This study shows that both, UC and ME lead to a similar histopathologic pattern of coagulation necrosis at the resection plane. However, the chosen dissection tool significantly affects the depth of this coagulation necrosis with UC generating a greater necrotic margin than ME when used for soft tissue dissection using standard power level settings.
Few previous studies exist specifically on morphological changes of soft tissue caused by UC and ME. Addressing skin and subcutaneous soft tissue dissection in a pig model, Hambely et al. [12
] reported significantly less extensive and more localized tissue damages with UC compared to ME. Focusing on quality in contrast to extent of tissue damage, Foschi et al. [13
] identified coagulation necrosis to be the predominant thermal injury by scanning and transmission electron microscopy which is consistent with our results.
Examining the efficacy of UC for hemostasis, Diamantis et al. [14
] have investigated the safety and efficacy of multiple dissection tools including UC and ME for dissection and coagulation of short gastric vessels in a New Zealand rabbit model. In contrast to our results, they reported a deeper tissue damage caused by ME compared to UC. However, they applied a different, more descriptive approach referring to histological layers but did provide neither exact measurement data nor statistical comparisons. By analyzing the efficacy of UC for the hemostasis of small-, medium- and large-sized arteries in pigs, Harold et al. [15
] observed an increase in thermal injury concomitant to increased vessel size. This direct correlation between power level settings, activation time and thermal injury has been reported in more detail by Emam et al. shortly after [11
These mentioned animal studies share a relevant limitation which is the missing description of morphometric measurement. Our data clearly indicate that both UC and ME do not cause a uniform necrotic zone at the resection margin (Figure ), most likely not only because of dissection related but local factors like tissue quality and vessel density. This suggestion is supported by the findings of Hoenig et al. [16
] They examined the thermal injury of laparosonic coagulating shears with either sharp or blunt tip compared to bipolar electrocautery in a porcine model and observed different extent of injury depending on the type of tissue dissected.
The special contribution of this animal study is that we tried to design an experimental setup that reduces handling related bias as much as possible. In particular, we implemented a randomization-process for sample retrieval, the comparative application of the automatic device versus manual dissection, the excision of 2 samples of each kind (A and B) per animal and multiple measurement points per sample for quantifying the depth of coagulation necrosis.
Facing our result of wider necrotic margin in UC, one might hypothesize that in terms of clinical relevance this might lead to more competent ligation of both, blood vessels and lymphatics. This is supported by Morino et al. [17
] who investigated the safety and efficacy of UC compared to ME in laparoscopic colorectal surgery within a prospective randomized clinical trial. They found a significantly lower median intraoperative blood loss for UC. Schmidbauer et al. [18
] also reported this convincing coagulating effect with minimal blood loss for UC for the field of liver resection. In contrast, clinical studies evaluating the postoperative seroma rate following breast cancer surgery could not confirm a significant benefit of UC on seroma formation [19
]. On the other hand, the greater depth of necrosis could also contribute to postoperative nerval dysfunctions when UC is used close to susceptible structures in colorectal surgery. Furthermore, based on our described experimental setup we were able neither to investigate additional relevant but later occurring aspects of tissue alteration in particular inflammatory responses or induction of fibrosis nor to examine the healing sites for differences in wound healing processes or nerval dysfunctions. Therefore, future clinical trials are needed to investigate the clinical relevance of our findings and reason practical recommendations. However, our preliminary data argue for cautious use of UC when susceptible structures are close.