title: Hepatic "BOLSA" a novel method of perihepatic wrapping for hepatic hemorrhage "BOLSA".
abstract: BACKGROUND
  Severe traumatic liver hemorrhage quickly leads to exsanguination. Perihepatic packing is frequently used in damage control surgery. This method can be unsuccessful and accompanied by complications. Vicryl mesh wraps have been described in the treatment of liver hemorrhage. In this report, we describe an enhanced technique of hepatic wrapping in a case of hepatic bleeding after liver biopsy in a coagulopathic patient. The technique is called the hepatic "BOLSA" (Bag on Liver Supporting Anti-Hemorrhage).
  
  
  METHODS
  A 59 year old male presented in the recovery room after liver biopsy of a mass, followed by angio-embolization of the hepatic mass 9h earlier. The patient was acidotic, coagulopathic, and demonstrated intra-abdominal hypertension. Computed tomography demonstrated perihepatic fluid. The patient continued hemorrhaging despite attempts to correct coagulopathy by transfusion. Multiple operating room visits were required where a combination of packing and hemostatic agents could not stop hepatic venous parenchymal hemorrhage. Mesh wrap consisting of Vicryl and PDS suture were used to create the "BOLSA" to achieve hemostasis.
  
  
  CONCLUSIONS
  Perihepatic packing compromises pulmonary excursion, elevates intra-abdominal pressure, is a risk factor for sepsis, and requires an additional trip to the operating room for removal. The use of Vicryl mesh wrap obviates these complications. Previously described mesh wraps require anchoring. The self-supporting structure of the BOLSA simplifies construction and application.
  
  
  CONCLUSIONS
  The BOLSA is an effective tool in treatment of severe liver hemorrhage in coagulopathic patients. It is the modern simplification of hepatic wrapping and the solution to the side effects of perihepatic packing.
authors.affiliation: Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, Department of Surgery, 4800 Alberta Ave., El Paso, TX 79905, USA.
authors.forename: Nathaniel
authors.initials: N
authors.lastname: Ng
authors.affiliation: Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, Department of Surgery, 4800 Alberta Ave., El Paso, TX 79905, USA. Electronic address: Susan.Mclean@ttuhsc.edu.
authors.forename: Susan F
authors.initials: SF
authors.lastname: McLean
authors.affiliation: Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, Department of Radiology, 5001 El Paso Drive, El Paso, TX 79905, USA.
authors.forename: Melhem R
authors.initials: MR
authors.lastname: Ghaleb
authors.affiliation: Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, Department of Surgery, 4800 Alberta Ave., El Paso, TX 79905, USA.
authors.forename: Alan H
authors.initials: AH
authors.lastname: Tyroch
keywords: Hepatic trauma; Liver laceration; Vicryl mesh wrap; management