Background/Objectives: Hemorrhage is associated with most preventable combat-related deaths. Management of non-compressible truncal and junctional hemorrhage remains challenging, especially with prolonged evacuations. This study evaluated the efficacy of commercial topical hemostatic agents in uncontrolled hemorrhage models under coagulopathic conditions, examining differences based on applicator experience. Methods: Sixty Yorkshire swine were randomized to 5 groups: Combat Gauze (CG), Celox Rapid (CR), ChitoSAM 100 (CS), EVARREST® Fibrin Sealant Patch (EP), and X-Stat 30 (XS). After 50% hemodilution, a 5 mm femoral arteriotomy or 6 cm liver laceration was created, and the agents were applied as per device instructions. Hemostatic agents were placed by experienced (≥5 previous applications) or non-experienced (<5 previous applications) users. Animals were then monitored for rebleeding for 60 minutes. Results: In the junctional hemorrhage model, only ChitoSAM required more applications by novice applicators (2.3 vs. 1, p = 0.0104). No significant differences in rebleed rates among devices (CG 0%, CS 33%, CR 17%, EP 17%, XS 33%, p = 0.73) or by user experience were observed. No differences in perfusion were noted on angiography. In the hepatic laceration model, no significant differences in applications or rebleed rates for any agent (CG 0%, CS 50%, CR 17%, EP 17%, XS 0%, p = 0.21) or by user experience were found. Overall survival did not significantly vary by device. Conclusion: All 5 hemostatic agents showed similar efficacy in controlling junctional and intra-abdominal hemorrhage, with no significant differences in hemostasis, rebleed rate, or survival by experience level. However, more ChitoSAM applications were needed for junctional hemorrhage control in the absence of experience. All tested dressings show promise for rapid hemorrhage control.

Background: Choledocholithiasis complicates 10–15% of patients undergoing cholecystectomy. While endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy is common, access to ERCP is inconsistent in rural and military hospitals, highlighting the role for single-stage laparoscopic common bile duct exploration (LCBDE). Methods: We describe a technical approach for fluoroscopy-guided, wire-based transcystic LCBDE using standardized endovascular tools, the “Biliary Endovascular Toolkit”. We performed a retrospective review of five patients undergoing cholecystectomy and transcystic LCBDE at our military hospital between May 2024 and October 2025. The operative technique employed percutaneous micropuncture sheath access, fluoroscopy-guided transcystic wire cannulation of the ampulla, and balloon dilation with sphincteroplasty for stone clearance. Results: Five patients (mean age 35.4 years) underwent single-stage cholecystectomy with transcystic LCBDE. Transcystic cannulation, duodenal wire access, and ductal clearance were successful in all cases (100%), without conversion or postoperative ERCP (0%). Mean operative time was 208 min (range 161–275). No patient experienced postoperative pancreatitis, pleural complications, or other 30-day adverse events. Conclusions: The Biliary Endovascular Toolkit offers a standardized, wire-guided workflow for transcystic LCBDE using off-the-shelf equipment. This technical note provides a practical framework for general surgeons managing choledocholithiasis, particularly in resource-limited settings.