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The comparison of thermal tissue

injuries caused by ultrasonic scalpel and


electrocautery use in rabbit tongue tissue
Guclu Kaan Beriat1*, Sek Halit Akmansu1, Hande Ezerarslan1, Cem Dogan1,
Unsal Han2, Mehmet Saglam3, Oytun Okan Senel3, Sinan Kocaturk1
1
Department of Otorhinolaryngology, Medical School, Ufuk University, Ankara,Turkey. 2 Department of Pathology, Yldrm Beyazt
Training and Research Hospital, Ankara,Turkey. 3 Department of Surgery, Veterinary Medicine School, Ankara University, Ankara, Turkey

Abstract

The aim of this study compares to the increase in tissue temperature and the thermal histological eects of ultrasonic scalpel, bipolar and uni-
polar electrosurgery incisions in the tongue tissue of rabbits. This study evaluates the histopathological changes related to thermal change and
the maximum temperature values in the peripheral tissue brought about by the incisions carried out by the three methods in a comparative way.
To assess thermal tissue damage induced by the three instruments, maximum tissue temperatures were measured during the surgical pro-
cedure and tongue tissue samples were examined histopathologically following the surgery. The mean maximum temperature values of the
groups were .. C for the unipolar electrocautery group, whereas .. C for the bipolar electrocautery group, and ..
C for the ultrasonic scalpel group.
There was a statistically signicant relationship between the increase in maximum temperature values and the separation among tissue lay-
ers, edema, congestion, necrosis, hemorrhage, destruction in blood vessel walls and brin accumulation, and between the existence of brin
thrombus and tissue damage depth (p<.).
It was concluded that the bipolar electrocautery use gives way to less temperature increase in the tissues and less thermal tissue damage in
comparison to the other methods. Association of Basic Medical Sciences of FBIH. All rights reserved

KEY WORDS: Rabbit, tongue, electrocautery, scalpel, temperature, thermal injury.

INTRODUCTION portant to pay careful attention to the process of determining


the thermal method for surgical dissections that would pre-
Surgical interventions in tongue tissue frequently include vent extreme temperature rise in the tissue and cause mini-
excision of the masses in the tongue or surgical tech- mum spread of temperature to the surrounding tissues [].
niques carried out in order to lessen the volume of the An ample amount of studies carried out on human and ani-
tongue in OSAS treatment. Within the framework of mal models have focused on tissue damages related to sur-
these treatments, tools such as radiofrequency, unipolar- geries using ultrasonic scalpel, bipolar electrocautery, and
bipolar electrocautery, laser, and coblator can be used. unipolar electrocautery [-]. No study, however, has evalu-
All these surgical tools cause temperature rise related to the ated the relationship between tissue damage in the tongue
eect of thermal energy, protein denaturation, and tissue de- tissue and the temperature rise caused by the tools used.
struction. During the use of these tools peripheral area sur- The objective of this study is to research the relationship
rounding the incised part is also subjected to temperature rise. between the maximum temperature rise in the rabbit
This situation may lead to delays in wound healing, decrease tongue tissue caused by these three methods and thermal
in blood circulation, and damage to sensorial nerves and oth- tissue damage, and to determine which method would be
er peripheral vital structures. Thermal tissue damage during more advantageous in reducing thermal tissue damage.
the surgery is an important parameter aecting postoperative
tissue healing, infection, pain, transition to oral feeding, and MATERIALS AND METHODS
hospitalization. Because of the reasons listed above, it is im-
The study was carried out at Ankara University, Faculty
* Corresponding author: Guclu Kaan Beriat, of Veterinary Medicine, Animal Research Lab with the
Department of Otorhinolaryngology, Medical School, same universitys Animal Ethics Board approval dated
Ufuk University, Ankara 06520, Turkey,
Phone: +90 312 204 41 84; Fax: +90 312 284 40 88 May , and with the protocol number . All
e-mail: beriat4@gmail.com the procedures were performed in accordance with the
Submitted: 14 February 2012 / Accepted: 18 May 2012 rules set by Ankara Universitys Animal Ethics Board.

Bosn J Basic Med Sci 2012; 12 (3): 151-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

Animals mometer during the incision were recorded. The same pro-
Sixteen albino rabbits weighing between . and kg cedure was repeated with all the three devices each time cov-
were used in the experiment. The experimental animals ering enough distance towards the proximal of the tongue.
were kept alone in separate cages with constant wa- A -minute recess was observed among the procedures in
ter and food supply at humidity and C degrees. order to allow the tongue tissue to return to normal levels.
Maximal temperature values were recorded in three dierent
Procedures groups. Subsequently, tongue tissue samples were taken and
The surgical procedures were done in operating room the animals were sacriced with additional anesthetic doses.
conditions. The procedures carried out on the experi- Each tissue sample was fixed in buffered formalde-
mental animals were done under general anesthesia. In- hyde taken into separate storage boxes, labeled, and three
traperitoneal ketamine (mg/kg) (KETALAR, Pfiz- different groups were formed in a total of bottles. The
er- Pharmaceutical Company) with Xylazine (mg/ histopathological analysis of the tissues was done at An-
kg) (Rompun, Bayer) were used for general anesthesia. kara Social Security Administrations Teaching Hospital,
The tongues of all the animals were put out and fixed Pathology Clinic Laboratory. The material was sliced per-
under general anesthesia. Three full layer incision lines pendicularly to the incision line in - mm thickness and
were done along equal length segments from the dis- all the material was followed. Following the routine tissue
tal towards the proximal, parallel, perpendicular to the follow-ups all the tissue samples were stained with hema-
vertical axis of the tongue in the tongue tissue with all toxylin-eosin, having been taken into microns of incisions,
three different tools alternately. Special attention was and evaluated with the Olympus Bx light microscope.
paid to the completion of the incision without apply- Tissue changes that can be seen in thermal tissue dam-
ing too much pressure on the tissue while using the tool ages (thermal damage level) were rated subjectively dur-
tips having them on hold until the tongue tissue was cut. ing the building of pathological rating parameters. The
Megapower Megadyne Electrosurgical Generator (MEGA- evaluation method was devised according to the param-
DYNE MEDICAL PRODUCTS, Inc., Draper, US) cautery eters set by the pathologist performing the evaluation and
was used for electrocauterization procedures. The device was based on the classic histopathological tissue changes
was used at ACE (Advance cutting effect) mode for uni- known to happen in thermal tissue damage cases []. In
polar cauterization. The device has watts of power and terms of the followed tissue changes, the histopathologi-
is at Hz frequency at this mode. The ACE mode is de- cal evaluation parameters were set in the Table and Fig-
signed to provide a scalpel-like cutting effect for minimal ures - to- ., The results obtained from these tissue
thermal necrosis and reduced scarring. When the device parameters were separately scored for each parameter.
is used at this mode there is a consistent cutting effect at
minimum power settings for improved patient safety. It
reaches this effect by adjusting its power to the changing TABLE 1. Histopathological changes after thermal tissue dam-
tissue resistance. Rocker Switch Pencil with ACE Blade and age.
Holster were used as cautery pens while . inches stan- A.Epithelial/subepithelial separation:
dard blade electrode was used as unipolar cautery tip. The 0: No separation
device power was set at watts for bipolar cauterization 1: Maintained at the basal layer, separated at the surface layer
2: Full layer separation
and Scoville-Greenwood forceps, . mm tip (. cm) was
B. Inammation:
used as cautery pen. The maximum power of the device was Oedema 0: None, 1: Yes
watts and its frequency was Hz for bipolar cautery. Congestion 0: None, 1: Yes
Harmonic (Ethicon Endosurgery, Inc., Cincinnati, Ohio, Inflammatory cell existence 0: None, 1: Yes
USA) was used as the ultrasonic scalpel device. The pro- C. Necrosis
0: No necrosis
cedure was performed when the device power was at the
1: Focal, in one or more than one cell group
third level using ENSEAL RF Generator and with a 2: Diuse
shaft length of cm and a shaft diameter of mm tips. D. Vascular changes:
Deep maximum temperature measurements were done Hemorrhage 0: None, 1: Yes
with electrode thermometer device (Fluke II, Fluke Cor- Blood vessel wall destruction and fibrin accumulation 0: None, 1: Yes
Fibrin thrombus existence 0: None, 1: Yes
poration, Washington, USA) located at a depth of - mm.
E. Damage depth:
The tip of the thermometers metal probe was xed in the 0: Limited to the epithelium
tongue, mm proximal of the incised line during the incision. 1: Exposed to the subepithelial tissue
The maximum temperature data obtained from the ther- 2: Moved on to the striated muscle

Bosn J Basic Med Sci 2012; 12 (3): 152-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

FIGURE 1. Epithelial/subepithelial separa- FIGURE 2. Full layer epithelial/subepithelial FIGURE 3. Separation whereby the basal
tion (H&Ex100). separation (H&Ex200). layer is maintained (H&Ex100).

FIGURE 4. Full layer separation with epi- FIGURE 5. Edema and congestion in the FIGURE 6. Total epithelial necrosis (H&Ex-
dermal necrosis and subepithelial changes subepithelial tissue (H&Ex200). 200).
(H&Ex200).

FIGURE 7. Intraepithelial and subepithelial FIGURE 8. Subepithelial bleeding in the co- FIGURE 9. Fibrin accumulation on the
bleeding in the bipolar group (H&Ex100). blation group (H&Ex100). blood vessel walls (H&Ex400).

FIGURE 10. Fibrin and necrosis on blood FIGURE 11. Fibrin and hemorrhage on FIGURE 12. Tissue reaction moving towards
vessel walls forming occlusion in the lumen blood vessel walls (H&Ex200). total epithelial necrosis and striated muscle
(H&Ex400). tissue (H&Ex100).

Bosn J Basic Med Sci 2012; 12 (3): 153-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

TABLE 2. Tissue damage according to the methods used, Chi-Square analysis results,
frequency, percentage and p values are displayed.

Unipolar, Bipolar, Ultrasonic


Tissue Damage Parameters p value
n (%) n (%) scalpel, n (%)
On the surface
Epitelial/subepitelial layer 9 (64.3%) 8 (53.3%) 2 (15.4%)
0.028
separation
Full layer 5 (35.7%) 7 (46.7%) 11 (84.6%)
Yes 3 (21.4%) 5 (33.3%) 12 (92.3%)
Edema 0.000
None 11 (78.6%) 10 (66.7%) 1 (7.7%)
Yes 6 (42.9%) 6 (40.0%) 12 (92.3%)
Congestion 0.009
None 8 (57.1%) 9 (60.0%) 1 (7.7%)
Diuse 3 (21.4%) 5 (33.3%) 12 (92.3%)
Necrosis 0.000
FIGURE 13. Tissue reaction moving to- Focal 11 (78.6%) 10 (66.7%) 1 (7.7%)
wards total epithelial necrosis and striated Yes 3 (13.6%) 7 (46.7%) 12 (92.3%)
Hemorrhage 0.001
muscle tissue in close view (H&Ex200). None 11 (78.6%) 8 (53.3%) 1 (7.7%)
Inammatory cell Yes 13 (92.9%) 15 (100%) 11 (84.6%)
0.286
RESULTS existence None 1 (7.1%) 0 2 (15.4%)
Blood vessel Yes 3 (21.4%) 8 (53.3%) 12 (92.3%)
0.001
destruction None 11 (78.5%) 7 (46.7%) 1 (7.7%)
Two of the experimental animals
Fibrin thrombus Yes 2 (14.3%) 7 (46.7%) 12 (92.3%)
died because of infection before the 0.000
existence None 12 (85.7%) 8 (53.3%) 1 (7.7%)
procedure during the feeding phase Limited to the
13 (92.9%) 4 (26.7%) 0
of the animals. The evaluation of tis- epithelium
Damage depth Subepithelial 1 (7.1%) 11 (73.3%) 1 (7.7%) 0.000
sue samples of out of a total of
Reaching up to the
samples was completed because of 0 0 12 (92.3%)
striated muscle
the problems that happened in two
animals during the procedures. Tem-
perature measurements and histopathological evalua- depth and the maximum mean tissue temperature rise
tion of a total of tissue samples were completed and according to the ANOVAs analysis (p<.), (Table ).
(.) of them were done with unipolar cautery, (.) The power analysis revealed that the test had a power of
with bipolar cautery, and () with ultrasonic scalpel. .
The mean maximum temperature values obtained during the
procedures were .. Co for the unipolar cautery group, DISCUSSION
.. Co for the bipolar cautery group, and ..
Co for the ultrasonic scalpel group. The maximum tempera- Excessive heat is an important cause of tissue injury (burn).
ture values of each of the three groups were found to be inde- Burns used to be classied from the rst to the fourth degree,
pendent of one another according to the ANOVA test. The according to the depth of injury (rst degree burns being the
intergroup dierences were evaluated by the Tukey test and most supercial). Supercial burns (rst degree burns) are
a statistical dierence was found among the results (p<.). conned to the epidermis. Partial thickness burns (second de-
The relationship between the surgical methods and the his- gree burns) involve injury to the dermis. Full thickness burns
tological parameters was evaluated by the Chi-Square test. (third degree burns) extend to the subcutaneous tissue [].
The results of histopathological evaluation related to full layer The surgical tools that work based on the princi-
separation between tissue layers, edema, congestion, hemor- ple that thermal energy is applied to the tissue bring
rhage, blood vessel wall destruction and brin accumulation, about some changes depending on the level of heat in
fibrin thrombus existence, and diffuse necrosis existence the tissue. These changes happen in different forms
changed according to the methods used (p<.), (Table ). in proportion to the amount and period of the trans-
The relationship between the obtained maximum tem- ferred energy to the tissue by the tool used [, ] .
perature values and the histopathological parameters was The destruction in the tissue related to the rise in tempera-
evaluated by the Independent T-test. There was a statisti- ture may cause local and systemic side eects. The burn site
cally signicant relationship between the rise in maximum is ideal for the growth of microorganisms; the serum and
temperature values and the separation among the tissue debris provide nutrients, and the burn injury compromises
layers, edema, congestion, necrosis, hemorrhage, blood blood ow, blocking eective inammatory responses. The
vessel wall destruction and fibrin accumulation, and fi- most common offender is the opportunist, and hospital
brin thrombus existence (p<.). There was also a statis- acquired microorganisms. Cellular and humoral defence
tically significant relationship between the tissue damage against infections are compromised, and both lymphocyte

Bosn J Basic Med Sci 2012; 12 (3): 154-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

TABLE 3. The results of maximal temperature measurement according to the tis-


sue damage parameters, Independent T-test results, frequency, mean standard a histological evaluation of these incisions.
deviation and p values are displayed. The authors concluded that the modular
wave form and low frequency values cause
Tissue Damage Parameters Frequency MeanSD p value
Epithelial/subepithelial On the surface layer 19 91.586.89 more tissue damage. Therefore, we pre-
0.054
separation Full layer 23 98.1713.07 ferred to use the full wave mode for cautery
Yes 20 100.0013.55 use in order to have less tissue damage [].
Edema 0.009
None 22 90.825.75
Electrocautery is divided into two forms;
Yes 24 100.5410.62
Congestion
None 18 88.067.15
0.000 monopolar and bipolar. These systems are
Diuse 20 101.0512.09 different from each other in terms of their
Necrosis 0.001
Focal 22 89.866.83 working principles and the eects they cre-
Yes 22 99.4612.60 ate. High energy is used in order to obtain the
Hemorrhage 0.007
None 20 90.506.84
desired results with monopolar units. Bipolar
Inammatory cell Yes 3 98.004.00
0.655 units, on the other hand, need less energy.
existence None 39 94.9711.48
Yes 23 98.9112.61 There are two electrodes, one active one neu-
Blood vessel destruction 0.011
None 19 90.686.93 tral, in monopolar cauterization. The neutral
Fibrin thrombus Yes 21 99.9512.61 pole is the land line in these types of tools and
0.005
existence None 21 90.436.83
they are called monopolar since they function
Limited to the epithelium 17 91.356.61
Subepithelial 13 87.385.91 passively []. Neutral electrodes also have
Damage depth 0.000
Reaching up to the forms like sitting electrodes, hand electrodes,
12 109.087.30
striated muscle and armband or wristband electrodes [].
Bipolar cauteries are tools that have
and phagocyte functions are impaired. Direct bacteremic low impedance and they exhibit maximum Watts of
spread and release of toxic substances such as endotoxin exit. The reason for this is the fact that the route through
from the local site have dire consequences. Pneumonia, which the high-frequency current will complete its cir-
septic shock with renal failure and the acute respiratory dis- cuit is very short; otherwise an arc will be created [].
tress syndrome are the most common serious sequelae []. The monopolar technique enables the current to be transmit-
In thermal tissue damage survivors, the development of hy- ted to the surgical area from the tip of the active electrode.
pertrophic scars, of both the site of the original burn and at In other words, the monopolar technique uses the patients
donor graft sites, and itching may become long term, dif- body as a circuit complement. With bipolar cautery, on the
ficult to treat problems. Hypertrophic scars after burn other hand, the electrical current ows through the distance
injuries may be a consequence of continuous angiogen- between the two tips of the cautery. The current spreads
esis in the wound caused by excess neuropeptides, such into the peripheral tissues on its way to the passive electrode
as substance P released from injured nerve endings []. on its way back in the monopolar cautery. Therefore, the
High temperature is brought about by this resistance and monopolar technique is not appropriate to use if the pa-
as a result of the dehydration caused by the generated heat tient has a pacemaker, if he has neural or cardiac problems.
incision is created. The pre-condition for a successful elec- Since the bipolar surgical instruments have an electrical resis-
trocauterization is preventing burns while cutting the tis- tance within a range of - , they can be used in the wet ar-
sue. In order to have a burn-free incision the appropriate eas in intraoral procedures. Moreover, because of the fact that
form of current and dose need to be carefully selected []. the tissues are cut and coagulated under permanent irrigation
When the tool is used at the full wave generating mode, also enable the tissues to be kept healthy during the operation
the incision made produces an eect similar to the classic they can be specically preferred. When the intraoral pro-
scalpel incision in the tissue since there will not be a wide cedures are taken into consideration, the saliva has a poor
gap between the voltage and power. Besides it reduces electrical resistance by nature. Viscous saliva forming a thick
bleeding because of the temperature rise in the incised layer, however, gives way to the dispersal of a large portion of
area. At the modulation wave mode the exit voltage of the the current and the desired result might not be obtained. The
tool is high but the active power is low. It enables coagula- most appropriate environment is the one that is humidied
tion through generating more heat in the tissue but it also with normal saline. We performed the procedures in a rela-
causes burns in the periphery and more tissue damage []. tively dry environment having taken the tongue tissues out in
Mannes et al. created incisions of mm depth with a speed our study since our aim was to have the procedures in rabbit
of mm/sec in rat tongues using the electrocautery method tongues under equal conditions with all the three methods.
at varying frequencies and wave forms and they carried out The results of our study also revealed that bipolar cautery

Bosn J Basic Med Sci 2012; 12 (3): 155-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

causes less thermal tissue damage in the tongue tissue com- method were higher than the other electrocautery methods
pared to unipolar cautery. The mean values of maximum at .. Co. In line with this result, we found out that
temperature in the tissue were .. Co and . Co the separation among the tissue layers, edema, congestion,
for bipolar and unipolar cautery respectively. There were sta- necrosis, hemorrhage, destruction in blood vessel walls and
tistically meaningful results (p<.) in favor of bipolar elec- brin accumulation, brin thrombus existence and tissue de-
trocautery, between separation among tissue layers, edema, struction depth were higher than both electrocautery meth-
congestion, necrosis, hemorrhage, destruction in blood vessel ods in a statistically meaningful manner (p<.). According
walls and brin accumulation, brin thrombus existence, and to these results, we concluded that the ultrasonic scalpel
tissue damage depth in proportion to temperature degrees. causes more temperature rise and thermal tissue damage
In the light of the classical information listed above and the in the peripheral tissues than the electrocautery methods.
results obtained by our study, we can conclude that bipolar When the dierence between the results obtained by each
cautery is more advantageous regarding the risk of thermal of the three methods is taken into consideration, it is seen
tissue damage in the healthy peripheral tissues when used in that bipolar cautery causes the least temperature rise and
the tongue tissue compared to unipolar cautery. On the other thermal tissue damage in the peripheral tissues in rab-
hand, the most important advantage of the unipolar method bit tongue tissue, whereas the ultrasonic scalpel method
compared to the bipolar one is that unipolar cautery pens de- gives way to the highest temperature rise and the largest
signs are more ergonomic and therefore it yields more com- tissue damage. This result shows us that the bipolar elec-
fort to surgical manipulation during the surgical procedures. trocautery, which is a classical method, is a reliable tech-
Ultrasonic scalpel spreads vibration at so high a fre- nique that we can use to prevent thermal damage and com-
quency that it cannot be perceived by the ear or the eye plications in procedures performed in the tongue tissue.
and this mechanical energy is transmitted to the tissue. It Since bipolar cautery is a highly successful method
works mechanically with a vibration at - KHz fre- in bleeding control there is no need to have an addi-
quency. The vibrating knife causes protein denaturation tional method for bleeding control in the tongue tis-
by minimal tissue heating through rupturing the tertiary sue, which has very well blood circulation, it is also a
hydrogen ligaments in the protein molecules. The dena- time-saving and a convenient method for the surgeon
tured proteins give way to homeostasis by forming adhe- during the procedure. Besides, it is advantageous be-
sive coagulum. In this way, the instrument performs the cause it is an inexpensive and widespread method.
cutting and coagulation procedures simultaneously []. On the other hand, because the bipolar cautery tips
Tissue dissection is created through separation by cutting or by structure are not designed for surgical dissection
forming a cavity. Separation by forming a cavity takes place in they may cause some troubles regarding the surgi-
collagen-poor areas like the tonsils and the liver, cutting takes cal technique. We believe that this problem, too, can
place in collagen-rich tissues such as the fascia and tendons be overcome through designing new tip for dissection.
[]. It is stipulated that ultrasonic scalpel forms protein de-
naturation by mechanically breaking the hydrogen ligaments CONCLUSION
placed in the protein molecules and therefore enabling less
tissue damage by creating less temperature increase around Bipolar electrocautery is the method which causes the
the surgical area as compared to the other methods []. least temperature rise in the surrounding tissues among
The balance between cutting and coagulation is maintained these methods. In order to minimize complications
according to tissue tension, power level, and sharpness due to high temperature in the tongue tissue, we be-
of the knife. If a sharp knife is used at a high power and is lieve that bipolar electrocautery should be the method
applied to a tense tissue it cuts rapidly with less homeosta- chosen, provided that tip revisions suitable for dissec-
sis, but if it is applied to a low-tension tissue with an obtuse tion are made in conventionally used electrocautery tips.
knife at low power it cuts slower with a strong homeo-
stasis. Since the tongue tissue has a medium tissue ten- DECLARATION OF INTEREST
sion and because the tongue has well blood supplies, the
power level to be used was selected as level three, which There is no nancial support received for this present study
is the medium level for the model we used, in order to for all authors, no nancial involvement of any kind or ali-
maintain the balance between cutting and coagulation []. ation with any organization whose nancial interests may be
In contrast to the information provided above, the results aected by material in the manuscript or which may poten-
of our study revealed that the mean maximum temperature tially bias it.
values of the tongue tissue obtained by the ultrasonic scalpel

Bosn J Basic Med Sci 2012; 12 (3): 156-157


GUCLU KAAN BERIAT ET AL.: THE COMPARISON OF THERMAL TISSUE INJURIES CAUSED BY ULTRASONIC
SCALPEL AND ELECTROCAUTERY USE IN RABBIT TONGUE TISSUE

[] Gnanasekhar JD, al-Duwairi YS. Electrosurgery in dentistry. Quin-


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