Swenson’s Procedure

  • Eiji NishijimaEmail author


Swenson’s procedure for the patients with Hirschsprung’s disease was introduced after strictly controlled laboratory works by Orvar Swenson in 1948. The procedure needed meticulous rectal dissection to reduce complications to the surrounding structures. The largest series including 880 patients studying both the immediate operative and the long-term outcomes of the patients treated with the Swenson’s procedure was reported in 1989. The result was affirmative and supportive, never inferior to Soave and Duhamel’ pull-through. This approach has changed considerably over the past four decades, changing to primary repair, using laparoscopy, and approaching transanally.

The author describes technical advances relating complete removal of the aganglionic segment, an oblique anastomosis above the dentate line, an extra-pelvic anastomosis, and a transanal technique. The dentate line is a key landmark for Swenson’s pull-through procedure in order to preserve fecal continence and facilitate voluntary bowel movement. Swenson described the oblique line of resection and anastomosis that is 0.5–1.0 cm apart from the dentate line on the posterior midline and 2.0 cm above the dentate line anteriorly. The author emphasizes importance of adjustment to the resection level of the internal sphincter on the posterior midline according to the various levels of pull-through bowel. As for the transanal pull-through, Soave’s technique is approaching to Swenson’s concept by reducing the residual length of the muscle cuff to 1.0 cm above the dentate line, now referred as “Soaveson’s” procedure. Pediatric surgeons must keep learning details of the new techniques for Hirschsprung’s disease on the proper training system.


Hirschsprung’s disease Swenson’s procedure Modified Swenson’s procedure Kimura’s colon patch Extensive aganglionosis Transanal approach Dentate line 


  1. 1.
    Swenson O, Bill AH. Resection of the rectum and rectosigmoid with preservation of the sphincter for benign spastic lesions producing megacolon: an experimental study. Surgery. 1948;24:212–20.PubMedGoogle Scholar
  2. 2.
    Swenson O, Neuhauser EBD, Pickett LK, et al. New concepts of the etiology, diagnosis and treatment of congenital megacolon (Hirschsprung’s disease). Pediatrics. 1949;4:201–9.PubMedGoogle Scholar
  3. 3.
    Swenson O, Rheinlander HF, Diamond I. Hirschsprung’s disease: a new concept of the etiology. Operative results in thirty four patients. N Engl J Med. 1949;241:551–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Swenson O, Fisher JH, MacMahon HE. Rectal biopsy as an aid in the diagnosis of Hirschsprung’s disease. N Engl J Med. 1955;253:632–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Swenson O. Follow-up on 200 patients treated for Hirschsprung’s disease during a ten-year period. Ann Surg. 1957;146:706–14.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Swenson O, Sherman JO, Fisher JH. Diagnosis of congenital megacolon: an analysis of 501 patients. J Pediatr Surg. 1973;8:587–94.CrossRefPubMedGoogle Scholar
  7. 7.
    Swenson O. Hirschsprung’s disease. In: Raffensperger JG, editor. Swenson’s pediatric surgery. 4th ed. New York, NY: ACC; 1980. p. 506–31.Google Scholar
  8. 8.
    Swenson O. Early history of the therapy of Hirschsprung’s disease: facts and personal observations over 50 years. J Pediatr Surg. 1996;31(8):1003–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Swenson O. How the cause and cure of Hirschsprung’s disease were discovered. J Pediatr Surg. 1999;34(10):1580.CrossRefPubMedGoogle Scholar
  10. 10.
    Swenson O. Hirschsprung’s disease: a review. Pediatrics. 2002;109:914–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Swenson O. Hirschsprung’s disease – a complicated therapeutic problem: Some thoughts and solutions based on data and personal experience over 56 years. J Pediatr Surg. 2004;39(10):1449–53.CrossRefPubMedGoogle Scholar
  12. 12.
    Sherman JO, Snyder ME, Weitzman J, et al. A 40-year multinational retrospective study of 880 Swenson procedures. J Pediatr Surg. 1989;24:833–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Teitelbaum DH, Coran AG. Hirschsprung disease. In: Spitz L, Coran AG, editors. Operative pediatric surgery. 7th ed. New York, NY: Taylor & Francis Group; 2013. p. 560–81.CrossRefGoogle Scholar
  14. 14.
    Avansino JR, Levitt MA. Hirschsprung disease. In Fundamentals of pediatric surgery, 2, Mattei P. et al (eds.) pp 513–524, 2017, Springer International Publishing, Cham.Google Scholar
  15. 15.
    So HB, Schwartz DL, Becker JM, et al. Endorectal “pullthrough” without preliminary colostomy in neonates with Hirschsprung’s disease. J Pediatr Surg. 1980;15:470–1.CrossRefPubMedGoogle Scholar
  16. 16.
    Cass DT. Neonatal one-stage repair of Hirschsprung’s disease. Pediatr Surg Int. 1990;5:341–6.CrossRefGoogle Scholar
  17. 17.
    Langer JC, Fitzgerald PG, Winthrop AL, et al. One vs two stage Soave pull-through for Hirschsprung’s disease in the first year of life. J Pediatr Surg. 1996;31:33–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Georgeson KE, Fuenfer MM, Hardin WD. Primary laparoscopic pullthrough for Hirschsprung’s disease in infants and children. J Pediatr Surg. 1995;30:1017–21.CrossRefPubMedGoogle Scholar
  19. 19.
    Kumar R, Mackey A, Borzi P. Laparoscopic Swenson procedure-an optimal approach for both primary and secondary pull-through for Hirschsprung’s disease. J Pediatr Surg. 2003;38(10):1440–3.CrossRefPubMedGoogle Scholar
  20. 20.
    Curran TJ, Raffensperger JG. Laparoscopic Swenson pull-through: a comparison with the open procedure. J Pediatr Surg. 1996;31(8):1155–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Georgeson KE, Robertson DJ. Laparoscopic-assisted approaches for the definitive surgery for Hirschsprung’s disease. Semin Pediatr Surg. 2004;13(4):256–63-2.CrossRefPubMedGoogle Scholar
  22. 22.
    Hebra A, Smith VA, Lesher AP. Robotic Swenson pull-through for Hirschsprung’s disease in infants. Am Surg. 2011;77(7):937–41.PubMedGoogle Scholar
  23. 23.
    De la Torre-Mondragon L, Ortega-Salgado JA. Transanal endorectal pull-through for Hirschsprung’s disease. J Pediatr Surg. 1998;33:1283–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Langer JC, Minkes RK, Mazziotti MV, et al. Transanal one-stage Soave procedure for infants with Hirschsprung’s disease. J Pediatr Surg. 1999;34:148–52.CrossRefPubMedGoogle Scholar
  25. 25.
    Dasgupta R, Langer JC. Transanal pull-through for Hirschsprung disease. Semin Pediatr Surg. 2005;14(1):64–71.CrossRefPubMedGoogle Scholar
  26. 26.
    Sookpotarom P, Vejchapipat P. Primary transanal Swenson pull-through operation for Hirschsprung’s disease. Pediatr Surg Int. 2009;25(9):767–73.CrossRefPubMedGoogle Scholar
  27. 27.
    De la Torre L, Langer JC. Transanal endorectal pull-through for Hirschsprung’s disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms. Semin Pediatr Surg. 2010;19:96–106.CrossRefGoogle Scholar
  28. 28.
    Nasr A, Langer JC. Evolution of the technique in the transanal pull-through for Hirschsprung disease: effect on outcome. J Pediatr Surg. 2007;42:36–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Weidner BC, Waldhausen JHT. Swenson revisited: a one-stage, transanal pull-through procedure for Hirschsprung’s disease. J Pediatr Surg. 2003;38(8):1208–11.CrossRefPubMedGoogle Scholar
  30. 30.
    Rouzrokh M, Khaleqhnejad AT, Mohejerzadeh L, et al. What is the most common complication after one-stage transanal pull-through in infants with Hirschsprung’s disease? Pediatr Surg Int. 2010;26(10):967–70.. (86 patients. Swenson-like procedure, rectum at 1 cm above dentate line)CrossRefPubMedGoogle Scholar
  31. 31.
    Levitt MA, Hamrick MC, Eradi B, Bischoff A, Hall J, Pena A. Transanal, full-thickness, Swenson-like approach for Hirschsprungs disease. J Pediatr Surg. 2013;48(11):2289–95.CrossRefPubMedGoogle Scholar
  32. 32.
    Nasr A, Haricharan RN, Gamarnik J, Langer JC. Transanal pullthrough for Hirschsprung disease: matched case-control comparison of Soave and Swenson techniques. J Pediatr Surg. 2014;49(5):774–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Yokoi A, Satoh S, Takamizawa S, et al. The preliminary study of modified Swenson procedure in Hirschsprung disease. J Pediatr Surg. 2009;44(8):1560–3.CrossRefPubMedGoogle Scholar
  34. 34.
    Dickie B, Webb K, Eradi B, Levitt MA. The problematic Soave cuff in Hirschsprung disease: manifestations and treatment. J Pediatr Surg. 2014;49(1):77–81.CrossRefPubMedGoogle Scholar
  35. 35.
    Ziegler MM, Royal RE, Brandt J, et al. Extended myectomy-myotomy. A therapeutic alternative for total intestinal aganglionosis. Ann Surg. 1993;218:504–9.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Kimura K, Nishijima E, Muraji T, et al. A new surgical approach to extensive aganglionosis. J Pediatr Surg. 1981;6:840–4.CrossRefGoogle Scholar
  37. 37.
    Nishijima E, Kimura K, Tsugawa C, Muraji T. The colon patch graft procedure for extensive aganglionosis: long-term follow-up. J Pediatr Surg. 1998;33(2):215–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Lawal TA, Chatoorgoon K, Collins MH, Coe A, Pena A, Levitt MA. Redo pull-through in Hirschsprung disease for obstructive symptoms due to residual aganglionosis and transition zone bowel. J Pediatr Surg. 2011;46(2):342–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Levitt MA, Dickie B, Pena A. Evaluation and treatment of the patient with Hirschsprung disease who is not doing well after a pull-through procedure. Semin Pediatr Surg. 2010;19(2):146–53.CrossRefPubMedGoogle Scholar
  40. 40.
    Levitt MA, Dickie B, Pena A. The Hirschsprungs patient who is soiling after what was a considered a “successful” pull-through. Semin Pediatr Surg. 2012;21:344–53.CrossRefPubMedGoogle Scholar
  41. 41.
    Van Leeuwen K, Teitelbaum DH, Elhalaby EA, Coran AG. Long-term follow-up of the redo pull-through procedures for Hirschsprung’s disease: efficacy of the endorectal pull-through. J Pediatr Surg. 2000;35(6):829–34.CrossRefPubMedGoogle Scholar
  42. 42.
    Pena A, Elicevik M, Levitt MA. Reoperations in Hirschsprung disease. J Pediatr Surg. 2007;42(6):1008–13.CrossRefPubMedGoogle Scholar
  43. 43.
    Garrett KM, Levitt MA, Pena A, Kraus SJ. Contrast enema findings in patients presenting with poor functional outcome after primary repair for Hirschsprung disease. Pediatr Radiol. 2012;42(9):1099–106.. (Distal narrow segment residual, distal/hypomotile segment residual, Soave cuff thickness, dilated Duhamel pouch, active enterocolitis, twisting. Radiologic evaluation is key to assessing such patients)CrossRefPubMedGoogle Scholar
  44. 44.
    Chatoorgoon K, Pena A, Lawal T, Levitt M. The problematic Duhamel pouch in Hirschsprung’s disease: manifestations and treatment. Eur J Pediatr Surg. 2011;21(6):366–9.CrossRefPubMedGoogle Scholar

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© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Pediatric SurgeryTakatsuki General HospitalTakatsukiJapan

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