From scalpel to CO₂ laser surgery: Perspective of a veterinary surgeon in Germany

By Anya Glazkova, PhD For The Education Center
Originally Published In Veterinary Practice News, August 2019 – Download as a PDF

Jakub Kaczmarek, DVM, is a resident of the European College of Veterinary Surgeons (ECVS) at Germany-based AniCura, a referral clinic where the CO₂ laser is used as the main surgical modality. He has extensive experience with laser surgery and performs laser procedures on a daily basis (mainly perineal, oncologic, and facial). In this interview, Dr. Kaczmarek talks about his professional journey from the moment he first picked up the laser, to the time he taught laser surgery to his fellow surgeons across Europe and the U.S. through numerous presentations and wet labs.

Q: How did you learn about laser surgery?

A: My first contact with the laser was during the Southern European Veterinary Conference (SEVC) Congress in Barcelona in 2014. I had an opportunity to talk to one of Aesculight Lasers’ representatives and learn about its numerous benefits, and see how different procedures are performed with it. It caught my attention and piqued my interest on the spot.

Q: When did you incorporate the Aesculight laser into your practice and what motivated you to do so?

A: I started using the laser more than three years ago. For me, the most important motivators were the clinical benefits, such as less bleeding and swelling, reduced postop pain, less risk of infection (due to the noncontact nature of CO₂ laser surgery), and shorter surgical time. I also was very encouraged by current research regarding laser surgery and how beneficial it is. Eventually, many pet owners also became interested in getting surgeries done with the laser.

Q: How difficult was it for you to learn to use your CO₂ laser? How did you learn? What was most helpful in the learning process?

A: As with any surgical tool, a laser scalpel—which is essentially what a CO₂ laser is—has its own learning curve. It isn’t nearly as long as with tibial-plateau leveling osteotomy (TPLO) or arthroscopy, but it needs to be considered. Before starting a surgery, it is critical to learn anatomy, the proper technique, and the pathomechanism behind the disease. Before starting to utilize the laser in your practice, it is critical to learn and understand laser physics and the basics of laser-tissue interaction. Being a good laser surgeon requires combining these two elements.

Reading and continuing education are very important— there are many good publications focusing on CO₂ laser surgery and a new book has just come out that is directed specifically to veterinarians (Laser Surgery in Veterinary Medicine, edited by Christopher Winkler). A very significant element regarding education is participation in workshops and symposia. For example, there is a yearly American Laser Study Club Symposium that offers a veterinary track and labs (the next symposium will be held in February 2020 in Fort Lauderdale, Fla.). This event is a great place to learn about laser surgery. And of course, if possible, it is very helpful to shadow a laser surgeon at his/her clinic and observe them working.

I had an opportunity to attend both laser workshops and symposia. They were really helpful in developing the proper technique. I started with simple procedures, such as removal of small cutaneous masses, and slowly moved on to more advanced procedures, including nephrectomy, scrotal urethrostomy, amputations, treating brachycephalic obstructive airway syndrome, and many more.

Q: What mistakes can a novice CO₂ laser surgeon easily make? What would you recommend to avoid them?

A: In my opinion, underestimation of laser power and the fact the laser beam is invisible may result in underlying tissue damage. In-depth knowledge of anatomy and basic laser physics will help avoid potential complications (e.g. using a backstop can prevent undesirable tissue effects to the underlying tissue; understanding higher power, smaller focal spot size; slower hand speed results in deeper incisions and allows for a more efficient surgery). Also, as I mentioned before, attending workshops and educational meetings, as well as having discussions with experienced colleagues, will help the surgeon achieve better clinical outcomes for the patient and pet owner. In the beginning, during the surgery, if one is not feeling 100 percent comfortable or confident when using a laser, it is OK to turn to standard tools such as Metzenbaum scissors or even a regular scalpel. The main goal is to provide safe treatment for the patient.

Q: What type of surgeries do you perform with your laser? What are your preferred settings?

A: When used properly, a laser can replace the standard scalpel in any surgery. I regularly perform routine oral, cutaneous, perianal, and urogenital (also intraabdominal) surgeries with the laser.

I don’t have a preferred setting because every anatomical region is different and every patient is unique. As such, it’s important to adapt laser settings to each surgery. For instance, to perform a skin incision in a dog, I use a 0.25-mm focal spot size (the smallest setting) at 15 to 20 watts in the continuous SuperPulse mode. For a skin incision in cats, I tend to use much less energy—between 10 to 12 watts continuous SuperPulse—with a 0.25-mm spot size. But the surgical technique really affects the choice of power settings. Things that need to be considered are tissue tension, the surgeon’s hand speed, and the patient’s body condition. For perineal or oral procedures, I don’t go above 12 watts. With these cases, I usually change the spot size or the tip-to-tissue distance in order to obtain the desired effect.

I utilize the SuperPulse mode daily, and the continuous wave (CW) only when performing oral surgeries. A very handy feature is the ability to set the laser in the SuperPulse mode and sending pulses at a specific frequency (e.g. 10, 15, or 40 Hz). This feature provides very good control in areas where proximity to anatomical structures requires high precision.

Q: Which particular surgical procedures would you much prefer doing with a laser, rather than a scalpel?

A: As a result of minimal bleeding, all perineal procedures (e.g. hepatoid cell tumor, anal sac carcinoma, rectal polyps, anal sacculectomy) have become much more pleasant, faster, and consequently, easier.

Q: Do you ever leave your laser surgical site to heal by second intention?

A: Yes, I do on distal limbs (tumors) or on the tail (mostly hepatoid cell tumors in dogs) where the primary closure could cause too much tension and result in wound dehiscence. Healing after utilizing the CO₂ laser is very good, patients are very comfortable, and I haven’t noticed any complications.

Q: In your opinion, what laser features are most useful and why?

A: I think every laser feature is unique, and all of them combined make the laser a great surgical tool. Freedom to cut, coagulate, and ablate using the same instrument is very helpful and creates new ways of treating many conditions, not only surgical.

Q: Could you go over the clinical benefits of your surgical laser that you have personally observed?

A: In my opinion, pain reduction in my patients is a huge benefit. I can see it very clearly in patients with perianal problems (chronical anal sac infections, tumors, etc.). These patients are very often already in pain and traumatized from their initial examination. Noticeable reduction of pain and an increase in postoperative comfort are noted by owners a few days after the laser procedure. In this case, it is not only beneficial for patients, but also for owners who are pleased to see their pet recovering so quickly and so well.

Q: Is there anything else you would like to share with new laser surgeons?

A: Keep calm and love the laser beam!

Anya Glazkova, PhD, earned her doctorate at the University of Washington, Seattle. She helps conduct laser surgery educational programs at Aesculight and LightScalpel LLC.

After graduating with a degree in veterinary studies in Wroclaw (Poland) in 2013, Jakub Lukasz Kaczmarek, DVM, began a two-year surgical internship at the referral clinic in Birkenfeld, Germany. He is currently a resident of the European College of Veterinary Surgeons (ECVS) at a referral clinic in Augsburg, Germany.

This Education Center article was underwritten by Aesculight of Bothell, Wash., manufacturer of the only American made CO₂ laser.