a quicker return to function , earlier discharge from the hospital , less postoperative pain , and better cosmesis due to the smaller incisions have been reported by multiple authors . decreased intraoperative blood loss and transfusion requirements have also been described . laparoscopic splenectomy for splenic trauma has been described in only a few instances in the literature . the original report by basso et al from italy in 2003 describes laparoscopic splenectomy 10 days postinjury for a grade iv ruptured spleen . in the united states , nasr et al in 2004 reported on a series of 4 stable patients undergoing delayed laparoscopic splenectomy for blunt trauma . we describe the successful treatment using a total laparoscopic approach shortly after admission of a young man with a grade v splenic injury . a 21-year - old man was transferred to our level 1 trauma center after sustaining a blow to his left flank from a falling construction pipe while working on an oil rig . he did not have peritoneal signs , and his examination was unremarkable except for left flank tenderness . he underwent a computed tomography ( ct ) scan with intravenous contrast that demonstrated hemoperitoneum with an american association for the surgery of trauma grade v splenic laceration and a grade ii left peri - nephric hematoma 
 ( figures 1 , 2 , and 3 ) . the various management options were discussed with the patient , including observation , angiographic embolization , and splenectomy . given the severity of his splenic injury and the presence of a renal injury that could complicate conservative management , we decided to proceed with splenectomy . the patient remained hemodynamically stable , and we elected to attempt laparoscopic splenectomy , with readiness to convert to an open operation if the patient became unstable or if we were unable to quickly obtain vascular control . the patient was placed in the right lateral decubitus position with the bed flexed at the waist . we were able to easily visualize the spleen , which was noted to have a large hematoma and venous blood oozing from the hilum ( figures 4 and 5 ) . the spleen was carefully retracted upward with a blunt grasper and the hilum was visualized . a 15-mm endoscopic stapler ( autosuture , us surgical , hartford , ct ) with a 60-mm gray vascular cartridge was used to transect the hilum . no bleeding occurred from the remaining splenic artery or vein , and the pancreas was visualized and protected during this process . the remaining hemoperitoneum was suctioned and a # 10 jackson pratt drain was placed in the splenic fossa . the patient was able to tolerate a regular diet the next day with pain controlled by oral analgesics only . he was monitored for his renal injury on the wards for the next 3 days by the trauma and urology service . a follow - up renal ultrasound before discharge revealed no progression of his injury , and his hematuria resolved . this fell to 10 on the next measurement immediately after surgery , and remained stable postoperatively . he received his vaccinations for pneumococcus , meningococcus , and h. influenzae on the day of discharge . mandatory laparotomy with splenorrhaphy or splenectomy has been replaced in most cases by nonoperative management . initially proposed in the pediatric trauma literature , close observation has become the accepted treatment of stable splenic injuries from blunt trauma . patients with severe ( grade iii and higher ) splenic injuries have a higher failure rate than with injuries of lesser severity . several recent trials have shown that blood transfusion causes a dose - dependent immunosuppression and significantly increased mortality in critically ill patients , including trauma victims . further risks of nonoperative treatment include delayed splenic rupture , persistent pain , and prolonged immobilization which is contraindicated in a group at high risk for venous thromboembolism . splenic artery angio - embolization has been described as an alternative to operative management of splenic injuries . this has improved the rate of splenic salvage to greater than 90% in several series . complications of angioembolization include the need for delayed splenectomy due to splenic infarction , infection , abscess , or persistent pain . the rate of these complications has been described as high as 33% in some series . splenectomy is not indicated for all of the injuries , and angiographic embolization is an acceptable option to further define the injury and prophylactically reduce the rate of observation . we believe that in those institutions where a vascular surgeon or radiology specialist for embolization is available 24 hours a day , this can be the best option . when a vascular surgeon or radiologist specialist is not available for patients who are questionable , splenectomy , in our opinion , is still the best option , particularly if the splenectomy can be performed laparoscopically . prevention of overwhelming postsplenectomy sepsis ( opsi ) has often been cited as a reason for advocating splenic preservation . however , the incidence of opsi in adults , in contrast with children , is very low ( < 1% ) and with modern vaccination and antibiotics is expected to decline further . in adult patients , the risks of transfusion and delayed splenic rupture , abscess , and pain should be weighed against the risk of opsi in determining the best approach to severe splenic injuries . the role of laparoscopy in blunt trauma has yet to be defined . in experienced hands , it has been shown to reduce the negative laparotomy rate and identify and treat diaphragmatic and visceral injuries . several authors have used laparoscopy to apply hemostatic agents to solid organ lacerations and perform spleen preserving procedures in lower grade injury . we believe that if there is a splenic injury and no other injury in the abdomen , as shown by ct and fast scans , the laparoscopic approach is feasible , even though the gold standard is still considered exploratory laparotomy . we believe any injury of the hilum , specifically in the vein in the splenic area , is an indication for laparoscopy while the injury of the artery could not be a good indication at this point . laparoscopic splenectomy has not been well described in patients with splenic trauma . to our knowledge , this is the first report of laparoscopic splenectomy as first - line treatment for a grade v injury in a trauma patient . one patient had previously undergone splenic artery embolization and re - presented with delayed splenic rupture . based on our experience , we would like to point out that laparoscopic splenectomy can be safely performed in a high - grade injury by an experienced surgeon and should be considered in stable patients . the reason why we reported this case is to raise the question of whether we are ready to move into laparoscopy . we do not believe that we are at this point , but it is good to raise controversy and maybe in the future , a single injury to the spleen with no other injuries reported by ct and fast in patients who are hemodynamically stable could be an indication for laparoscopic splenectomy . in our case , a grade v injury was reported with the ct scan , and there was a big hematoma at the level of the hilum . we believe retrospectively that the hematoma made the bleeding decrease , and no more bleeding was coming out from the hilum . no vascular surgeon or radiologist was available ; therefore , embolization was not an option . we agree that there is nothing in the literature that requires immediate splenectomy in a young , healthy , stable patient with a high - grade injury based on the ct scan , but laparoscopic exploration in trauma is an acceptable option . transfusion is being increasingly recognized as an independent factor in poor outcomes , and avoidance of transfusion is likely to become a priority in managing stable trauma patients . laparoscopic splenectomy should be considered as an option in these patients , either on admission or after failure of nonoperative management . the benefits of smaller incisions , less postoperative pain , and the potential for earlier discharge from the hospital should be weighed when deciding on an operative approach . the risk of injury to the tail of the pancreas during a laparoscopic dissection of the splenic hilum in the presence of a hematoma / hemoperitoneum is not different from an exploratory laparotomy in experienced hands . we believe that with the laparoscopic technique , the experience of the surgeon and the visualization of the hilum are of utmost importance , and the pancreatic tail can be visualized well and decrease the risk of the pancreatic tail injury . our patient remained in the hospital for 3 days solely for observation of his associated renal injury . he was able to resume a regular diet immediately and had minimal requirements for pain medication . a patient with an isolated splenic injury would likely be stable enough to be discharged the next day , following laparoscopic surgery . laparoscopic splenectomy can be successfully used as an immediate treatment option in hemodynamically stable patients with severe splenic injury .