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Carbon Dioxide Laser Surgery in Gynecology

History of the Procedure

The key mechanisms of action of the laser were first discovered by Albert Einstein in the early 1900s. Initial results from the use of a carbon dioxide laser for the management of cervical dysplasia were initially less successful than anticipated because of the inability to determine appropriate depth of penetration for prevention of recurrent disease. Not until 1978 did Anderson and Hartley emphasize the actual mechanics for the depth of cervical involvement.
Laser technique was further refined and shown to be both practical and efficacious by Jordan in 1985
and by Dorsey in 1979,
 when the Greater Baltimore Medical Center published the first clinical experience with cervical conizations by carbon dioxide laser. See the image below.

Cervix after laser conization.

Cervix after laser conization.

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Lasers have provided the laparoscopic surgeon with an efficient method of achieving rapid excision, coagulation, or vaporization of pelvic abnormalities. Most familiar is therapy for pelvic endometriosis or adhesions. When laser is used in combination with other laparoscopic instruments, the variety of procedures performed with the laparoscope may be enhanced.

The carbon dioxide laser has been considered an effective modality for multiple tasks related to the treatment of intraepithelial neoplasia of the lower genital tract, most commonly for large lesions and for multifocal manifestations of human papilloma virus (HPV). The use of this technology is limited in some areas because of healthcare provider training and experience and because of a lack of availability of equipment. Many hospitals require that specific credentials be obtained before using this modality, including documentation of didactic instruction and clinical supervision of initial procedures. 

Since the earliest use of the CO2 laser for managing squamous abnormalities of the lower genital tract and intra-abdominal treatment of endometriosis and adhesions, it has been employed for other medical therapies including : treatment of  condylomata  in women who are pregnant,
treatment of Bartholin gland cysts and abscesses,
ablation of pigmented follicular cysts of the vulva,
treatment of chronic anal fissures,
excision of an  imperforate hymen,
excision of a vaginal septum,
excision of hypertrophied labia minora
or vaginal polyps,
management of Nabothian cysts
and even to assist the treatment and care of girls who have had Type III female genital mutilation.

The C02 laser has also been utilized as an option for management of anal dysplasia
or treatment of refractory ano-genital lichen sclerosis.

Intra-abdominal use of the CO2 laser is now being compared to other instruments such as the Ultrasonic scalpel and employed via robotic management of endometriosis. It is of value in not only resection of endometriotic implants and treatment of endometriomas, but of value in deep endometriotic implants and in combination with bowel resections for endometriosis.
Case reports also address the use of the CO2 laser in the laparoscopic resection of myomas and adenomyomas.
Other traditional uses of the CO2 laser laparoscopically included ovarian “drilling” or even wedge resection for adjuvant therapy of women with polycystic ovaries to assist ovulation.

The most recent focus of attention on gynecologic use of the carbon dioxide laser has been as a treatment option for vulvovaginal rejuvenation and vaginal atrophy. Most studies fail to cite the absence of FDA approval of this device for this purpose and report observational case studies or case series with success defined as patient reports of satisfaction. Little mention is made of postoperative adhesions or pain or need for retreatments (duration of therapy). Although the FDA did clear a fractional CO2 laser for indications of “incision, ablation, vaporization and coagulation of body soft tissues in medical specialties including genitourinary surgery”, the indication for treatment of genital atrophy was not listed. The American College of Obstetricians and Gynecologists (ACOG) published a position statement about fractional laser treatment of vulvovaginal atrophy in 2016 and reaffirmed this position statement July 2018.
ACOG has also published a Committee Opinion on vaginal “rejuvenation” and cosmetic vaginal procedures.

Observational studies utilizing the CO2 laser for vaginal atrophy generally lacked comparison to other treatment modalities and have no long term follow-up.
  A single study from Menopause 2018 was a randomized, double-blind, placebo-controlled clinical trial comparing the CO2 laser with topical estriol alone, and with use of laser and topical estriol together. It enrolled 45 women and assessed symptoms, vaginal appearance and vaginal maturation at 8 and 20 weeks and noted increased pain in the laser alone group at 8 weeks but at 20 weeks female sexual function scores were comparable for all groups (estriol alone, estriol and CO2 laser and CO2 laser alone).
Another study assessed epidermal thickness in an effort to more quantify results of CO2 laser use in women with vaginal atrophy.

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