But it is much better to prevent the bleeding. So to do this, you need to know the characteristic of the vessel network, vessel architecture. Vessel in the geotrax is coming into the submucosa by penetrating the muscle layer, then branching side to side in the middle of the submucosa. So we are coming from the mucosal level, so always we will see the branch network. But if you can remain the incision above the branch network, and after breakthrough the branch network by dissecting deep submucosa layer, you can minimize the treatment of the blood vessel, and you can minimize the bleeding. That's why appropriate level for incision and dissection is quite important. This is my proposal. One is the inside the mucosa very shallow, but underneath the musculoskeletal mucosa is needed so that you can see through the submucosa level. Then you can see, if you don't bleed, you can see every single branch networks. Then by dissecting branch network, by reducing the tension of the vessel, incision edge will open. So from now on, by keeping the dissection level underneath the branch vessel, you only need to treat penetrating vessel. That's all. Then you will succeed all the time. But to break through this branch vessel, it is better to coagulate. But small bleeding can stop by using the forced coagulation mode very well usually. But there are so many large vessels. In such situation, you need to switch to the forceps. This is time consuming and very much uncomfortable. That's why we try to cut it directly and fail and bleed. That's why I wanted to improve such a technique. So first, you need to explore the vessel. But there are so many vessels. So every time if you change to the forceps, you will lose your concentration. That's why first I used the soft coagulation mode by compressing the vessel. Then when it was whitened, by emitting the spark, we can cut it without massive bleeding. This is a real procedure. By compressing the vessel after the exposure of the vessel, then conducting the soft coagulation mode, because this is the totally pure coagulation. And after additional coagulation by the forced coagulation, then by emitting spark, you can cut it. Now recently, we are changing this mode to the forced coagulation effect 110 watts, so-called 110, very low output of the power. So this is a fundamental phenomenon. When you start the conduction, temperature is coming up. And after steam is coming, when your setting was over 200 volt, current is come, and spark is coming. But if you control the voltage less than 200, nothing happens, because the electric current doesn't jump such a gap. Then if you set watt higher, this phenomenon coming faster. And if you set watt set very low, this phenomenon coming very, very slow. So this is a video of the low output setting. This is forced coagulation mode. Now heat is coming up, steam has come, and the spark is jumping between the gap. This is the usual setting. But when you control the voltage less than 200, after steam has come, because the intensity, impedance is coming higher, no current come. So again, but at the beginning, forced coagulation mode also almost the same phenomenon is coming. That's why if you can use this phase very efficiently, you can coagulate much more. So at 110 consists with around 600 volt, and of course 10 watt. Then soft coagulation mode has the less than 200 volt. Then we measured the eruption time. If you use this soft coagulation mode, it will be stopping very quickly. But forced coagulation effect 1, 10 watt has the higher voltage. That's why after the impedance coming up, current is coming longer. So as if you put the same energy, if your time was longer, coagulation depth will be coming deeper. Both do the same energy dose. As a result, you see a much deeper coagulation is coming. Then we conducted the study. If this cell is larger than 2 centimeters, pre-coagulation, after pre-coagulation, breathing rate is significantly lower in the 1, 10 group. It means success rate of the pre-coagulation is significantly higher in 1, 10 group. So now we can use the VIA3. VIA3 has the much higher power because maximum electric current is double than the 300D. So this is very, very important. Blood vessel, the blood is very low resistance impedance. That's why if you don't have the higher electric current, only small heat is coming. So this is the larger vessel after exposure. Now we are using the 0.4. It consists with 600 volt and 8 watt in VIA3. So now you can see by compressing the vessel and conducting force coagulation 0.4 longer, then you see the whitening is expanding to the upper side or lower side. Now vessel have been shrinked. Then after shrink, by emitting the spark, effect 5,300 volts. So this vessel can be cut without massive lead. So to cut it, spark is needed. But to coagulate it, spark doesn't need. Only steam phase can be used. You can pre-coagulate very well. So this is not a real measurement, but VIA3 has excellent sampling feedback. That's why even the force coagulation can be controlled. Voltage of the force can be controlled totally. And also, that's why always the 600 volt is coming. That's why eruption time is very long. So sometimes in VIA3, sometimes the voltage doesn't reach to the 560. That's why eruption time is very various. That's why I guess VIA3 has a much higher pre-coagulation ability. Technically, please expose vessel without bleed and compress the vessel by the knife itself and conduct pre-initial cutting phase. It means this force 110 or force 0.4 in VIA3. Then without spark, please coagulate the vessel. And after that, by spark, by emitting spark, you can cut it. Thank you very much. Thanks. Any questions from audience? So for F110, you continuously press until quite correct? As much as long as possible. Then you can see the effect is extending. So if it is coming, you can continue. But when the impedance is coming higher, no coagulation effect can be seen. Then it is a time to stop the coagulation. Great. Can you just use knife on soft coagulate and just do a very slow motion to burn the vessel? Yeah. But if you burn the vessel slow motion, sometimes much more often you are causing the bleeding. That's why it is better to try no risk pre-coagulation, such as a soft coag 110, VIA3 0.4. But soft coag has very few pre-coagulation ability. That's why I changed the mode. Technically same, but the mode was different. Soft coag doesn't really work well with this very short, small contact area? For the forceps, soft coag is best, because it can compress much wider. But for small equipment, it's not enough, because they're less than 200. And heating up is very small. I have one more comment. The electric current needed for pre-coagulation is different depending on the size of the electrode. Because I'm using a dual knife j, which is much smaller than a flash knife, that's why it requires much lower current. Therefore, I usually use 0.3 of VIA3 for soft coag, or effect one, only 5 watt when we use VIA300D. So you should understand the character of your own device when you conduct this technique. So if you raise it a little bit more, a spark may be coming. Also, by compressing the vessel, the current density is coming lower. So the spark doesn't come so well. That's why compress, widely capturing the vessel is needed. From the side? Yeah, on the side. Hopefully, both is better. But we only have a blade, that's all. That's why compress. Thank you.

bleeding prevention

vessel architecture

minimizing bleeding

coagulation techniques

voltage and current control