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Minimal access surgery and the future of interventional laparoscopy.

Minimal access surgery is intended to minimize the trauma of access without compromising exposure of the operative field. Its major benefits include diminished cost of therapy due to a reduced hospital stay and accelerated recovery with early return to full activity. The approaches used in minimal access surgery are laparoscopic, endoluminal, perivisceral, intra-articular, and combined. Many abdominal and thoracic procedures are being adapted to the minimal access approach. Developmental requirements include improvements in light delivery systems; three-dimensional television imaging; better surgical instrumentation; ultrasound probes for internal and external scanning; stapling devices; and tunable, portable solid-state diode lasers. In addition, however, adequate prospective evaluation of laparoscopic procedures, established or new, must be undertaken in the major academic institutions.

Evaluation Studies as Topic↗

Holmium laser thermokeratoplasty.

PURPOSE: Corneal curvature can be altered by shrinking stromal collagen with a pulsed solid-state holmium: YAG laser in a procedure termed laser thermokeratoplasty. METHODS: The authors performed laser thermokeratoplasty in 40 human cadaver eyes using a ring pattern of 32 spots, each spot having a diameter of 300 microns. RESULTS: The amount of induced corneal steepening decreased as ring diameter was increased in 1 mm increments, with 22.2 +/- 3.3 and 3.7 +/- 2.0 diopters (D) of central steepening with diameters of 3 and 7 mm, respectively. Results of histologic examination showed a cone-shaped zone of increased stromal hematoxylin uptake extending posteriorly for 90% of stromal thickness. Energy levels greater than those needed to induce topographic changes produced limited endothelial injury in rabbit corneas and, in some cases, intraocular inflammation. A computerized, finite element model of the globe demonstrated central corneal steepening as a result of heat-induced stromal contraction to a depth of 75% corneal thickness. CONCLUSIONS: These data support previous studies indicating that central corneal topography can be modified by heating corneal stroma in a controlled fashion with the mid-infrared holmium:YAG laser.

Animals↗

Transient tension changes initiated by laser temperature jumps in rabbit psoas muscle fibres.

1. A technique was developed to generate 2-8 degrees C step temperature perturbations (T-jumps) in single muscle fibres to study the thermodynamics of muscle contraction. A solid-state pulsed holmium laser emitting at 2.065 microns heated the fibre and surrounding solution in approximately 150 mus. The signal from a 100 microns thermocouple fed back to a heating wire maintained the elevated temperature after the laser pulse. 2. Tension of glycerol-extracted muscle fibres from rabbit psoas muscle did not change significantly following T-jumps when the fibre was relaxed. 3. In rigor, tension decreased abruptly on heating indicating normal (not rubber-like) thermoelasticity. The thermoelastic coefficient (negative ratio of relative length change to relative temperature change) of the fibre was estimated to be -0.021 at sarcomere lengths of 2.5-2.8 microns. Rigor tension was constant after the temperature step and returned to the original value on recooling. 4. In maximal Ca2+ activation, tension transients initiated by T-jumps had several phases. An immediate tension decrease suggests that thermoelasticity during contraction is similar to that in rigor. Active tension then recovered to the value before the T-jump with an apparent rate constant of approximately 400 s-1 (at 10-20 degrees C). This rate constant did not have an appreciable dependence on the final temperature. Finally, tension increased exponentially to a new higher level with a rate constant of approximately 20 s-1 at 20 degrees C. This rate constant increased with temperature with a Q10 of 1.4. 5. At submaximal Ca2+ activation the tension rise was followed by a decay to below the value before the T-jump. This decline was expected from the temperature dependence of steady pCa-tension curves. The final tension decline occurred on the 1-5 s time scale. 6. The value and amplitude dependence of the rate constant for the quick recovery following T-jumps were similar to those of the quick recovery following length steps during active contractions. The enthalpy change associated with the quick tension recovery following temperature-step perturbations was estimated to be positive suggesting that the recovery process is an endothermic reaction. Slower reaction steps on the 10-30 ms timescale, as well as reactions corresponding to the quick recovery, may contribute to the cross-bridge power stroke.

Animals↗

Rapid quantitative analysis of differential PCR products by high-performance liquid chromatography.

We describe the use of high-performance liquid chromatography (HPLC) for the rapid quantitative analysis of short DNA fragments generated in differential PCR, where a target gene and a control gene are in vitro coamplified in one single reaction. Using an anion-exchange nonporous column, both separation and quantitation of the differential PCR products are achieved in about 5 min per sample. The performance of this technique proved to be superior to that of conventional gel electrophoresis and subsequent analysis by a laser densitometer, a solid-state scanner and a charge coupled device video camera imaging system. The usefulness for clinical testing is described in the example of the quantitative analysis of the c-erbB-2 oncogene copy number of human breast carcinomas by differential PCR. The combined use of differential PCR and automated HPLC analysis of the PCR products may well substitute for classical Southern blot hybridization in routine clinical analysis of oncogene amplification.

Base Sequence↗

[Retinal photocoagulation with a pulsed, frequency-doubled Nd:YAG laser (532 nm)].

The small difference in wavelength between an argon laser (514 nm) and a frequency-doubled Nd:YAG laser (532 nm), together with the advantage of the solid-state technology, makes the Nd:YAG laser likely to play a major role in retinal photocoagulation in the near future. For technical reasons all frequency-doubled Nd:YAG lasers work in a quasi-continuous mode, emitting a burst of highly repetitive short laser pulses during the exposure time desired. We investigated the side effects due to high peak irradiances of those short laser pulse trains (Crystal Focus Nd:YAG laser, Emerald; pulse duration 1-10 microseconds, repetition rate 13 KHz) in rabbits in comparison with a standard argon laser system (Zeiss, Visulas, Argon II). The energy necessary for blanching the retina was similar in both cases. As opposed to the argon laser system, subretinal bubbles were regularly visible ophthalmoscopically with the Nd:YAG system, when average powers as high as 200 mW were used. The ED50 power for bubble formation is about 2-3 times above the ED50 power for blanching. Thermal calculations show that this bubble formation effect is likely to be related to the peak power of the short pulses. The hemorrhage threshold is similar in both systems. However, light microscopically there is no difference between the two laser systems. Panretinal photocoagulation (300-500 microns, 100-200 ms) in patients with proliferative diabetic retinopathy produced such bubbles about once per 1000 lesions.

Animals↗

Comparison of the erbium-yttrium aluminum garnet and carbon dioxide lasers for in vitro bone and cartilage ablation.

The in vitro bone- and cartilage-ablation characteristics of the solid-state erbium:yttrium aluminum garnet laser were compared to those of the carbon dioxide laser. Ablations of fresh, frozen cadaver septal cartilage and maxillary sinus bone were performed using total energies between 1 and 6 J. Specimens were studied using hematoxylin and eosin stain and digitized, computer-assisted measurements of 35-mm photographs. Erbium-yttrium aluminum garnet-ablated bone averaged 5 microns of adjacent tissue thermal injury, compared with 67 microns with carbon dioxide-ablated bone. Erbium-yttrium aluminum garnet-ablated cartilage averaged 2 microns of adjacent tissue thermal injury, compared with 21 microns with the carbon dioxide-ablated cartilage. The tissue-ablation characteristics of the erbium-yttrium aluminum garnet laser are promising for future otolaryngologic applications.

Aluminum↗

Fluorescence lifetime imaging microscopy: homodyne technique using high-speed gated image intensifier.

In the previous sections we demonstrated imaging of intracellular Ca2+ using our approach to FLIM. What other analytes can be imaged using FLIM? We have now characterized the lifetime of a good number of ion indicators. Based on these studies we know that Cl- can be imaged using FLIM with probes such as SPQ or MQAE, pH can be imaged using resorufin and probes of the SNAFL and SNARF (Molecular Probes) series, and Mg2+ can be imaged using Magnesium Green, Mag-quin-2, or Mag-quin-1 (Molecular Probes). At present, the probe for K+, as PBFI, are just adequate as a lifetime probe, but it seems likely that newer probes for Na+ (Sodium Green) and K+ will be practical for effective imaging. Of course, imaging of oxygen is possible using a wide variety of fluorophores. It should be noted that a wide variety of substances and/or phenomena are known to alter decay times, acting as quenchers. These include the phenomena of resonance energy transfer, collisional quenching, temperature effects, and viscosity effects. Also, the FLIM method is not limited to microscopic objects but can be possibly used in remote imaging of any object. Hence, FLIM will allow the imaging of the chemical and physical properties of objects based on the effects of the local environment on the decay kinetics of fluorophores. The instrumentation for FLIM is presently complex and requires a moderately complex laser source, a gain-modulated image intensifier, and a slow-scan CCD camera. However, one can readily imagine the instrumentation becoming rather compact, and even all solid-state, owing to advances in laser and CCD technologies and, more importantly, advances in probe chemistry. To be specific, the dye laser shown in Fig. 1 may be replaced by a simpler UV laser, such as the 354 nm HeCd laser which has become available (Fig. 11). Intensity modulation of a continuous wave sources can be accomplished with acoustooptic modulators. The scientific slow-scan CCD cameras are presently rather expensive, but they are used in the present instrumentation because of their linearity and high dynamic range. However, the increasing use of CCD detectors suggest that even the scientific-grade CCD cameras will soon become less costly. Additionally, the frame rates of these detectors continue to increase in response to the need for faster imaging. Furthermore, the performance of the video CCD cameras is increasing, as seen by the introduction of 10-bit video analog-to-digital (A/D) converters.(ABSTRACT TRUNCATED AT 400 WORDS)

Aminoquinolines↗

Laser scleral buckling for retinal reattachment.

The holmium:yttrium aluminum garnet (Ho:YAG) laser produces infrared light that is absorbed inside scleral tissues, which increases local temperature, thereby shrinking collagen and inducing a buckle effect. Scleral indentation was induced in ten cadaver eyes by shrinkage of scleral collagen fibers by using a pulsed solid-state Ho:YAG (2.1-microns) laser with fiberoptic delivery. The amount of laser-induced buckling effect is controlled by selecting laser treatment settings such as beam spot, radiant exposure, and number of pulses. With treatment using 11.3 +/- 1.2 J/cm2 of laser radiant exposure and five pulses, laser-induced scleral shrinkage affected only the external two thirds of the scleral tissue. No thermal damage or disruption was observed in subjacent retinal pigment epithelium, choroid, or retina. The coupling of two appropriately selected lasers may allow laser-induced scleral buckling and transscleral retinal photocoagulation by using the same laser probe for retinal reattachment.

Collagen↗

Holmium: YAG laser-assisted coronary angioplasty with multifiber delivery catheters.

Mid-infrared lasers are attractive for coronary angioplasty based upon their excellent fiberoptic transmission and enhanced tissue absorption. Using a solid-state, mid-infrared holmium:YAG laser with prototype multifiber laser delivery catheters, we performed coronary laser angioplasty with or without adjunctive balloon angioplasty or directional atherectomy in 14 patients with 17 stenoses. Procedural laser success was obtained in 13/14 (93%) patients and 16/17 (94%) lesions; however clinical success was achieved in 9/14 (64%) patients and 12/17 (71%) stenoses. Angiographic restenosis at 4.6 +/- 1.6 months was found in 5/8 (63%) patients. We achieved an excellent procedural laser success rate in patients with generally unfavorable angioplasty anatomy. However, our clinical success rate was not different from that expected with conventional angioplasty alone. The holmium laser remains an attractive energy source for laser angioplasty; but as is the case for all coronary laser systems, its utility as a stand-alone therapy is limited by catheters which create small channels. In this small group, we could demonstrate no clinical benefit for laser-assisted angioplasty in complex coronary lesions. Our results suggest that a randomized trial comparing laser-assisted angioplasty and conventional angioplasty be performed to determine the clinical benefits of this more expensive therapy.

Adult↗

[Possible applications of laser in otorhinolaryngology].

Laser therapy in otolaryngology--head and neck surgery using laser types working in the range of the visible and infrared part of the electromagnetic spectrum is well established. The laser types usually employed for micro- and macrosurgery of the aero-digestive tract and for microsurgery of the middle ear, involving thermal ablation of tissue and extensive areas of damage are described, as well as recent advances in laser technology for future use. The mechanisms by which non-thermal, photo-ablative pulsed solid-state crystal infrared and UV-excimer lasers and photodynamic therapy affect biological tissues are reported. The advantageous main areas of application of the different types of laser according to their physical properties are compared on the basis of the results of our own studies and the relevant literature.

Animals↗

Laser facilitated angioplasty and thrombolysis in acute myocardial infarction complicated by prolonged or recurrent chest pain.

To date, application of laser angioplasty in acute myocardial infarction (MI) has not been reported. In nine patients with acute myocardial infarction complicated by continuous or recurrent severe ischemia and chest pain, a mid-infrared, solid-state, pulse-wave holmium/thulium:YAG coronary laser was applied. In six of these patients the laser was specifically utilized for the purpose of coronary thrombolysis. In each case a guidewire was placed across the stenosis and a multifiber laser catheter was utilized, emitting 250-600 mJ/pulse at 5 Hz, followed by adjunctive balloon angioplasty. Laser success (defined as ability to cross the lesion, reduction of > or = 20% in stenosis and thrombolysis when a thrombus is present) was achieved in all patients. Final angiograms revealed residual stenosis < or = 30%, adequate thrombolysis and no major complication (MI, perforation, emergency CABGS, CVA, death) in each patient. Clinically, all nine patients improved, survived the acute infarction and were discharged. This initial clinical experience demonstrates the feasibility and safety of holmium/thulium:YAG laser application in thrombolysis and plaque ablation in selected patients who experience acute myocardial infarction complicated by prolonged or recurrent ischemia and chest pain.

Adult↗

Lithotripsy with a Q-switched alexandrite laser system. Preliminary in vivo and in vitro results.

An alexandrite laser system which emits a wavelength of 750 nm, has recently been proposed as a substitute for the pulsed-dye laser (504 nm) for laser lithotripsy. We have carried out in vitro lithotripsy trials in order to evaluate the efficiency of a flashlamp pumped Q-switched alexandrite laser. In the first experiment, we compared the Q-switched alexandrite laser to the pulsed-dye laser with respect to their effectiveness in fragmentizing urinary and model stones (HMT target stones). In the second experiment, we evaluated the effect of Q-switched alexandrite radiation on the urinary wall (bladder, ureter, renal pelvis and liver) of animals (Wistar rats and rabbits) under general anesthesia. In conclusion, the alexandrite laser system is comparable to the pulsed dye laser. The 750-nm wavelength involves minimal risk of damage to the urinary tract and constitutes a safe alternative, especially during blind lithotripsy. It is a compact solid-state system, with no toxic chemical agents as laser material.

Animals↗

THC:YAG nasolacrimal duct recanalization.

In an early exploration of a new technique for creating a patent nasolacrimal duct system, a chromium-sensitized and thulium- and holmium-doped YAG laser was used to canalize the nasolacrimal duct of a fresh-frozen bisected human cadaver head. The laser--long-pulsed (300 milliseconds), compact, self-contained, and solid-state--operates in the near infrared range (2.1 microns). The technique involved passing a 550-micrometer quartz fiberoptic through the dilated superior punctum and canalicular system, down through the nasolacrimal duct. The quartz fiberoptic was then withdrawn into the area of the lacrimal sac. Pulse energies of 500 mJ were used at a repetition rate of five pulses per second to ablate the duct lining. The nasolacrimal duct was then unroofed and the epithelial lining of the duct histopathologically evaluated.

Dacryocystorhinostomy↗

Chiral detection in high-performance liquid chromatography by vibrational circular dichroism.

A novel chiral detector for high-performance liquid chromatography has been developed. This detector is based on the measurement of circular dichroism of chiral effluents in the infrared region, i.e., vibrational circular dichroism (VCD). In this instrument, a solid-state spectral tunable (from 2.4 to 3.5 microns) F-center laser was used as the light source. The linearly polarized laser beam was converted into left circularly polarized light (LCPL) and right circularly polarized light (RCPL) at 42 kHz by means of a photoelastic modulator. The intensity of the LCPL and RCPL transmitted through the sample was measured by a liquid nitrogen cooled indium antimonide detector. Double modulation was employed to reduce the noise associated with the laser beam. Specifically, the linearly polarized laser beam, prior to being converted to CPL, was modulated at 85 Hz by a mechanical chopper. Demodulation and amplification were accomplished with the use of two lock-in amplifiers. In its present configuration, the instrument can be used to measure the VCD of O-H groups. Its sensitivity is so high that it was able, for the first time, to detect chirally (with limits of detection of micrograms) (R)- and (S)-2,2,2-trifluoro-1-(9- anthryl)ethanol and (R)- and (S)-benzoin when these compounds were chromatographically separated from the corresponding racemic mixtures by a Chiralcel-OD column. The main advantage of this chiral detector is, however, its universality; i.e., it can be used to virtually detect any chiral compounds which has O-H group (e.g, aliphatic alcohols such as 2-octanol).

Chromatography, High Pressure Liquid↗

Systemic nitric oxide synthase inhibition does not affect brain oxygenation during cortical spreading depression in rats: a noninvasive near-infrared spectroscopy and laser-Doppler flowmetry study.

Cortical spreading depression (CSD) has been implicated in the migraine aura and in stroke. This study demonstrates near-infrared spectroscopy (NIRS) for the first time as capable of noninvasive on-line detection of CSD in the pentobarbital-anesthetized rat. CSD was accompanied by a brief and rapid increase of regional CBF (by laser-Doppler flowmetry) to 200-400% baseline. NIRS demonstrates that this hyperperfusion is associated with concentration increases of oxyhemoglobin, while deoxyhemoglobin decreases. Simultaneously, oxygen partial pressure, measured on the brain surface with a solid-state polarographic probe, was shown to be raised by at least 14 mm Hg during CSD. Oxygen-dependent phosphorescence life-time quenching measurements confirmed this finding. NIRS data on cytochrome aa3, however, showed a CSD-related shift toward a more reduced state, despite raised blood oxygenation. This may suggest either limited O2 transport from the blood to mitochondria or decreased oxygen utilization during CSD as supposed by theories about compartmentalization of energy metabolism favoring glycolytic rather than aerobic energy supply during CSD. However, the data on cytochrome aa3 warrant caution and are discussed critically. Nitric oxide synthase inhibition by systemic application of N'-nitro-L-arginine had no significant effect on the perfusion response or the tissue PO2 during CSD. During most CSD episodes, a brief decrease in MABP by 4-8 mm Hg was noted that might be caused by functional decortication during CSD.

Animals↗

Diffusion-induced Ramsey narrowing.

Diffusion-induced Ramsey narrowing is characterized and identified as a general phenomenon, in which diffusion of coherence in and out of an interaction region such as a laser beam induces spectral narrowing of the associated resonance line shape. Illustrative experiments and an intuitive analytical model are presented for this spectral narrowing effect, which occurs commonly in optically interrogated atomic systems and may also be relevant to quantum dots and other solid-state spin systems.

Journal Article↗

A new method for characterizing beta-ray ophthalmic applicator sources.

A technique is described which enables one to obtain detailed dose characteristics of 90Sr beta-ray ophthalmic applicators. A radiochromic radiation detector which is a solid-state solution of hexahydroxyethyl pararosaniline cyanide in a nylon polymer (i.e., thin foil), has been used to determine the surface dose rate and dose distribution of these sources. The detectors are rugged, easily handled, have an equivalent response (optical density per unit absorbed dose) to photons and electrons, and produce high-resolution images. They have been found useful for this application due to the high surface dose rates [0.10-1.0 Gy (H2O)/s] and their low sensitivity (approximately 10(4) Gy for an optical density of 1.0). The foils have been evaluated on a He-Ne scanning laser densitometer with a resolution of 0.3 mum. Comparison with NIST (formerly NBS) extrapolation ionization chamber measurements indicates surface dose-rate agreement within 6%. Spectral dosimetric characteristics are presented and discussed.

Beta Particles↗

Transition dipole orientations in the early photolysis intermediates of rhodopsin.

The linear dichroism spectrum of rhodopsin in sonicated bovine disk membranes was measured 30, 60, 170, and 600 ns after room temperature photolysis with a linearly polarized, 7-ns laser pulse (lambda = 355 or 477 nm). A global exponential fitting procedure based on singular value decomposition was used to fit the linear dichroism data to two exponential processes which differed spectrally from one another and whose lifetimes were 42 +/- 7 ns and 225 +/- 40 ns. These results are interpreted in terms of a sequential model where bathorhodopsin (BATHO, lambda max = 543 nm) decays toward equilibrium with a blue shifted intermediate (BSI, lambda max = 478 nm). BSI then decays to lumirhodopsin (LUMI, lambda max = 492 nm). It has been suggested that two bathorhodopsins decay in parallel to their products. However, a Monte Carlo simulation of partial photolysis of solid-state visual pigment samples shows that one mechanism which creates populations of BATHO having different photolysis rates at 77 K may not be responsible for the two decay rates reported here at room temperature. The angle between the cis band and 498-nm band transition dipoles of rhodopsin is determined to be 38 degrees. The angles between both these transition dipoles and those of the long-wave-length bands of BATHO, BSI, and LUMI are also determined. It is shown that when BATHO is formed its transition dipole moves away from the original cis band transition dipole direction. The transition dipole then moves roughly twice as much towards the original cis band direction when BSI appears. Production of LUMI is associated with return of the transition dipole almost to the original orientation relative to the cis band, but with some displacement normal to the plane which contains the previous motions. The correlation between the lambda max of an intermediate and its transition dipole direction is discussed.

Animals↗