Patient: Male, 4-day-old Final Diagnosis: Gastric perforation and necrosis Symptoms: Acute abdominal distension • metabolic acidosis • respiratory distress Medication: — Clinical Procedure: — Specialty: Pediatrics and Neonatology • Surgery Objective: Congenital defects/diseases Background: Gastric necrosis and perforation are rare life-threatening conditions in preterm neonates, which require urgent diagnosis and surgical intervention. Case Report: We report a case of a 4-day-old patient with neonatal gastric necrosis. The patient presented with sudden acute abdominal distension, respiratory distress, and metabolic acidosis. The abdomen was markedly distended, tender, and tympanic with collateral circulation. An X-ray of the abdomen showed a huge pneumoperitoneum. An urgent exploratory laparotomy revealed 2 wide horizontal perforations and necrosis of the fundus and gastric body. Subtotal gastrectomy with esogastric anastomosis was done. Postoperatively, the patient was administered total parenteral nutrition and triple antibiotics and improved gradually. He passed stool and the abdomen was soft, lax, and non-distended and the wound healed. An upper gastrointestinal tract (UGIT) contrast study 1 week after the operation showed no leakage or stricture. The patient was discharged 2 months postoperatively with a bodyweight of 2 kg and was followed in the Outpatient Department (OPD). The patient survived after 80% gastric resection for necrosis of the stomach, which was a unique outcome for this major surgery. Conclusions: Gastric perforation is a rare life-threatening condition in preterm neonates, usually managed by direct closure in layers. Exceptionally, partial gastrectomy is needed, which is a major operation, with a high mortality rate and poor outcome. We present a case of a preterm neonate who survived after 80% gastric resection for stomach necrosis.