposure duration. This mode allows the tissue to cool down during the interval between pulses so that the energy can be delivered with more precise thermal effects and less chance of thermal spread to adjacent tissue. In both the continuous-wave mode and the pulsed mode, the user adjusts the power output and the exposure time; in the pulsed mode, the rate of repetition can also be adjusted. As a safety feature,

most laser units have power meters that can be used to compare the power output at the tip of the fiber and at the laser head and automatically adjust the lasers output power so that the power delivered from the fibers tip matches the desired power. Because laser fibers are very small (typical diameters are 0.4 to 1 mm) and delicate, they are easily broken or damaged by overheating. Damaged fibers can sustain substantial energy transmission loss at their tips; fibers with excessive transmission loss (e.g., >30%) can melt and ignite from the energy absorbed by the fiber. A calibration mode can be used to assess the transmission loss of the fiber. Other safety features include interlocks that turn off the laser or block the beam with a shutter when a laser fiber is not connected, a removable key to prevent unauthorized operation of the laser, and a visual and/or audible alarm signal of laser beam emission. Other safety and alarm features alert users to gas- and water-cooling-system malfunctions (e.g., low water pressure, high temperature, blocked gas line). Nd:YAG lasers operate from either a 120 or 240 VAC single- or threephase electrical system; many require substantial power. The CO2 laser, in a combination unit, requires 240 VAC, and the KTP/Nd:YAG laser may require up to 240 VAC. Hospitals must provide appropriate electrical services and sometimes special high amperage outlets in the expected areas of use (e.g., operating room [OR], cystoscopy or endoscopy rooms).