Background: Currently, the treatment of hydrocephalus in children involves numerous operations and often results in poor prognosis, complicating their condition. Objectives: To reduce the number of operations and improve the treatment of pediatric complex hydrocephalus, we propose a definition of pediatric complex hydrocephalus and a surgical treatment procedure. Methods: This study retrospectively reviewed data from patients with pediatric complex hydrocephalus admitted to Xiangya Hospital between January 2019 and January 2024. The data include basic demographic characteristics, etiology, complicating factors, surgery, and prognosis. We analyzed the therapeutic effect of the new surgical management procedure on complex hydrocephalus in children. Additionally, we refined valuable experiences from previous studies by extensively reviewing the literature and integrating it with our clinical work. Results: We collected data from 114 pediatric patients with complex hydrocephalus, including 72 males and 42 females. There were 5 patients aged within 1 month, 38 patients aged between 1 month and 1 year, and 71 patients aged between 1 year and 14 years. According to the etiology and risk factors for surgical failure, there were 20 premature infants with very low birth weight, 54 patients with intracranial hemorrhage, 59 patients with intracranial infection, 24 patients with multiloculated hydrocephalus, and 26 patients who had undergone previous surgeries. These patients underwent a total of 279 surgeries, ranging from 1 to 7 per patient, with an average of 2.4 surgeries per patient. Of these, 35 involved extra ventricular drainage with an Ommaya reservoir, 22 involved cyst fenestration, 91 involved ventriculoperitoneal shunt, 5 involved ventriculoatrial shunt, 25 involved endoscopic third ventriculostomy, 17 involved choroid plexus cauterization, and 84 involved other types of surgeries. After a mean follow-up time of 5.4 months, 113 patients experienced symptom relief post-surgery, 79 patients showed normalization of ventricles on imaging, 94 patients had normal cognition, 89 patients had normal development, 87 patients had normal function, 81 patients experienced complications, 81 patients required reoperations, and 113 patients survived. More specific information and statistical comparison results are shown in the table. Different responsiveness to surgery between premature infants with very low birth weight and full-term infants is shown in the table.Conclusions: We propose a comprehensive definition of complex hydrocephalus, which includes cases requiring multiple surgeries, associated with hemorrhage and/or infection, multiloculated hydrocephalus, and preterm infants with very low birth weight. A surgical management procedure for pediatric complex hydrocephalus was summarized. Early identification and diagnosis enable personalized treatment approaches, which are divided into two stages. Postoperative follow-up and regular radiological examinations are essential to assess ventricular system restoration and promptly identify any changes in the patient's condition, facilitating the implementation of necessary interventions.