Assessment and Management of Liver Laceration in Trauma Patients
Initial Assessment: Hemodynamic Status Determines Everything
The diagnostic and management pathway for liver laceration is fundamentally determined by the patient's hemodynamic status—this single factor dictates whether the patient receives non-operative management (NOM) or proceeds directly to surgery. 1
Hemodynamic Classification
A patient is considered unstable when presenting with: 1
- Blood pressure <90 mmHg AND heart rate >120 bpm
- Evidence of skin vasoconstriction (cool, clammy skin, decreased capillary refill)
- Altered level of consciousness and/or shortness of breath
Diagnostic Approach by Hemodynamic Status
For hemodynamically unstable patients:
- E-FAST (Extended Focused Assessment with Sonography for Trauma) should be performed immediately to rapidly detect intra-abdominal free fluid 1
- Proceed directly to operative management without delay for CT imaging 1
For hemodynamically stable patients:
- CT scan with intravenous contrast is the gold standard and must be performed 1
- CT provides sensitivity and specificity approaching 96-100% for liver injury assessment 1
- Delayed-phase CT helps differentiate active bleeding from contained vascular injuries 1
Critical caveat: E-FAST has low sensitivity (42-52% in pediatrics) and should not be used alone in stable patients to rule out injury—CT confirmation is mandatory 1, 2
Management Algorithm: The WSES Classification System
The World Society of Emergency Surgery (WSES) classification integrates both anatomic injury grade (AAST) and hemodynamic status to guide management: 1
WSES Grade I (Minor): AAST I-II, Hemodynamically Stable
- Management: Non-operative management with serial clinical/laboratory/radiological evaluation 1
WSES Grade II (Moderate): AAST III, Hemodynamically Stable
- Management: Non-operative management with serial clinical/laboratory/radiological evaluation 1
- ICU admission required 1
WSES Grade III (Severe): AAST IV-V, Hemodynamically Stable
WSES Grade IV (Severe): Any AAST Grade, Hemodynamically Unstable
- Management: Immediate operative management 1
Non-Operative Management (NOM): The Standard of Care for Stable Patients
NOM should be the treatment of choice for ALL hemodynamically stable liver injuries (minor, moderate, and severe) in the absence of other internal injuries requiring surgery—this applies regardless of injury grade. 1
Absolute Contraindications to NOM
NOM is contraindicated in: 1
- Hemodynamic instability
- Peritonitis
- Other internal injuries requiring surgery
Requirements for NOM of Moderate/Severe Injuries
NOM should only be attempted in facilities with: 1
- Capability for intensive patient monitoring (ICU or high-dependency unit)
- Immediate access to angiography and angioembolization
- Immediately available operating room
- Immediate access to blood and blood products
- 24/7 availability of trained surgeons
Monitoring During NOM
Serial clinical evaluations are mandatory and must include: 1
- Physical examinations
- Laboratory testing (serial hemoglobin monitoring)
- Continuous hemodynamic monitoring
Duration: Patients should be monitored in ICU/high-dependency for at least 48-72 hours 3
Role of Angiography/Angioembolization in NOM
Angiography with embolization may be considered as first-line intervention in hemodynamically stable patients with arterial blush (contrast extravasation) on CT scan. 1
- This represents an "extension" of resuscitation rather than operative management 1
- In hemodynamically stable children, contrast blush is NOT an absolute indication for angioembolization 1
Important caveat: Only 47% of patients with CT findings of active bleeding have confirmation at angiography, highlighting potential discrepancy 1
Operative Management: For Unstable Patients
Hemodynamically unstable and non-responder patients (WSES Grade IV) must undergo immediate operative management. 1
Primary Surgical Goals
The surgical priorities are: 1, 4
- Control hemorrhage (determines survival)
- Control bile leakage (prevents complications)
- Initiate damage control resuscitation (including massive transfusion protocols)
Hemorrhage Control Techniques by Severity
For minor to moderate bleeding: 4, 5
- Manual compression alone
- Electrocautery, bipolar devices, or argon beam coagulation
- Topical hemostatic agents
- Simple suture of hepatic parenchyma
- Omental patching
- Perihepatic packing is the cornerstone technique and should be employed early
- Manual compression with hepatic packing
- Ligation of vessels in the wound
- Hepatic debridement and finger fracture
- Balloon tamponade
Critical "What NOT to Do" During Initial Surgery
Major hepatic resections MUST be avoided during the initial damage control operation. 1, 4
- Major resections should only be considered in subsequent operations for resectional debridement of large areas of devitalized liver tissue 1, 4
- This must be performed by experienced surgeons only 1
Management of Specific Vascular Injuries
Hepatic artery injuries: 4
- Primary repair if possible
- Selective hepatic artery ligation if repair fails
- Mandatory cholecystectomy if right or common hepatic artery requires ligation
Portal vein injuries: 4
- Primary repair whenever possible
- Portal vein ligation should be avoided due to high risk of liver necrosis
Retrohepatic caval/hepatic vein injuries: 4
- Perihepatic packing is the safest initial approach
Adjunctive Techniques
REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta): 1, 4, 5
- May be used as a temporizing bridge to definitive hemorrhage control in hemodynamically unstable patients
Post-operative angioembolization: 1, 4, 5
- Essential tool for persistent arterial bleeding after damage control procedures
- Should be immediately available
Temporary Abdominal Closure
Should be utilized when: 4
- High risk of abdominal compartment syndrome
- Planned second-look operation needed
- Patient remains physiologically deranged despite initial hemorrhage control
Special Considerations
Concomitant Head Trauma/Spinal Cord Injuries
NOM should be attempted in patients with concomitant head trauma and/or spinal cord injuries with reliable clinical exam, UNLESS the patient cannot achieve specific hemodynamic goals for neurotrauma and instability might be due to intra-abdominal bleeding. 1, 5
- Specific hemodynamic goals for neurotrauma: SBP >110 mmHg and/or CPP between 60-70 mmHg 5
Low-Resource Settings
NOM could be considered in patients with: 1, 5
- Hemodynamic stability
- No evidence of associated injuries
- Negative serial physical examinations
- Negative imaging and blood tests
Management of Complications
Early Complications
Persistent arterial bleeding: 1, 5
- Angioembolization for delayed hemorrhage without severe hemodynamic compromise
Hepatic artery pseudoaneurysm: 1, 5
- Managed with angiography/angioembolization to prevent rupture
Late Complications
- Treated with percutaneous drainage
Bilomas (symptomatic or infected): 1, 5
- Managed with percutaneous drainage
- Combination of percutaneous drainage and endoscopic techniques for post-traumatic biliary complications not suitable for percutaneous management alone
Post-Injury Care
Thromboprophylaxis
- Mechanical prophylaxis is safe and should be considered in all patients with no absolute contraindication 1
- LMWH-based prophylaxis should be started as soon as possible following trauma 1, 5
Mobilization and Nutrition
- Early mobilization should be achieved in stable patients 1, 5
- Enteral feeding should be started as soon as possible in the absence of contraindications 1, 5
Critical Pitfalls to Avoid
The "lethal triad" of hypothermia, acidosis, and coagulopathy must be aggressively reversed—this drives mortality in severe liver trauma 4
Failure to activate massive transfusion protocols early increases mortality 4
Using E-FAST alone in stable patients without CT confirmation will result in missed injuries (sensitivity only 41-43% in stable blunt trauma) 2
Attempting NOM in facilities without immediate access to angiography, OR, and blood products is dangerous 1
Performing major hepatic resections during initial damage control surgery significantly increases mortality 1, 4