Introduction When medical treatment fails, necrotizing enterocolitis (NEC) in neonates, especially preterm infants, requires surgery in ۲۰-۴۰% of cases. The conventional procedure is open laparotomy, but laparoscopic surgery may reduce morbidity due to smaller incisions, less tissue trauma and faster recovery. Evidence comparing short-term (postoperative complications, mortality) and long-term (neurodevelopmental outcomes, growth) outcomes between these techniques is limited and inconsistent. This systematic review compares open and laparoscopic surgery for neonatal necrotizing enterocolitis (NEC) to see if laparoscopic surgery reduces morbidity, mortality and prolonged complications. Methods From their inception to July ۲۰۲۵, we searched PubMed, Embase, Sincedirect and Scopus using keywords like "necrotizing enterocolitis," "neonates," "open surgery," "laparotomy," "laparoscopic surgery," "outcomes," and various combinations. The study included randomized controlled trials, cohort studies and case-control studies evaluating open and laparoscopic techniques for neonates (≤۲۸ days old) with surgical necrotizing enterocolitis (Bell's stage III). Case reports, non-comparative studies, adult populations and non-NEC indications were excluded. ROBINS-I was used to assess bias in non-randomized studies, while Cochrane RoB ۲ was used in RCTs. Narratives and random-effects meta-analysis were used to synthesize data and present odds ratios (OR) or mean differences (MD) with ۹۵% confidence intervals. We employed I statistics to evaluate heterogeneity. Results Eight cohort studies and two randomized controlled trials involving ۴۵۲ neonates (۲۴۸ open and ۲۰۴ laparoscopic) were included. Most studies were from Europe and North America, with an average ۲۸-week gestation. NEC started ۱۰-۱۴ days postpartum.In ۰.۵۲, ۹۵% CI ۰.۳۵-۰.۷۸; ۸ studies, ۴۱۲ participants) and mortality (OR ۰.۶۱, ۹۵% CI ۰.۴۲-۰.۸۹; ۷ studies, ۳۷۸ participants). Hospitalization was shorter after laparoscopy (MD -۷.۲ days, ۹۵% CI -۱۰.۵ to -۳.۹; ۶ studies, ۳۲۰ participants). Long-term results showed improved neurodevelopmental scores at ۲ years (MD +۸.۳ points on Bayley Scales, ۹۵% CI ۳.۱-۱۳.۵; ۴ studies, ۲۱۰ participants; favoring laparoscopic) and decreased growth faltering (OR ۰.۴۸, ۹۵% CI ۰.۲۹-۰.۷۹; ۵ studies, ۲۵۶ respondents). Conclusion A systematic review shows that laparoscopic surgery for neonatal necrotizing enterocolitis improves short-term complications, mortality and neurodevelopmental and growth outcomes compared to open surgery. When possible, laparoscopy is preferred because it reduces surgical stress in vulnerable neonates. To confirm benefits across diverse populations, standardized protocols and RCTs are needed, while addressing limitations like study heterogeneity (F ۵۰%) and selection bias favoring less severe cases for laparoscopy. Neonatal care can be improved by adoption, but it requires specialized training and equipment.
