What is the best approach to manage and heal a liver laceration?

Management of Liver Laceration

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with liver lacerations, regardless of injury severity (AAST I-V), in the absence of other internal injuries requiring surgery. 1, 2

Initial Assessment and Diagnosis

• The diagnostic approach must be determined by the patient's hemodynamic status upon presentation 2
• E-FAST (Extended Focused Assessment with Sonography for Trauma) is rapid and effective for detecting intra-abdominal free fluid in the initial evaluation 1
• CT scan with intravenous contrast is the gold standard for evaluating liver injuries in hemodynamically stable patients and should always be performed when considering NOM 1, 2

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Stable Patients (First-Line Approach)

• NOM is indicated for all hemodynamically stable minor (WSES I/AAST I-II), moderate (WSES II/AAST III), and severe (WSES III/AAST IV-V) injuries 1
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status during NOM 1
• Intensive care unit admission is required only for moderate and severe lesions 1
• Angiography/angioembolization (AG/AE) may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan 1
• In children, the presence of contrast blush on CT scan is not an absolute indication for AG/AE 1

For Hemodynamically Unstable Patients (Operative Management)

• Hemodynamically unstable and non-responder patients should undergo immediate operative management 1
• Primary surgical intention should be to control hemorrhage and bile leak while initiating damage control resuscitation 1
• Major hepatic resections should be avoided initially and only considered in subsequent operations for large areas of devitalized liver tissue 1
• Angioembolization is useful for persistent arterial bleeding after non-hemostatic or damage control procedures 1
• Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used as a bridge to more definitive procedures for hemorrhage control 1
• Laparoscopy may be considered in selected cases to minimize invasiveness and tailor the procedure to the lesion 1, 3

Management of Complications

• Intrahepatic abscesses should be treated with percutaneous drainage 1
• Delayed hemorrhage without severe hemodynamic compromise may be managed with AG/AE 1
• Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture 1
• Symptomatic or infected bilomas should be managed with percutaneous drainage 1
• For biliary complications not suitable for percutaneous management alone, a combination of percutaneous drainage and endoscopic techniques may be considered 1
• Biliary fistulas without other indications for laparotomy should be managed with lavage/drainage and endoscopic stenting 1

Special Considerations

• In patients with concomitant head trauma and/or spinal cord injuries, NOM should be attempted with reliable clinical exam, unless the patient cannot achieve specific hemodynamic goals for the neurotrauma 1
• In low-resource settings, NOM could be considered in patients with hemodynamic stability without evidence of associated injuries, with negative serial physical examinations and negative imaging and blood tests 1
• For patients taking anticoagulants, individualization of the risk-benefit balance of anticoagulant reversal is suggested 1

Follow-up Care and Recovery

• Mechanical thromboprophylaxis should be considered in all patients without absolute contraindications 1
• LMWH-based prophylaxis should be started as soon as possible following trauma 1
• Early mobilization should be achieved in stable patients 1
• In the absence of contraindications, enteral feeding should be started as soon as possible 1
• Most isolated liver injuries can heal with NOM, with resumption of light exercise possible after approximately 5 weeks and full activity after 3 months 4

Pitfalls and Caveats

• Persistent right upper quadrant pain, especially when accompanied by referred pain to the right shoulder, abdominal rigidity, guarding, or rebound pain should raise suspicion for liver injury 4
• Hemodynamic deterioration during NOM requires immediate reassessment and possible conversion to operative management 1
• Bile leaks may occur as a delayed complication and require drainage procedures 5
• Even seemingly minor handlebar injuries in children can result in severe liver lacerations with bile duct injuries 5