CO2 laser laparoscopic surgery. Adhesiolysis, salpingostomy, laser uterine nerve ablation and tubal pregnancy

Used endoscopically, the CO2 laser offers some advantages over other operative techniques for endometriosis and adhesions but, in spite of the continuing development of new instrumentation there are still problems with the system. The technique needs specialized equipment requiring ongoing biomedical maintenance and specialized technical care in the operating room. Some problems such as the intraperitoneal accumulation of smoke, gas leakage, and difficulty with maintenance of proper beam alignment still occur. In spite of these problems the advantages are numerous: the system allows precise bloodless destruction of diseased tissue and eliminates the risks of cautery. In the hands of an experienced laparoscopist, it appears safe and effective in vaporization of endometriotic lesions, utero-sacral neurectomy, adhesiolysis and salpingostomy. The judicious use of these techniques, combined with carefully planned further investigations by well-trained and experienced laparoscopists and continuing improvements in the delivery systems, will soon reveal the true efficacy of the CO2 laser laparoscope. If studies continue to show pregnancy rates and pain relief to be equivalent to those patients treated by laparotomy, CO2 laser laparoscopy will become the preferred procedure for the management of pelvic endometriosis and its associated adhesions, distal tubal occlusion, pelvic pain and tubal pregnancy. With the exception of using the argon laser to treat endometriosis, the selective absorption characteristic of lasers has not been greatly utilized. While the CO2 laser is heavily absorbed by water and hence vaporizes most cells in a rather indiscriminate fashion, this is not true for other wavelengths, such as argon, Nd-YAG, KTP, krypton, xenon, copper and gold vapour lasers. The energy form of each of these lasers has different properties of penetration, absorption, reflection and heat dissipation. Many of these lasers have not yet been evaluated in human subjects. An exciting, although not new, area of possible laser application involves the use of photosensitizers and fluorescing agents (Dougherty et al, 1978). Some recent experimental studies (Schellhas and Schneider, 1986; Schneider et al, 1988) may lead to new therapeutic possibilities. The surgical laser is not, however, a panacea. Only controlled trials carried out carefully over the next few years will clearly define its potential. In the meantime it is incumbent upon all of us to investigate the clinical, gynaecological and surgical applications in a careful, methodical and scientific manner.