Associate Editor's Note

"Oh No — Not Another Pitch for a Laser
Where Conventional Treatment Works Fine."

Bruce W. Pearson, M.D.,
Associate Editor, Jacksonville Medicine

In the late 70's and early 80's, in my specialty and others, lasers became a hot topic. The meetings were flush with exciting talk about bloodless precision, painless surgery, micromanipulators, target areas, joysticks, and even cash flow analyses. I was in the first decade of a surgical practice then, and I wondered if anyone felt underwhelmed like me.

Lasers seemed to be expensive thermal knives. They could reproduce a limited number of existing operations, without much visible advantage. I was skeptical that a burn wound in the larynx could have less pain, less scarring. Compared to a scalpel blade, a fifty thousand-dollar laser made an incision that provided no tactile feedback and couldn't cut around corners. Vessels more than 2 mm still required conventional ligatures. There was no reconstructive capacity. New complications like laser tube ignition were rumored at medical meetings. And the accessories in the O.R. were nearly suffocating - laser endotracheal tubes, protective eye gear, articulated arms, smoke evacuators, gas bottles, foot pedals, handpieces, control consoles, new risks to the staff, a book ful of safety regulations to be memorized and eventually a credentialing bureaucracy. Sales reps always had a new model that made the "old" one obsolete. Colleagues plied us with inter-specialty sharing concepts to justify new purchases. There seemed to be an unused laser in every hospital "attic," and I couldn't ask for another, even at the risk of appearing behind the times.

During this time, at least in the field of head and neck surgery for tumors, "cold steel" operations were steadily improving. Conservation techniques and reconstructive procedures (like free flaps) are examples. Radiation therapy did more with higher dosages, and new radiation oncologists emerged better at managing high dose technology and its complications. Organ-sparing oncology programs attracted a following. Immunotherapy, chemotherapy, tumor necrosis factor, and gene therapy all held great promise. It seemed the future in our work lay with advances in open surgery, radiotherapy, and molecular biology, not the application of hot light beams.

The advances I speak of gave us a lot of reading to do - in English. Meanwhile (as I hope my article on minimally invasive laser surgery shows) colleagues in Europe were quietly refining laser technology. They were publishing something called minimally-invasive transoral laser micro-resection - in German. As late as the mid-nineties, I heard of their work at meetings (in English), but continued to misunderstand its significance. I thought I understood from the names. Now I know one needs to look beyond.

For example, "minimally invasive" was misleading. Patients with neck node disease did get invasive surgery - neck dissections. Patients with large tongue base resections had temporary gastrostomies. When the airway was threatened by post-op bleeding or swelling, a temporary tracheostomy was performed. And "laser resection" was not done with a laser alone. For vessels more than 2 mm, insulated suction cautery instruments were used. Named blood vessels got arterial clips. Endoscopic basket forceps manipulated the specimens. All these tools were familiar, but not in their new laser adapted designs. I underestimated the safety and efficacy they conferred to this new technology. "Microscopic" procedures were not completely microscopic. Intra-operative video systems were vital ancillaries to the microscope. Not even the term "resection" was entirely accurate. Sometimes cavitary vaporization was required, or the laser was defocused to cauterize.

This issue is directed at doctors like the doctor I used to be - "laser-challenged" but nevertheless curious. If your basic instinct is to think of reasons the laser option you've heard about won't work (but you wish it would), read on. Dr. Schneider describes an incredible laser-based development in refractive eye surgery. Drs. Harris and Randle explain why patients marked by unwanted vascular or pigmented skin lesions are helped by a special laser with a long name. Dr. Bernhardt explains a safer way to treat a disease we all get - the aging face. And my own article shares my excitement at discovering a new alternative to the age-old radiation-versus-surgery paradigm for the treatment of head and neck cancer.

"Oh No — Not Another Pitch for a Laser Where Conventional Treatment Works Fine."

Jacksonville Medicine / February, 1998

"Oh No — Not Another Pitch for a Laser
Where Conventional Treatment Works Fine."