What is the management strategy for liver lacerations?

Management of Liver Lacerations

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with liver lacerations of any severity (minor, moderate, or severe injuries), while hemodynamically unstable patients require immediate operative intervention. 1

Initial Diagnostic Approach

The management strategy is fundamentally determined by hemodynamic status at presentation:

• E-FAST ultrasound should be performed immediately to rapidly detect intra-abdominal free fluid 1
• CT scan with intravenous contrast is the gold standard for hemodynamically stable patients and must always be obtained before attempting NOM 1, 2
• The diagnostic method selection is dictated entirely by whether the patient is stable or unstable 1

Management Algorithm Based on Hemodynamic Status

Hemodynamically Stable Patients (WSES I-III)

NOM is the definitive treatment approach for all grades of injury (AAST I-V) when hemodynamic stability is maintained and no other injuries require surgery 1, 2:

• Serial clinical examinations and laboratory testing are mandatory to detect any deterioration during NOM 1
• Angiography with angioembolization (AG/AE) should be considered as first-line intervention when arterial blush is visible on CT scan 1
• ICU admission is required only for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions 1

Critical caveat for transient responders: Patients with moderate-to-severe injuries who respond transiently to resuscitation should only undergo NOM in facilities with immediate access to trained surgeons, operating rooms, ICU monitoring, angiography capabilities, blood products, and transfer systems to higher-level care 1

Hemodynamically Unstable Patients (WSES IV)

Immediate operative management is mandatory for non-responders and unstable patients 1:

Primary surgical goals 1:

• Control hemorrhage and bile leaks immediately
• Initiate damage control resuscitation without delay

Surgical technique hierarchy 2:

• For minor bleeding: compression, electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, simple suturing, or omental patching
• For major hemorrhage: manual compression with hepatic packing, Pringle maneuver, ligation of vessels within the wound, hepatic debridement with finger fracture technique, balloon tamponade, or shunting procedures

Critical surgical principle: Major hepatic resections must be avoided initially and only considered in subsequent operations for devitalized tissue, performed by experienced surgeons 1

Adjunctive interventions:

• Angioembolization is essential for persistent arterial bleeding after initial damage control procedures 1
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may serve as a bridge to definitive hemorrhage control in unstable patients 1

Management of Complications

Early Complications

• Delayed hemorrhage without severe compromise: Manage with AG/AE as first-line treatment 1
• Hepatic artery pseudoaneurysm: Requires AG/AE to prevent rupture 1

Late Complications

• Intrahepatic abscesses: Treat with percutaneous drainage 1
• Symptomatic or infected bilomas: Manage with percutaneous drainage 1
• Post-traumatic biliary fistula: Consider percutaneous drainage combined with endoscopic stenting as first approach when no other indication for laparotomy exists 1
• Complex biliary complications: Use combination of percutaneous drainage and endoscopic techniques when percutaneous management alone is insufficient 1

Special Populations and Circumstances

Pediatric Patients

Contrast blush on CT is not an absolute indication for AG/AE in hemodynamically stable children 1—a more conservative approach is appropriate in this population.

Patients with Concomitant Neurotrauma

NOM should be attempted in patients with head trauma or spinal cord injuries if clinical examination is reliable, unless specific hemodynamic goals for neurotrauma cannot be achieved (SBP > 110 mmHg and/or CPP 60-70 mmHg) and instability may be due to intra-abdominal bleeding 1, 2

Low-Resource Settings

NOM can be considered in hemodynamically stable patients without associated injuries, with negative serial examinations and negative imaging/blood tests 1

Post-Injury Care and Prophylaxis

• Mechanical thromboprophylaxis should be initiated in all patients without absolute contraindications 1
• LMWH prophylaxis should be started as soon as possible and is safe in selected NOM patients 1
• Early mobilization should be achieved once patients are stable 1
• Enteral feeding should begin as soon as possible when no contraindications exist 1

Common Pitfalls

Failure of NOM occurs in 17.2% overall but increases to 46.7% in grade III-V injuries 3, with mortality reaching 50% in failed grade IV-V injuries 3. This underscores the importance of appropriate patient selection and continuous monitoring. The key is recognizing that severe injuries (grade IV-V) often require surgical intervention 3, and delayed recognition of NOM failure significantly increases mortality risk.