The policy of conservative nonoperative management of the injured spleen is reviewed, and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of thes, ten were operated on (four splenorrhaphies, three total splenectomies, one partial splenectomy; in two, the spleen had stopped bleeding spontaneously) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the ICU was reduced. The results of this review show that, in comparison with our previous 5-year report, the number of patients treated without surgery increased from 70% to 87%, those receiving blood transfusions decreased from 36% to 23%, and the number undergoing a splenectomy decreased from 24% to 4%. These data suggest that almost all children with splenic injury can be successfully treated without an operation, those who are hemodynamically stable do not require ICU care, and the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.