procedure guide

PROCEDURE GUIDE
TABLE OF CONTENTS
Therapy Attachment Procedure
Clinical Research #1: The Histo-Path of Laser vs. Scalpel Incision
Clinical Research #2: Laser-Assisted Incision Options
Therapy- Clinical Case #1- Canine Foreign Body Tract
Therapy- Clinical Case #2: Hogfish Cutaneous Ulcer
Therapy- Clinical Case #3: Canine Abscess Repair
Therapy- Clinical Case #4: Owl Wing Wound
Therapy- Clinical Case #5: Tinkerbird Chronic Scalp Wound
Surgical- Clinical Case #6: Felie Declaw
Surgical- Clinical Case #7: Feline Castration
Surgical- Clinical Case #8: Skin Tumor Removal
Surgical- Clinical Case #9: Oral Mass Removal
Surgical- Clinical Case #10: Mybomian Gland Tumor
Surgical- Clinical Case #11: Endoscopic Laser Tumor Ablation
Surgical- Clinical Case #12: Entropion
Surgical- Clinical Case #13: Canine Staphylectomy
Surgical- Clinical Case #14: Canine Excisional Biopsy
Surgical- Clinical Case #15: Feline Prepucial Surgery
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INTRODUCTION
Your Pilot diode laser is equipped with two therapy attachments. These therapy attachments aid in the use
of the Pilot laser for bio-stimulation, wound therapy and lameness therapy. Common treatments include:
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Post surgical treatment of incision
Pre-surgical treatment for hemostasis
Wound and ulcer treatment
Hot spots
Granulomas
Infection treatment
Otitis Externa
Lameness treatment
Arthritis
Osteoarthritis
ATTACHMENTS
Two sizes of Pilot therapy attachments are provided:
• 5 Watt (larger attachment)
• 3 Watt (smaller attachment)
Both therapy attachments are designed to provide optimum energy delivery, laser penetration and
therapeutic benefits with the laser power at the indicated setting, used in direct contact with the tissue on
medium pigmented tissue. Adjustments need to be made for darker/lighter pigment, hand speed and depth
of penetration desired. With a little experience and visual observation, the clinician will quickly be able to
make necessary and skilled adjustments.
CONTINUOUS
These attachments are easy to attach and easy to
use following these instructions:
1. Strip the end of the fiber to 20mm using the
measurements on the fiber stripping tool.
3 Watt
Note: 20mm is the length of the metal
Attachment
coupling piece on the end of the attachment.
5 Watt
2. Cleave the end of the fiber to assure a proper
Attachment
cleave.
3. Insert the fiber through the black handpiece.
4. Insert the fiber into the hole in the therapy
attachment.
Note: the fiber will stop when the fiber jacket reaches the hole.
5. Connect the therapy attachment to the end of the handpiece.
6. Tighten the cap on the handpiece to capture the fiber in place
PULSE
Min
Max
Min
Max
2
4.5
4
7
4
6.5
6
8
With the fiber stripped to 20mm, the fiber end will protrude beyond the metal coupling piece. The natural
angle of the laser will result in treatment of the complete area at the end of the attachment.
SELECTION OF ATTACHMENT
The selection of the attachment is simply a function of the area to be treated. For small areas, small limbs,
etc. the smaller 3 Watt attachment is sufficient. The larger 5 Watt attachment should be used for larger
areas.
1
USING THE PILOT THERAPY ATTACHMENTS
The ability of laser energy to penetrate and benefit deep tissue is based on several variables.
• Power setting
• Patient tissue pigment
• Distance
• Angle
• Minimal interference (hair/fur)
• Hand Speed
Most of these variables are under the control of the clinician. Maximum laser penetration and benefit will
be achieved if the clinician:
1. Adjusts the power setting to achieve a “warmth” sensation at the end of the attachment. Adjustments
need to be considered for darker and/or pale pigments.
2. Maintain handpiece attachment perpendicular to the area being treated.
3. For ulcer or surface wound treatment, keep the end of the attachment 1 cm from tissue.
4. For deep tissue, muscle and joint treatment, place the end of the attachment in contact with the patient
and use the sturdy end of the attachment to move/displace the hair to achieve minimal obstruction for
the laser.
5. If appropriate, use the sturdy attachment to provide stimulating massage while laser treating the area.
6. Maintain a slow and steady hand speed.
POWER SETTINGS
The power setting should be adjusted higher or lower based on the depth of penetration desired, skin
pigment, hair obstruction and hand speed.
HAND SPEED
Laser energy does not penetrate instantly. Penetration for deep tissue therapy takes time. Hand speed
should be adjusted to allow several seconds at any given point. A total therapy treatment will often take
from 10 to 15 minutes.
TREATMENT FREQUENCY
Like any other method of treatment, a single treatment is seldom adequate. Repeated treatments over a
period of 1 – 2 weeks is generally recommended. Treatments may range for multiple treatments per day to
every couple of days. Over-treating in a single treatment does not compensate for multiple treatments. This
does not work with antibiotics and it does not work with laser therapy.
CONTINUOUS MODE VS PULSE MODE
The attachment power specification (5W/ 3W) is determined for continuous mode.
OBSERVATION AND VENTILATION PORTS
The therapy attachments are designed with open ports to aid observation and ventilation. The clinician
should closely observe the treatment to make assure that hair is being displaced to remove obstructions and
to make adjustments as necessary in power settings and hand speed.
2
WOUND TREATMENT
3 Watt
5 Watt
1x1
1 min
2x2
3 min
3x3
5 min
2 min
4x4
8 min
4 min
5x5
10 min
6 min
DEEP PENETRATION AND MUSCULOSKELATAL CONDITIONS
FELINE
3 Watt
5 Watt
CANINE <20 LBS
3 Watt
Carpus/ Tarsus
3 min
5 Watt
Carpus/ Tarsus
2 min
Elbow
4 min
2 min
Elbow
5 min
3 min
Shoulder
4 min
2 min
Shoulder
5 min
3 min
Stifle
5 min
3 min
Stifle
7 min
4 min
Hip Dorsal Aspect
2 min
Hip Dorsal Aspect
4 min
3 min
Hip Ventral Aspect
2min
Hip Ventral Aspect
3 min
Neck
3 min
2 min
Neck
4 min
2 min
Back
6 min
4 min
Back
7 min
5 min
CANINE <40 LBS
3 Watt
5 Watt
CANINE <60 LBS
3 Watt
5 Watt
Carpus/ Tarsus
4 min
Carpus/ Tarsus
5 min
Elbow
6 min
4 min
Elbow
7 min
5 min
Shoulder
7 min
4 min
Shoulder
9 min
6 min
Stifle
8 min
5 min
Stifle
9 min
7 min
Hip Dorsal Aspect
5 min
3 min
Hip Dorsal Aspect
7 min
6 min
Hip Ventral Aspect
4min
3 min
Hip Ventral Aspect
6min
4 min
Neck
6 min
5 min
Neck
7 min
5 min
Back
8 min
7 min
Back
9 min
7 min
CANINE <80 LBS
3 Watt
5 Watt
CANINE >80 LBS
3 Watt
5 Watt
Carpus/ Tarsus
6 min
Carpus/ Tarsus
8 min
Elbow
8 min
6 min
Elbow
9 min
7 min
Shoulder
10 min
7 min
Shoulder
12 min
9 min
Stifle
10 min
8 min
Stifle
12 min
9 min
Hip Dorsal Aspect
8 min
6 min
Hip Dorsal Aspect
9 min
7 min
Hip Ventral Aspect
7min
5 min
Hip Ventral Aspect
8min
6 min
Neck
8 min
6 min
Neck
9 min
7 min
Back
10 min
8 min
Back
12 min
9 min
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CLINICAL RESEARCH #1:
The Histopathology of Laser vs. Scalpel Incision
PROCEDURE: Comparison of Laser Incision vs. Scalpel
Incision. Both pre-treated with 3LT for Hemostasis.
ANESTHESIA: N/A
EQUIPMENT: #15 Scalpel blade, 9.0 Watt Pilot Laser set
at 8.5 watt in both continuous and pulsed modes.
Figure CR-1-1
COMMENTS: Figure CR-1-1 – Abdominal hernia
repair provided an opportunity to prepare these photomicrographs of the histopathologic sections the thin sliver
of skin to compare Pilot Laser Incision with scalpel incision.
Figure CR-1-2 & CR-1-3 – Compares the laser incision
seen along the top of both images with the scalpel incision
seen only along the lower right corner of the CR-1-2
image. Notice that there is no cellular charring in the
laser incision, and only a minimal cellular depth in the
zone of tissue vaporization and coagulation.
Figure CR-1-4: Diagrammatically represents the tissue
impact zone surrounding the end of the Optical Fiber
Tip with each pulsed emission of laser beam energy. It is
essential to note that in each clinical application, every
layer of tissue has a different laser Energy Absorption
Coefficient, and the laser beam generates a well defined
sphere of diffusing energy levels as the thermal energy
wave expands away form the optical fiber tip into the
surrounding cellular matter. The direction of the laser
beam is rarely perpendicular to the surface of the skin, so
the refracted portion of laser energy varies constantly at
the tissue surface as a function of the contour irregularities
along the surface of the target tissue.
Figure CR-1-2
Figure CR-1-3
The surgeon quickly learns to intuitively compensate for
these variables by adjusting the position of the laser handpiece to achieve the desired effect.
Figure CR-1-4
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CLINICAL RESEARCH #2:
Laser-Assisted Incision Options
PROCEDURE: Laser assisted incision options for any
surgical candidate include: Pre-treatment of incision site
for biostimulation, decontamination, and hemostasis, as
well as the post-treatment of incision site for additional
biostimulation and decontamination.
EQUIPMENT: 9.0 Watt Pilot Laser at various settings.
Figure CR-2-1
COMMENTS:
Figure CR-2-1: Shows pre-operative laser treatment of
incision site for biostimulation, decontamination, collagen
contraction and hemostasis.
Figure CR-2-2: Shows incomplete laser incision, despite
presence of dark green pigmented dye. Char results from
both remaining hair and insufficient power setting. The
red arrow identifies a small plume of debris elimination by
vacuum source at right margin of image. Notice that there
is no bleeding.
Figure CR-2-2
Figure CR-2-3: Shows completed incision using a steel
scalpel blade with essentially no bleeding.
Figure CR-2-4: Shows the pre-treatment of an incision
site with laser energy without photosensitive dye. In this
instance, only the right ½ of the proposed Incision site
received pre-operative laser treatment.
Figure CR-2-3
Figure CR-2-4
Figure CR-2-5: This image was captured immediately after
the incision was made using a steel scalpel blade, clearly
shows that only the non-treated half of the incision is
freely bleeding with no hemostatic effect. The laser treated
portion of the incision shows effective hemostasis.
Figure CR-2-5
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THERAPY- CLINICAL CASE #1
Canine Foreign Body Tract
BREED: German Shorthaired Pointer, female, 4 years old,
spayed (Figure CC-11-1).
PROCEDURE: Non-healing foreign body (foxtail) tract.
ANESTHESIA: None, Laser set at 2.0 Watts and avg. 7 cm
for nerve desensitization. Light manual restraint.
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
Figure CC-11-1
TECHNIQUE: Laser set at 2.0 watts at approximately 7 cm
for pre-operative nerve desensitization. Tract opened and
probed with sterile mosquito forceps, negative findings,
flushed with dilute chlorhexidine solution. Laser set a 4.0
watts at an average 5 cm distance, three passes once
daily for three days was used for decontamination and
biostimulation of the wound.
COMMENTS: Foreign body (i.e. foxtail/grass awn) tracts
are commonly found on dogs, especially in the feet (Figure
CC-11-2). This dog’s abscess was surgically probed under
heavy sedation and local anesthesia three days prior and
she was put on systemic non-steroidal anti-infammatory
and antibiotic medications at that time. A presumptive
exit-wound was identifed on the plantar surface of the
inter-digital webbing. Never-the-less, the tract healed
over and re-abscessed. Often foreign body tracts must
be re¬opened to drain multiple times. Foot soaks and
bandaging may also be used to help the wound healing.
In one day, this tract was dry and swelling was signifcantly
reduced (Figure CC-11-3). By day four the tract was
approximately 50% smaller and remained dry. No
bandaging or other treatment changes were made. The
tract was resolved with residual scar tissue ten days after
the onset of laser treatment.
CLOSURE: Healing by second intention.
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Figure CC-11-2
Figure CC-11*3
THERAPY- CLINICAL CASE #2
Hogfish Cutaneous Ulcer
BREED: Hogfish
PROCEDURE: Treatment of long-standing non-responsive
with Low-Level Laser Therapy (3LT).
ANESTHESIA: MS-222 on early procedures; none used
on later procedures.
Figure CC-10-1
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
TECHNIQUE: Laser therapy was applied at 1.0 watts
for 2 seconds, at a distance of approximately 1.0 cm to
achieve decontamination and biostimulation. Treatment
was repeated once weekly for eight weeks.
Figure CC-10-2
COMMENTS: This is a lesion that had not responded to
parenteral antibiotics over several weeks of treatment.
(Figure CC-10-1) The wound was actually getting worse
with the antibiotic treatment alone. Figure CC-10-2 shows
a close-up of the lesion. Antibiotic treatment was stopped
when laser treatment was initiated. Steady improvement
was seen with laser therapy and is resolving better than
with any previous conventional therapy. Weekly laser
treatments will continue and resolution of lesion is
expected. Figure CC-10-3 shows near resolution at eight
weeks of once weekly 3LT therapy.
CLOSURE: Healing by second intention.
Figure CC-10-3
7
THERAPY- CLINICAL CASE #3
Canine Injection Site Abscess Repair
BREED: Border Collie mix, female, 6 weeks old, intact.
PROCEDURE: Second repair of an injection site abscess.
(First repair dehisced after five days).
ANESTHESIA: General anesthesia
ketamine-valium and isoflurane.
with
morphine,
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
Figure CC-13-1
TECHNIQUE: Routine surgical repair, Penrose drain
placement, laser decontamination and biostimulation at
4.0 Watts. Three passes of the laser at approximately 5 cm
distance over the caudal half of incision only, once daily
for four days (Figure CC-13-1) Rx: Clavamox, meloxicam,
buprenorphine.
COMMENTS: Initial surgical debridement and treatment
with a systemic cephalosporin was deemed inadequate
to resolve the infection when the site dehisced. E. coli
was cultured, indicating fecal contamination of the site
following the initial repair. Additionally, abscess cavitation
had increased by the time of the second surgery.
The second surgical repair included both drain placement,
and laser decontamination/biostimulation, followed by an
antibiotic change. It is apparent in only three days that the
treated half of the incision has better epithelialization and
less scabbing following low level laser therapy (3LT) than
the untreated half (Figure CC-13-2).
The Penrose drain was pulled on day four. At this time,
3LT was applied to the entire affected area, including
subcutaneously via the drain sites. At 15 days post-op, the
entire wound was nicely healed (Figure CC-13-3) with an
atypically large amount of new hair growth. The difference
in healing suggests that 3LT is beneficial for all surgical
procedures. A sibling who was not treated with 3LT is also
pictured (Figure CC-13-4) for overall comparison.
Figure CC-13-2
Figure CC-13-3
CLOSURE: 3-0 nylon, horizontal mattress and simple
interrupted patterns.
Figure CC-13-4
8
THERAPY- CLINICAL CASE #4
Owl Wing Wound
BREED: Barn Owl, adult, male.
PROCEDURE: Superficial cutaneous trauma (degloving)
of the ventral surface of the wing after being caught in a
soccer net overnight.
ANESTHESIA: The owl was restrained, but not sedated.
Figure CC-3-1
Figure CC-3-2
Figure CC-3-3
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
TECHNIQUE: The wound was abraded repeatedly during
the night while the bird struggled to escape, leaving no
soft tissue covering the bone (Figure CC-3-1). The wound
was cleaned and debrided, but could not be closed
surgically because there was no tissue remaining over the
denuded bone to provide primary closure. No additional
feathers were removed. The laser was set at 2.0 watts and
held about 2 cm distance from the damaged tissue (Figure
CC-3-2). Operator hand movement was slow but steady
for approximately 2 minutes to slowly “paint” the entire
wound and marginal area, using the red aiming light for
guidance for biostimulation and decontamination (Figure
CC-3-3). Treatment was administered once every other
day for 2 weeks.
COMMENTS: The wound healed faster than expected.
Surprisingly, the wound healed without the usual scabbing
or crusting, which generally occurs with degloving injuries
(Figure CC-3-4). From day one, the owl was able to
spread its wing without disturbing, cracking or reopening
the healing wound. In two weeks the healed wing was
completely functional, and the owl was released back into
the wild.
CLOSURE: Healing by second intention.
Figure CC-3-4
9
THERAPY- CLINICAL CASE #5
Tinkerbird Chronic Scalp Wound
BREED: Tinkerbird, male, 2 years old, (Figure CC-7-1)
with a chronic wound from scalp trauma (Figure CC-7-2).
PROCEDURE: Laser biostimulation of Chronic wound
from scalp trauma.
ANESTHESIA: None; manual restraint.
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
Figure CC-7-1
TECHNIQUE: Laser was set at 0.7 watts for each of four,
two-second, eraser-sized applications. A Duoderm paste
cap was also applied over the wound. The caudal edge
of the Duoderm cap was sealed to the skin with tissue
glue. Additional biostimulation was performed 24 hours
later, and the lesion was covered with a Duoderm paste
cap again at that time. This same process was repeated
for subsequent treatments every two days for 3 more
treatments.
Figure CC-7-2
COMMENTS: The laser was noted to be easy and fast to
use for all treatments. The extent of lesion healing was
profound and estimated to be reduced by 60% within 24
hours. Figure CC-7-3 shows the progression of healing.
The outer drawn red line shows the margins of the lesion
pre-treatment. The inner drawn green line shows the
margins of the lesion at 24 hours. Figure CC-7-4 is an
unmarked photo of the wound at 48 hours, and Figure
CC-7-5 shows the wound on day seven.
CLOSURE: Healing by second intention.
Figure CC-7-3
Figure CC-7-5
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Figure CC-7-4
SURGICAL- CLINICAL CASE #6
Feline Declaw
BREED: Domestic Calico, male, 1½ years old, in good
health.
PROCEDURE: Feline Onychectomy (Declaw)
ANESTHESIA: The cat was placed under general
anesthesia for the surgery (Figure CC-1-1).
Figure CC-1-1
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
TECHNIQUE: The laser was set at 9 watts and was used
as a scalpel, with very light surface contact. There was no
carbonization (char) on the tip of the optical fiber. The fiber
tip was maintained in gentle contact at the cartilaginous
tissue margin, following the contour of the joint to precisely
dissect the third phalanx and facilitate the coagulation of
the associated vascular structures (Figure CC-1-2). The
laser was used without any other surgical instruments.
Several passes were required to complete the amputation
(Figure CC-1-3).
Figure CC-1-2
COMMENTS: The diode laser performed very similar to
the CO2 laser, except the laser tip is in contact mode almost
as though one were using a scalpel to incise the tissue.
The technique, hand speed, fiber tip orientation, etc. was
described by the surgeon as “exactly as a scalpel would
be used”. The incision was clean with very little charring,
except for an occasional hair. No bleeding was present
along the margins, and there was no need to deal with
stray “bleeders”. The procedure progressed very swiftly,
with a timely closure and clean-up.
CLOSURE: Closure was completed with a surgical
cyanoacrylate adhesive.
Figure CC-1-3
11
SURGICAL- CLINICAL CASE #7
Feline Castration
BREED: Domestic Calico, male, 1½ years old, in good
health.
PROCEDURE: Castration.
ANESTHESIA: The cat was placed under general
anesthesia for the surgery.
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
Figure CC-2-1
TECHNIQUE: Patient was immobilized, shaved and
prepped (Figure CC-2-1). The laser was set at 1 watt,
and several slow passes over the intended incision site
were made, producing collagen contraction with vascular
constriction and effective hemostasis. The laser was then
set at 7 watts and used as a scalpel with very light surface
contact to create a full-thickness skin incision. Several
passes were made to penetrate the layers of tissue and
membranes. The first testicle was removed and then the
laser was used to surgically access the second testicle.
Testicle removal was completed per standard protocol.
COMMENTS: The laser incision was very “scalpel like”.
Technique, hand speed, etc. was exactly as a scalpel would
be used. The incision was very clean, with no bleeding at
the incision. The procedure went very swiftly and closure
and clean-up was very fast.
Figure CC-2-2
CLOSURE: Closure was completed with sutures and a
surgical cyanoacrylate adhesive.
Figure CC-2-3
12
SURGICAL- CLINICAL CASE #8
Skin Tumor Removal
BREED: Lhasa Apso, 17 years old, female.
PROCEDURE: Laser Treatment of 6 skin tumors ranging in
size from 5 mm to 3 cm
FiguCe CC-5-1
ANESTHESIA: Due to patient’s age, the owner elected not
to do general anesthesia. Local Lid Cane was used at each
of the 6 tumor sites.
EQUIPMENT: 7.0 Watt Pilot Diode Laser, Pulse Mode.
Figure CC-5-2
TECHNIQUE: The Pilot© Diode Laser was used to ablate/
vaporize 5 of the smaller tumors and excise the larger
tumor. The laser tip was held 2 mm distance from the
tumors painting the entire area very slowly until the tumor
vaporizes leaving a small divot around the margin of the
tumor. The larger tumor was excised using the Pilot with
no bleeding. The residual remnants of the tumor tissue
around the margin was ablated. The laser was used postop on the larger excision at .5” distance to contract the
tissue to about ½ of the size before applying Solviden
Cream and a patch. No suture was required.
COMMENTS: The patient was examined 5 days post-op.
CLOSURE: Not applicable.
Figure CC-5-3
Figure CC-5-4
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SURGICAL- CLINICAL CASE #9
Oral Mass Removal
BREED: Domestic Long Hair feline, female, 2 years old, in
good health.
PROCEDURE: Oral mass removal from ventral surface of
tongue.
ANESTHESIA: General anesthesia
ketamine-valium and isoflurane.
with
morphine
Figure CC-14-1
EQUIPMENT: 9.0 Watt Pilot Diode Laser at various
settings.
TECHNIQUE: Patient was immobilized, and the ventral
surface of the tongue including a very vascular, raised
tissue mass was surgically prepped (Figure CC-14-1).
The laser was set at 4.0 watt, and several slow passes
over the intended incision site were made, producing
collagen contraction with conspicuous localized blanching
of the surrounding tissue indicating vascular constriction
producing an effective Hemostasis. Upon completion of
the circumferential excision of the mass a slight degree of
tissue charing was observed (Figure CC-14-3). Closure of
the Excisional wound was completed with three individual
sutures using 4-0 Monocryl as a precautionary measure
(Figure CC-14-4). The laser was then set at 2 watts and
used to biostimulate the entire ventral surface of the
tongue.
COMMENTS: Keeping in mind that the rate of ablation
varies with the composition of the tissue at the surgical
site, the clinician should be careful not to tear any
structures but rather allow the laser energy to do all the
work (Figure CC-14-2). Although open excisional wounds
utilizing the Pilot diode laser generally do not bleed, it
is always a good idea to gently close all open mucosal
wounds as a precautionary measure (Figure CC-14-4).
Immediate post operative 3LT treatment seems to improve
not only the rate of healing, but demonstrates marked
residual photo-induced-paresthesia producing noticeable
reduction of post operative oral discomfort. This surgical
patient was comfortably lapping up fresh water shortly
after full recovery – something not commonly seen with
traditional oral surgery procedures involving lingual tissues
or musculature. The patient healed uneventfully.
Figure CC-14-2
Figure CC-14-3
Figure CC-14-4
14
SURGICAL- CLINICAL CASE #10
Meibomian Gland Tumor
BREED: Retriever, female, 11 years old
PROCEDURE: Patient was present with Meibomian glad
tumors essentially covering the entire upper and lower eye
lids of both eyes.
ANESTHESIA: Standard general anesthesia.
Figure CC-13-4
EQUIPMENT: 9.0 Watt Pilot Diode Laser, 7.0 Watt setting,
Pulse Mode.
TECHNIQUE: The Pilot diode laser was used to ablate or
vaporize the tumors around both eyes.
COMMENTS: The patient was examined 5 days post-op.
CLOSURE: Not indicated.
Figure CC-13-4
Figure CC-13-4
Figure CC-13-4
Figure CC-13-4
Figure CC-13-4
15
SURGICAL- CLINICAL CASE #11
Endoscopic Laser Tumor Ablation
BREED: Domestic Short Hair feline, female, 5 years old,
spayed, presented for ablation of a nasal tumor at the
nasal choanae (posterior nasal aperture).
PROCEDURE: Endoscopically guided laser ablation of the
mass.
ANESTHESIA: Induction with an intravenous injection of
Propofol and maintenance with isoflurane via oxygen and
an endotracheal tube.
Figure CC-8-1
EQUIPMENT: 9.0-Watt Pilot Diode Laser, Pentax 6 mm
diameter flexible video endoscope.
TECHNIQUE: The endoscope was passed through the
mouth and retroflexed above the soft palate. It was then
guided anteriorly to the level of the internal nasal choanae
to allow visualization of the mass. The laser fiber was
passed through the working channel of the endoscope and
the mass was visualized (Figure CC-8-2). Power was set at
0.5 watt at pulsed mode and near contact with the tip of
the optical fiber in very close quarters (Figure CC-8-3).
The laser was fired for only a few seconds at a time. The
smoke plume was evacuated using suction to allow visual
evaluation. (An 8 French red rubber catheter was placed
into the nares and inserted to the level of the choanae.
Suction was applied to the catheter to remove the smoke
produced in the confned area of the nose). The ablation
was completed (Figure CC-8-4).
COMMENTS: The confined nature of the cat’s nasal
passages renders aiming of the laser fiber very difficult.
However, with persistence, most of the mass was ablated.
Figure CC-8-2
Figure CC-8-3
FOLLOW-UP: Two months after the initial procedure, nasal
obstruction recurred due to re-growth of the mass. It was
ablated a second time. The use of a laser intensifying dye
applied to the mass might facilitate ablation and should
be considered.
Figure CC-8-4
16
SURGICAL- CLINICAL CASE #12
Entropion
BREED: Shih Tzu, [x] years old, [female]. etc.
PROCEDURE: Patient was presented with entropion
condition on the medical canthus of the left eye. The
condition had developed a corneal ulcer with significant
discomfort.
Figure CC-9-2
ANESTHESIA: Standard General Anesthesia. A Sharpie
marker is used to artificially pigment the skin to aid in laser
absorption.
EQUIPMENT: 4.0 Watt Pilot Diode Laser, Continuous
Mode.
Figure CC-9-3
TECHNIQUE: The Pilot© Diode Laser will be used to
create a series of three surface incisions in the shape
of “X” of aobut 1 cm in length, criss-crossing across the
medial aspect of the lower eye lid. This will cause the eye
lid to contract adn pull the canthus back into the original
position. When the canthus and eye lashes retract, then
the corneal ulcer will be abel to heal.
COMMENTS: The patient was examined 5 days postop. The canthus had retracted into proper position and
the corneal ulcer had healed. No further treatment was
needed.
CLOSURE: Not Indicated.
Figure CC-9-4
Figure CC-9-4
17
SURGICAL- CLINICAL CASE #13
Canine Staphylectomy (Reduction of Soft Palate)
BREED: Boston Terrier male, 8 months old, neutered,
presented with a history of difficulty breathing, especially
during periods of excitement. (Figure CC-6-1).
PROCEDURE: Excision of excessive soft palate tissue
obstructing the laryngeal airway.
ANESTHESIA: General anesthesia achieved with
morphine, acepromazine, Ketamine and diazepam.
An endotracheal tube was placed and the patient was
maintained on oxygen and isofurane.
Figure CC-6-1
EQUIPMENT: 9.0 Watt Pilot Diode Laser, 4-0 Monocryl
suture, and curved metzenbaum scissors.
TECHNIQUE: Stay sutures were placed laterally just
above the line of resection and at the distal midline of the
elongated soft palate (Figure CC-6-2). A visual estimation
of the tissue to be removed was made. Tissue coagulation
and vaporization began at the left margin with the laser
set at 7.o watts. Gradual lasing was continued two-thirds
of the way across toward the right lateral margin. (Figure
CC-6-3) Tissue coagulation followed by cutting with curved
metzenbaum scissors was used to remove the remaining
tissue. An injection of dexamethasone SP was given at the
anti-infammatory dose immediately following surgery to
reduce potential tissue swelling. The patient recovered well
and had limited stridor overnight. A noticeable decrease in
respiratory effort and noise was noted the following day
and the patient began eating soft food.
COMMENTS: The goal is for the soft palate to just meet
the epiglottis, providing complete separation from the
nasopharynx without obstructing the pathway of air
through the oropharynx. Surgical bleeding and postoperative swelling increase patient morbidity and mortality
associated with the surgery.
CLOSURE: Given that no bleeding occurred with either
laser cutting or laser coagulation followed by scissors,
closure was likely not required. However, the surgical site
was over sewn in a simple continuous pattern using 4-0
Monocryl as a precautionary measure.
18
Figure CC-6-2
Figure CC-6-3
SURGICAL- CLINICAL CASE #4
Canine Excisional Biopsy
BREED: Pomeranian, female, 16 years old, spayed.
PROCEDURE: Surgical excision of chronic dermal mass.
ANESTHESIA: Owner declined general anesthesia, and
elected to restrain the patient for the procedure. Local
anesthesia provided with infused 2% lidocaine (without
epinephrine).
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
Figure CC-4-1
Figure CC-4-2
Figure CC-4-3
TECHNIQUE: Surgical site was clipped but no pre-op
surgical scrub applied. Only the laser was utilized for
decontamination, biostimulation, and also initial preoperative photo-paresthesia (Figure CC-4-1). Laser was
set at 2.0 watts with dime-sized impact zone. Using the
laser hand-piece directed perpendicular to the surface
of the skin around the mass; the diode laser energy was
directed into the dermal layer to induce parasthesia. Then,
the 2% lidocaine was injected for deeper subcutaneous
anesthesia. Photo-contraction and hemostasis along the
proposed incision line was achieved with the addition of
laser intensifying dye. The scalpel was used to finish the
incision through the skin to the subcutaneous layers (Figure
CC-4-2). Scissors were used for sharp/blunt dissection of
the mass. Laser decontamination and biostimulation of
the surgical site was repeated following mass removal
(Figure CC-4-3).
COMMENTS: The area healed extremely well and
rapidly. This laser assisted technique provided moderate
parasthesia, excellent hemostasis and excellent
decontamination. Furthermore this combination with
tissue biostimulation effects of the laser produced minimal
tissue reaction with no visible erythema, infammation,
thickening of the wound margins or discharge. Three
months post-operatively the scar was wider than expected
but there was no palpable fibrosis. There was also a
noticeable increase in pigmentation of the surrounding
hair. It’s suspected that these sequelae were the result
of inadequate wattage and would not have occurred with
the 9-0 watt laser.
CLOSURE: A continuous subcutaneous suture (Figure CC04-04) was followed by simple interrupted skin sutures.
Biostimulation and decontaminated were performed twice
daily for 1 week post-op.
Figure CC-4-4
19
SURGICAL- CLINICAL CASE #15
Feline Prepucial Surgery
BREED: Domestic Long Hair feline., male, 6 weeks old.
PROCEDURE: Corrective surgery of prepuce damage
secondary to genital suckling. Because general anesthesia
was required, the kitten was also neutered at this time.
ANESTHESIA: General anesthesia using bupreorphine
and Sevofurane. Post-operatively, applied 1% lidocaine
and dexamethasone SP topically.
Figure CC-12-1
EQUIPMENT: 9.0 Watt Pilot Diode Laser.
TECHNIQUE: Laser set at 6.5 Watts following standard
surgical preparation. Gentle traction applied to elevate
prepuce away from end of penis. Laser ablated granulation
tissue covering (Figure CC-12-1), creating a new orifice
(Figure CC-12-2). 1% lidocaine and dexamethasone
SP were applied topically. RX: systemic meloxicam and
bupreorphine, topical triple antibiotic ointment twice daily.
COMMENTS: Genital suckling is common among
neonatal orphan kittens and causes significant genital
damage. Often, the result is urinary tract obstruction by
granulation tissues produced in attempt to heal the injury.
Typically, the kitten then requires perineal urethrostomy
(PU), a major surgical “re-plumbing” of the urinary system
to allow urination. This laser facilitated surgery to re-open
the prepuce has prevented this kitten from undergoing
such a traumatic procedure. In this group of six orphans,
all four males were suckled excessively. Three required
surgical attention. Of these three, one kitten underwent
PU surgery and is still dealing with minor incontinence
issues. Two were successfully treated by laser surgery. The
laser was set at 8 Watts on the first kitten, causing both
charring and scabbing that required warm packing. The
surgery was perfected for this, the second kitten. Figure
CC-12-3 shows a completely healed new prepuce opening
at 15 days post-op. Figure CC-12-4 shows the kitten that
underwent PU surgery. This may have been avoided with
the early application of 3LT, and here the healing remains
in progress at 28 days post-op.
Figure CC-12-2
Figure CC-12-3
CLOSURE: Not indicated.
Figure CC-12-4
20
HOW LASER STIMULATES TISSUE REGENERATION,
REDUCES INFLAMMATION AND RELIEVES PAIN IN
MUSCULOSKELETAL DISORDERS
James Carroll FRSM AInstP
Low Level Laser Therapy (LLLT) had been used as a therapy for pain and tissue repair for over thirty years despite
a lack of published scienEfic evidence, but in the last decade scientists have been busy publishing over 1,000
laboratory studies and 100 randomised double blind placebo controlled clinical trials in peer reviewed medical
journals. This is a brief summary of the photobiological mechanism that leads to reduction of inflammation, tissue
regeneration and analgesia in musculoskeletal injuries.
The Mechanism Can Be Described In Three Steps:
Primary Effect: Light is absorbed by chromophores and porphyrins in mitochondria and cell membranes
causing an increase in Adenosine Triphosphate (ATP), modulaEon of Reactive Oxygen Species (ROS) and
release of Nitric Oxide (NO).
Secondary Effect: The primary effects leads to a cascade of indirect effects on cell signalling such as exchange of
calcium ions, secretion of growth factors, activation of enzymes and other secondary messengers.
Tertiary Effect: Neutrophils, macrophages, mast cells, fibroblasts, endothelial cells, keratinocytes and leukocytes
have all been shown to be influenced by LLLT in-vivo. This is true for all cells with mitochondria, but results depend
on the local environment. Healthy cells show little or no response whereas cells in hypoxic or other stressed states
are more likely to show some change. There are also measurable changes in blood flow, a reduction in apoptosis
and protection of cells after ischemic injury.
The Three Main Clinical Benefits In Musculoskeletal Injuries And Wounds Are:
Tissue Repair: Rapid regeneration of skin, muscle, tendon, ligament, bone and neural tissue.
Inflammation: Resolution of inflammation at least equal to NSAIDS but without the side effects.
Analgesia: Temporary (48 hours) inhibition of nerve conduction in small and medium diameter
peripheral nerve fibres.
All effects are subject to total “dose” (energy / joules) and dose-rate effects (W/cm2). There is an intensity and total
energy threshold below which there is no effect, and there are limits beyond which cellular function is temporarily
inhibited.
Three Step Treatment Method
Local: Stimulation of a wound or injury with LLLT will promote repair and reduce inflammation.
Lymphatics: Stimulation of lymphatics reduces oedema and stimulates the immune system.
Spine And Trigger Points: Treatment of the spinous processes and “trigger points” induces a 48-hour neural
blockade (analgesia) reducing central sensitisation (pain memory).
1. Lane N, Power Games. Nature 2006 Oct 26 443 901-03
2. Tafur et al Low-intensity light therapy: exploring the role of redox mechanisms. Photomed Laser Surg 2008 Aug 26(4) 323-8
3. Zhang Low-power laser
irradiation activates Src tyrosine kinase through reactive oxygen species-mediated signaling pathway. J Cell Physiol 2008 Jul 9
4. Oron et al Ga-As (808 nm) Laser Irradiation Enhances ATP Production in Human Neuronal
Cells in Culture. Photomed Laser Surg 2007 Jun 25(3) 180-2
5. Saygun et al Effects of laser irradiation on the release of basic fibroblast growth factor (bFGF), insulin like growth factor-1 (IGF-1), and receptor of IGF-1
(IGFBP3) from gingival fibroblasts. Lasers Med Sci. 2008 Apr;23(2):211-5
6. Arany et al Activation of latent TGF-beta1 by low-power laser in vitro correlates with increased TGF-beta1 levels in laser-enhanced oral wound
healing. Wound Repair Regen. 2007 Nov-Dec;15(6):866-74
7. Fujimaki et al Low-level laser irradiation attenuates production of reactive oxygen species by human neutrophils.J Clin Laser Med Surg. 2003 Jun;21(3):16570.
8. Gavish et al, Irradiation with 780 nm diode laser attenuates inflammatory cytokines but upregulates nitric oxide in lipopolysaccharide-stimulated macrophages: implications for the prevention of aneurysm progression.
Lasers Surg Med. 2008 Jul;40(5):371-8
9. Chen et al Low-level laser irradiation promotes cell proliferation and mRNA expression of type I collagen and decorin in porcine achilles tendon fibroblasts In Vitro. J Orthop Res.
2008 Nov 7
10. Prado et al Effect of Application Site of Low-Level Laser Therapy in Random Cutaneous Flap Viability in Rats. Photomed Laser Surg. 2008 Nov 23
11. Medrado et al, Influence of laser photobiomodulation
upon connective tissue remodeling during wound healing. J Photochem Photobiol B. 2008 Sep 18;92(3):144-52
12. Stergioulas et al Effects of low-level laser therapy and eccentric exercises in the treatment of recreational
athletes with chronic achilles tendinopathy. Am J Sports Med. 2008 May;36(5): 881-7
13. Carrinho et al, Comparative study using 685-nm and 830-nm lasers in the tissue repair of tenotomized tendons in the mouse.
Photomed Laser Surg. 2006 Dec;24(6):754-8.
14. Markovic et al Postoperative analgesia aUer lower third molar surgery: contribution of the use of long-acting local anesthetics, low-power laser, and diclofenac. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2006 Nov;102(5):e4-8
15. Chow et al The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain. 2006 Sep;124(12):201-10
16. Chow et al, 830 nm laser irradiation induces varicosity formation, reduces mitochondrial membrane potential and blocks fast axonal flow in small and medium diameter rat dorsal root ganglion neurons:
implications for the analgesic effects of 830 nm laser. J Peripher Nerv Syst. 2007 Mar;12(1):28-39
21
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