The authors have no acknowledgments.

Procedures involving animal subjects have been approved by the Animal Care Committee at the University of Calgary and follow the guidelines set by the Canadian Council of Animal Care. The committee ensures the study is ethical and that the animals are treated humanely.
1. Model Preparation
<ol>
	<li>House the 50 kg adult male pig in an animal care facility for 1 week prior to the surgery to acclimatize the animal to the housing conditions and the handlers. Fast the model for a minimum of 6 h prior to the initiation of anesthesia.</li>
	<li>Anesthetize the model using an intramuscular injection of ketamine (33 mg/kg), atropine (0.04 mg/kg), and buprenorphine (0.05 mg/kg) as well as inhaled isoflurane (5%)9.</li>
	<li>Move the model into the supine position and spray the vocal cords with lidocaine (1%) in order to prevent laryngospasm. Perform direct endotracheal intubation using a 6.5 Fr cuffed endotracheal tube. Confirm the correct position of the endotracheal tube using capnography.</li>
	<li>Insert an 18G IV in the marginal ear vein and begin an infusion of Ringer&#39;s lactate at a rate of 200 mL/h. Apply a bland ointment to the model&#39;s eyes to prevent dryness while under general anesthesia.</li>
	<li>Monitor the model&#39;s heart rate and oxygen saturation using a pulse oximeter applied to the model&#39;s tail. Ventilate the model between 14 - 16 breaths/min using a mechanical ventilator and a tidal volume of 5 - 10 mL/kg. Maintain an adequate anesthesia by targeting a minimal alveolar concentration (MAC) of isoflurane between 2 to 2.5.</li>
	<li>Prior to the initiation of surgery, confirm the adequate depth of anesthesia by testing pain reflexes with a hind leg toe pinch. Reevaluate pain reflexes at regular intervals throughout the surgery.</li>
</ol>
2. Device Preparation
<ol>
	<li>Prepare the ignited saline/bipolar radiofrequency (SBRF; Figure 1) device as per the manufacturer&#39;s specifications.
	<ol>
		<li>Open the handpiece (6.0 bipolar sealing tip) and connect it to the generator.</li>
		<li>Set the saline flow rate setting to Low. Use 0.9% saline for a maximal energy conduction.</li>
		<li>Set the radiofrequency power setting to 160 W.</li>
	</ol>
	</li>
</ol>
3. Surgery: Laparotomy
<ol>
	<li>Perform a long open midline laparotomy incision using a #10 scalpel extending from the xiphisternum to the pubis and passing through all layers of the abdominal wall.</li>
	<li>Establish an adequate exposure of the solid organs of interest (e.g., liver, spleen, kidney), mobilize other structures, and insert a retractor as necessary. 
	NOTE: For simplicity, the liver will be referred to as the solid organ of interest for the remainder of this protocol. This protocol will also include creating injuries of similar grade within the kidney and spleen.</li>
</ol>
4. Surgery: Simulated Solid Organ Injury
NOTE: The injuries described below represent a worsening hierarchy of injuries. The injuries are created by an expert trauma surgeon and hemostasis will be obtained by another surgeon.
<ol>
	<li>Using a #10 scalpel blade, apply an abrasive (back and forth) force to the liver capsule in order to induce capsular bleeding. The injury should be superficial (i.e., 1 - 2 mm) and 2 cm2 in size. The size of the injury can then be increased in increments of 1 cm2 at the operator&#39;s discretion.</li>
	<li>Create solid organ lacerations of increasing severity using the direct application of a scalpel. The length of the laceration can extend from 5 cm to the entire length of the organ. The depth of the laceration should be 1 cm and then increased in increments of 1 cm at the operator&#39;s discretion.</li>
	<li>Create penetrating injuries with a blunt device such as a Kelly clamp using a stabbing motion. These can be of a partial thickness (i.e., 50% of the organ) or of full thickness (i.e., passing completely through the organ).</li>
</ol>
5. Hemostasis
<ol>
	<li>Depress the handpiece&#39;s button, initiating the simultaneous flow of saline and the delivery of bipolar radiofrequency energy. The saline will boil at the site of application.</li>
	<li>Apply the device&#39;s tip directly onto the liver&#39;s raw surface, to superficial areas of bleeding, or within defects in the liver itself. Do not stab the organ with the end effector.</li>
	<li>Apply concurrent suctioning from a standard surgical sucker as needed in order to deliver the heated saline and energy directly to the areas of ongoing hemorrhage. This also helps visualize the precise location of the ongoing hemorrhage.</li>
	<li>Heat the tissues to approximately 100 &#176;C (thermal coagulation without significant charring) using a gentle back and forth motion. An auditory &#39;pop&#39; will occur after 3 - 5 s and signifies that the burn is complete. The user may then move the instrument in an organized manner to the next targeted site.</li>
	<li>If necessary, apply precisely directed high-voltage electrocautery in conjunction with the application of the SBRF and suction devices in order to obtain hemostasis. This may be required for the largest and most vigorous hemorrhage.</li>
</ol>
6. Sealing Small to Medium Bile Ducts
<ol>
	<li>Using the same method as described above, apply the instrument tip across the cut/injured edge of the liver parenchyma to seal small to medium bile ducts.</li>
</ol>
7. Model Euthanasia
<ol>
	<li>At the completion of the experiment, euthanize the anesthetized model via exsanguination according to the institution&#39;s Animal Care Guidelines.</li>
</ol>

<ol>
	<li>Kauvar, D. S., Lefering, R., Wade, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+hemorrhage+on+trauma+outcome:+an+overview+of+epidemiology,+clinical+presentations,+and+therapeutic+considerations.">Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.</a> Journal of Trauma and Acute Care Surgery. 60 (6), S3-S11 (2006).</li><li>Shrestha, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Damage-control+resuscitation+increases+successful+nonoperative+management+rates+and+survival+after+severe+blunt+liver+injury.">Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury.</a> Journal of Trauma and Acute Care Surgery. 78 (2), 336-341 (2015).</li><li>Kozar, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+Association/critical+decisions+in+trauma:+operative+management+of+adult+blunt+hepatic+trauma.">Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma.</a> Journal of Trauma and Acute Care Surgery. 71 (1), 1-5 (2011).</li><li>Peitzman, A. B., Richardson, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+injuries+to+the+solid+abdominal+organs:+a+50-year+perspective+from+the+Journal+of+Trauma.">Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma.</a> Journal of Trauma and Acute Care Surgery. 69 (5), 1011-1021 (2010).</li><li>Aloia, T. A., Zorzi, D., Abdalla, E. K., Vauthey, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two-surgeon+technique+for+hepatic+parenchymal+transection+of+the+noncirrhotic+liver+using+saline-linked+cautery+and+ultrasonic+dissection.">Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection.</a> Annals of surgery. 242 (2), 172-177 (2005).</li><li>Ball, C. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+a+novel+energy+technology+for+arresting+ongoing+liver+surface+and+laceration+hemorrhage.">Use of a novel energy technology for arresting ongoing liver surface and laceration hemorrhage.</a> Canadian Journal of Surgery. 57 (4), E146 (2014).</li><li>Ball, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+a+novel+saline/bipolar+radiofrequency+energy+instrument+as+an+adjunct+for+arresting+ongoing+solid+organ+surface+and+laceration+bleeding+in+critically+injured+patients.">Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients.</a> Injury. 47 (9), 1996-1999 (2016).</li><li>Ball, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+efficacy+of+a+novel+saline/bipolar+radiofrequency+energy+instrument+for+arresting+ongoing+solid+and+non-solid+organ+hemorrhage+in+a+swine+model.">The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model.</a> Injury. 47 (12), 2706-2708 (2016).</li><li>Swindle, M. M., Smith, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Best+practices+for+performing+experimental+surgery+in+swine.">Best practices for performing experimental surgery in swine.</a> Journal of Investigative Surgery. 26 (2), 63-71 (2013).</li><li>Cantle, P. M., Roberts, D. J., Holcomb, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Damage+Control+Resuscitation+Across+the+Phases+of+Major+Injury+Care.">Damage Control Resuscitation Across the Phases of Major Injury Care.</a> Current Trauma Reports. 3 (3), 238-248 (2017).</li><li>Gaarder, C., Naess, P. A., Buanes, T., Pillgram-Larsen, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advanced+surgical+trauma+care+training+with+a+live+porcine+model.">Advanced surgical trauma care training with a live porcine model.</a> Injury. 36 (6), 718-724 (2005).</li><li>Harvin, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Control+the+damage:+morbidity+and+mortality+after+emergent+trauma+laparotomy.">Control the damage: morbidity and mortality after emergent trauma laparotomy.</a> The American Journal of Surgery. 212 (1), 34-39 (2016).</li></ol>

The authors have nothing to disclose.

The rapid and effective control of hemorrhage is an essential component of modern damage control resuscitation10. A variety of operative and adjunctive techniques are available to arrest hemorrhage in a solid organ injury3. None of these techniques has proven to be universally applicable or successful in achieving hemostasis. The initial experience with the SBRF device described here has been positive6,7,8. This device is a valuable adjunct in achieving rapid and effective hemostasis in complex solid organ injuries.
In the current protocol, a porcine model was employed to simulate traumatic solid organ injuries. In doing so, the characteristics of the study&#39;s device are demonstrated in a high-fidelity setting. Porcine models have previously been demonstrated to be an effective model for equivalent human disease processes, particularly in the area of surgical education and simulation11.
This protocol does have one notable limitation. The simulated injuries are created in a porcine model which is anesthetized under standardized conditions. Although the simulated injuries are relatively realistic, they are created in isolation to the physiologic state of the model. As a result, the model is not necessarily exposed to the acute coagulopathy and other physiological derangements that normally influence outcomes in traumatically injured patients.
Despite this limitation, the human patient experience with the device in solid organ hemorrhage has been extremely encouraging6,7. The SBRF device is simple to use and has demonstrated effective hemostasis in a highly selected group of trauma patients with challenging solid organ injuries. The SBRF device also allows simultaneous hemostasis and the sealing of small- and medium-sized bile ducts within the liver.
To our knowledge, there have been no reports of short-term or long-term complications related directly to the use of an SBRF device in trauma patients or during its use in elective surgery. Because the device functions at a relatively low operating temperature (e.g., 100&#176;C), there is less risk of injury to innocent bystander vascular structures in the operative field. For example, there appears to be no or very limited risk to structures such as the inferior vena cava and portal vein due to the strong heat sink created by the high blood flow through these structures. As the use of and the experience with the SBRF device increases, its users will have to remain observant for any potential complications.
Damage control laparotomy is associated with significant potential morbidity and mortality11,12. This is particularly true in the management of complex solid organ injuries. Possessing a versatile device for effective primary hemostasis in these complex injuries may lead to a reduction in the need for temporary abdominal closure and its inherent risks. It is also a superb instrument for surgeons who must stop ongoing hemorrhage in these challenging areas, but do not necessarily have comfort in either the intra-organ anatomy or the anatomical region of the injury.

Uncontrolled hemorrhage due to solid organ injury remains a leading cause of morbidity and mortality in both blunt and penetrating trauma1. With the advent of effective damage control resuscitation strategies, the rate of non-operative management for abdominal trauma continues to increase2. As a result, patients requiring operative management have increasingly complex injuries and associated physiologic derangement. In these patients, early control of hemorrhage is an essential component of effective damage control resuscitation and desirable outcomes.
The surgical management of solid organ injuries remains a key competency for trauma, acute care, and general surgeons. A wide variety of surgical techniques and hemostatic adjuncts for these injuries have been described3. Traditional techniques for treating solid organ bleeding include coagulation by high-voltage electrocautery, application of topical hemostatic agents, sutured repairs, and partial or total organ excision. Argon beam coagulation has also been described4. While each of these techniques has a role in achieving hemostasis, none is universally applicable or successful.
Many novel tools and hemostatic therapies have been described in the elective surgical setting. This is especially true in the realm of hepatobiliary surgery5. As familiarity with these tools increases, many of them have also shown promise in the surgical management of traumatic injuries. One such device utilizes a combination of ignited saline and bipolar radiofrequency energy to arrest hemorrhage. Additionally, it has the ability to simultaneously seal small- to medium-sized bile ducts within the liver6. The positive experience with this tool in the management of solid organ injuries has been described previously6,7,8.
The goal of this publication is to demonstrate the potential application of this novel device using simulated solid organ injuries in a porcine model.

<table><tbody><tr><td>Aquamantys pump generator</td><td>Medtronic</td><td>40-402-1</td><td></td></tr><tr><td>Aquamantys 6.0 bipolar sealer</td><td>Medtronic</td><td>23-112-1</td><td></td></tr><tr><td>Electrosurgical pencil with tip</td><td>Megadyne</td><td>0039</td><td></td></tr><tr><td>Porcine animal</td><td></td><td></td><td></td></tr><tr><td>Porcine ventilator/induction and anesthetic medications</td><td></td><td></td><td></td></tr><tr><td>2 x 1 liter bags of 0.9% normal saline</td><td></td><td></td><td></td></tr><tr><td>2 x scalpels (#10)</td><td></td><td></td><td></td></tr><tr><td>Belfour abdominal retractor</td><td></td><td></td><td></td></tr><tr><td>Suction tubing</td><td></td><td></td><td></td></tr><tr><td>Suction tip</td><td></td><td></td><td></td></tr><tr><td>Suction device/wall connector</td><td></td><td></td><td></td></tr><tr><td>Suction canister</td><td></td><td></td><td></td></tr><tr><td>Debakey forceps</td><td></td><td></td><td></td></tr><tr><td>Metz scissors</td><td></td><td></td><td></td></tr><tr><td>Curved Mayo scissors</td><td></td><td></td><td></td></tr><tr><td>Closing suture (1-0 Nylon)</td><td></td><td></td><td></td></tr><tr><td>20 x Laparotomy sponges</td><td></td><td></td><td></td></tr><tr><td>2 x Kelley clamps</td><td></td><td></td><td></td></tr><tr><td>2 x snap clamps</td><td></td><td></td><td></td></tr></tbody></table>

a saline/bipolar radiofrequency energy device as an adjunct for hemostasis in solid organ injury/trauma

Solid organ (liver, spleen, and kidney) hemorrhage is often life-threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage electrocautery, topical hemostatic application, and the delivery of ignited argon gas. The goal of this study/video was to demonstrate the efficacy of a new energy device for arresting persistent solid organ hemorrhage.A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple handpiece is employed to arrest ongoing bleeding from solid organ injuries in a porcine model. This instrument is extrapolated from experience within elective hepatic resections. An escalating series of injuries to solid organs within a porcine model will be created. This will be followed by arresting hemorrhage with this novel energy device in sequence. A standard suction device will also be employed. This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate hemorrhage associated with deep lacerations.

The SBRF device described herein provides effective hemostasis for a variety of solid organ injuries. The efficacy of the SBRF device in a porcine model has been described previously8. The results of this study are republished here with permission from the authors.
Using a porcine model, injuries of increasing severity were applied to four separate models. The injuries were described as surface decapsulation, superficial laceration, deep laceration, penetrating &#39;through and through&#39; missile trajectories, and complete transection. Effective hemostasis was determined by five operating surgeons as well as a careful video review by a separate group of two surgeons. Regardless of the injury severity, the SBRF device was determined to be effective in achieving hemostasis by the operating surgeons in 99% of the injuries, and by the video review surgeons in 97% of the injuries. Additionally, due in large part to the simple design, the operating surgeons involved in the initial study also found the device very easy to use8.
The depth of the tissue penetration by the SBRF device was also determined in the previous porcine study8. The tissue penetration varied by target organ (Table 1). Notably, no tissue coagulation was observed when the inferior vena cava was targeted. This is likely due to the heat sink effect from significant blood flow and further supports the safety of the device&#39;s use around large vascular structures.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57333/57333fig1.jpg" /> 
Figure 1: Saline/bipolar radiofrequency (SBRF) energy device. (A) This panel shows the SBRF device handpiece with the single-button design. (B) This panel shows the SBRF&#39;s 6.0 blunt bipolar sealing tip. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57333/57333fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Target organ</td>
			<td>Depth of tissue penetration (mm)</td>
		</tr>
		<tr>
			<td>Liver</td>
			<td>2.7</td>
		</tr>
		<tr>
			<td>Spleen</td>
			<td>2.5</td>
		</tr>
		<tr>
			<td>Kidney</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Abdominal wall</td>
			<td>2.4</td>
		</tr>
		<tr>
			<td>Lung</td>
			<td>1.1</td>
		</tr>
		<tr>
			<td>Heart</td>
			<td>1.3</td>
		</tr>
		<tr>
			<td>Inferior vena cava</td>
			<td>0</td>
		</tr>
	</tbody>
</table>
Table 1: Tissue penetration by target organ. This table has been modified from Ball et al8.

Watch this Scientific Journal Video about A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma at JoVE.com

A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma

The goal of this publication is to demonstrate the potential application of a novel device using simulated solid organ injuries in a porcine model.

Solid organ (liver, spleen, and kidney) hemorrhage is often life-threatening and can be difficult to stop in critically ill patients. Traditional ...

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5.2K Views.  University of Calgary. The goal of this publication is to demonstrate the potential application of a novel device using simulated solid organ injuries in a porcine model.

Video: A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma

Fixed Volume or Fixed Pressure: A Murine Model of Hemorrhagic Shock

It is common knowledge that severe blood loss and traumatic injury can lead to a cascade of detrimental signaling events often resulting in mortality. 1, 2, 3, 4, 5 These signaling events can also lead to sepsis and/or multiple organ dysfunction (MOD). 6, 7, 8, 9 It is critical then to investigate the causes of suppressed immune function and detrimental signaling cascades in order to develop more effective ways to help patients who suffer from traumatic injuries. 10 This fixed pressure Hemorrhagic Shock (HS) procedure, although technically challenging, is an excellent resource for investigation of these pathophysiologic conditions. 11, 12, 13 Advances in the assessment of biological systems, i.e. Systems Biology have enabled the scientific community to further understand complex physiologic networks and cellular communication patterns. 14 Hemorrhagic Shock has proven to be a vital tool for unveiling these cellular communication patterns as they relate to immune function. 15, 16, 17, 18 This procedure can be mastered! This procedure can also be used as either a fixed volume or fixed pressure approach. We adapted this technique in the murine model to enhance research in innate and adaptive immune function. 19, 20, 21 Due to their small size HS in mice presents unique challenges. However due to the many available mouse strains, this species represents an unparalleled resource for the study of the biologic responses. The HS model is an important model for studying cellular communication patterns and the responses of systems such as hormonal and inflammatory mediator systems, and danger signals, i.e. DAMP and PAMP upregulation as it elicits distinct responses that differ from other forms of shock. 22, 23, 24, 25 The development of transgenic murine strains and the induction of biologic agents to inhibit specific signaling have presented valuable opportunities to further elucidate our understanding of the up and down regulation of signal transduction after severe blood loss, i.e. HS and trauma 26, 27, 28, 29, 30. 
There are numerous resuscitation methods (R) in association with HS and trauma. 31, 32, 33, 34 A fixed volume resuscitation method of solely lactated ringer solution (LR), equal to three times the shed blood volume, is used in this model to study endogenous mechanisms such as remote organ injury and systemic inflammation. 35, 36, 38 This method of resuscitation is proven to be effective in evaluating the effects of HS and trauma 38, 39.

The Hemorrhagic Shock model has been a reliable and reproducible resource facilitating the identification and understanding of signaling cascades associated with inflammation and end-organ damage after trauma. This article provides a step-by-step description of surgical and mechanical aspects associated with the Hemorrhagic Shock experimental procedure in mice.

It is common knowledge that severe blood loss and traumatic injury can lead to a cascade of detrimental signaling events often resulting in mortality. 1, ...

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

Cancer Research

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent hemorrhages at a later stage. The exact effects of plasma coagulation on liver tissue are only poorly examined. In our porcine model, the coagulation effects can be examined close to the clinical application. A combined laser Doppler flowmeter and spectrophotometer documents microcirculation changes during coagulation at 8 mm tissue depth noninvasively, providing quantifiable information about hemostasis beyond the subjective clinical impression. The temperature at coagulation site is assessed with an infrared thermometer prior and post coagulation and with a thermographic camera during coagulation, a measurement of the gas beam temperature is not possible due to the upper threshold of the devices. The depth of coagulation is measured microscopically on hematoxylin/eosin stained sections after calibration with an object micrometer and gives an exact information about the power setting-coagulation depth-relation. The sealing effect is examined on the bile ducts as it is not possible for a plasma coagulator to seal larger blood vessels. Burst pressure experiments are carried out on explanted organs to rule out blood pressure related effects.

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Here we present a protocol to experimentally assess plasma coagulation in liver tissue in vivo. In a porcine model, microcirculation is examined by laser Doppler, coagulation depth is measured histologically, temperature at coagulation site by infrared thermometer and thermographic camera, and duct sealing effect is documented by burst pressure experiments.

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for hemorrhage control. With the advent of purpose-built devices, REBOA has become increasingly common in civilian trauma and acute care settings. Currently available REBOA catheters were designed as complete aortic occlusion devices. However, the therapeutic window for complete aortic occlusion is time-limited due to ischemia-reperfusion injury. The partial procedure allows blood flow past the level of occlusion while maintaining targeted proximal pressure, which has been shown to reduce distal ischemia and adjunctive resuscitation requirements in preclinical studies with prolonged occlusion times as compared to traditional complete occlusion.
pREBOA-PRO is the first catheter designed to enable partial and complete aortic occlusion and is currently in limited market release at seven Level I trauma centers in North America. This paper will focus on procedural considerations for REBOA, including patient selection criteria and a comparison of complete and partial aortic occlusion in a simulator, along with highlighting critical steps to improve clinical outcomes. Additionally, this paper reviews a contrast-enhanced CT scan from a trauma patient that shows distal perfusion after 2 h of partial aortic occlusion using this newly designed catheter and discusses representative results from the limited market release to highlight the profound effect of technological innovation on outcomes in vascular emergencies.

A commercial catheter was designed to facilitate true partial resuscitative endovascular balloon occlusion of the aorta (REBOA) and address the complications associated with complete aortic occlusion. Initial clinical reports indicate that partial REBOA improves transition to reperfusion, reduction of distal ischemia, and extension of safe occlusion time compared to complete occlusion.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for ...

Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune functions. As a new method of preserving the spleen, laparoscopic partial splenectomy (LPS) has been increasingly applied in clinical practice with people&#39;s deeper insights into minimally invasive treatment and the development of technical equipment. Compared with conventional open splenectomy, LPS can preserve normal spleen tissue as much as possible, decrease the occurrence of complications after total splenectomy, and reduce postoperative hospital stay. The bipolar radiofrequency excision hemostatic device used for LPS can solidify the splenic tissue and close the small blood vessels, which reduces the hemorrhage of the spleen cross-section and clears the operative field, thus achieving the ideal effect of &#34;bloodless partial splenectomy&#34;. Therefore, under the premise of strictly mastering the indications and fully understanding the vascular anatomy of the spleen, the application of the bipolar radiofrequency excision hemostatic&#160;device in LPS is worthy of clinical promotion.

The present protocol describes that bipolar radiofrequency device-assisted laparoscopic partial splenectomy (LPS) is safe and effective. A bipolar radiofrequency device in LPS can reduce intraoperative bleeding and achieve the clinical effect of a "bloodless spleen incision", which is worthy of clinical application.

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune ...

Rat Model for Visceral Organ Malperfusion Studies

Controlled Reversible Visceral Arterial Ischemia, Venous Congestion and Combined Malperfusion via Midline Laparotomy in Rats

Besides sepsis and malignancy, malperfusion is the third leading cause of tissue degradation and a major pathomechanism for various medical and surgical conditions. Despite significant developments such as bypass surgery, endovascular procedures, extracorporeal membrane oxygenation, and artificial blood substitutes, tissue malperfusion, especially of visceral organs, remains a pressing issue in patient care. The demand for further research on biomedical processes and possible interventions is high. Valid biological models are of utmost importance in enabling this kind of research. Due to the multifactorial aspects of tissue perfusion research, which include not only cell biology but also vascular microanatomy and rheology, an appropriate model requires a degree of biological complexity that only an animal model can provide, rendering rodents the obvious model of choice. Tissue malperfusion can be differentiated into three distinct conditions: (1) isolated arterial ischemia, (2) isolated venous congestion, and (3) combined malperfusion. This article presents a detailed step-by-step protocol for the controlled and reversible induction of these three types of visceral malperfusion via midline laparotomy and clamping of the abdominal aorta and caval vein in rats, underscoring the significance of precise surgical methodology to guarantee uniform and dependable results. Prime examples of possible applications of this model include the development and validation of innovative intraoperative imaging modalities, such as Hyperspectral Imaging (HSI), to objectively visualize and differentiate malperfusion of gastrointestinal, gynecological, and urological organs.

Author Spotlight: Advancing Spectral Characterization of Physiological and Malperfused Tissues

This article introduces a standardized procedure for controlled, reversible malperfusion of visceral organs in rat models. The aim is to induce these malperfusion states with a high degree of methodological certainty and control while maintaining technical simplicity and error resilience.

Besides sepsis and malignancy, malperfusion is the third leading cause of tissue degradation and a major pathomechanism for various medical and surgical ...

Reducing Bleeding in Laparoscopic Partial Splenectomy with Microwave Ablation

Application of Microwave Ablation in Laparoscopic Partial Splenectomy

Splenic hemangioma is the most common pathological classification of splenic tumors, and its surgical indication and treatment have been controversial. Before, open splenectomy was usually used to treat splenic hemangioma. Following the rapid development of laparoscopic techniques, people's requirements for minimally invasive treatment have gradually increased, and laparoscopic splenectomy has gradually become the main treatment method. However, through the deeper study of spleen function, it was found that partial splenectomy can cut down the incidence of postoperative thrombocythemia and decrease side effects on the physiological function of the body, so laparoscopic partial splenectomy came into being. However, due to the special anatomical structure, the incidence of hemorrhage during partial splenectomy is greater. Therefore, during the operation, we removed part of the splenic blood vessels, combined with microwave ablation, which perfectly solved the problem of intraoperative bleeding. Laparoscopic partial splenectomy combined with microwave ablation not only achieves the requirements of minimally invasive treatment but also reduces the risk of intraoperative bleeding, meriting clinical application and promotion.

The use of laparoscopic partial splenectomy has been limited due to the high risk of bleeding during surgery. Therefore, we introduce a laparoscopic method combined with microwave ablation to solve the problem of intraoperative bleeding.

Splenic hemangioma is the most common pathological classification of splenic tumors, and its surgical indication and treatment have been controversial. ...

Swine Axillary Artery Injury Model for Testing Pre-Hospital Hemostatic Products

A New Hybrid Quantitative Evaluation Model for Axillary Junctional Hemorrhage in Swine

In this study, we developed and validated a hybrid quantitative model for simulating upper extremity junctional hemorrhage in swine, aiming to advance the development of pre-hospital hemostatic products. Utilizing 12 healthy 8-month-old male Yorkshire swine, we demonstrated the feasibility of a swine axillary artery injury model for evaluating hemostatic efficacy. Animals were divided into three groups to undergo volume-controlled hemorrhage (VCH), mimicking Class I-III hemorrhagic shock by withdrawing blood at different rates. Subsequent external compression was applied using a novel device consisting of a mechanical arm and an inflatable hemostatic balloon, achieving controlled pressure to enhance clot formation. Hemodynamic parameters, including heart rate and blood pressure, were continuously monitored, highlighting the impact of controlled hemorrhage and external compression on physiological responses. The findings suggest that the combination of VCH with targeted external compression effectively simulates clinical scenarios of axillary artery injury, providing a valuable model for testing hemostatic interventions in a controlled, standardized manner. This study underscores the potential of the model in facilitating the development and evaluation of new hemostatic agents and devices for managing junctional hemorrhages.

This study presents a hybrid quantitative model for axillary junctional hemorrhage in swine, enhancing pre-hospital hemostatic intervention evaluation.

In this study, we developed and validated a hybrid quantitative model for simulating upper extremity junctional hemorrhage in swine, aiming to advance the ...

A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma

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Fixed Volume or Fixed Pressure: A Murine Model of Hemorrhagic Shock

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device

Controlled Reversible Visceral Arterial Ischemia, Venous Congestion and Combined Malperfusion via Midline Laparotomy in Rats

Application of Microwave Ablation in Laparoscopic Partial Splenectomy

A New Hybrid Quantitative Evaluation Model for Axillary Junctional Hemorrhage in Swine