Perforated NEC in the fragile, premature infant remains a complex neonatal and surgical problem. Future investigation into the basic mechanisms of the intestinal inflammatory response in the premature neonate may allow for preventive strategies in the management of NEC. Until then, surgical management for perforated NEC will remain a necessary intervention to treat the complications of this disease. The two most commonly used surgical strategies for perforated NEC are laparotomy, bowel resection, and enterostomy versus primary peritoneal drainage. There are no compelling, prospective, controlled data supporting one procedure over the other. Although there are several surgical options for treating perforated NEC, definitive evidence-based guidelines for the best surgical treatment in terms of survival outcome remain to be determined.