Surgical management of spina bifida here is discussed as a 2-point discussion: first is surgical management prior to the advent of in utero repair of open spina bifida and second is in utero repair leading to the Management of Myelomeningocele Study (MOMS) trial . Postnatal repair of open spina bifida repair is a requirement in order to prevent further mechanical damage and infection. The lesion either may be closed primarily with the aid of skin and muscle flaps or may require a synthetic patch such as AlloDerm (LifeCell Corp., Branchburg, NJ) , gelatin, or collagen hybrid sponges . In utero MMC repair in humans was first reported in the landmark paper published in 1998 . However, since then, a handful of centers have been offering in utero repair. Furthermore, its popularity has increased in Europe . The principle of in utero repair is to prevent the 2-hit hypothesis much described in previous literature that the child is exposed to neurological deterioration contributed first by failure of the neural tube to form and secondly by physical and chemical perturbation inflicted on the exposed neurological tissue of the open lesion [128, 194]. In an elegant experimental study, Meuli et al.  concluded that surgical exposure of the normal spinal cord to the amniotic space in a 75-day sheep fetus results in a MMC-type pathology at birth with clinical, histological, and morphological attributes comparable to human MMC. Heffez et al.  has demonstrated that spinal cord injury caused by exposure to the intrauterine milieu can be prevented by primary closure of the fetal skin incision as late as hours after creating the defect. It also demonstrated that ongoing exposure beyond 24 hours leads to spinal cord damage and permanent neurological deficit. Moreover, animal studies have previously shown that prenatal coverage of a spina bifida-like lesion preserves neurologic function and improves hindbrain herniation [195, 197, 198].