Liver Laceration Management

Anatomic Grading System

The American Association for the Surgery of Trauma (AAST) classification grades liver injuries from I to VI based on anatomical severity, with Grade I being minimal and Grade VI being unsurvivable 1, 2
The AAST classification defines Grade I as a subcapsular hematoma <10% surface area or a capsular tear <1 cm parenchymal depth 2
The AAST classification defines Grade II as a subcapsular hematoma 10-50% surface area or an intraparenchymal hematoma <10 cm diameter, and a laceration 1-3 cm parenchymal depth 2
The AAST classification defines Grade III as a subcapsular hematoma >50% surface area or an expanding/ruptured subcapsular or parenchymal hematoma, and a laceration >3 cm parenchymal depth 2
The AAST classification defines Grade IV as a parenchymal disruption involving 25-75% of hepatic lobe, and juxtavenous hepatic injuries (retrohepatic vena cava/central major hepatic veins) 2
The AAST classification defines Grade V as a parenchymal disruption >75% of hepatic lobe, and juxtavenous hepatic injuries 2
The AAST classification defines Grade VI as a hepatic avulsion 2

The World Society of Emergency Surgery (WSES) classification addresses hemodynamic stability, with WSES Grade I being minor, WSES Grade II being moderate, WSES Grade III being severe, and WSES Grade IV being severe/critical 1, 2
WSES Grade I includes AAST Grade I-II injuries in hemodynamically stable patients (blunt or penetrating) 1, 2
WSES Grade II includes AAST Grade III injuries in hemodynamically stable patients (blunt or penetrating) 1, 2
WSES Grade III includes AAST Grade IV-VI injuries in hemodynamically stable patients (blunt or penetrating) 1, 2
WSES Grade IV includes any AAST grade (I-VI) in hemodynamically unstable patients (blunt or penetrating) 1, 2

The American College of Surgeons recommends that hemodynamic status trumps anatomic grade in determining management, with hemodynamically unstable patients requiring immediate operative management regardless of anatomic injury grade 1, 2
For hemodynamically stable patients (WSES I-III), non-operative management should be attempted regardless of AAST grade, with intensive monitoring and immediate access to interventional radiology, operating room, and blood products 1, 3
For hemodynamically unstable patients (WSES IV), immediate operative management is required regardless of anatomic injury grade, with no additional imaging delaying surgical intervention 1, 2

Hemodynamic instability is defined as blood pressure <90 mmHg and heart rate >120 bpm, evidence of skin vasoconstriction, altered level of consciousness, or shortness of breath 1, 2
The American College of Surgeons recommends that facilities lacking immediate surgical/interventional capabilities should transfer patients to an appropriate center instead of attempting nonoperative management 1, 3