Surgical Treatment and the Pull-Through Procedure

The goal of surgery for Hirschsprung disease is to remove the part of the intestine that lacks nerve cells and connect the healthy, working bowel to the anus ^[1][2]. This procedure is called a pull-through. While it is a major operation, most children go on to have good bowel function and lead active lives ^[3][4].

Preparing for Surgery: The “Washout”

Before surgery, the bowel must be kept clear to prevent infection and stretching. This is often done through rectal irrigations (also called washouts) ^[5]. Using a small tube and a salt-water solution, you or a nurse will gently flush the stool out of the baby’s colon.

• Safety Warning: Never force the catheter if you feel resistance, as this could puncture the baby’s bowel. If the water goes in but does not come back out, gently massage the belly or carefully pull the tube back slightly. If it still doesn’t return, contact your medical team.
• Effective Decompression: If washouts work well to keep the belly flat, the surgeon may wait until the baby is about 3 months old to perform the pull-through ^[5].

The Three Main Techniques

There are three classic ways to perform a pull-through. Your surgeon will choose the one they are most experienced with and that best fits your child’s anatomy.

1. Soave Procedure: The surgeon slides the healthy bowel through the “sleeve” of the abnormal rectum, leaving the outer layer of the rectum in place ^[6][7]. Why choose it? It protects the nerves around the rectum, minimizing the risk of injuring structures that control urine or sexual function.
2. Duhamel Procedure: The surgeon pulls the healthy bowel down behind the abnormal rectum and joins them together, creating a new, larger pouch for stool ^[8][9]. Why choose it? It is often preferred for Total Colonic Aganglionosis (TCA) because the larger pouch can help absorb more water and slow down bowel movements.
3. Swenson Procedure: The surgeon removes the entire abnormal segment of the rectum and colon and connects the healthy bowel directly to the anal canal ^[10][11]. Why choose it? It is the original procedure and completely removes all the aganglionic tissue, which some surgeons believe reduces long-term constipation.

Many of these surgeries are now done using Transanal Endorectal Pull-Through (TEPT), meaning the surgery is done through the anus without large abdominal incisions ^[2][3].

What to Expect in the Hospital

A typical pull-through surgery requires a hospital stay of a few days to a week. The baby will likely receive IV pain medication initially before transitioning to oral pain relievers. Oral feedings (breastmilk or formula) usually resume once the bowel “wakes up,” signaled by the baby passing gas or having their first stool.

The Immediate Aftermath: Severe Diaper Rash

Warning: Immediately after a pull-through, your child will begin passing stool constantly—sometimes 10 to 20 times a day. Because this stool has not sat in the colon to absorb water, it is highly acidic and will cause a severe, blistering diaper rash within hours if untreated.

• Proactive Care: Before surgery, stock up on heavy barrier creams (like Ilex paste or thick zinc oxide). Apply a thick layer to the baby’s bottom immediately after surgery and reapply diligently with every diaper change to protect their skin.

One Stage or Two?

• Primary Pull-Through (One Stage): The abnormal bowel is removed and the healthy bowel is connected all in one surgery ^[2][3].
• Staged Procedure (Two or Three Stages): If the baby is very sick, the surgeon may first perform an ostomy (stoma) ^[12][13]. A small opening is made on the belly for stool to pass into a bag. The pull-through happens in a later surgery.

For what to watch out for after returning home, see Managing Complications and HAEC.