e rst priority upon entering the abdomen is control of exsanguinating hemorrhage. Such control can usually be achieved by direct control of the lacerated site or obtaining proximal vascular control. After major hemorrhage is con­trolled, blood and blood clots are removed. Abdominal packs (radiologically labeled) are used to tamponade any bleeding and allow for identication of any injury bleeding. e pre­ferred approach to packing is to divide the falciform ligament and retract the anterior abdominal wall. is will allow man­ual placement of the packs above the liver. Abdominal packs should also be placed below the liver. is arrangement of the packs on the liver creates a compressive tamponade eect. After manually eviscerating the small bowel out of the cavity, packs should be placed on the remaining three quadrants, with care taken to avoid an iatrogenic injury to the spleen. During the packing phase after ongoing hemorrhage has been controlled, the surgeon should communicate with the anes­thesia team that major hemorrhage has been controlled and that this would be an optimal time to establish a resuscitative advantage with uid/blood product administration.

tinues to be controversial subject matter in the literature with numerous reports claiming that age greater than 55 years is or

Documentation of a mod­erate or large hemoperitoneum is suggestive of a major injury and should be considered a signicant factor in individual patient assessment.

Patients with splenic subcapsular hematoma or history of portal hypertension are specic subgroups of patients who deserve special consideration. Patients with subcapsu­lar hematoma in our experience tend to ooze from the raw parenchymal surface and further disrupt the capsule lead­ing to more raw surface area to bleed. ese patients are at increased risk for delayed rupture 6 to 8 days following injury and may already be discharged from the hospital if they have isolated injury. Furthermore, splenic embolization is not a very eective treatment of this condition because it usually necessitates coiling of the main splenic artery that can lead to signicant pain and abscess formation. A his­tory of portal hypertension or cirrhosis, while not absolute contraindications to nonoperative management, certainly should raise concerns. e general risks of laparotomy in a Childs B or C cirrhotic need to be carefully weighed against the risk of ensuing and worsening coagulopathy. is sce­nario may, indeed, call for main splenic artery embolization. None of these risk factors alone should dictate the decision to proceed immediately to operative intervention. Nonop­erative management does reduce hospital length of stay and transfusion requirement; however, the morbidity of splenec­tomy should remain low in any surgeon’s hands. Overall, the patient’s condition, including comorbidities, coagulopathy, and other problems (such as traumatic brain injury, aortic injury and suspicion for concomitant hollow viscus injury) factor into the decision making process. No one should ever succumb to splenic hemorrhage that was undergoing nonop­erative management.