Necrotizing enterocolitis (NEC) is the commonest life-threatening acquired gastrointestinal problem of prematurity carrying a significant morbidity and mortality. A national British Association of Paediatric Surgeons audit in 1999 found that 32/162 (20%) of neonates operated on for NEC died and many similar rates are still reported. The predominant morbidity is protracted intestinal failure with many babies needing months of parenteral nutrition whilst adaptation takes place. Up to a third respond to medical support and surgical consultation is not sought. Amongst the remaining two-thirds surgical intervention is required in about half and without which death would usually follow. Some infants require intestinal transplantation which has around a 50% 5-year survival. This article will help you decide who will benefit from an operation, when to operate and what operations to consider after opening the abdomen.