With respect to "alternative" surgery in trauma management, the indications have become clearer and the great debates over the futility of alternative or nonoperative trauma management have become academic discussions of evidence-based data. Alternative surgery in the trauma discipline essentially means nonoperative or selective management. After military campaigns such as World War II, the Korean War, and the Vietnam War, the urban trauma centers that were spawned from these efforts endorsed many of the established trauma management paradigms. Aggressive operative intervention, including mandatory exploration, was the accepted approach to such injuries as penetrating central (zone II) neck, anterior abdominal, and back and flank injuries. As resuscitative and diagnostic capabilities improved, the acceptance of a high incidence of negative explorations, associated with a mandatory operative policy, began to be challenged. This evolving alternative management appropriately coincided with an era of high technology that included advance endoscopic fiberoptics, computed tomography, ultrasonography, transesophageal echocardiography, and minimally invasive surgery. Currently, the trauma surgeon is afforded state-of-the-art diagnostic options that makes selective and nonoperative management very efficacious. This concept is not just applicable to certain subsets of victims of penetrating trauma, but has also been successfully incorporated in the management paradigm of blunt trauma. In fact, the acceptance of nonoperative management has become the rule rather than the exception in respect to both blunt hepatic and splenic injuries. The essential component of successful management remains good clinical judgement; however, evidence-based practice guidelines are being established by the major trauma organizations to provide a template for decision making.2,3 Although nonoperative management is now a critical part of the trauma management options, there are still clear indications for emergency operative intervention (Table 1).