From 1979 through 1981, 64 premature infants who weighed less than 1,500 g underwent 68 operations and 52 survived (81 percent). Twenty-six of 31 infants who weighed less than 1,000 g (84 percent) and 26 of 33 infants who weighed between 1,000 and 1,500 g survived (84 and 79 percent, respectively). The most common operation was ligation of a patent ductus arteriosus in 53 infants, of whom 43 survived (81 percent). Ten infants were operated on for necrotizing enterocolitis and 7 survived (70%). Four of five infants (80 percent) survived other major operations. Factors which influence survival include appropriate timing of operation, preoperative and postoperative mechanical ventilation, and parenteral nutrition. Intraoperative management includes short-duration anesthesia, continuous monitoring of vital signs, and judicious use of small amounts of amnestic and neuromuscular blocking agents combined with low fractional inspired oxygen concentration to reduce the risk of oxygen toxicity. Utilizing these principles, the survival rate compared favorably with the survival rate of all premature infants, which establishes that major surgery can be undertaken with only moderate risk in the infant with very low birth weight.