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Introduction: Trauma-related liver injuries are a leading cause of morbidity and mortality in pediatric populations. High-grade liver lacerations (Grades III–V) pose significant clinical challenges. This study aimed to evaluate the effectiveness of conservative versus surgical management in pediatric patients with severe liver lacerations. We hypothesized that non-operative management remains appropriate and effective for hemodynamically stable patients regardless of laceration severity. Methods: We conducted a retrospective observational study of 29 pediatric patients (0–21 years) with Grade III–V liver lacerations admitted to the PICU at a tertiary pediatric hospital from March 2015 to March 2022. Data collected included demographics, liver laceration grade, type of trauma, management approach, complications, and outcomes. Spearman’s correlation was used for continuous variables, and chi-square tests were used for categorical data. Logistic regression models evaluated relationships between laceration grade, management type, and PICU LOS. Results: Of 29 patients, 48% had Grade III, 42% Grade IV, and 10% Grade V lacerations, A 86% did not required surgery, and no mortality was observed. There was an association between laceration grade and management approach (p = 0.00012), with higher grades more likely to require surgical intervention. However, no significant correlation was observed between laceration grade and PICU LOS. Liver enzyme testing frequency showed a moderate positive correlation with laceration grade (ρ = 0.39, p = 0.052). No significant associations were found between laceration grade and pseudoaneurysm, hemoperitoneum, transfusions, trauma type, or mortality. Conclusions: While prior literature has suggested an association between liver laceration grade and PICU length of stay, our findings did not demonstrate a statistically significant correlation. These results support that, in hemodynamically stable pediatric patients, conservative management is appropriate regardless of laceration severity. Clinical decision-making should prioritize hemodynamic stability over injury grade when determining management strategies. Future research with larger cohorts and incorporation of physiologic markers is warranted to refine treatment protocols and optimize outcomes.