AbstractNecrotizing enterocolitis (NEC) has become a frequent neonatal surgical emergency. This disease, characterized by crepitant intestinal necrosis, occurs primarily in premature infants. Operation is necessary if intestinal perforation or gangrene occurs. Of the many proposed indications for operation in NEC, those of proven validity are: pneumoperitoneum, a fixed dilated loop on serial x‐rays, erythema of the abdominal wall, an abdominal mass, or a positive paracentesis (consisting of brown fluid and/or bacteria on Gram's stain). Paracentesis has aided the early identification of infants with intestinal gangrene prior to perforation. Early recognition of gangrene is important because the mortality rate following operation after perforation (64%) is double that of operation for gangrene (30%). The cardinal principles of operation for acute NEC are excision of all the gangrenous bowel, exteriorization of the marginally viable ends, and preservation of as much intestine as possible. Our preferred method of exteriorization is by the Mikulicz enterostomy, because its subsequent closure appears to be safer than closure of a double enterostomy with separated stomas. The survival of infants operated on for NEC at the University of New Mexico Hospital was 34 of 63 (54%). Six late deaths occurred, for an overall survival of 28 of 63 (44%). Nine survivors (32%) required treatment for late intestinal strictures. Recent follow‐up studies on infants surviving NEC show an encouraging prognosis for normal growth and development.