Surgical palliation for hypoplastic left heart syndrome has become standard therapy in many centers throughout the world. Significant improvements in management, from preoperative diagnosis and intraoperative technique to postoperative care, have resulted in a dramatic increase in survival. With this improved survival, however, come new challenges and unforeseen problems. The first stage of the reconstructive surgery remains the highest risk procedure for the reason that establishing a stable circulation that is dependent on a single, volume-overloaded right ventricle with the potential for jeopardized coronary blood flow remains a surgical challenge. In this review, current management strategies for the conventional reconstructive surgical approach are examined.