Electrosurgery as a coupled system: From energy deposition and interfacial transport to tissue response and clinical outcomes

Generator mode and instrument class are commonly used to compare electrosurgical systems, but these categories do not reliably predict tissue response. This Review treats electrosurgery as a coupled generator-instrument-tissue system and organizes the literature along a causal sequence from electrical boundary conditions and material interfaces to transport, tissue transformation, repair, and clinical outcome. Heat and moisture transfer, phase change, contact mechanics, and plume transport are examined together with electrode composition, geometry, surface state, and use history. Displayed power is not a biological dose because compression, dehydration, fouling, vaporization, and discharge continually reshape the interface. The Review evaluates electrode materials as active transport interfaces that alter wetting, contact resistance, heat spreading, adhesion, and material release. Task-specific process windows provide a common basis for comparing cutting, coagulation, sealing, and ablation. An evidence ladder separates mechanistic findings from translational and clinical claims, avoiding the use of acute thermal injury as proof of healing or clinical benefit. The Review identifies longitudinal tissue endpoints, lifecycle-qualified interfaces, traceable sensing, and bounded feedback as priorities for responsive electrosurgery. This framework links device design to reproducible tissue and clinical outcomes within explicit evidence and operating limits.