Management and Outcome of High-Grade Hepatic and Splenic Injuries

Purpose of ReviewHepatic and splenic injuries are commonly found in patients who experience trauma and result in significant morbidity and mortality. Historically, operative intervention was the first and only approach to high grade injury. Recently non-operative and endovascular interventions are increasingly utilized. However, exact indications for these approaches have yet to be fully characterized. This paper discusses the management options and outcomes of these high-grade hepatic and splenic injuries.Recent FindingsHigh-grade injuries include American Association for the Surgery of Trauma grade IV and V injuries or World Society of Emergency Surgery class III and IV. Prehospital interventions should allow for permissive hypotension. Once patients arrive at the trauma bay, they should undergo primary and secondary survey and hemodynamically unstable patients should be resuscitated with balanced blood products. Patients who remain unstable should be taken to the operating room for laparotomy. Patients who transiently respond to resuscitation or are hemodynamically stable should undergo CT scanning. Those with hepatic or splenic injury and signs of active bleeding or patients who become unstable again should proceed to angiography for embolization. Stable patients, either without active signs of bleeding or after embolization, should be closely monitored with serial exams, laboratory, and radiological studies. Operative intervention varies widely from simple packing or splenectomy to complex partial hepatectomy.Non-surgical management is an increasingly common approach to high-grade hepatic and splenic injury. Adjuncts such as angioembolization can be used to control hemorrhage in stable and transient responders to resuscitation. Operative interventions remain the modality of choice for unstable patients.