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Hirschsprung Disease Rapid Fire: Update Course 2015

Video Published 2019-01-11 Updated 2026-06-10

Timestops (7)

Laparoscopic Biopsy vs Transanal Approach

Laparoscopic Mobilization Technique and Benefits

Postoperative Complications and Obstructive Symptoms

Contrast Enema and Exam Findings

Anastomosis Level Above Dentate Line

Dentate Line Identification in Newborns

Ultra Short Segment Hirschsprung Considerations

Topic Overview

A rapid-fire case discussion on Hirschsprung disease management focusing on operative approach selection and complication workup. The primary debate centers on whether to perform laparoscopic biopsy and mobilization versus primary transanal pull-through for a newborn with confirmed Hirschsprung disease showing a high transition zone. Speakers emphasize that laparoscopic biopsy prevents the risk of encountering unexpectedly high aganglionosis during transanal dissection, which occurs in approximately 1 in 10 to 1 in 15 cases. A secondary discussion addresses the technical definition of the dentate line and optimal dissection level, with consensus around 1 centimeter above the anal columns to avoid sphincter injury while accepting the risk of leaving ultra-short segment aganglionosis.

Key Takeaways

1 in 10-15 transanal cases encounter unexpectedly high aganglionosis; laparoscopic biopsy prevents intraoperative surprises. (1:47)
Post-op obstruction needs anatomic vs pathologic workup: contrast enema, EUA for stricture/twist, then biopsy if negative. (5:53)
Dissect 1cm above dentate line: ultra-short segment (treatable with laxatives) beats sphincter injury (irreversible incontinence). (8:33)
Laparoscopic mobilization with 3mm ports takes ~45min vs 2hr transanal for standard rectosigmoid disease; consider invasiveness trade-offs. (3:50)

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

Jason — guest
Mark — guest
Speaker 3 — host
Doctor Holcomb — guest
Belinda — guest
Speaker 6 — guest

Chapters

0:00Case presentation and operative approach poll — Newborn with abdominal distention, feeding intolerance, and no meconium passage. Contrast enema shows high transition zone. Rectal biopsy confirms Hirschsprung disease. Panel discusses laparoscopic versus transanal approach, with emphasis on safety of laparoscopic biopsy to avoid unexpected findings.
3:44Invasiveness of transanal versus laparoscopic approach — Discussion of whether pure transanal approach is truly less invasive. Speakers note that prolonged transanal dissection with sphincter stretching may be more traumatic than three small abdominal ports. Time considerations favor laparoscopy for high lesions but transanal may be equivalent for standard rectosigmoid disease.
5:40Complications workup algorithm — Overview of post-Hirschsprung complications divided into obstructive symptoms versus soiling. Workup includes contrast enema and exam under anesthesia looking for stricture, stretched sphincter, dentate line injury, and twist. Biopsy performed if no anatomic cause found.
7:59Dentate line definition and dissection level — Technical debate on defining the dentate line and optimal dissection starting point. Consensus around 1 centimeter above the top of anal columns (transition from squamous to columnar epithelium). Speakers prioritize avoiding dentate line injury over risk of leaving ultra-short segment aganglionosis, which can be managed with laxatives.

Key claims

1:47For the average pediatric surgeon doing transanal pull-through without prior biopsy, approximately 1 in 10 to 1 in 15 cases will have aganglionosis higher than expected or involve total colon — Doctor Holcomb
3:50Putting three abdominal incisions may be less invasive than prolonged transanal dissection with torquing in the anal canal — Speaker 3
4:57Laparoscopic mobilization with three 3-millimeter ports can be completed in approximately 45 minutes — Jason
5:06Standard rectosigmoid Hirschsprung disease 6 to 10 centimeters up can be done transanally in approximately 2 hours — Jason
5:53Post-Hirschsprung complications divide into obstructive symptoms (enterocolitis, failure to thrive, abdominal distention) and soiling issues (true incontinence versus pseudo-incontinence) — Jason
6:13Obstructive symptoms after Hirschsprung surgery require determining whether the cause is anatomic or pathologic — Jason
6:20True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line — Jason
6:53Workup for post-Hirschsprung problems includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twist — Jason
6:53If no anatomic cause is found on exam under anesthesia, biopsy should be performed — Jason
7:20A stretched sphincter is determined by observation of a patulous anus, whereas Hirschsprung anus should appear normal with a normal anal canal — Jason
7:33MRI utility for Hirschsprung complications is uncertain because unlike anorectal malformations where anus placement within sphincters is assessed, Hirschsprung dissection goes through the sphincter and anal canal without anus repositioning — Jason
8:33Starting dissection approximately 1 centimeter above the dentate line in a newborn may result in 2.5 to 3 centimeters of retained aganglionic segment when the child reaches 7 years old — Jason
8:59If dissection starts too high and subsequent biopsy is not taken high enough, the biopsy may show transition zone rather than definitive aganglionosis — Jason
9:11Injury to the dentate line can render patients fecally incontinent, which is a devastating injury — Jason
9:37The dentate line is defined as the transition from squamous epithelium to columnar epithelium, located somewhere within the anal columns — Jason
10:07In J-pouch surgery for ulcerative colitis or FAP, dissection is performed right at the top of the columns or slightly lower if polyps are present in that region — Jason
11:50Ultra-short segment aganglionosis can be overcome with laxatives, whereas fecal incontinence cannot be overcome — Belinda
12:04The surgical approach hedges on the side of leaving ultra-short segment Hirschsprung disease rather than injuring the anal canal — Jason

Cases discussed

0:07Newborn with Hirschsprung disease and high transition zone on contrast enema

Points of disagreement

1:16Necessity of laparoscopic biopsy versus primary transanal approach for standard rectosigmoid Hirschsprung disease
- Mark: Would perform laparoscopy even for standard rectosigmoid lesion because the surgeon can be fooled about the level
- Jason: For standard rectosigmoid disease 6-10 cm up with good contrast study, transanal approach can be done in same timeframe as laparoscopic approach
- Doctor Holcomb: For average pediatric surgeon, laparoscopic approach is safer because 1 in 10-15 cases will have higher aganglionosis than expected, leaving surgeon with colon in hand and uncertain how to proceed
8:05Definition and measurement of the dentate line for determining dissection starting point
- Doctor Holcomb: Goes 1 centimeter or slightly less above the top of the anal columns
- Jason: Defines dentate line as transition from squamous to columnar epithelium within the columns, then goes 1 centimeter above that transition
- Belinda: Goes to the top of the columns, intentionally leaving a zone of aganglionosis that can be managed with laxatives to avoid fecal incontinence

Open questions

What is the utility of MRI in evaluating complications after Hirschsprung surgery?
Is there a standardized measurement from anoderm to the top of the anal columns in newborns that could serve as a universal landmark?
What is the optimal management strategy when unexpectedly high aganglionosis is encountered during transanal dissection?
How should surgeons manage cases where pathology services are unavailable or unreliable, such as during mission trips?

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:

When Transanal Dissection Meets Unexpected Anatomy in Hirschsprung Disease

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 abdominal distention, feeding intolerance, and failure to pass meconium 1:47. Contrast enema demonstrated a transition zone at the level of the descending colon — higher than the typical rectosigmoid location 1:47. Suction rectal biopsy confirmed Hirschsprung disease with absent ganglion cells, hypertrophic nerve trunks, and abnormal acetylcholinesterase staining.

The Decision Point

The discussants debated operative approach for this high lesion. The central tension was between starting with transanal dissection — potentially less invasive if the anatomy cooperates — versus accepting three small abdominal incisions upfront to control what might become a difficult dissection from below.

Doctor Holcomb framed the risk plainly: "for the standard. Average pediatric surgeon, if you just do the transanal, if you just do the transanal one to begin with, you're going to 1 in 10 times or so or 1 in 15 times, sometime in your career, you're going to find one that's higher than you wanted it or a total colon" 1:47. The scenario he described — standing transanally with mobilized colon in hand and no clear exit strategy — is a position no surgeon wants to occupy.

One discussant challenged the premise that transanal is inherently less invasive, arguing that abdominal ports may involve less sphincter traction than prolonged deep transanal dissection in a confined space 3:50. Laparoscopic mobilization with three 3-millimeter ports can be completed in approximately 45 minutes 4:57, comparable to the roughly 2 hours required for standard rectosigmoid disease managed transanally 5:06.

The panel reached consensus that this high lesion warranted laparoscopic biopsy and mobilization rather than starting from below. For standard rectosigmoid disease 6 to 10 centimeters proximal, opinions diverged based on individual comfort and operative efficiency.

The Broader Problem

The discussion then shifted to the complications that define long-term outcomes. Post-Hirschsprung problems divide into obstructive symptoms — enterocolitis, failure to thrive, distention — and soiling issues, which separate further into true incontinence versus pseudo-incontinence from overflow 5:53. Obstructive symptoms require determining whether the cause is anatomic or pathologic 6:13. True fecal incontinence can result from injury to the sphincter or injury to the dentate line 6:20.

Workup includes water-soluble contrast enema and exam under anesthesia, specifically assessing dentate line position, stricture, sphincter patency, and any twist in the pull-through 6:53. If no anatomic cause emerges, biopsy is indicated 6:53. A stretched sphincter is identified by observation of a patulous anus, whereas the Hirschsprung anus should appear normal with an intact anal canal 7:20.

The Technical Dilemma

The discussants debated where to start the transanal dissection relative to the dentate line — the transition from squamous to columnar epithelium located within the anal columns 9:37. Starting approximately 1 centimeter above the dentate line in a newborn may result in 2.5 to 3 centimeters of retained aganglionic segment when the child reaches 7 years old 8:33. If dissection starts too high and subsequent biopsy is not taken high enough, the biopsy may show transition zone rather than definitive aganglionosis 8:59.

But the alternative carries worse consequences. "The patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients" 9:11. One discussant stated the trade-off explicitly: "we probably leave a zone of angliosis, but we do that on purpose because you can overcome that with laxatives. You can't overcome fecal incontinence, right?" 11:50.

The surgical approach hedges on the side of leaving ultra-short segment Hirschsprung disease rather than injuring the anal canal 12:04. In J-pouch surgery for ulcerative colitis or familial adenomatous polyposis, dissection is performed right at the top of the columns or slightly lower if polyps are present in that region 10:07 — a reference point that does not translate directly to Hirschsprung surgery, where preservation of continence mechanism takes precedence over complete resection of aganglionic bowel.

What the Case Changes

The case illustrates that "less invasive" is not a fixed property of an approach but a function of anatomy, surgeon experience, and the risk of conversion. For high lesions or uncertain anatomy, three small ports may spare the sphincter complex more than prolonged transanal traction. The dentate line is not a target but a boundary — cross it and the injury is irreversible. Ultra-short segment aganglionosis can be overcome with laxatives, whereas fecal incontinence cannot be overcome 11:50.

Takeaways from this story

For transanal pull-through without prior biopsy, approximately 1 in 10 to 1 in 15 cases will have higher aganglionosis than expected.
Three small abdominal ports may be less invasive than prolonged transanal dissection with sphincter traction in high or uncertain lesions.
Starting dissection 1 cm above the dentate line in a newborn may leave 2.5-3 cm of aganglionic segment by age 7.
Injury to the dentate line causes irreversible incontinence; ultra-short segment aganglionosis can be managed with laxatives.

Balancing Sphincter Preservation Against Complete Resection in Hirschsprung Pull-Through

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

This discussion addresses the judgment calls that separate routine Hirschsprung management from the decisions that prevent long-term complications. The teaching centers on risk stratification, operative time awareness, and the irreversible nature of certain technical errors.

Expect the unexpected in 1 of 10 cases.

Even experienced surgeons performing primary transanal pull-through without laparoscopic biopsy will encounter aganglionosis extending higher than anticipated in approximately 1 in 10 to 1 in 15 cases 1:47. The critical question is not whether this will happen, but whether you have a predetermined plan when you find yourself holding colon you cannot reach transanally. For surgeons without extensive colorectal experience, laparoscopic biopsy and mobilization provides both diagnostic certainty and a technical advantage — three 3-millimeter ports allow complete mobilization in approximately 45 minutes 4:57. The alternative is discovering intraoperatively that your approach is inadequate.

Watch the clock during transanal dissection.

Prolonged transanal dissection inflicts sphincter trauma that three small abdominal incisions do not 3:50. Standard rectosigmoid disease 6 to 10 centimeters proximal can be completed transanally in approximately 2 hours 5:06, but if you are approaching that time frame without completing mobilization, conversion to laparoscopy may be less invasive than continued torquing in the anal canal. This is not about technical capability — it is about recognizing when the anatomy is not cooperating and choosing the approach that minimizes sphincter stretching.

Err toward leaving ultra-short segment disease rather than injuring the dentate line.

The most consequential decision in pull-through surgery is where to start the dissection relative to the dentate line. Starting approximately 1 centimeter above the dentate line in a newborn may result in 2.5 to 3 centimeters of retained aganglionic segment when the child reaches school age 8:33. This creates a management problem — but one that responds to laxatives 11:50. The alternative error — injury to the dentate line — renders patients fecally incontinent, which is devastating and irreversible 6:20. The surgical approach therefore hedges deliberately on the side of leaving ultra-short segment Hirschsprung disease rather than injuring the anal canal 12:04. You can overcome residual aganglionosis medically; you cannot overcome incontinence.

Use the top of the anal columns as your landmark.

The dentate line is defined as the transition from squamous to columnar epithelium, located somewhere within the anal columns 9:37. In practice, the top of the columns provides a consistent visual landmark. In J-pouch surgery for ulcerative colitis or FAP, dissection is performed right at the top of the columns or slightly lower if polyps are present 10:07. For Hirschsprung pull-through, starting 1 centimeter above this landmark balances the competing risks. If you start dissection too high and subsequent biopsy is not taken high enough, the biopsy may show transition zone rather than definitive aganglionosis, complicating interpretation 8:59.

Distinguish anatomic from pathologic causes of obstruction.

Post-operative complications divide into obstructive symptoms — enterocolitis, failure to thrive, abdominal distention — and soiling issues, which separate into true incontinence versus pseudo-incontinence 5:53. Obstructive symptoms require determining whether the cause is anatomic or pathologic 6:13. Workup includes water-soluble contrast enema and exam under anesthesia, looking specifically for dentate line position, stricture, stretched sphincter, and twist 6:53. A stretched sphincter is determined by observation of a patulous anus, whereas a properly performed Hirschsprung pull-through should leave a normal-appearing anus with a normal anal canal 7:20. If no anatomic cause is found, biopsy should be performed 6:53.

The discussants emphasized that the choice to leave a small segment of aganglionosis is deliberate, not a technical failure — it reflects an understanding that the consequences of the two possible errors are not equivalent.

Takeaways from this story

Primary transanal approach without laparoscopic biopsy will encounter unexpectedly high aganglionosis in ~1 in 10-15 cases — have an exit strategy.
If transanal dissection approaches 2 hours without completion, conversion to laparoscopy may cause less sphincter trauma than continued dissection.
Start dissection ~1 cm above the dentate line; leaving ultra-short segment disease is preferable to dentate line injury causing incontinence.
A stretched sphincter appears as a patulous anus on exam; normal Hirschsprung pull-through should leave a normal-appearing anal canal.

Surgical Judgment in Hirschsprung Pull-Through: Balancing Speed, Safety, and Long-Term Function

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 specialists · Teaching arc · AI-written, human-reviewed

Preoperative risk assessment determines operative strategy

The decision to proceed with primary transanal pull-through versus laparoscopic biopsy and mobilization is fundamentally a risk calculation, not a technical preference. Even for experienced surgeons, approximately 1 in 10 to 1 in 15 cases will have aganglionosis extending higher than anticipated or involving the total colon when approached transanally without prior biopsy 1:47. The critical question is not whether the surgeon can complete a transanal dissection, but whether they have a predetermined exit strategy when the transition zone is higher than expected. For surgeons without extensive colorectal experience, laparoscopic biopsy and mobilization provides definitive information about the extent of disease before committing to a transanal approach. The standard rectosigmoid case—6 to 10 centimeters proximal—can be completed transanally in approximately 2 hours 5:06, but this assumes the preoperative assessment is correct.

Operative time is a proxy for sphincter trauma

The concept of "less invasive" must account for what happens inside the anal canal, not just what is visible on the abdominal wall. Prolonged transanal dissection with torquing and stretching may be more traumatic than three 3-millimeter abdominal ports 3:50. Laparoscopic mobilization can be completed in approximately 45 minutes 4:57, establishing a time benchmark: if transanal dissection is taking substantially longer, the surgeon is likely causing sphincter injury that will not be apparent until the patient is older. Monitoring operative time during transanal dissection is not about efficiency—it is about recognizing when the anatomy is unfavorable and conversion would be safer. A stretched sphincter is identified by observation of a patulous anus, whereas the Hirschsprung anus should appear normal with a normal anal canal 7:20.

Growth amplifies neonatal dissection errors

Starting dissection approximately 1 centimeter above the dentate line in a newborn may result in 2.5 to 3 centimeters of retained aganglionic segment when the child reaches 7 years old 8:33. This growth factor creates a dilemma: dissect too low and risk dentate line injury with permanent incontinence; dissect too high and leave symptomatic ultra-short segment disease. The surgical approach deliberately hedges toward leaving ultra-short segment Hirschsprung disease rather than injuring the anal canal 12:04, because ultra-short segment aganglionosis can be overcome with laxatives, whereas fecal incontinence cannot be overcome 11:50. Injury to the dentate line—the transition from squamous to columnar epithelium located within the anal columns 9:37—can render patients fecally incontinent, which is a devastating injury 9:11. In J-pouch surgery for ulcerative colitis or FAP, dissection is performed right at the top of the columns or slightly lower if polyps are present in that region 10:07, but in Hirschsprung surgery the stakes are different because the patient is a child who will grow.

Diagnostic workup must distinguish anatomic from pathologic obstruction

Post-Hirschsprung complications divide into obstructive symptoms—enterocolitis, failure to thrive, abdominal distention—and soiling issues, which separate into true incontinence versus pseudo-incontinence 5:53. Obstructive symptoms require determining whether the cause is anatomic or pathologic 6:13. True fecal incontinence can result from injury to the sphincter or injury to the dentate line 6:20. The workup includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twist 6:53. If no anatomic cause is found on exam under anesthesia, biopsy should be performed 6:53. The challenge is that if dissection starts too high and subsequent biopsy is not taken high enough, the biopsy may show transition zone rather than definitive aganglionosis 8:59, leaving the diagnosis uncertain and the patient symptomatic.

Takeaways from this story

1 in 10-15 transanal cases without prior biopsy will have higher aganglionosis than expected—have an exit strategy before starting
Transanal dissection taking longer than 45 minutes suggests unfavorable anatomy; conversion may cause less sphincter trauma than continuing
1 cm of retained tissue in a newborn becomes 2.5-3 cm by age 7; growth amplifies dissection level errors
Deliberately leave ultra-short segment disease rather than risk dentate line injury—laxatives treat one, nothing treats the other
If biopsy after failed pull-through shows transition zone rather than aganglionosis, the biopsy was not taken high enough

Keywords

Hirschsprung disease enterocolitis failure to thrive abdominal distention fecal incontinence pseudo-incontinence constipation short segment Hirschsprung disease ultra short segment Hirschsprung disease total colonic aganglionosis ulcerative colitis FAP anorectal malformations suction rectal biopsy laparoscopic biopsy

Hashtags

#HirschsprungDisease #PediatricSurgery #MinimallyInvasive #ColorectalSurgery

Transcript

All right, excellent. So I have a couple of patient presentations to do. The first one's a simple just to get a poll of the audience. So a newborn with increased abdominal distention, not tolerating feeds and hasn't passed meconium, you get a contrast study with whatever material you want to use, and it's demonstrated on the screen. What, how would you proceed? Would you proceed with a laparoscopic and you get a suction rectal biopsy that demonstrates no ganglion cells, hypertrophic nerves, and abnormal ACE staining. So you have confirmation of Hirschprung's disease with this contrast enema. Would you do lapa laparoscopic biopsies, mobilization of the colon and a transanal technique? Would you do a transanal dissection and then only go to laparoscopy or a laparotomy if needed? Would you do an open biopsy and immobilization in the colon, or would you do a leveling colostomy or some other technique you may have developed? How about in the audience, Mark, what would you do on a with this contrast enema? I'd do a laparoscopic biopsy and pull through in laparoscopic mobilization, yeah, yeah. Mac, what same. What happens if it showed a more Standard rectosigmoid, I think this is a higher, it's almost like at the descending colon, where's the transition, but if it was a rectosigmoid lesion that you think you could reach from below, would you still do laparoscopy or would you start transanally? No, I'd still do laparoscopy because I think you can be fooled. Same. I think that Jason, you're more of an expert at colorectal disease than I am, and there are 2 or 3 others around our country, but for the standard. Average pediatric surgeon, if you just do the transanal, if you just do the transanal one to begin with, you're going to 1 in 10 times or so or 1 in 15 times, sometime in your career, you're going to find one that's higher than you wanted it or a total colon. And then you're going to have the colon in your hands and not know what to do with it. So I, I just want to put that out there. Yeah, it's not going to happen very often, but it will probably happen in your career at some point. And so if you're going to do the transanal without a biopsy, just figure out what you're going to do in that situation. And you know this more than I do, but you're an expert, and, and I'm just an average practicing pediatric surgeon. I, I, Doctor Holcomb, I appreciate your comments, and I, I agree with you. I, every time that I Do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble, um, but The safe way to do this is some sort of biopsy, whether you do it laparoscopically or a laparoscopic mobilization, maybe do the biopsy through the umbilicus if you want to get a nice full thickness biopsy, whatever your technique or trick is, that's certainly the safest way to go. Jason, um, I was noticing on the poll, almost 30% of the folks in the audience are going to do a leveling colostomy, so you can comment on that. I think Uh, I think that's a safe thing to do. It depends on what pathologists, your pathology at your home institution, if you have concern about your pathologist, if you don't have someone comfortable reading, um, for Hirschberg's disease, uh, that might be the safest thing to do. I know people who go on mission trips and trips where you don't have pathologists. It's a almost a 3 stage type procedure to do that. So our audience is diverse and so it might depend where they're coming from. Let's ask those who answered leveling colostomy if you could leave a comment on on on why you chose that. I just want to make one comment that Belinda and I talked about and uh is that I, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm going to be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach. I think this is just like anything else. Belinda, go ahead. It depends on your comfort level. I mean, we've talked about this before, you know, I, with the transanal trying to get high past the pelvic reflection. You're, you're pulling and you're stretching. So if you're comfortable with that, then OK. But um, I think if it's beyond that, then you're going to do laparoscopy or laparotomy if you're not Belinda and I talk about this a lot, and it's about a comfort level and how I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in. I easily put 3. 3 millimeter ports in and mobilize laparoscopically in 45 minutes or so and get the same what's so because I could do it from the bottom in the same time frame if it's a nice standard rectosigmoid's rectosigmoid you can get it done in a couple hours. I mean if you know where your level is and if you have a good contrast study, I think the image on the screen I would do with laparoscopy without question, but a standard rectosigmoid 68, 10 centimeters up, I could do transamally in the same time frame. OK. We, did we cut you off? Were you gonna say something? OK. So that was not controversial at all, and I'm gonna, that was the simple question. Now I wanted to go on to complications a little bit, and this is the, the patient population I really enjoy taking care of, and I think that pediatric surgeons need to be aggressive at caring for these patients because they are our patients, and I think we know what's. How to help them best and so patients who have complications after Hirschberg's disease, we sort of put into two piles. They either have obstructive symptoms and things like enterocolitis, failure to thrive, abdominal distention, or they have soiling issues and then divide them into true incontinence and pseudo incontinence. And then the patients with obstructive symptoms you have to discern whether it's an anatomic problem or a pathologic problem. And Soiling, like I said, you have to discern whether it's true fecal incontinence, and that could be due to injury to the sphincter, injury to the dentate line, or pseudo incontinence. Is there a constipation issue causing the incontinence? This is a, I include this in the slides, and I'm not going to go over it. I think Jack Langer published this in a paper, um, a few years ago, this algorithm, which really does a nice job of describing how to work up patients with, um. With problems after Hirschrung's disease. The workup I, I include, includes a contrast enema, water soluble, and then an exam under anesthesia, looking for the listed items below which dentate lines, stricture, stretched sphincter, um, looking for twists, and then I, if I don't find a reason for the patient having problems, I'll do a biopsy. A paulous anus. So if it, if it, so just looking at it, not, no. The question was how do I determine a stretched sphincter, and it was basically by observation. If you have a patchless anus, Hirschberg's anus should be a normal appearing anus with a normal anal canal. Is MRI for anal rectal malformations. Do you think it's of any utility in looking at problems? I think with anal rectal malformations they're looking at placement of the anus within the sphincters and you're splitting the sphincters when you do that procedure versus Hirschberg's disease you're dissecting right through in the sphincter and in the anal canal and you're not placing the anus, so I, I'm not sure we haven't done it. I don't know if other centers are doing anything of that nature. So patient two is a 3 year old. Uh, you had a question. Yeah, Jason, quick question I've asked. This question to several experts and I'm interested in your feeling. What do you, where do you start your anal rectal dissection? And if you use the so-called dentate line, how do you define what the dentate line actually is? Oh, great question, and I took those slides out because this is rapid fire, but from to answer, where do I go above the dentate line? I go approximately 1 centimeter above the dentate line, so some people will go 0, like 0.5 centimeter, 1 centimeter, 1 centimeter, 2, and I, I worry about this because if we're doing this in a newborn, that, that distance of 1 centimeter might become 2.5 or 3 centimeters when they're 7 years old and having constipation issues. So then you're left with a situation of what some would call short segment or ultra short segment Hirschprung's disease. And then if you go back and biopsy, you, if you don't go high enough, you might get a biopsy that shows transition zone or something, so it's a great question. I go approximately 1 centimeter above the dentate line. I want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients. I'd go 1 centimeter or slightly less above the top of the anal columns. What do you call the dentate line in relation to the columns? So you go 1 centimeter above the columns. So I, I measure the dentate line is the transition of of columnar epithelium. And so I look at, and I obviously don't have a microscope there, but it's somewhere within those columns where that is. So I take. I go at the line of where you see the transition from squamous epithelium to columnar epithelium and go 1 centimeter above that, so it's easier for me just to see, to use the columns as a landmark. Is that right or not going pretty high. I do that when I do my J pouches. I take my, when I do my J pouches, I'll go right at the top of the columns in an ulcerative colitis patient, an FAP patient. I may even hedge a little lower than that, especially if they have polyps in that region. So, so how, how variable is, how variable is that distance of the from the skin to the top of the columns if it's almost always exactly the same. But it's not, and it grows with the patient, but they're almost always doing it right neonate as a neonates. Yeah, I'm talking about a newborn, a newborn in a newborn, if you measure it, you guys should do that since you get so many is measure if that is almost always the same in every newborn, to measure from, from skin to the top of the columns, annoderm to, yeah, anoderm to the top of the columns. If that number is always there, then you skin. I mean, use a thing that everyone can, there's a true landmark, a true landmark. I give this presentation in our course that we have in a couple of weeks, and I have pictures from the internet from Netter and from other sources. The dentate line, whether in cartoon fashion or in anatomic dissection, is pointed to, and you could call it the pectinate line, the dentate line. It's very variable where people point it at. It's somewhere within those columns where people point at you as the surgeon. everybody always talks about, I define as the transition from squamous to columnar, and that's where the bottom of the columns really sort of lie. I don't know, Belinda, Keith George and I used to argue about this. So I also have taken the tops of the column as a standard spot, and whether you go there, you go above there, I have found that to be the best landmark. I think we actually go to the top of the columns. I mean, when we do it, because you always hide the dentate line and go above, and, and we probably leave a zone of angliosis, but we do that on purpose because you can overcome that with laxatives. You can't overcome fecal incontinence, right? So I, I think we hedge on the side of leaving an ultra short segment Hirschrung's disease versus injuring the anal canal. Great, that's a great.

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