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Thirty cervical conization specimens obtained by thin-loop electric excision were compared with 30 carbon dioxide laser excisional cone specimens. Zones of thermal artifact were measured with a precise stage micrometer technique calibrated to a Zeiss standard. The mean depth of coagulation at the ectocervical margin measured 0.187 and 0.164 mm for thin loop and laser, respectively. Thermal artifact at the endocervical margin was greater with electric loop (0.295 mm) than with superpulsed carbon dioxide laser (0.137 mm). The zones of thermal injury induced by both electric loop and laser made no significant impact on the interpretation of margin adequacy.

Objective: To determine the effectiveness of Neodymium-YAG (Nd-YAG) laser for hysteroscopic transection of the septate uterus to improve pregnancy outcome., Design: Patients treated for recurrent pregnancy loss and/or infertility were evaluated for before versus after treatment pregnancy outcomes., Setting: All patients were referred to a University Reproductive Endocrine and Infertility practice from 1986 through 1990., Patients, Participants: Nineteen patients underwent hysteroscopic transection of uterine septa after exclusion of other factors that may cause recurrent fetal wastages and/or infertility. They were allowed to conceive 8 weeks after surgery after a postoperative hysterosalpingogram. Fourteen women attempted conception during a time span of 11 to 42 months; 3 patients declined to conceive, and 2 were lost to follow-up., Interventions: Hysteroscopic transection of the uterine septum with a Nd-YAG laser was performed in all patients. The Nd-YAG laser delivered via a 600-microns bare fiber or an 800-microns sculpted fiber through operative hysteroscopy., Main Outcome Measures: To evaluate the success and complications of this new laser technique., Results: (1) Thirteen patients conceived; 10 delivered a live infant at term; (2) 87% of the postoperative pregnancies were considered successful as compared with 11% preoperative; (3) complications included a small perforation of the uterus (no treatment needed) and development of uterine adhesions (1 case only)., Conclusions: Hysteroscopic metroplasty with the Nd-YAG laser is a valuable alternative new technique for the treatment of uterine septum.

Sixteen pregnant women with genital condylomata acuminata were treated with laser vaporization to assess effectiveness, complication rate, and impact on recurrence. Patients were treated at a gestational age of 13-35 weeks. No recurrences occurred before delivery. Five patients experienced uterine contractions before 37 weeks. Only one delivery before 37 weeks may have been attributed to the laser therapy. Four recurrences were detected during postpartum follow-up. Laser vaporization is a safe and effective treatment for condyloma during pregnancy. It is effective in maintaining a lesion-free state during pregnancy, but postpartum recurrences are not rare.

Eight patients underwent carbon dioxide (CO 2) laser excision of benign cervical tumors during a 5-year period. Six patients had symptoms of abnormal vaginal bleeding, and 2 had asymptomatic cervical masses. All but one procedure was performed as outpatient surgery. Blood loss was minimal in 7 patients and less than 50 ml in the other patient. There were no cases of morbidity, and long-term follow-up showed excellent results. The technique to perform CO 2 laser excision of large benign cervical tumors is described.

Between 1976 and 1981, 412 women with biopsy-proven cervical intraepithelial neoplasia (CIN) were treated by means of the carbon dioxide laser. A previous publication reported the author's initial therapeutic results with laser surgery for CIN, carried out between 1976 and 1978. This report includes data on 297 patients who were followed for 6 months to 5 years after laser vaporization and on 55 women treated by laser excisional cone. Major improvements in the technique of carbon dioxide laser vaporization evolved as experience was gained, and related to elimination of the entire squamocolumnar junction, to destruction of neoplastic tissue to a depth of 5 to 7 mm, and to utilization of power densities greater than 1000 watts/cm2. Cures were achieved in 285 of the 297 patients treated by vaporization, ie, the failure rate was 4% (52 of 55 women treated by excisional cone). Complications during this study were minor and usually correlated with delayed bleeding. One patient developed cervical stenosis following laser excisional cone. No patient was found to have invasive carcinoma after laser surgery to the cervix. Because laser vaporization and laser excisional cone are best adapted for the outpatient setting, financial savings accruing to the patient are considerable. Rapid healing, minimal pain, and a general absence of noxious symptomatology also promote early return to work and daily routines.

Rigid carbon dioxide wave guides measuring 300 to 500 mm in length and 3.0 mm in diameter were evaluated in rabbits and humans. The wave guide provided an effective laser delivery system for operative laparoscopy. The tested guide was introduced into the abdominal cavity alternatively via the operating channel of a 9-mm operating laparoscope, through the central channel of a smoke evacuation/irrigation cannula, or via a 3.25-mm second puncture trocar. In contrast to previously tested flexible guides, the rigid device transmitted a visible helium-neon aiming beam, power up to 50 watts, and a beam diameter of less than 1 mm. The hollow guide was kept free of smoke by-products by continuous purging with carbon dioxide gas flowing at 800 to 1000 cc per minute. All wave guides could be sterilized by ethylene oxide gas or Cidex (Surgikos, Arlington, TX) soaking. Fourteen women with a variety of reproductive disorders underwent laser laparoscopy. The rigid wave guide was fired at distances ranging from less than 1 mm to 30 mm from the target and performed with maximal impact at distances of 3 to 5 mm. Perhaps the greatest advantage of this system is its ability to focus-defocus while directly coupling to the handpiece of standard lasers and requiring no special alignment procedures.

A flexible, hollow fiber measuring 1.5 mm diameter was used in conjunction with the laparoscope to deliver a CO2 laser beam to the rabbit uterine horn. The fibers tested consistently transmitted 5 to 15 W of laser power without loss of input mode. Several fiber-to-target distances were evaluated from the standpoint of crater characteristics. Microscopic sections were studied, and crater heights and widths were quantified. All lesions produced by the CO2 laser fiber closely mimicked those delivered by the free-hand piece or micromanipulator. In two chronic experiments, rapid fibrosis and "filling in" of the craters was evident at 5 days. No adhesions were observed. The CO2 laser fiber has several advantages over current techniques for the performance of laser laparoscopy as well as over alternative systems, e.g., neodymium:yttrium-aluminum-garnet(ND:YAG) and argon-coupled fibers. The CO2 laser fiber will further increase the options available to the gynecologist for operative endoscopy.

The effect of pulsed CO2 laser treatment on tissue reaction and fertility was evaluated. The left uterine horn was cut with a pulsed CO2 laser in 16 rats. In eight other rats, the left uterine horn was cut with microscissors. The anastomosis in both groups was accomplished by microsurgical techniques. The adhesions were mostly filmy after laser treatment, as compared with thick adhesions in the conventional group. Absence of adhesions was found in 62.5% and 50% of the laser and conventional surgery group, respectively. Histologically, some degree of fibrosis in the muscularis layer of the uterine horn was seen in the conventional group, whereas proper muscle continuity was seen in the laser-treated group. The pregnancy rates were 81% and 87.5% in the laser and conventional groups, respectively.

A significant number of patients with severe pelvic endometriosis are at risk of developing pelvic adhesions and/or loss of ovarian function. Although numerous surgical techniques have been advocated, none has any clear advantage over the others. This article presents a new surgical method for conservative management of pelvic endometriosis. The CO2 laser, directed via the microscope or the freehand piece of the articulated arm, was utilized to vaporize focal endometrial implants, to excise endometrial cysts, and to lyse pelvic adhesions in 54 patients. Fourteen of 23 patients (60.8%) attempting pregnancy have conceived at the time of this report. The observed advantages of laser surgery for endometriosis are a bloodless field, precision destruction (vaporization), precision cutting, and the ability to treat poorly accessible areas.

One hundred twenty patients with cervical intraepithelial neoplasia who were treated by laser excisional conization were compared with a group of 100 women who had similar diagnoses and were treated by laser vaporization. Every operation in the series was performed in the outpatient surgical unit or in the office. In two thirds of the cases the procedures were carried out with the patients under local anesthesia. The parameters studied included time required to perform the procedure, immediate and delayed bleeding, postlaser stenosis, healing time, patient discomfort, persistence or recurrence of disease, and risk of invasion. The results of this study revealed few disadvantages to performing a laser excisional procedure. Immediate and delayed complications were less frequent with laser excisional conization. The time required to perform an excisional conization was on the average only 4 minutes longer than that for a vaporization. Most significantly, the laser excisional cone provides a large and excellent specimen for the pathologist to review.

Two women undergoing intrauterine surgery with the neodymium:yttrium-aluminum-garnet laser delivered by the artificial sapphire tip had catastrophic cardiovascular collapse during operation. In each case the evolution of clinical events was consistent with the diagnosis of air embolus. Investigation of causative factors links the use of the sapphire tip and the gaseous cooling of the tip to the calamitous outcomes. Both women died.

A multichannel operating hysteroscope was developed for use with the Nd-YAG laser. The telescopes measure 350 mm in length, with a 4 mm outer diameter (OD), and are available with 0 degree or 30 degrees objectives. The operating sheath incorporates two isolated operating channels (2 mm OD) through which an Nd-YAG quartz fiber and an aspiratory cannula can be inserted simultaneously. The design of this instrument permits constant or intermittent aspiration of debris from the intrauterine milieu and very clear vision throughout the operative procedure. The entire cavity of the uterus may be flushed with the distending medium by injecting the liquid through the instillation channel and opening one of the two operating channels.

Viral venereal infections caused by herpes simplex virus 2 and papillomavirus (wart) are epidemic diseases in the United States. Unfortunately, these two infections have eluded conventional therapy to date. Therefore, 306 women were treated for viral venereal diseases with the CO2 laser. Two hundred twenty-eight patients were treated for condyloma acuminatum and 78 for genital herpes. All the patients who underwent treatment for herpes were enrolled in an investigative protocol. Since the viral organisms of both diseases replicate in either the basal or prickle cell layers of the epithelium, deep laser treatment is not necessary; treatment to a depth of 1 to 2 mm is adequate. The average power densities ranged from 311 to 660 w/cm2. Herpes patients responded with relief of pain and elimination of viral infectivity for that cycle. Patients with primary herpes were "cured" in 83% of cases. C. acuminatum could be eliminated with the CO2 laser in virtually every woman.

Condylomata acuminata virus accounts for a significant number of venereal infections in the western world and constitutes a major public health problem. Unfortunately, conventional therapeutic measures have given inconsistent and largely unsuccessful results for the elimination of genital warts. A 3.5-year experience with 110 women using the carbon dioxide (CO2) laser for evaporation of viral warts is presented. Six patients (5.5%) developed recurrent lesions and were retreated. Several patients were staged for 2 or 3 treatments because of extensive condylomata; this occurred especially during pregnancy and other altered states of immunity. The principal advantages of CO2 laser therapy are precision, which results in sparing of normal tissue; probable elimination of the infective agent; and rapid healing without scar formation. Sixty-three patients had atypical cytology associated with condylomata acuminata; this finding suggests an association with lower genital tract neoplasia.

The CO2 laser produces a highly directional and collimated light beam that may be precisely focused to a fine point. Because the laser beam physically removes tissue by vaporization, causes little damage to neighboring cells and seals small vessels, a minimum amount of suture material is required and scar formation is reduced. Although the laser has been utilized commonly in recent years to treat lower genital tract pathology, its application to intraabdominal surgery is in the early developmental phase. Special adaptations of the operative microscope and special accessory instruments are necessary before the laser can be used within the abdominal cavity. One hundred twenty-one cases are described to illustrate the technique and use of the laser for infertility surgery and for the treatment of pelvic endometriosis.

Fifteen women diagnosed with cervical stenosis were treated by vaporization of scar tissue using the carbon dioxide laser. Ninety-three percent of the cases demonstrated binding constriction of the cervical os to a 2-mm diameter or less and 40% of the cases had either a pinpoint opening or total endocervical obliteration. The technique for laser treatment and the success of the method depend on precise variations of mode, power, beam diameter, and "buttoning" the endocervical mucosal remnant. Twelve of the 15 patients were relieved of stenosis and 9 achieved pregnancy within 2 years of the operative procedure. Critical analysis of possible causative factors in this study revealed that virtually every case of stenosis had been iatrogenic.

Two series of patients with genital warts were compared for effectiveness of treatment by means of the carbon dioxide laser. In the earlier series (1977 to 1981) laser vaporization was used to remove overt warts while surrounding normal skin was spared. Examination of anal, urethral, and other extragenital sites for possible involvement was done only when warts persisted or recurred. In the later series (1983 to 1985), patients were similarly treated by carbon dioxide laser techniques; however, two additional measures supplemented laser vaporization of gross condyloma acuminatum. The brush technique superficially coagulated skin and mucosal surfaces contiguous to warts. This methodology was hypothesized to eliminate subclinical human papillomavirus infection within normal-appearing epithelium. Compulsive examination and treatment of extragenital sites at the time of the initial laser surgical procedure eliminated the most likely locations for persistence or recurrence. The primary cure rate for the earlier series was 65.8% compared to 91% for the later series. This difference was highly significant (p less than 0.005).

The carbon dioxide (CO2) laser was used to perform microsurgical excision of obstructed tubal segments in rabbit and human subjects. Approximation of the freshly severed tubes by means of laser "welding" was evaluated in both groups investigated. More important, the laser beam cuts accurately and atraumatically while sealing small vascular channels. Scanning electron microscopic studies of the human fallopian tube following laser surgery were done to determine the extent of tissue injury. At a distance of 1 mm distal to the vaporization and necrotic impact zone, normal tubal anatomy was observed. Follow-up data are presented for 7 women who underwent laser beam tuboplasty between 1979 and 1980. The principle advantages of the CO2 laser are its precise control, minimal tissue injury, and hemostatic properties.

Fourteen women underwent endometrial ablation by use of the Nd:YAG laser. All patients had significant risk factors that precluded safe hysterectomy for intractable bleeding. All patients had demonstrated anemia, menorrhagia, and metrorrhagia uncontrolled by hormonal therapy or curettage. Specifically, seven (50%) women in this group had proved major clotting abnormalities as their principal diagnosis. Three new techniques are described as modifications of the original Nd:YAG ablation methodology and include: (1) the use of Hyskon as the uterine distending medium; (2) the attachment of a high-resolution endoscopic television camera to the eyepiece of the hysteroscope, which permits the surgeon to view the endometrial cavity and operate via a video monitor; and (3) the application of a specially designed dual-channel operating hysteroscope that allows simultaneous laser ablation and aspiration of debris. Although this operation is a valuable alternative to hysterectomy in selected clinical situations, its major deficiencies are the lack of long-term follow-up data and the absence of a surgical specimen for pathologic analysis.

Between 1977 and 1987, the CO2 laser was used to treat 4024 women who were diagnosed by cytology studies, colposcopy, and biopsy examination to have cervical intraepithelial neoplasia. On the basis of specific indications, these women were treated by vaporization, excisional conization, or combination conization procedure. The evolution of methodology for each laser technique was based on specific pathophysiology and long-term observation of results. A total of 3070 patients underwent vaporization, 2881 of whom had no evidence of disease after one laser exposure (93.8%). Of the 954 patients who had laser excisional procedures, 925 (97%) had no evidence of disease. The most common complications observed were intraoperative and postoperative bleeding; however, sutures were required in only 1.34% of the latter. The risks of cervical stenosis (1.1%), incompetent cervix (0%), and pelvic infection (0.05%) were very low. This 10-year study demonstrated that the CO2 laser was a highly effective method for treating cervical epithelial neoplasia and had the added benefit of preserving reproductive function and anatomic integrity.

A new conservative method for treating carcinoma in situ of the vulva is presented. The carbon dioxide laser offers the advantage of a microsurgical technique combined with the benefits of sharp local excision. As one third of the 35 patients treated in this series are under 30 years of age, preservation of the anatomic and functional integrity of the vulva is of paramount importance. Laser therapy has proved to be precise and has resulted in rapid healing without scar formation. The laser regimen conveniently unifies the therapeutic program directed against multicentric squamous neoplasia of the lower genital canal.

Five women undergoing endometrial ablation with the Nd-YAG laser developed sudden gas embolism. In each case laser intrauterine contact surgery was carried out utilizing coaxial fibers with (three cases) and without (two cases) artificial sapphire tips but commonly cooled by air or nitrogen. Four of the five women died in a sequence of sudden cardiovascular collapse followed by irreversible cardiac arrest. One woman was critically ill and following prolonged hospitalization survived with neurological deficits.

Extensive cervical intraepithelial neoplasia may simultaneously involve large areas of the ectocervix, even extending to the vaginal fornices, as well as the endocervical canal. In such instances conventional sharp knife conization would result in virtual removal of the cervix if the surgeon wished to completely circumscribe the entire lesion. By combining a narrow carbon dioxide laser excisional conization with ectocervical vaporization, cervical intraepithelial neoplasia may be eradicated by a virtually bloodless surgical procedure and fertility may be preserved. Sixty-one combination conizations with 6 months to 4 years of follow-up are reported. In 95% of the cases biopsy demonstrated cervical intraepithelial neoplasia in three or more ectocervical quadrants, and 16% had extension of disease into the vagina. The technique of combination conization uses 20 to 30 W of power and 1/2 to 1 mm spots for excision and 10 to 15 W and 1 to 1.5 mm spots for vaporization. The average time to complete the entire procedure was 21 minutes. In three of 61 cases endocervical margins were positive; there were no instances of persistence of neoplasia at either the ectocervical or the vaginal margins. Four complications were observed, all related to delayed bleeding; however, only two patients required the placement of a suture. The volume of tissue removed by a large excisional conization is more than two times greater than that of a laser combination conization.

A flexible carbon dioxide laser fiber delivery system was used in conjunction with the laparoscope to treat 12 women. The 77 by 2 mm hollow fiber could subtend an arc of 90 degrees without significant loss of power or unfavorably affecting the delivery mode. As many as 20 W of power was transmitted through the fiber; however, carbon dioxide gas flow rates as high as 2000 cc/min reduced power by approximately 25%. Replaceable tips preserved fiber integrity to the extent that a single fiber could be reused repeatedly and gas sterilized without jeopardizing laser transmission. Of the 12 cases, endometriotic implants were vaporized in eight women, adhesiolysis was performed in four women, endometrial cysts were drained in two women, and vaporization of myomata was accomplished in two patients. The fiber was also used as a manipulating instrument and could be internally bent with a grasping forceps to better site the laser beam on a lesion. No complications related to the use of the carbon dioxide laser fiber were observed. The safety aspects of carbon dioxide laser fiber technology are not inconsiderable and could provide laser laparoscopy with an extra margin of security.

Continuous wave (CW) CO2 laser using a power of 20 W and a spot size of 0.2 mm was used to cut the left uterine horn in 15 rats. Pulsed CO2 laser using a power of 14 W, pulse repetition rate of 400 pps, and a spot size of 0.2 mm was used to cut the left uterine horn in 16 rats. The right uterine horn was sham-operated and used as a control in each group. Microsurgical anastomosis of the cut horn was performed. The effect on fertility showed a pregnancy rate of 66.6% and 81.25% for the CW and pulsed CO2 laser, respectively. Histopathology studies of the anastomotic site revealed thinning of muscularis with fibrosis of both muscularis and subserosal layers in the CW CO2 laser-treated group. There was no thinning, disruption, or fibrosis of muscularis in pulsed laser-treated group. Adhesion score was not different in the two groups.

A total of 115 women with various grades of CIN were treated with high-power--density, continuous time mode CO2 laser beams. During the 2-year follow-up period, residual tumor was noted in 4.34% of the treated cases. Detailed observations of the rapid healing of tissues after laser exposure were carried out in 50 women who were colposcoped every other day for 4 weeks. The CO2 laser is an acceptable instrument for use in treating early gynecologic malignancy, with its principal advantage being the precision with which it destroys tissue.