Liver injury accounts for approximately 20–30% of abdominal trauma cases, with ruptures of the right lobe being more common. The etiology, pathological classifications, and clinical manifestations of liver injury are similar to those of splenic injury. Major risks include hemorrhagic shock, bile peritonitis, and secondary infections. Since bile leakage may occur in liver injuries, abdominal pain and signs of peritoneal irritation are often more pronounced compared to splenic rupture. In some instances, blood may enter the duodenum through injured bile ducts, leading to melena or hematemesis. This condition, known as traumatic hematobilia, should be carefully distinguished during diagnosis. Subcapsular liver rupture has the potential to progress into true rupture, while hematomas from central liver rupture may be absorbed but carry the risk of secondary infection and liver abscess formation.
For grading liver injuries, the classification system developed by the American Association for the Surgery of Trauma (1994) is commonly used:
- Grade I: Hematoma is subcapsular and involves less than 10% of the liver's surface area; laceration involves the capsule with a depth of less than 1 cm.
- Grade II: Hematoma is subcapsular and involves 10–50% of the liver's surface area or an intraparenchymal hematoma with a diameter of less than 10 cm; laceration involves parenchymal tears 1–3 cm deep and less than 10 cm long.
- Grade III: Hematoma is subcapsular and involves more than 50% of the liver's surface area, is expanding, or involves ruptured subcapsular/intraparenchymal hematomas; intraparenchymal hematoma diameter exceeds 10 cm and is expanding. Laceration depth exceeds 3 cm.
- Grade IV: Laceration involves 25–75% of a hepatic lobe or includes 1–3 Couinaud segments in a single lobe.
- Grade V: Laceration involves more than 75% of a hepatic lobe or more than three Couinaud segments in a single lobe. Vascular injuries include damage to the retrohepatic inferior vena cava or major hepatic veins.
- Grade VI: Vascular injuries result in hepatic avulsion.
For patients with multiple liver injuries graded at or below Grade III, the overall injury severity may be upgraded by one level.
Management
Gunshot wounds to the liver and non-gunshot trauma involving hollow organs typically require surgical treatment. The fundamental objectives of surgical management are to achieve effective hemostasis, thoroughly debride the wound, eliminate bile leakage, and ensure adequate drainage. For other penetrating or blunt trauma, treatment approaches are determined based on the patient’s overall condition. Mild hepatic parenchymal lacerations in hemodynamically stable patients, or those who stabilize after receiving volume resuscitation, may be managed non-surgically under close observation. In recent years, arterial interventional techniques for hepatic bleeding control have been widely reported. If appropriate equipment and expertise are available, this approach should be considered. Patients with uncontrollable bleeding using this technique, hemodynamic instability even after volume resuscitation, or massive transfusion requirements to maintain blood pressure likely have severe active bleeding requiring early surgical intervention.
Surgical Treatment
Temporary Hemostasis and Injury Assessment
After opening the abdomen, intraperitoneal blood should be promptly removed, followed by excision of the round ligament and falciform ligament for exploration under direct vision of the diaphragmatic and visceral surfaces of the left and right hepatic lobes. Care should be taken to avoid excessive traction to prevent aggravating liver injuries. In cases of liver rupture with significant active bleeding, temporary hemostasis is achieved by finger or rubber tube clamping of the hepatoduodenal ligament. Direct compression of the bleeding surface with gauze may also be employed to facilitate exploration and management.
Under normal liver function, the hepatoduodenal ligament can be safely clamped for 20–30 minutes at a time. In pathological conditions such as cirrhosis, intermittent clamping is recommended, with each interval not exceeding 15 minutes. If there is significant ongoing bleeding after occluding hepatic blood flow, damage to the major hepatic veins and/or the inferior vena cava should be considered. In such cases, occlusion of the retrohepatic inferior vena cava may be necessary, and if bleeding remains substantial, both the suprahepatic and infrahepatic vena cava should also be clamped. The injured liver’s triangular ligament and coronary ligament should be incised to fully expose the injury and determine the surgical approach.
Debridement and Suturing
Following thorough assessment, debridement is performed to remove blood clots, foreign bodies, and necrotic or devitalized liver tissue within the laceration. Bleeding points and disrupted bile ducts are ligated individually. For small subcapsular hematomas, no further intervention is needed. Hematomas with high tension or large size require capsular incision, debridement, and subsequent hemostasis and bile duct ligation.
Tears involving major vessels, such as the main hepatic veins, portal vein, or caval veins, are repaired using non-traumatic sutures. For superficial, clean-edged injuries with minimal bleeding, direct suturing of the laceration is feasible after debridement. Care must be taken to eliminate dead space within the wound to prevent secondary hemorrhage or abscess formation. Packing the wound with omentum or gelfoam prior to suturing has been shown to eliminate dead space, enhance hemostasis, and reduce the risk of secondary abscess formation.
Hepatic Artery Ligation
For uncontrolled arterial bleeding from the laceration site, ligation of the hepatic artery may be considered. Efforts should focus on isolating the proper hepatic artery and the left or right hepatic artery for selective ligation based on the injured lobe. Ligation of the entire proper hepatic artery or common hepatic artery should be avoided when possible.
Hepatic Resection
Patients with extensive liver tissue destruction, particularly comminuted ruptures or severe contusions, may require hepatic resection. Regular anatomic resection with significant trauma should generally be avoided. Instead, debridement-oriented resection, emphasizing the preservation of healthy liver tissue, is recommended. Hemostatic suturing of all exposed vessels and bile ducts in the resection margin is essential.
Gauze Packing Method
In patients with deep lacerations or large areas of liver tissue loss where hemostasis is inadequate and extensive surgery is not feasible, gauze packing retains value. Materials such as omentum, gelfoam, or hemostatic powder may be used to pack the wound, with layered gauze strips applied to achieve compressive hemostasis. The gauze tail should protrude through the abdominal incision or a separate puncture site. Gradual gauze removal begins on postoperative day 3–5, with complete removal within 7–10 days. This method poses risks of infection or rebleeding during gauze removal and should only be employed when absolutely necessary.
Additionally, laparoscopic surgery is frequently utilized for the treatment of liver injuries graded III or below. Regardless of the surgical approach, multiple drainage tubes or negative-pressure drainage systems should be placed around the injured liver and in the surgical cavity to prevent secondary infections caused by accumulated blood or bile leakage.