What is the recommended management approach for a hemodynamically stable patient with blunt abdominal trauma resulting in a liver laceration and moderate hemoperitoneum according to the 2020 WSES (World Society of Emergency Surgery) guidelines?

Management of Hemodynamically Stable Blunt Liver Trauma with Moderate Hemoperitoneum

Non-operative management (NOM) should be the treatment of choice for hemodynamically stable patients with liver laceration and moderate hemoperitoneum, regardless of injury severity, provided appropriate monitoring and interventional resources are immediately available. 1

Initial Diagnostic Approach

• CT scan with intravenous contrast is mandatory and represents the gold standard for all hemodynamically stable patients before initiating NOM 1, 2
• E-FAST ultrasound should be performed immediately on arrival for rapid detection of intra-abdominal free fluid 1, 2
• Critical CT findings that increase risk of NOM failure include:
  • Intraperitoneal contrast extravasation (arterial blush) - increases operative risk 12.5-fold 3
  • Hemoperitoneum in all six abdominal compartments - increases operative risk 22-fold 3
  • These findings should prompt immediate consideration for angiography/angioembolization rather than abandoning NOM 1, 2

ICU Admission and Monitoring Requirements

• Moderate injuries (WSES II/AAST III) require ICU admission for continuous monitoring 1, 2

• The following resources must be immediately available for NOM to be appropriate 1, 2:

  • Trained surgeons on-site
  • Operating room ready for immediate use
  • Angiography and angioembolization capabilities
  • Blood products readily accessible
  • Capability for rapid transfer to higher level of care if needed

• Serial clinical evaluations are the cornerstone of monitoring and must include 2, 4:

  • Continuous physical examinations to detect peritoneal signs
  • Serial hemoglobin measurements
  • Liver enzyme monitoring (rising levels may indicate parenchymal ischemia) 4

Angioembolization Strategy

• If arterial blush is present on CT scan, proceed directly to angiography/angioembolization as first-line intervention rather than waiting for hemodynamic deterioration 1, 2
• Angioembolization is highly effective for persistent arterial bleeding and should be used liberally in the NOM pathway 1
• Delayed hemorrhage without severe hemodynamic compromise should be managed first with angiography/angioembolization rather than surgery 1, 2

Thromboprophylaxis

• Mechanical prophylaxis (intermittent pneumatic compression) should be initiated immediately in all patients without absolute contraindication 1, 2
• LMWH-based prophylaxis should be started as soon as possible following trauma and is safe in selected patients with liver injury treated with NOM 1
• For patients on anticoagulants at time of injury, individualize reversal decisions based on injury severity and bleeding risk (Grade 1C recommendation requiring clinical judgment) 1, 2

Early Supportive Care

• Enteral feeding should be started as soon as possible in the absence of contraindications such as bowel injury or hemodynamic instability 1, 2
• Early mobilization should be achieved once the patient is stable to reduce venous thromboembolism risk 1, 2

Management of Delayed Complications

• Symptomatic or infected bilomas require percutaneous drainage as first-line management 1, 2
• Intrahepatic abscesses should be treated with percutaneous drainage 1, 2
• Hepatic artery pseudoaneurysm must be managed with angiography/angioembolization to prevent catastrophic rupture 1, 2
• Post-traumatic biliary fistulas without indication for laparotomy should be managed with combination of percutaneous drainage and endoscopic stenting 1
• Overall, 85% of complications can be successfully managed with non-operative interventional procedures 5

Critical Pitfalls to Avoid

• Do not apply external abdominal compression devices (such as abdominal binders) in patients with known liver hematomas, as this could mask clinical deterioration, increase intra-abdominal pressure, or precipitate delayed rupture 4
• Do not use injury grade alone as a contraindication to NOM - even grade IV-V injuries can be managed non-operatively if hemodynamically stable with appropriate resources 1, 6
• Do not delay angioembolization if arterial extravasation is present on CT - this is a proactive intervention, not a rescue measure 1, 2
• Do not restrict serial physical examinations - any intervention that obscures abdominal examination reliability should be avoided 4

Conversion to Operative Management

• Hemodynamic instability or non-response to resuscitation mandates immediate operative management (WSES IV classification) 1
• Primary surgical goals are hemorrhage control and bile leak management with damage control principles 1
• Major hepatic resections should be avoided initially and only considered in subsequent operations for devitalized tissue by experienced surgeons 1