Bedside vs Conventional Operating Room Surgery in Critically Ill Newborns: Systematic Review and Meta-analysis

Background: Surgical procedures in critically ill neonates are typically performed in the operating room, though transferring unstable patients from the NICU carries risks such as hypothermia and clinical deterioration. Bedside surgery in the NICU has emerged as an alternative for patients unfit for transport. This systematic review and meta-analysis compared perioperative outcomes of bedside versus operating room surgery in neonates. Methods: Following PRISMA guidelines and PROSPERO registration (CRD420251001354), we searched PubMed, Ovid, and CENTRAL (1990-2025) for studies comparing neonatal surgeries performed in the operating room or bedside. Primary outcomes were mortality and surgical site infections; secondary outcomes included intra- and post-operative hypothermia, operative time, and hospital length of stay. Risk of bias was assessed with ROBINS-I and evidence certainty with GRADE. Results: Nine studies (1098 neonates: 693 operating room and 405 bedside group) were included. Mortality was significantly higher in the bedside group (25.82%) than operating room group (7.32%) (p<0.0001). Subgroup analysis showed this difference was significant for congenital diaphragmatic hernia, but not for patent ductus arteriosus. Surgical site infections did not different significantly. Bedside was associated with lower intra-operative hypothermia (p=0.024), while no differences were found in postoperative hypothermia, length of stay, or operative time. Conclusions: This meta-analysis found higher mortality in the bedside surgery group, though infection risk, post-operative hypothermia, operative time, and hospital stay were similar between groups. Bedside surgery reduced intraoperative hypothermia. Due to study variability and observational designs, surgical approach should be tailored to the neonate's clinical condition and available resources.