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CO2 Laser Versus Electromicrosurgery
CO 2 Laser Versus Electromicrosurgery
1. Luciano AA, Whitman G, Maier DB, Randolph J, Maenza
To the Editor: The informative article by Luciano et al. l needs the following clarifications and recommendations: 1. The proper language, respectively, definition,
should finally be accepted with respect to electrosurgical techniques. The authors refer to "electrocautery." Since an electro surgical cutting technique is described, the term electrocautery is certainly misleading. The proper definition is electro surgical cutting or electro surgical bisection. 2. In the review "Laser vs. Electrosurgery,"2 the advantages and disadvantages of both laser and electrosurgery were discussed. The authors' conclusions are in agreement with this review: that the laser does not improve clinical results. 3. Even though the authors mention a specific model electrosurgical generator, output wattage, electrode diameter, and current density, in comparison to the laser output, one should recognize that within this 20 watts electrosurgical output, the waveform, respectively, the peak-to-peak voltages, plays an important role in the thermic effect on the tissue. It is assumed that a nonmodulated, cutting current was utilized for the electrosurgical bisections. 4. In conclusion, the laser has glamor, is highly popularized, and is rather expensive. Still, it is useful but no more useful than the proper microelectrosurgical instrumentation. In the selection of different electrodes, specific waveforms, and appropriate output settings of the microelectrosurgical generator and also in considering the unique features of the bipolar technique for hemostasis, the electro surgical approach seems to be the method of choice. Too often, microsurgeons use whatever electrosurgical equipment is available; and when they do not get the results expected, they condemn the device and seek the ultimate answer in the laser. This study is perhaps one of the finest on the subject published to date and is certainly worthwhile reading for every gynecologist who is interested in microsurgery.
Karl Hausner President Elmed Incorporated January 14, 1988 1092
Letters-to-the-editor
REFERENCES R: A comparison of thermal injury, healing patterns, and postoperative adhesion formation following CO 2 laser and electromicrosurgery. Fertil Steril 48:1025, 1987 2. Hausner K. Laser vs electrosurgery. Medical Electronics July 1985
.
Reply of the Author: I wish to thank Mr. K. Hausner for his interest in our manuscript l and for his complimentary remarks regarding our work. Indeed, the term electrocautery should not be applied when describing electro surgical cutting techniques. Electromicrosurgery, as used in the title of our paper, or electro surgical dissection or cutting is more appropriate terminology. As emphasized in the discussion of our article for open abdominal cases the laser offers no ad~ vant~ges over the more traditional microsurgery, and it may actually have some distinct disadvantages. Besides being expensive, cumbersome and difficult to maintain sterile over the oper~tive fields, the use of laser in open cases requires the surgeon, the assistants, and everybody else involved in the operating room to wear goggles, which invariably become foggy and impair vision. Therefore, at laparotomy, I prefer using sharp scissors or microelectrodes. Nevertheless, the laser remains a very useful tool and will have a tremendous impact on the practice of gynecologic surgery because of its application in endoscopic surgery, which is being successfully employed for pelvic adhesiolysis, neosalpingostomy, ovarian cystectomy, ectopic pregnancy, endometriosis, and essentially all benign gynecologic procedures except for tubal anastomosis. Regarding Mr. Hausner's comment that "microsurgeons use whatever equipment is available to them" instead of selecting the most appropriate electrode and power output setting for each specific procedure, it is sad but very true. However, his company and the medical electronics industry is largely (not exclusively) to blame for failing to properly educate its consumers (gynecologic surgeons) about the capability and sophistication of their product. This is in sharp contrast to the laser industry, which has been very diligent in propagating (if not exaggerating) the potential and application of their product. Again, we appreciate Mr. Hausner's comments regarding our work and the opportunity to respond to the interesting points that he raised on the subject. Fertility and Sterility
•
Anthony A. Luciano, M.D. Associate Professor of OblGyn Director, Division of Reproductive Endocrinology and Fertility Farmington, CT February 29, 1988
,+
REFERENCE 1. Luciano AA, Whitman G, Maier DB, Randolph J, Maenza
R: A comparison of thermal injury, healing patterns, and postoperative adhesion formation following C02 laser and electromicrosurgery. Fertil Steril 48:1025, 1987
Selective Termination in Multiple Gestations
To the Editor:
Dr. Birnholz and his colleagues describe two cases of selective termination in high-order multiple gestations early in pregnancy.1 In each case, at least two fetuses were selectively terminated via injection of air into each fetus through a needle placed transabdominally with ultrasound guidance. They claim that "it is generally accepted that, after fetal cardiac activity is established, pregnancy loss is unlikely." We would like to point out two recent reports indicating spontaneous early pregnancy loss in multiple gestations. 2•3 Despite ultrasound documentation of viable twins early in pregnancy, a 21.2% incidence of "vanishing twins" has been reported. 2 The incidence of "vanishing" sacs was even higher in cases where fetal cardiac activity was not noted in the additional gestational sacs. 2 •3 Although selective termination early in pregnancy of high order multiple gestations is advantageous in certain circumstances, the relatively high spontaneous disappearance rate of gestational sacs, both with and without documented fetal cardiac activity, needs to be considered before undertaking such a procedure early in the first trimester. Helain J. Landy, M.D. Division of Maternal Fetal Medicine and Paul R. Gindoff, M.D. Division of Reproductive Endocrinology and Fertility The George Washington University Medical Center Washington, DC December 7, 1987 REFERENCES 1. Birnholz JC, Dmowski WP, Binor Z, Radwanska E: Selec-
tive continuation in gonadotropin-induced multiple pregnancy. Fertil Steril 48:873, 1987 2. Landy HJ, Weiner S, Corson SL, Batzer FR, Bolognese RJ: The "vanishing twin:" Ultrasonographic assessment of fetal Vol. 49, No.6, June 1988
disappearance in the first trimester. Am J Obstet Gynecol 155:14, 1986 3. Gindoff PR, Yeh M-N, Jewelewicz R: The vanishing sac syndrome: Ultrasound evidence of pregnancy failure in multiple gestations, induced and spontaneous. J Reprod Med 31:322, 1986
Reply of the Authors:
The comment isolates an issue that we have recognized in our practice but not reported specifically, namely, that we anticipate a spontaneous fetal loss rate less than 2% when a 7- to 8-week ultrasound study demonstrates (1) fetal cardiac activity, (2) appropriate size relations between fetus and yolk sac, (3) satisfactory thickness and structural integrity of the decidual boundary, and (4) fundal or upper uterine body implantation site. This includes gonadotropin aided conceptions and compares well with a 3.2% spontaneous abortion rate after ultrasound demonstration of fetal cardiac activity alone at 8 weeks from the collaborative diabetes study.1 We and others reported2 on the "blighted" twin appearance a decade ago, which is recognizable by the mid-first trimester with suprapubic scanning. Despite early detection of such conditions or suspicion about wastage, there is no technical reason to rush to a selective continuation procedure before 10 or 11 weeks' gestational age, particularly if a local experience is less confident (or different) about early evaluation. The only difference in approach then (or later) would be the use of 2 mEq potassium chloride instead of air. In practice, we have found that for most of our referrals, by the time the counseling and decision processes are concluded and scheduling is arranged, 2 months or more will usually have elapsed since conception. Jason C. Birnholz, M.D. Paul Dmowski, M.D., Ph.D. Zvi Binor, M.D. Ewa Radwanska, M.D. Rush-Presbyterian-St. Luke's Medical Center Chicago, Illinois February 15, 1988 REFERENCES 1. Simpson JL, Mills JL, Holmes LB, Ober CL Aarons J, Jo-
vanovic L and Knopp RH. Low fetal loss rates after ultrasound-Proved viability in early pregnancy. JAMA 258:2555, 1987 2. Finberg HJ, Birnholz JC. Ultrasound observations in multiple gestation with frst trimester bleeding: The blighted twin. Radiology 132:137, 1979 Letters-to-the-editor
1093
1. Luciano AA, Whitman G, Maier DB, Randolph J, Maenza
To the Editor: The informative article by Luciano et al. l needs the following clarifications and recommendations: 1. The proper language, respectively, definition,
should finally be accepted with respect to electrosurgical techniques. The authors refer to "electrocautery." Since an electro surgical cutting technique is described, the term electrocautery is certainly misleading. The proper definition is electro surgical cutting or electro surgical bisection. 2. In the review "Laser vs. Electrosurgery,"2 the advantages and disadvantages of both laser and electrosurgery were discussed. The authors' conclusions are in agreement with this review: that the laser does not improve clinical results. 3. Even though the authors mention a specific model electrosurgical generator, output wattage, electrode diameter, and current density, in comparison to the laser output, one should recognize that within this 20 watts electrosurgical output, the waveform, respectively, the peak-to-peak voltages, plays an important role in the thermic effect on the tissue. It is assumed that a nonmodulated, cutting current was utilized for the electrosurgical bisections. 4. In conclusion, the laser has glamor, is highly popularized, and is rather expensive. Still, it is useful but no more useful than the proper microelectrosurgical instrumentation. In the selection of different electrodes, specific waveforms, and appropriate output settings of the microelectrosurgical generator and also in considering the unique features of the bipolar technique for hemostasis, the electro surgical approach seems to be the method of choice. Too often, microsurgeons use whatever electrosurgical equipment is available; and when they do not get the results expected, they condemn the device and seek the ultimate answer in the laser. This study is perhaps one of the finest on the subject published to date and is certainly worthwhile reading for every gynecologist who is interested in microsurgery.
Karl Hausner President Elmed Incorporated January 14, 1988 1092
Letters-to-the-editor
REFERENCES R: A comparison of thermal injury, healing patterns, and postoperative adhesion formation following CO 2 laser and electromicrosurgery. Fertil Steril 48:1025, 1987 2. Hausner K. Laser vs electrosurgery. Medical Electronics July 1985
.
Reply of the Author: I wish to thank Mr. K. Hausner for his interest in our manuscript l and for his complimentary remarks regarding our work. Indeed, the term electrocautery should not be applied when describing electro surgical cutting techniques. Electromicrosurgery, as used in the title of our paper, or electro surgical dissection or cutting is more appropriate terminology. As emphasized in the discussion of our article for open abdominal cases the laser offers no ad~ vant~ges over the more traditional microsurgery, and it may actually have some distinct disadvantages. Besides being expensive, cumbersome and difficult to maintain sterile over the oper~tive fields, the use of laser in open cases requires the surgeon, the assistants, and everybody else involved in the operating room to wear goggles, which invariably become foggy and impair vision. Therefore, at laparotomy, I prefer using sharp scissors or microelectrodes. Nevertheless, the laser remains a very useful tool and will have a tremendous impact on the practice of gynecologic surgery because of its application in endoscopic surgery, which is being successfully employed for pelvic adhesiolysis, neosalpingostomy, ovarian cystectomy, ectopic pregnancy, endometriosis, and essentially all benign gynecologic procedures except for tubal anastomosis. Regarding Mr. Hausner's comment that "microsurgeons use whatever equipment is available to them" instead of selecting the most appropriate electrode and power output setting for each specific procedure, it is sad but very true. However, his company and the medical electronics industry is largely (not exclusively) to blame for failing to properly educate its consumers (gynecologic surgeons) about the capability and sophistication of their product. This is in sharp contrast to the laser industry, which has been very diligent in propagating (if not exaggerating) the potential and application of their product. Again, we appreciate Mr. Hausner's comments regarding our work and the opportunity to respond to the interesting points that he raised on the subject. Fertility and Sterility
•
Anthony A. Luciano, M.D. Associate Professor of OblGyn Director, Division of Reproductive Endocrinology and Fertility Farmington, CT February 29, 1988
,+
REFERENCE 1. Luciano AA, Whitman G, Maier DB, Randolph J, Maenza
R: A comparison of thermal injury, healing patterns, and postoperative adhesion formation following C02 laser and electromicrosurgery. Fertil Steril 48:1025, 1987
Selective Termination in Multiple Gestations
To the Editor:
Dr. Birnholz and his colleagues describe two cases of selective termination in high-order multiple gestations early in pregnancy.1 In each case, at least two fetuses were selectively terminated via injection of air into each fetus through a needle placed transabdominally with ultrasound guidance. They claim that "it is generally accepted that, after fetal cardiac activity is established, pregnancy loss is unlikely." We would like to point out two recent reports indicating spontaneous early pregnancy loss in multiple gestations. 2•3 Despite ultrasound documentation of viable twins early in pregnancy, a 21.2% incidence of "vanishing twins" has been reported. 2 The incidence of "vanishing" sacs was even higher in cases where fetal cardiac activity was not noted in the additional gestational sacs. 2 •3 Although selective termination early in pregnancy of high order multiple gestations is advantageous in certain circumstances, the relatively high spontaneous disappearance rate of gestational sacs, both with and without documented fetal cardiac activity, needs to be considered before undertaking such a procedure early in the first trimester. Helain J. Landy, M.D. Division of Maternal Fetal Medicine and Paul R. Gindoff, M.D. Division of Reproductive Endocrinology and Fertility The George Washington University Medical Center Washington, DC December 7, 1987 REFERENCES 1. Birnholz JC, Dmowski WP, Binor Z, Radwanska E: Selec-
tive continuation in gonadotropin-induced multiple pregnancy. Fertil Steril 48:873, 1987 2. Landy HJ, Weiner S, Corson SL, Batzer FR, Bolognese RJ: The "vanishing twin:" Ultrasonographic assessment of fetal Vol. 49, No.6, June 1988
disappearance in the first trimester. Am J Obstet Gynecol 155:14, 1986 3. Gindoff PR, Yeh M-N, Jewelewicz R: The vanishing sac syndrome: Ultrasound evidence of pregnancy failure in multiple gestations, induced and spontaneous. J Reprod Med 31:322, 1986
Reply of the Authors:
The comment isolates an issue that we have recognized in our practice but not reported specifically, namely, that we anticipate a spontaneous fetal loss rate less than 2% when a 7- to 8-week ultrasound study demonstrates (1) fetal cardiac activity, (2) appropriate size relations between fetus and yolk sac, (3) satisfactory thickness and structural integrity of the decidual boundary, and (4) fundal or upper uterine body implantation site. This includes gonadotropin aided conceptions and compares well with a 3.2% spontaneous abortion rate after ultrasound demonstration of fetal cardiac activity alone at 8 weeks from the collaborative diabetes study.1 We and others reported2 on the "blighted" twin appearance a decade ago, which is recognizable by the mid-first trimester with suprapubic scanning. Despite early detection of such conditions or suspicion about wastage, there is no technical reason to rush to a selective continuation procedure before 10 or 11 weeks' gestational age, particularly if a local experience is less confident (or different) about early evaluation. The only difference in approach then (or later) would be the use of 2 mEq potassium chloride instead of air. In practice, we have found that for most of our referrals, by the time the counseling and decision processes are concluded and scheduling is arranged, 2 months or more will usually have elapsed since conception. Jason C. Birnholz, M.D. Paul Dmowski, M.D., Ph.D. Zvi Binor, M.D. Ewa Radwanska, M.D. Rush-Presbyterian-St. Luke's Medical Center Chicago, Illinois February 15, 1988 REFERENCES 1. Simpson JL, Mills JL, Holmes LB, Ober CL Aarons J, Jo-
vanovic L and Knopp RH. Low fetal loss rates after ultrasound-Proved viability in early pregnancy. JAMA 258:2555, 1987 2. Finberg HJ, Birnholz JC. Ultrasound observations in multiple gestation with frst trimester bleeding: The blighted twin. Radiology 132:137, 1979 Letters-to-the-editor
1093