An alternative technique for the use of absorbable mesh in an isolated liver injury

Hepatic "BOLSA" a novel method of perihepatic wrapping for hepatic hemorrhage "BOLSA"

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Perihepatic packing has significant inherent risks.

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Vicryl liver mesh wrap does not possess the complications of packing.

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BOLSA construction is simpler to construct than previously describe liver mesh wrap.

Introduction

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).

Presentation of case

A 59 year old male presented in the recovery room after liver biopsy of a mass, followed by angio-embolization of the hepatic mass 9 h 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.

Discussion

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.

Conclusion

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.

Mesh wrap in severe pediatric liver trauma

PURPOSE

This study reviews the authors' experience in treating severe pediatric liver injuries with absorbable mesh wrapping. The authors found this relatively new therapeutic method very useful in selected cases, although its use is not very common in children. The authors analyze the indication describe some technical aspects, and discuss the advantages and the pitfalls of the method.

METHODS

In a 10-year period between 1990 and 2000, 181 children were admitted to Hillel-Yaffe Medical Center with blunt hepatic trauma. A total of 132 children were treated conservatively, and 49 (27%) were operated on. The operated group included 35 cases of isolated liver injuries and 14 cases of additional intraabdominal injuries. Thirty-four children were operated on between 1990 and 1995 (36% of 96 children), whereas between 1995 and 2000, 15 children were operated on (17% of 85 children), including 4 children aged 18 months to 15 years with massive liver bleeding who were treated with mesh wrap technique. The retrospective analysis of these 4 cases indicates a progressive policy in the recognition of cases suitable for mesh wrapping and gallbladder conservation.

RESULTS

The perihepatic mesh wrap technique controlled the bleeding in all children. In 3 of them the right lobe was wrapped, and, in 1 case, total liver wrapping was performed. Hepatic enzymes and bilirubin levels were elevated in the first 3 to 7 days and declined gradually to normal levels. The perihepatic mesh was not an obstacle to a transcutaneous drainage of an intrahepatic biloma. All 4 children returned to normal physical activities.

CONCLUSIONS

Liver mesh wrap is a simple, effective, and rapid way to obtain hemostasis and to conserve parenchyma in severe traumatized liver. The decision to wrap the liver should be done early to prevent acidosis and hypothermia. Cholecystectomy is not an integral part of the procedure in children. The morbidity is low, and most of the complications can be treated nonsurgically.