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Background: Transumbilical laparoscopic-assisted (TULA) surgery is a minimally invasive technique that combines laparoscopic exploration with extracorporeal surgical management, offering potential advantages in neonatal abdominal surgery. However, comparative data with conventional open surgery in neonates remain limited. This study reports our single-center experience with TULA and compares its outcomes with those of a matched cohort of neonates undergoing open surgery. Methods: We performed a retrospective study on neonatal patients (<28 days of life) treated at our Pediatric Surgery Unit between 2015 and 2023. Twenty-five neonates underwent TULA for various intra-abdominal malformations. Each TULA patient was matched in a 1:2 ratio with neonates treated with open surgery based on gestational age, birth weight, and underlying diagnosis, resulting in a matched cohort of 50 patients. Primary outcomes included operative and anesthesia times, conversion rate, postoperative complications, length of hospital stay, and mortality. Results: The TULA cohort included 11 males and 14 females, with a mean gestational age of 37.5 ± 1.9 weeks and a mean birth weight of 2989 ± 675 g. Indications comprised intestinal malrotation, ileal atresia, duodenal stenosis, meconium ileus, and other abdominal pathologies. Mean operative time was comparable between groups (116 ± 37 min in the TULA group vs. 137 ± 65.9 min in the open surgery group; p = 0.52). Conversion from TULA to open surgery occurred in 16% of cases. No significant differences were observed in major postoperative complications or length of hospital stay between groups (p > 0.05). No mortality was reported. Conclusions: TULA represents a safe and effective surgical option for selected neonatal abdominal pathologies, with outcomes comparable to conventional open surgery. When performed in specialized centers with appropriate patient selection and multidisciplinary expertise, TULA offers favorable safety and cosmetic results.

Background/Objectives: The gut microbiota (GM) is pivotal for immune regulation, metabolism, and neurodevelopment. Infants undergoing surgery for congenital gastrointestinal anomalies are especially prone to microbial imbalances, with a paucity of beneficial bacteria (e.g., Bifidobacteria and Bacteroides) and diminished short-chain fatty acid production. Dysbiosis has been associated with severe complications, including necrotizing enterocolitis, sepsis, and feeding intolerance. This narrative review aims to critically examine strategies for microbiota modulation in this high-risk cohort. Methods: An extensive literature analysis was performed to compare the evolution of GM in healthy neonates versus those requiring gastrointestinal surgery, synthetizing strategies to maintain eubiosis, such as early nutritional interventions—particularly the use of human milk—along with antibiotic management and supplementary treatments including probiotics, prebiotics, postbiotics, and lactoferrin. Emerging techniques in metagenomic and metabolomic analysis were also evaluated for their potential to elucidate microbial dynamics in these patients. Results: Neonates undergoing gastrointestinal surgery exhibit significant alterations in microbial communities, characterized by reduced levels of eubiotic bacteria and an overrepresentation of opportunistic pathogens. Early initiation of enteral feeding with human milk and careful antibiotic stewardship are linked to improved microbial balance. Adjunctive therapies, such as the administration of probiotics and lactoferrin, show potential in enhancing gut barrier function and immune modulation, although confirmation through larger-scale studies remains necessary. Conclusions: Modulating the GM emerges as a promising strategy to ameliorate outcome in neonates with congenital gastrointestinal surgical conditions. Future research should focus on the development of standardized therapeutic protocols and the execution of rigorous multicenter trials to validate the efficacy and safety of these interventions.