Beyond Scalpels: Surgical Substitutes
While lasers represent the more precise and beneficial technology during surgery, the price and maintenance are barriers to overcome for any veterinarian.
A laser is used instead of a scalpel for this vulvoplasty incision.
Photo courtesy of William E. Schultz, DVM
Veterinarians generally agree that the ability of laser surgery and electrosurgery to control hemorrhaging during surgery is among the benefits that make the technologies superior to the scalpel. Still, the price of the units, marketing and maintenance concerns delay some practitioners from becoming consumers.
“Many veterinarians still use a scalpel instead of a laser or radiosurgery,” says Robert Slobody, DVM, of Meadowlands Veterinary Center in Willoughby, Ohio. “Scalpels are cheap and they work, but the veterinarians who stay with the scalpel exclusively don’t realize they can get their money back in little time using laser or electrosurgery and create practice revenue while enhancing the level of care for patients.”
Any high-tech unit is a substantial financial investment, so there’s a lot to consider before making a purchase. Considering which procedures you’d use laser or radiosurgery for is a starting point. The type of animals operated on and your level of comfort with the technology are additional considerations. Veterinarians who have invested in these modalities suggest that a buyer learn how to use them before making the purchase and then create a marketing plan.
“The success or failure of these technologies largely depends on technique,” says Martin G. Orr, DVM, owner of Creekside Animal Hospital in Draper, Utah. “I use diode and CO2 lasers in my practice and I decide which I want to use depending on the procedure. Training to use lasers doesn’t take very long, and in four to five treatments you’re past the learning curve.”
The Bottom Line
The type of technology a veterinarian purchases is based mostly on preference. A veterinarian may believe his clients will be more receptive to one modality over another. Practitioners who make these purchases can use them exclusively or offer clients a scalpel alternative for certain procedures and alter the charges accordingly.
“I do not perform castrations with a scalpel anymore,” Dr. Orr says. “Using a laser keeps the animal’s tongue away from the site post-surgically because there’s less itching and the incision is smaller than one made by a scalpel. For most other procedures, I use a diode laser to pre-treat on therapy mode. I make the skin incision with a scalpel, then use the CO2 laser for the procedure.”
As with any equipment, maintenance costs need to be considered as well as the price for attachments and accessories. The durability and life expectancy of equipment should be discussed.
“My radiosurgery unit price was about $15,000 and it was paid for within the first year,” Dr. Slobody says. “I need to buy new tips and handpieces regularly and contact lenses that go on a patient’s eye for certain procedures. Each handpiece costs about $150 and different handpieces are used depending on the procedure.”
Slobody says he has tried other technologies but found that radiosurgery works best for him.
“A lot of people don’t know about radiosurgery, or when they hear the term don’t know how it works,” he says. “I use radiosurgery in 95 percent of my procedures. I do nothing but surgery two days a week and I use a scalpel maybe twice a month. There’s not much I do that can’t be done with radiosurgery.”
Electrosurgery aka Radiosurgery
When a Scalpel Is Preferred
While there isn’t a standard of care stating that a laser or electrosurgery equipment must be used for surgeries, veterinarians are trending toward making the distinction.
However, veterinarians experienced with scalpel-alternatives say scalpels still have uses.
“Using a scalpel for the skin incision ensures smooth healing and there’s no risk of charring skin, which can sometimes happen with a laser,” Orr says. “The initial incision is really the only time I use a scalpel blade.”
While surgery isn’t the only time a scalpel is used, one area in which a scalpel is superior is skin scrapings, Bennett says.
“Veterinarians who have purchased an underpowered laser for a certain surgery will still use a laser,” Bennett says. “Also, if a veterinarian has a low-power laser and needs to perform a surgery that requires a lot of cutting, he or she may prefer a scalpel. With the right laser, the only obvious scalpel over laser procedure is skin scrapings.”
Jack Poore, an engineer with Macan Manufacturing Co., a Delaware electrosurgical equipment company, says that during discussions of electrosurgery people tend to confuse the equipment that uses electric current and the device that uses heat.
“In electrosurgical procedures, the tissue is heated by an electric current,” Poore says. “Although electrosurgical devices may be used for the cauterization of tissue in some applications, electrosurgery uses a different method than electrocautery. While electrocautery uses heat conduction from a probe heated by a direct current, electrosurgery uses alternating current to directly heat the tissue itself. The RF [radiofrequency] unit tip doesn’t get hot like a cautery unit tip.”
acan offers two machines for veterinary medicine: the Vet-Star and the smaller MV-7A, which often is used on exotic animals.
The Vet-Star has monopolar, bipolar and two-point variations. Monopolar is used only on small patients. The bipolar method is used for vessel sealing, tubal electro-ligation and soft tissue coagulation in wet fields. The two-point setting can be used for altering males and for thoracic and abdominal surgery, amputation and declaw procedures.
“Radiosurgery is a refined type of electrosurgery that utilizes a wave of electrons at radio frequency,” Slobody says. “There is no charring of the skin or peripheral heat damage when used properly.”
Slobody uses a radiosurgery unit from Ellman International of Oceanside, N.Y. The company’s equipment has been used to separate conjoined twins and in other high-profile surgical cases.
One of Ellman’s radiosurgical devices, the Surgitron FFPF EMC, features a continuously linear power setting for precise, predictable control, the company says. Linear power promotes faster healing with minimal scarring and eliminates post-operative trauma, pain, swelling and infection.
“Benefits from radiosurgery include reduced surgical time once you have become comfortable using it,” Slobody says. “By reducing hemorrhage, there is an improved visibility of operative field. You can use one device from incision to closure and it can be used it for general surgery and dental applications.”
With the diode laser, energy is transferred from the housing to the tissue by a solid fiber-optic system. Fibers vary in size, typically 400 mm to 800 mm, Orr says.
“An advantage to this type of system is the ability to deliver laser energy to tissue through ports in fiber-optical devices and in aqueous environments,” Orr says. “I use my diode laser in just about all my declaws. I don’t need to use a tourniquet; there is no bleeding and healing is fast. I use a little skin glue to close and that’s it.”
Lane Jensen, general manager of the veterinary business segment CAO Group Inc. says a Pilot Diode Laser usually lasts seven to 10 years.
“You can get thousands of hours of use with a diode laser before worrying about needing an upgrade or replacement,” Jensen says. “It is lightweight and has a fine tip like a scalpel. The great thing about a diode laser is that it isn’t something you have to spend money on without getting a return, like an autoclave. You can expect to make a direct profit from a laser.”
Many veterinarians discuss alternative surgical options with clients in the exam room, but others find it easier to have them on board before a pet needs surgery. While some veterinarians offer presentations about laser or radiosurgery on television or Power Point in their waiting or exam rooms, others advertise their modalities more aggressively.
“We write about our surgery options in our website and newsletter and have videos for clients,” Slobody says. “Clients typically are enthusiastic about using a better technology on their pet and they tell others about it, too.”
Carbon Dioxide Laser
The medical application of a CO2 laser is based on the principle of photothermal ablation. When a CO2 laser is placed to soft tissue, the light energy is absorbed by the water in the tissue. Heating and vaporizing the water tears apart the tissue.
“The CO2 laser beam can be precisely controlled,” says Tim Montague, DVM, co-owner of Eads Animal Hospital in Eads, Tenn. “There are so many benefits to using this laser that I rarely use a scalpel. Some veterinarians think performing declaws is unethical, but when a laser is used, there is no bleeding. I call it the guilt-free declaw. Considering that indoor cats live about four times longer than ones owners put outside, declawing this way is a compromise.”
Dr. Montague also uses a therapeutic laser from LiteCure LLC of Newark, Del., that he purchased in 2006 for deep-tissue laser therapy. He will be conducting a study with a board-certified surgeon to test the therapy laser’s ability to reduce swelling in cats.
“Therapy lasers are in a way a scalpel replacement because they prevent the need for surgery,” Montague says. “We treat a lot of dogs with ruptured disks. In 11 dogs given six to 12 therapy laser treatments, 11 were able to walk again. Some of the dogs were completely paralyzed before the 10- to 15-minute therapy sessions.”
Many veterinarians find their systems to be a long-lasting investment.
In the latter half of 1996, waveguide lasers with flexible fibers were introduced to small-animal practices, says Carl Bennett, director of sales and marketing for Aesculight, LuxarCare & AccuVet Lasers.
“Those lasers are still working and are very dependable systems,” Bennett says, and they help a clinic’s bottom line.
“On average, veterinarians increase the client’s price of laser surgery procedures by $60,” Bennett says. “Even four surgeries a week would increase revenue by $960 a month, so it pays for itself in even small practices.”
Those with laser experience recommend making sure the handpiece is comfortable as ergonomics is an important factor.
When all the plusses and minuses of a modality are tallied, personal preference still reigns.
“It all comes down to opinion,” Slobody says. “With these new technologies, you have veterinarians that swear by it and you have veterinarians that swear at it.”
This article first appeared in the May 2010 issue of Veterinary Practice News.