Perceived high operative risk for splenectomy in children with hematologic disorders and hypersplenism has led to attempts at transcatheter splenic embolization (TSE) as a possibly safer alternative. A recent experience with a child who presented with an apparent acute subcapsular hematoma after TSE and who underwent complicated emergency splenectomy prompted review of the risks and complications of TSE. Although theoretically attractive in many respects, TSE is associated with significant morbidity. The resultant diagnostic and therapeutic difficulties of this procedure can potentially complicate patient management, and the often life-threatening sequelae warrant considerable restraint in its use. In addition, TSE often fails to produce the desired, long-term hematologic response. Because of the morbidity and risk associated with TSE, primary operative intervention is advised for most children in whom splenectomy is indicated. Morbidity associated with the direct operative approach may be minimized by judicious use of blood components and by meticulous surgical technique.