What is a hepatic laceration?

Hepatic Subscapular Laceration: Definition and Clinical Significance

A hepatic subscapular laceration is a traumatic tear in the liver parenchyma where the injury remains contained beneath the liver capsule (Glisson's capsule), creating a subcapsular hematoma that can range from small collections to large expanding blood accumulations between the liver tissue and its capsular covering. 1, 2

Anatomical Classification

The term "subscapular" specifically refers to injuries occurring beneath the liver capsule, which can be further categorized by:

• Surface area involvement: Grade I injuries involve <10% surface area, Grade II involve 10-50%, and Grade III involve >50% surface area or represent expanding/ruptured subcapsular hematomas 1, 2
• Location: Lacerations limited to the bare area of the liver (the superomedial hepatic surface not covered by peritoneal reflection) represent a unique subset where intraperitoneal bleeding may not occur despite significant injury 3

Clinical Significance and Risk Stratification

Subcapsular lacerations pose a significant risk of delayed rupture, with mortality rates up to 18% when rupture occurs, making continuous vigilance essential even in initially stable patients. 4, 2

Key Clinical Features:

• Contained bleeding: Unlike through-and-through lacerations, subscapular injuries initially contain blood between the parenchyma and capsule, potentially masking the severity of injury 2, 3
• Delayed presentation: The capsule can temporarily tamponade bleeding, but expanding hematomas may rupture hours to days after initial trauma 2
• Diagnostic challenges: Bare area injuries may not produce free intraperitoneal fluid, can yield normal diagnostic peritoneal lavage results, and may lack classic peritoneal signs 3

Hemodynamic Status Determines Management

The WSES classification upgrades any subscapular laceration from its anatomic grade to WSES Grade IV (severe) if hemodynamic instability develops, fundamentally changing management from observation to immediate intervention. 1

Management Algorithm:

• Hemodynamically stable patients: Non-operative management with intensive monitoring, serial hemoglobin checks every 6 hours for at least 24 hours, and ICU admission for moderate-to-severe injuries 4, 1, 2
• Expanding hematomas in stable patients: Angiography with embolization as first-line intervention 2
• Hemodynamically unstable patients: Immediate operative management, with perihepatic packing showing 80% success in controlling bleeding 5

Associated Complications

Subscapsular lacerations carry specific complication risks:

• Rupture with massive hemoperitoneum: Occurs in 1.7-5.9% of cases managed non-operatively 4
• Biliary complications: Bile leak, biloma formation, and bile peritonitis occur in 2.8-30% of cases 4, 6
• Pseudoaneurysm formation: Develops in approximately 1% of cases and requires early angiographic embolization due to high rupture risk 4
• Hepatic necrosis: Can occur with large subcapsular hematomas causing pressure-induced ischemia 4

Critical Pitfalls to Avoid

• Never assume stability is permanent: Delayed rupture can occur days after presentation, necessitating serial imaging and laboratory monitoring 2
• Don't miss bare area injuries: These may present with retroperitoneal hemorrhage (88% of cases), adrenal hematoma (48%), or pericaval fluid (36%) rather than intraperitoneal findings 3
• Avoid non-operative management in under-resourced settings: Facilities lacking immediate access to interventional radiology, operating rooms, and blood products should transfer patients to appropriate centers 1