Nonoperative management of major blunt liver injury with hemoperitoneum

We evaluated the role of nonoperative therapy in 16 patients with blunt multisystem trauma, hemodynamic stability following resuscitation, and major lobar liver injury; the patients were treated with a protocol of intensive care unit observation and computed tomographic scanning to identify and follow up the hepatic lesion. Computed tomographic scans showed right-lobe or bilobar liver lacerations and/or subcapsular hematomas in all patients and associated hemoperitoneum in 8 patients. Exploration was required in 2 patients; both were found to have a hemoperitoneum and a nonbleeding liver laceration. There were no deaths. Patients with hemoperitoneum requiring transfusion had significantly greater injury severity scores and longer intensive care unit and hospital stays. The major advantage of a nonoperative approach is the opportunity to stabilize major extra-abdominal (particularly head) injuries as the first priority. Unstable hemodynamics, abdominal distension, and falling hematocrit are indications for prompt exploration. Nonoperative care of these injuries requires a strict treatment protocol.