The Colorectal Quiz Episode 5: Proximal Hirschsprung Disease Surgical Technique

Published: 2021-03-01

10 Views

0 Likes

0 Shares

0 Comments

Colorectal Channel

View profile →

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Gerardo — host
Doctor Levitt — guest
Doctor Aaron Garrison — guest
Doctor Fisher — guest
Doctor Andrea Badillo — guest

Chapters

0:00Introduction and Case Setup — Host introduces the episode on proximal Hirschsprung disease, contrasting it with last week's rectosigmoid case. Describes a patient with mid-transverse transition zone on contrast enema and biopsy findings.
2:37Intraoperative Decision-Making with Uncertain Frozen Sections — Discussion of management when frozen sections show aganglionic sigmoid/left colon but ganglionic mid-transverse without hypertrophic nerves. Emphasis on avoiding permanent decisions based on frozen sections alone, with options including ileostomy diversion, colonic mapping, or waiting for permanent sections.
6:49Diversion Strategy and Biopsy Marking — Debate between ileostomy versus colonic diversion, with preference for ileostomy to ensure adequate diversion. Discussion of marking biopsies with permanent sutures using different numbers of tails for identification. Consideration of mucous fistula for irrigation access.
9:11Threshold for Primary Pull-Through vs Staged Approach — Establishes splenic flexure as the hard cutoff: if no ganglion cells at splenic flexure or beyond, do not perform pull-through that day. Emphasizes functional outcome differences between transverse versus left-sided pull-through and the importance of colon preservation.
10:42Technical Considerations for Proximal Pull-Through — Detailed discussion of blood supply management for mid-transverse pull-through: ligation of middle and right colic arteries, reliance on ileocolic and marginal vessels, de-rotation of right colon to bring cecum to liver bed and pull-through down right pelvis to avoid duodenal obstruction. Preference for open approach.
13:33Summary and Closing — Recap of key learning points and closing remarks with humor.

Key claims

5:48Hypertrophic nerves are mainly a sacral nerve plexus entity, found in sigmoid and rectum, not in more proximal colon — Doctor Levitt
5:23On frozen section, you can rule out Hirschsprung disease but cannot rule it in — Rod Gerardo
9:32If you don't have ganglion cells and you're at the splenic flexure, you should not do a pull-through that day and need to wait for permanent section — Doctor Levitt
10:20If you have even a little bit of colon, if you have your right colon, you can make one formed stool per day — Doctor Levitt
11:38For mid-transverse pull-through, you need to ligate the middle colic and very likely ligate the right colic, with blood supply dependent on ileocolic and the marginal artery paralleling the right colon — Doctor Levitt
11:58For proximal pull-through, you de-rotate by putting the cecum at the liver bed and bringing the pull-through down the right side, with all small bowel on the left side, which is essentially a rotation opposite to a Ladd's procedure — Doctor Levitt
11:21When bringing down mid-transverse colon, you need to de-rotate the bowel, otherwise you will bring the mesentery right across the duodenum and create an obstruction — Doctor Andrea Badillo
9:45There are functional outcome differences if you start pulling through transverse colon versus pulling through left-sided colon — Doctor Fisher
6:49An ileostomy almost definitely is going to successfully divert the patient, whereas with a diverting colostomy based on frozen section there is concern it may not be at a good level — Doctor Levitt
7:07In parts of the world without pathology support, diverting in the dilated segment is a very reasonable strategy, and if that bowel works, that is where the pull-through will go — Doctor Levitt
7:29Biopsies should be marked with permanent suture using different numbers of tails for each biopsy site to enable identification at subsequent operation — Doctor Fisher
12:10When doing a proximal pull-through, there is a slight twist in the mesentery when pulling it down, so ensuring adequate blood supply without kinking is very important — Doctor Fisher
12:24Personal preference is to do proximal pull-through open, probably through the incision for ileostomy closure, though some have done it laparoscopically — Doctor Levitt
6:09If you are going to do a primary pull-through 4 days later waiting for permanent sections, you must ensure the child is being irrigated and doing well with irrigation, not having smoldering or low-grade enterocolitis features — Doctor Fisher
4:18You can always get out of the OR without doing something permanent — Doctor Aaron Garrison
11:15For mid-transverse pull-through, the blood supply is based on right colic artery — Doctor Andrea Badillo
8:46If the colon is incredibly backed up with chalky stool after several months, irrigations will not do anything, but if you don't have that issue the colon can stay without needing a way to irrigate it — Doctor Andrea Badillo

Cases discussed

2:58Newborn with proximal Hirschsprung disease, mid-transverse transition zone

Open questions

If you're not going to pull a child through for 6 months, is beating that colon important?
Should a long mucous fistula or ostomy be created to irrigate a defunctionalized colon behind an ileostomy, or can the colon be left alone?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Surgical Decision-Making for Proximal Hirschsprung Disease: When to Stop and Reassess

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Frozen Section Cannot Rule In Hirschsprung Disease

The central teaching point in proximal Hirschsprung disease is understanding what frozen section pathology can and cannot tell you. On frozen section, you can rule out Hirschsprung disease if ganglion cells are clearly present, but you cannot definitively rule it in 5:23. When the pathologist reports no ganglion cells—particularly when nerves are also not visible—there remains real risk that ganglion cells are actually present but were missed in the frozen sample. The discussants emphasized that you risk resecting potentially normal colon based on inadequate sampling 5:23. This asymmetry in diagnostic certainty should fundamentally shape your intraoperative decision-making.

Hypertrophic Nerves Are a Distal Finding Only

Hypertrophic nerves are mainly a sacral nerve plexus entity, found in sigmoid and rectum, not in more proximal colon 5:48. When evaluating biopsies from the transverse colon or more proximal, the absence of hypertrophic nerves carries no diagnostic weight. At these levels, the entire question reduces to: are ganglion cells present or absent? Expecting to see hypertrophic nerves in proximal specimens reflects a misunderstanding of the pathology's anatomic distribution.

The Splenic Flexure Is Your Hard Stop

If frozen sections show no ganglion cells and you have reached the splenic flexure, you should not do a pull-through that day and need to wait for permanent sections 9:32. This is the threshold where uncertainty about pathology intersects with functional consequences. There are functional outcome differences if you start pulling through transverse colon versus pulling through left-sided colon 9:45. The risk of resecting potentially normal colon based on frozen section alone becomes unacceptable at this anatomic boundary. "You do not need to do this pull-through today" [q1].

Even Small Amounts of Colon Have Functional Value

If you have even a little bit of colon—if you have your right colon—you can make one formed stool per day 10:20. This single fact should govern your approach to uncertain proximal disease. The difference between having some colon and having none is not incremental; it is categorical. Conservative resection guided by permanent sections protects this functional capacity. When the alternative is waiting four days for definitive pathology, the choice is obvious.

Proximal Pull-Through Requires De-Rotation and Vascular Planning

For mid-transverse pull-through, you need to ligate the middle colic and very likely ligate the right colic, with blood supply dependent on ileocolic and the marginal artery paralleling the right colon 11:38. You cannot simply bring this segment straight down—you will bring the mesentery right across the duodenum and create an obstruction 11:21. Instead, you de-rotate by putting the cecum at the liver bed and bringing the pull-through down the right side, with all small bowel on the left side, which is essentially a rotation opposite to a Ladd's procedure 11:58. When doing a proximal pull-through, there is a slight twist in the mesentery when pulling it down, so ensuring adequate blood supply without kinking is very important 12:10.

Mark Your Biopsies or Lose Them

Biopsies should be marked with permanent suture using different numbers of tails for each biopsy site to enable identification at subsequent operation 7:29. Without this, returning to the operating room months later, "it's like you never biopsy" [q4]. Use prolene or similar permanent material. Document the marking system in your operative note. This is not optional technique—it is the only way to make intraoperative biopsies useful for staged management.

The Overriding Principle: You Can Always Get Out Without Doing Something Permanent

You can always get out of the OR without doing something permanent 4:18. When frozen sections suggest proximal disease, the correct move is often colonic mapping, ileostomy, and reassessment with permanent sections. An ileostomy almost definitely is going to successfully divert the patient, whereas with a diverting colostomy based on frozen section there is concern it may not be at a good level 6:49. If you are going to do a primary pull-through four days later waiting for permanent sections, you must ensure the child is being irrigated and doing well with irrigation, not having smoldering or low-grade enterocolitis features 6:09. The goal is not heroic completion—it is getting the child well while preserving as much functional colon as the pathology allows.

Takeaways from this story

Frozen section can rule out but not rule in Hirschsprung disease—when ganglion cells are not found proximally, wait for permanent sections.
Splenic flexure is the hard stop: if frozen shows no ganglion cells there, do not proceed with pull-through that day.
Even just the right colon can produce one formed stool per day—conservative resection guided by permanent sections protects function.
Proximal pull-through requires de-rotation (cecum to liver bed, bowel down right pelvis) to prevent mesenteric obstruction of duodenum.
Mark biopsies with permanent suture using different numbers of tails—without marking, returning months later is like you never biopsied.

Proximal Hirschsprung Disease: When Frozen Section Finds the Transition Zone at Mid-Transverse Colon

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

The Presentation

A newborn presented with bilious vomiting. Contrast enema showed a dilated mid-transverse colon with decompressed distal bowel — the radiographic signature of a proximal transition zone. Intraoperative biopsies confirmed aganglionic sigmoid and left colon with hypertrophic nerves, while the mid-transverse biopsy showed ganglion cells with no comment on nerve morphology 5:48. The team was in the operating room with frozen sections suggesting a transition zone far more proximal than usual.

The Decision Point

The question was whether to proceed with immediate pull-through based on frozen section. On frozen section, you can rule out Hirschsprung disease but cannot rule it in 5:23. The nightmare scenario: resecting colon based on absent ganglion cells on frozen, only to find ganglion cells were present on permanent sections 5:23. Hypertrophic nerves are mainly a sacral nerve plexus entity, found in sigmoid and rectum, not in more proximal colon 5:48 — so the absence of nerve hypertrophy in the transverse colon biopsy carried no diagnostic weight.

The hard rule applied here: if you don't have ganglion cells and you're at the splenic flexure, you should not do a pull-through that day and need to wait for permanent section 9:32. There are functional outcome differences if you start pulling through transverse colon versus pulling through left-sided colon 9:45. If you have even a little bit of colon, if you have your right colon, you can make one formed stool per day 10:20. Resecting more colon than necessary based on unreliable frozen sections would be irreversible harm.

The team had three options: divert at the dilated mid-transverse colon, perform an ileostomy, or close the biopsy sites and return in four days with permanent sections. If choosing the delayed primary approach, the child must be irrigated and doing well with irrigation, not having smoldering or low-grade enterocolitis features 6:09. An ileostomy almost definitely is going to successfully divert the patient, whereas with a diverting colostomy based on frozen section there is concern it may not be at a good level 6:49.

What They Did

The team performed colonic mapping with multiple biopsies and placed an ileostomy. Biopsies were marked with permanent suture using different numbers of tails for each biopsy site to enable identification at subsequent operation 7:29. In parts of the world without pathology support, diverting in the dilated segment is a very reasonable strategy, and if that bowel works, that is where the pull-through will go 7:07 — but with pathology available, the safer course was ileostomy diversion and definitive mapping.

Permanent sections confirmed the mid-transverse transition zone. The staged pull-through presented a technical challenge. For mid-transverse pull-through, you need to ligate the middle colic and very likely ligate the right colic, with blood supply dependent on ileocolic and the marginal artery paralleling the right colon 11:38. The blood supply is based on right colic artery 11:15. When bringing down mid-transverse colon, you need to de-rotate the bowel, otherwise you will bring the mesentery right across the duodenum and create an obstruction 11:21.

For proximal pull-through, you de-rotate by putting the cecum at the liver bed and bringing the pull-through down the right side, with all small bowel on the left side, which is essentially a rotation opposite to a Ladd's procedure 11:58. When doing a proximal pull-through, there is a slight twist in the mesentery when pulling it down, so ensuring adequate blood supply without kinking is very important 12:10. Personal preference is to do proximal pull-through open, probably through the incision for ileostomy closure, though some have done it laparoscopically 12:24.

What the Case Changes

The transferable judgment is about restraint. When frozen section places your transition zone at or proximal to the splenic flexure, the correct operation is not the pull-through — it is the mapping and the diversion. Colon is functional currency; you cannot afford to spend it based on provisional pathology. The technical execution of a proximal pull-through — ligating middle and right colic vessels, relying on ileocolic supply, de-rotating to bring the cecum to the liver bed — is straightforward once you have committed to it. The hard part is recognizing when not to commit.

Takeaways from this story

Frozen section can rule out Hirschsprung but not rule it in — at splenic flexure or proximal, defer pull-through for permanent sections.
Hypertrophic nerves are a sacral plexus finding; their absence in transverse colon carries no diagnostic weight.
For mid-transverse pull-through, ligate middle and right colic, rely on ileocolic supply, and de-rotate to avoid duodenal obstruction.
Mark biopsies with permanent suture using different tail counts — without this, re-exploration is like never having biopsied.
Even a small amount of preserved colon enables one formed stool per day; functional outcomes differ between transverse and left-sided pull-through.

Topic overview

This discussion addresses surgical management of proximal Hirschsprung disease with a transition zone in the transverse colon. The core clinical teaching emphasizes that when frozen sections show uncertain or proximal disease (splenic flexure or beyond), surgeons should perform colonic mapping and divert with an ileostomy rather than attempt immediate pull-through. The speakers detail the technical considerations for eventual pull-through when the transition zone is mid-transverse, including ligation of middle and right colic arteries, reliance on ileocolic blood supply, and de-rotation of the right colon to avoid duodenal obstruction. Preservation of even small amounts of colon (right colon alone) can produce one formed stool per day, making conservative resection critical.

Key takeaways

Frozen section can rule out Hirschsprung but not rule it in; if uncertain at splenic flexure, divert and wait for permanents. (5:23)
Preserving right colon alone yields one formed stool/day—resect conservatively when transition zone is mid-transverse. (10:20)
Mid-transverse pull-through requires ligating middle/right colic arteries; blood supply depends on ileocolic and marginal artery. (11:15)
De-rotate by placing cecum at liver bed to avoid duodenal obstruction; mesentery twist demands vigilance for vascular kinking. (11:21)
Ileostomy reliably diverts; mark biopsies with numbered suture tails for intraoperative identification at definitive pull-through. (6:49)

Keywords

Hirschsprung disease proximal Hirschsprung disease bilious vomiting enterocolitis duodenal obstruction pull-through ileostomy colostomy leveling colostomy colonic mapping rectal biopsy frozen section contrast enema irrigation mucous fistula

Hashtags

#HirschsprungDisease #PediatricSurgery #ColorectalSurgery #SurgicalTechnique

Transcript

Click "Show Transcript" to view the full text (12674 characters)

Hey there, listeners. How do you catch up on our podcast? Are you in Apple Podcast? Are you in Spotify or Stitcher? Well, I want you to use whatever is easiest for you, but you should know that if you're listening to this podcast on anything other than the Stay current in pediatric surgery app. You're missing out. Especially for these colorectal quizzes, because we have images that Doctor Levitt and Doctor Friisher are referring to in the app. So you can click on it, expand it, and you can look at exactly what they're talking about while they're talking about it to you. We also have links to journal articles when they reference them. There's a lot of content on there that you're missing out on. So if you haven't already, download the Stay Current and pediatric surgery app in the Apple App Store or your Google Play Store. But until then, enjoy the episode. Last week, Doctor Levitt and Doctor Fisher walked us through the surgical technique for your straightforward rectosigmoid Hirschsprung disease. It brought along a couple of friends, Doctor Aaron Garrison from Cincinnati Children's and Doctor Andrea Badillo from Children's National Hospital in Washington DC. It's such a good episode. If you missed it, then I would recommend jumping out of this one and going to last week's episode so you can catch it. But if you've been following along and you're ready for a more challenging case, Well, here it is. Now, to refresh everyone's memory, this is a patient who has more proximal disease, and I say that because I know the phrasing can get confusing, so instead of saying short segment, long segment, we're gonna try to stick with anatomic descriptions, transverse colon, hepatic flexure, versus last week, which is more of a sigmoid disease. This time, they're gonna walk you through the steps of surgical considerations for more proximal, as in transverse colon, Hirschberg disease. I'm Rod Gerardo from Cincinnati Children's, and this is the colorectal quiz. Now let's talk about the conduct of the operation when we have A more difficult transition zone. If you're in the stay current app, scroll down a little bit under the media player, you'll see some images. Pull it up. We have an X-ray and a contrast enema, and that's what Doctor Levitt's going to be talking about. Let's say we have this kid, you see the contrast study, mid-transverse looks dilated, the rest distal looks decompressed, and you do your biopsy, and you find ganglion cells in the mid-transverse colon only. And the biopsy that you did in the sigmoid and in the left colon were ganglionic. Now, what do we do? We're in the newborn period. It's a baby that had done well with irrigations, and we started off by doing our biopsies, and here's where, here's where we find ourselves. Um, well, I think like you, we mentioned in the last podcast, sometimes people take too many biopsies, so I think just, you know, confirming sort of that left colon is, um, is still a ganglionic. We've done that. And then you said transverse colon, we biopsied and that, um, has ganglion cells, but you didn't say whether they're hypertrophic nerves. So have they, have they commented on that? Yeah, yeah, so sorry, the, um, the, the sigmoid and the left colon are a ganglionic. And hypertrophic nerves. The mid-transverse biopsy is ganglionic, and they, they can't find any nerves. There's no comment. So I think these are the cases that are a little uh stressful, especially early in your career, and you're trying to decide uh what to do. And I think kind of keeping in mind that you can always get out of the OR without doing something permanent is, is kind of the goal. I think that's an awesome point, a really take-home point. This is all based on frozen sections. That's right, we're still in the OR, so you don't have to make a decision just now. In fact, in the back of Doctor Garrison's head, he's thinking. In the back of my mind, I would be thinking about whether we need to uh divert the patient, either with a colostomy or, or more likely uh an ileostomy. You do not need to do this pull through today. Instead, you could spend your time getting better biopsies all over the place, sigmoid, left colon, splenic flexure, transverse. You could do hepatic flexure or right colon, and then you got a choice. Divert at the dilated portion of the mid transverse colon, or divert at the ileum, or I'll even give you a third option. Close all your biopsy sites and stop, wait 4 days for the pathology to come back and then do your pull through. So you're waiting for your permanent section, because when it comes to frozen, you can rule out Hirschberg disease. But you can't rule it in. And what's the nightmare situation? And I've seen cases like this, where they are not finding ganglion cells, and particularly makes me nervous when they're not finding nerves. And in fact, there are ganglion cells there. You don't want to throw out a piece of coal and it might be good. And then the other thing to remember is the hypertrophic nerve concept is mainly a sacral nerve plexus entity. So hypertrophic nerves are sigmoid and rectum. So anything more proximal, don't worry about the nerves. Really, you just wanna know, are there ganglion cells? Yes or no? I do think if you're going to take that 3rd approach, which you mentioned, which I'm not suggesting we do. Of doing a primary pull through 4 days later, you have to make sure you're in a situation where that child is is getting irrigated and doing well with the irrigation. Because you don't want a baby who's gonna still smoldering and having low grade or enterocolitis-like features, um, and delaying the diversion, which will make that baby better. Uh, see, that's, that, I think that's a very vital point, and that's the reason why I personally would do colonic mapping and an ileostomy because I really wanna hit a home run today and get that baby well. And I'm always a little nervous with frozen section and a diverting colostomy, cause what if it's not in a good level, whereas an ileostomy almost definitely is going to divert successfully that patient, of course, we need to send a biopsy from that ileum. But if you're gonna do this empirically, and remember, there are there are many places in the world that do not have pathology to help them. They need to divert in the dilated segment, and that is a very reasonable strategy. To dilate and to divert in the dilated segment, and if that bowel then works, then that's where your pull through is going to go. And then don't forget, mark your biopsies with a permanent suture that I think is the key that we haven't mentioned. I use prolenes, permanent suture, and I use different number of tails for each biopsy, and then in my operative report, I label those biopsies. I think that's important because going back in a few months later. It's like you never biopsy. Then Doctor Levitt mentions if you're in a part of the world where you really can't do an ileostomy because you're worried about dehydrating the child, then you have to consider leveling at the colon. You know, if you're not gonna pull this kid through for 6 months, is beating that colon important? Not sure we have the answer. Would you, I think some people would probably ask if you're gonna do an ileostomy and leave that big colon in, would you do a long mucous fistula or like a yostomy to be able to irrigate, or do you just leave that deffunctionalized colon behind and um uh curious what you guys think. I typically would not. I think they're sort of two varieties that this comes in, um, that's Doctor Andrea Badillo from Children's National Hospital in DC and she brought up a good point. Hypothetically, let's say this patient comes in after several months, and the colon is incredibly backed up, the stool can be really chalky, and irrigations aren't gonna do anything. But if you don't have that issue, I think the colon can stay without really needing a way to irrigate it, and it's a smaller population of kids that are gonna need that colon addressed. Mark, can I ask one question? Sorry, but I think this is a question I get asked a lot. Where is your transition from primary pull through to, hey, Damage control, let's not do any harm. Is there a location? Where do you say, hold your horses, time to change the, the direction here. So, our, our hard fast rule here is if you don't have ganglion cells, and you're at the splenic flexure, you're not doing a pull-through today. You need to wait for permanent section because I agree with that. I mean, I think there's functional outcome differences if you start pulling through transverse colon versus pulling through left-sided colon, and it would be upsetting if you, if pathology just wasn't, you know, right at that time for whatever reason, and waiting, I think, to get that final pathology, uh, could make the difference for that child. So, if the frozen sections make it seem like you're gonna need to do an ileoanal, pump the brakes and reassess, because you don't want to resect more colon than you have to. You need colon. If you have even a little bit of colon, if you have your right colon, you can make 11 stool, one form stool per day. So I think that brings up uh like the real pearl, and we said this at, and what Aaron and Andrea really highlighted right at the beginning. And that is do no harm, especially for these complex patients. All right, getting back on track. Sorry, I keep diverting us. Ha ha ha. Oh Mark, a little slow there. OK, OK. So, let's say we did all of this, we made our ileostomy, and we have our permanent section, which shows what we thought previously. We have a transition zone in the transverse colon. It's pretty proximal. So now we have to do a pull-through, but look at this distance. So I think it's a nice uh exercise to think about what blood supply you're basing the pull-through on. And so at mid-transverse, you're gonna be Sort of right colic, right? And, and in order to bring that down, you're gonna need to de-rotate the bowel, otherwise, you're gonna be bringing that mesentery right across the duodenum and creating an obstruction. So you need to be able to bring that down the right pelvis. Yeah, I, I agree with that, and you need to ligate the middle colic. And very likely ligate the right colic, and your blood supply is dependent on your ileo colic and the marginal that parallels the right colon, and then you de-rotate, so you put the cecum. At the liver bed, and you bring the pull through down the right side, and you put all the small bowel over on the left side, which is essentially a a rotation opposite what you would do for a lad's procedure. And really, what happens when you think about this is you have a slight twist in your mesentery when you're pulling it down. So, obviously, making sure that the blood supply to your pull-through is adequate and not kinked in any way is very important. My personal preference is to do this kind of thing open. And I would probably do it through the incision for the ileostomy closure in this scenario. But I know uh some folks have done this laparoscopically, but it makes me a little bit nervous. Well, that's a tough case, huh? Yes, I think we discussed a lot of good points. Um, so you wanna, you want, um, to sum up a little bit? So this was a baby with bilious vomiting, and then contrast enema concerning for a proximal transition zone. On the transverse colon or more proximal, and you don't have to do a pull through today. Instead, think about potentially doing an ileostomy or a leveling colostomy depending on the situation. And then when the baby is better and you're ready to do the pull through, you have the permanent sections, you know exactly where you're gonna go. Look at the blood supply. You might have to do the rotation of the right colon to get the colon to reach the pelvis, and to not kink off or have that mesentery of the right colon, really making an accordion string, and that might cause a duodenal obstruction. Yikes. So, a lot more complex than last week's case, a lot of great learning points, and don't worry. I got not just 1, but 2 jokes for you. Wanna hear a poop joke? Nah, they always stink. Terrible, terrible. I've gone way down. And here's, here's a backup to that joke, OK? What do you call a snobby criminal going down the stairs? A condescending con descending. Oh boy. I think we've both digressed. You guys might have killed this feature. Well, I can't always guarantee we're gonna have quality humor, but we're always gonna give you quality surgical technique. I hope you enjoyed the episode. I'm Rod Gerarder from Cincinnati Children's, and remember, knowledge should be free.

Comments

Loading comments...