What is the management for a Grade 3 liver laceration (liver lac) with active bleeding?

Management of Grade 3 Liver Laceration with Active Bleeding

The management of a Grade 3 liver laceration with active bleeding is determined entirely by hemodynamic status: hemodynamically stable patients should undergo angioembolization as the primary intervention, while hemodynamically unstable patients require immediate operative management with damage control surgery. 1, 2

Initial Assessment and Risk Stratification

• Grade 3 liver lacerations are classified as WSES Grade II (moderate) when hemodynamically stable, but immediately escalate to WSES Grade IV (severe) if hemodynamically unstable, fundamentally changing the entire management approach. 1, 2

• Hemodynamic instability is defined as blood pressure <90 mmHg with heart rate >120 bpm, evidence of skin vasoconstriction (cool, clammy skin, decreased capillary refill), altered level of consciousness, or shortness of breath. 1, 3

• The presence of active bleeding on CT imaging (contrast extravasation or "blush") in a Grade 3 injury significantly increases the risk of NOM failure and requires immediate intervention regardless of initial hemodynamic status. 2, 4

Management Algorithm for Hemodynamically Stable Patients

For hemodynamically stable patients with Grade 3 liver laceration and active bleeding on CT:

• Proceed directly to angiography with embolization as the primary intervention—this is the definitive treatment for arterial bleeding in stable patients. 1, 2

• Admit to intensive care unit with continuous hemodynamic monitoring, serial clinical examination every 1-2 hours, and immediate access to operating room, interventional radiology suite, and blood products. 2

• Serial hemoglobin measurements every 4-6 hours initially to detect ongoing bleeding, with transfusion threshold typically at hemoglobin <7-9 g/dL unless active bleeding continues. 5

• Angioembolization is effective in 80-90% of cases for stopping arterial bleeding, but carries risk of hepatic necrosis (5-10%) and sepsis, requiring close monitoring for fever, leukocytosis, and abdominal pain in subsequent days. 1, 6

Critical Pitfall to Avoid in Stable Patients

• Do not attempt nonoperative management in facilities lacking 24/7 interventional radiology capability and immediately available operating room—transfer the patient to an appropriate trauma center instead. 2, 3

• Failed NOM occurs in 17-47% of Grade 3 injuries depending on associated injuries, with mortality reaching 50% in delayed operative intervention for Grade 3-5 injuries. 7, 8

Management Algorithm for Hemodynamically Unstable Patients

For hemodynamically unstable patients (WSES Grade IV):

• Proceed immediately to operative management without additional imaging—mortality increases with every minute of delay. 1, 2

• Initiate massive transfusion protocol immediately with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets to reverse the lethal triad of hypothermia, acidosis, and coagulopathy. 1, 5

Operative Technique for Active Bleeding

The surgical approach follows a hierarchical algorithm:

1. Manual compression of the liver for temporary hemorrhage control while simultaneously mobilizing the liver and initiating intensive resuscitation. 1, 5

2. Pringle maneuver (hepatic pedicle clamping) for up to 60 minutes intermittently to reduce inflow bleeding. 1, 5

3. Perihepatic packing is the first-line definitive technique for major hemorrhage—this controls bleeding in 80-82% of cases including retrohepatic venous injuries. 5, 7

4. If bleeding persists despite packing and Pringle maneuver, identify and ligate bleeding vessels within the liver substance using finger fracture technique or direct suture ligation. 1, 7

5. For evident hepatic artery injury: attempt repair first; if not possible, perform selective hepatic artery ligation (with cholecystectomy if right or common hepatic artery is ligated to prevent gallbladder necrosis). 1

Damage Control Strategy

• Temporary abdominal closure with synthetic mesh after packing to prevent abdominal compartment syndrome and allow for planned re-exploration in 24-48 hours. 1, 5

• Avoid anatomic hepatic resection during initial damage control surgery—defer to staged procedures by experienced hepatobiliary surgeons only after patient stabilization and only for large areas of devitalized tissue. 1

• Post-operative angioembolization should be performed if arterial bleeding persists after packing, as this allows hemorrhage control while reducing complications compared to re-operation. 1, 5

Specific Contraindications to Nonoperative Management

Absolute contraindications to NOM in Grade 3 liver laceration with active bleeding:

• Hemodynamic instability despite resuscitation (persistent hypotension or ongoing transfusion requirements >4 units in first hour). 1, 8

• Associated Grade IV-V splenic injury requiring splenectomy (odds ratio 14.0 for NOM failure). 8

• Peritonitis or evidence of hollow viscus injury requiring laparotomy. 1

• Penetrating mechanism with unreliable abdominal examination (severe head injury or spinal cord injury precluding meaningful clinical assessment). 1

Post-Intervention Monitoring

• CT follow-up at 48-72 hours for Grade 3 injuries managed nonoperatively to assess hematoma evolution and identify delayed complications (biloma, abscess, pseudoaneurysm). 1, 2

• Counsel patients to avoid strenuous activity for 3-4 months, return immediately for increasing abdominal pain, lightheadedness, nausea, or vomiting. 1

• Resume normal activity only after follow-up imaging demonstrates significant healing, typically not before 1 month even with uncomplicated course. 1