Splenic epidermoid cysts are a rare entity. The traditional treatment was splenectomy, performed to prevent infection, hemorrhage, or rupture of the cyst. The authors reviewed their series of 19 children with congenital splenic cysts from 1914 to 1993 to assess the change in management of these lesions. The age of time of presentation ranged from newborn to 17 years (median, 12.0 years) The male:female ratio was 1.0:1.1. Five cysts were found incidentally at the time of autopsy. The cysts were 0.5 to 24 cm in diameter (median, 12.0 cm). Only cysts greater than 8 cm presented with clinical symptoms: 64% with an abdominal mass and/or 78% with abdominal pain. One patient presented with a left varicocele. There were no complications related to the cysts. A variety of radiographic studies were performed, but ultrasonography provided all required diagnostic information. All patients treated before 1971 (n = 9) underwent splenectomy, and five patients treated since 1983 had hemisplenectomy or cystectomy. Postoperative spleen scans (obtained in three of these patients) and platelet counts showed preservation of splenic function. Pathological examination showed epidermoid cysts in all cases. There were no postoperative complications. In conclusion, in this series of epidermoid splenic cysts in children, (1) the cysts presented with an abdominal mass and/or abdominal pain only if they were greater than 8 cm in size, and there were no complications owing to the cysts; (2) ultrasonography was the most cost-effective and least invasive method of evaluation; and (3) splenic preservation by hemisplenectomy or cystectomy, used to avoid the long-term risks of splenectomy, proved to be a safe, easy procedure, with maintenance of splenic function.