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Resection

Once the tumor volume has been significantly reduced, resection can begin. Laser settings need not be modified at this time. Tumor destruction is carried out simply by approximating the laser fiber tip to the target, and then proceeding systematically along the tumor’s surface. In case of charring, one must be extremely prudent, since necrosis can occur rapidly and extend several millimeters beyond the target’s surface in a matter of seconds.



Use of excessive power can lead to the production of abundant smoke in the airway. If the smoke cannot be evacuated rapidly, the patient may begin coughing uncontrollably. This is particluarly problematic when a fiberoptic bronchoscope is used for resection. Rigid bronchoscopy under general anesthesia allows continuous aspiration of the smoke thereby preventing this complication. The discontinuous laser mode is best during resection, because it allows for the endoscopist to judge the tissue effect of each laser impact before proceeding with resection.

The manufacturer often provides the endoscopist with estimates of power usage, and Jules (power x time) administered. However, such estimates may be misleading since they don’t account for the variation in the distance between laser fiber and target. The fiber can be placed anywhere between 1 mm to 1-2 cm away from the point of impact, depending on whether the goal of treatment is coagulation or vaporization.

The rigid telescopic lens will remain clean if it is kept well within the confines of the bronchoscope and blood or secretions are methodically aspirated during the course of the procedure. The laser fiber should never be in contact with the target, because this can lead to severe damage caused by abnormal cooling. If a fiberoptic bronchoscope is used, the bronchoscope’s channel should be rinsed systematically with several mms of saline every time the laser fiber is introduced. The target lesion should also be cleaned with saline throughout the procedure in order to keep the target free of accumulated secretions and/or blood. If significant bleeding is encountered, a dilute solution of epinephrine can be used instead of saline.

 
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