Purpose <p>Splenic artery embolization (SAE) is the standard intervention for transient responders with high-grade splenic trauma. When SAE is unavailable, contraindicated, or declined, alternative minimally invasive approaches may be warranted. This study evaluates a totally laparoscopic strategy combining microwave ablation (MWA) for hemostasis with intraoperative autologous blood transfusion (ABT) in selected transient responders with initial WSES Grade IV splenic rupture.</p> Methods <p>This retrospective study included 10 consecutive transient responders (October 2021–June 2024) with initial WSES Grade IV splenic rupture who underwent totally laparoscopic MWA combined with intraoperative ABT. All patients exhibited transient hemodynamic response to limited resuscitation (≤ 1500 mL fluids) and preoperative shock index &gt; 0.9. Intraoperative injury was graded by the AAST system. Outcomes included technical success, transfusion requirements, complications, and follow-up.</p> Results <p>All 10 patients underwent successful spleen-preserving laparoscopy without conversion. AAST grades: II (<i>n</i> = 2), III (<i>n</i> = 4), IV (<i>n</i> = 4). Mean operative time was 191.3 ± 101.7&#xa0;min. Mean blood salvage was 1587.5 ± 663.9 mL, yielding 490.8 ± 80.2 mL autologous red cells. No patient required postoperative allogeneic transfusion. Hemoglobin, platelets, and lactate improved significantly by postoperative day 3 (<i>P</i> &lt; 0.05). No splenic abscess, overwhelming infection, or mortality occurred. At 12–18 months follow-up, no splenic atrophy or immune dysfunction was observed.</p> Conclusion <p>In selected transient responders with initial WSES Grade IV splenic rupture, a totally laparoscopic approach integrating MWA and ABT is technically feasible. The discrepancy between WSES and AAST grades suggests some WSES IV patients have less severe injuries, supporting laparoscopic exploration in selected cases.</p>