PURPOSE: Virtual reality (VR) has emerged as a valuable tool in surgical planning, offering detailed anatomical spatial orientation and three-dimensional (3D) navigation. This study explores using virtual reality head-mounted display (VR-HMD) technology in preoperative planning for pediatric surgery, aiming to improve outcomes in treating congenital malformations and tumors while advancing surgical education. METHODS: A retrospective analysis was performed on pediatric patients diagnosed with congenital malformations and tumors who received treatment between 2021 and 2024 at the "V. Buzzi" Children's Hospital in Milan, Italy. Patient-specific 3D VR models were generated from reconstructed computed tomography/magnetic resonance imaging (CT/MRI) images and analyzed preoperatively to optimize surgical planning and strategy development. The advantages of preoperative VR compared to traditional imaging techniques were assessed. RESULTS: Fifty VR models were included in the study (n = 35: congenital malformations and n = 15 tumors). The VR-HMD setup facilitated interactive anatomical exploration, enabling precise surgical navigation and planning. Compared to conventional imaging, preoperative VR simulations modified the surgical approach in 75.0% of cases, enabling minimally invasive strategies in complex congenital malformations and guiding the decision for open surgery in anatomically challenging tumors such as adrenal and hepatic masses. VR images demonstrated superior anatomical resolution and identified potential intraoperative complications in 92.0% of cases compared to conventional imaging. Remarkably, examining the vascular hilum in pulmonary, hepatic, and renal structures provided enhanced guidance for determining the surgical approach, ensuring a safer and more precise respect for the anatomy in complex cases. As a result, preoperative VR navigation demonstrated the feasibility of minimally invasive procedures in 45.6% of complex cases whereas recommending an open surgical approach in 55.4% of the models. Limitations in visualizing urological structures (e.g., ureters and bladder in complex urogenital malformations) limited the VR's utility in those cases, underscoring the need for future advancements in segmentation and multimodal imaging to enhance anatomical accuracy. CONCLUSION: Preoperative VR enables customized surgical planning, potentially minimizes intraoperative risks, and provides valuable educational opportunities for pediatric surgical teams. Future advancements in VR technology promise to further enhance its integration into clinical practice, ultimately improving pediatric patients' outcomes.