Successful utilization of angioembolization and delayed laparoscopy in the management of grade 5 hepatic laceration: Case report and literature review

INTRODUCTION: The liver is the most commonly injured solid organ in blunt abdominal trauma. Although the incidence of hepatic lacerations continues to rise, non-operative management with angioembolization is currently the standard of care. While active arterial hemorrhage is commonly embolized in grade 3 or 4 injuries, patients with grade 5 injuries frequently require operative intervention. PRESENTATION OF CASE: A 30-year-old man presented to our level I trauma center following a motor scooter accident. CT abdominal imaging revealed a grade 5 right lobar hepatic laceration. He underwent successful angioembolization without further hemorrhage. The patient later developed abdominal discomfort that worsened to peritonitis and he was taken for laparoscopic drainage of massive hemoperitoneum with bile peritonitis. Postoperatively, the patient’s abdominal pain abated and he tolerated oral dietary advancement. DISCUSSION: Surgical management of blunt hepatic trauma continues to evolve in tandem with minimally invasive interventional techniques. Patients with high-grade lacerations are at higher risk for developing biliary peritonitis, hemobilia, persistent hemoperitoneum, and venous hemorrhage after angioembolization. Accordingly, the primary role of surgery has shifted in select patients from laparotomy to delayed laparoscopy to address the aforementioned complications. CONCLUSION: While laparotomy remains crucial for hemodynamically unstable patients, angioembolization is the primary treatment option for stable patients with hemorrhage from liver trauma. The combination of angioembolization and delayed laparoscopy may be considered in stable patients with even the highest liver injury grades.