What is the best course of treatment for a patient with blunt trauma to the abdomen, resulting in a liver laceration and moderate hemoperitoneum?

Management of Blunt Abdominal Trauma with Liver Laceration and Moderate Hemoperitoneum

Non-operative management (NOM) should be the treatment of choice for hemodynamically stable patients with moderate liver lacerations and moderate hemoperitoneum, provided there are no other injuries requiring surgery. 1

Initial Assessment and Hemodynamic Status Determination

The management algorithm hinges entirely on hemodynamic status, which determines whether you pursue NOM versus operative management (OM):

• Perform E-FAST immediately to detect intra-abdominal free fluid—this is rapid and highly sensitive for hemoperitoneum 1
• Obtain CT scan with IV contrast in all hemodynamically stable patients, as this is the gold standard for characterizing liver injury severity and planning management 1
• Hemodynamic stability is the critical decision point: stable patients proceed to NOM, while unstable/non-responders require immediate operative intervention 1

Non-Operative Management Protocol (For Hemodynamically Stable Patients)

NOM is recommended for all hemodynamically stable patients with moderate (WSES II/AAST III) liver injuries in the absence of other injuries requiring surgery. 1

Key Requirements for Successful NOM:

• Continuous monitoring in ICU or ER setting with serial clinical examinations and laboratory testing to detect any change in clinical status 1
• Immediate availability of: trained surgeons, operating room, angiography/angioembolization capability, blood products, and ability to rapidly transfer to higher level care if needed 1
• ICU admission is required for moderate (WSES II/AAST III) liver lesions with hemoperitoneum 1

Angiography and Embolization:

• Consider angiography/angioembolization (AG/AE) as first-line intervention if CT scan shows arterial contrast blush, even in hemodynamically stable patients 1
• This can prevent progression to hemodynamic instability and avoid surgery 1

Common Pitfall to Avoid:

Do not attempt NOM in "transient responders" (patients who temporarily stabilize with resuscitation but remain borderline) unless you are in a highly specialized trauma center with all the above resources immediately available 1. These patients have higher failure rates and may decompensate rapidly.

Operative Management (For Hemodynamically Unstable Patients)

Hemodynamically unstable and non-responder patients (WSES IV) must undergo immediate operative management. 1

Surgical Priorities:

• Primary goal is hemorrhage control and bile leak control with initiation of damage control resuscitation as soon as possible 1
• Avoid major hepatic resections initially—these should only be considered in subsequent operations for large areas of devitalized tissue, and only by experienced surgeons 1
• Use damage control techniques: manual compression, hepatic packing, Pringle maneuver, topical hemostatic agents 1
• Consider temporary abdominal closure when risk of abdominal compartment syndrome is high or second-look operation is needed 1

Adjunctive Measures:

• Angioembolization remains useful even after non-hemostatic or damage control procedures if arterial bleeding persists 1
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be used as a bridge to definitive hemorrhage control in unstable patients 1

Management of Complications

Delayed Hemorrhage:

• Manage with AG/AE first if patient does not have severe hemodynamic compromise 1
• Hepatic artery pseudoaneurysm requires AG/AE to prevent rupture 1

Biliary Complications:

• Symptomatic or infected bilomas: percutaneous drainage 1
• Post-traumatic biliary fistula: combination of percutaneous drainage and endoscopic techniques (ERCP with stenting) 1

Intrahepatic Abscesses:

• Percutaneous drainage is successful in most cases 1

Special Consideration: Concomitant Head Injury

NOM can be attempted with concomitant head trauma/spinal cord injuries IF the clinical exam is reliable, unless the patient cannot achieve hemodynamic goals for neurotrauma management and instability might be due to intra-abdominal bleeding 1. However, some experts argue that unreliable clinical examinations from severe head injury should prompt urgent laparotomy 1. This remains a nuanced decision requiring multidisciplinary input.

Evidence Quality Note

The 2020 WSES guidelines 1 represent the most current, comprehensive, and authoritative guidance on liver trauma management, superseding older 2016 guidelines 1. These recommendations are based on systematic review of evidence with graded recommendations, making them the strongest available guidance for this clinical scenario.