Emergency Laparotomy in the Neonatal Intensive Care Unit: A Systematic Review of Indications and Outcomes

Cotside laparotomy is often performed in critically ill neonates, but its indications over in-theatre laparotomy remain unclear. This is the first systematic review of published evidence, aiming to clarify the feasibility, safety, and indications for neonatal intensive care (NICU)-based laparotomy.A systematic review was conducted following PRISMA guidelines. Quantitative data on patient demographics and outcomes were extracted, and where possible, aggregated comparative analyses were performed. Qualitative thematic analysis was used to explore reported institutional experiences of cotside laparotomy.Eighteen studies were included, reporting data from 20 surgical sites across 10 countries, published from 1994 to 2024. Eight studies reported a comparator group of theatre-based laparotomies. In total, data on 418 cotside and 453 theatre laparotomies were included. Cotside cohorts had lower birthweight (approximately 1,305 g vs. 2,941 g, p = 0.016) and gestational age (approximately 29.5 vs. 34.3 weeks, p = 0.047). Postoperative adverse event rates were similar between neonates in each group (8.1%, 33/407 vs. 6.8%, 30/442; χ 2 = 0.23, p = 0.63), as was in-hospital mortality (24.1%, 98/407 vs. 25.3%, 112/442; χ 2 = 0.15, p = 0.70). Thematic analysis identified transfer-related events as a significant concern in babies operated in theatre, particularly endotracheal tube dislodgement and hypothermia, while cotside operating space constraints and disturbance to NICU activities were frequently cited issues. Decisions on surgical location were multifactorial and multidisciplinary, influenced by cardiorespiratory status and institutional factors. Formal institutional guidelines for cotside surgery were reported in only 33% (6/18) of studies.Emergency cotside laparotomy is safe and feasible. Despite consisting of a higher risk population, mortality and morbidity are comparable to theatre-based surgery. Avoiding the risks of transfer may confer additional benefit. Large-scale, prospective studies are needed to clarify the indications for cotside operating.