1 3 4 6 7 4 Materials and methods The charts of all patients who underwent a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively analyzed. From June 1987 through March 1994 the Duhamel procedure was performed in an open way (OD), and from March 1994 through July 2003 it was performed laparoscopically (LD). To obtain a relatively homogeneous group of patients, patients were excluded from the study for the following reasons: preoperative colostomy, extended aganglionosis, trisomy 21, Waardenburg syndrome, or other associated malformations. 8 4 4 About 0.5 cm above the dentate line a transverse incision was made in the posterior rectal wall and the retrorectal space was entered to meet the space dissected from above. The proximal end of the bowel was grasped, pulled through, and anastomosed circumferentially with the created opening in the posterior rectum. A side-to-side anastomosis was then made between the anterior aganglionic rectum and the posterior pulled-through ganglionic bowel using an EndoGIA (blue cartridge 3.5cm long; Tyco Heathcare) under laparoscopic control. Usually two cartridges needed to be fired. Finally, the upper rectum was closed laparoscopically with a running 2 × 0 Vicryl suture. Outcome measures included postoperative complications, hospital stay, and long-term outcome such as constipation, enterocolitis, fecal incontinence, enuresis, stenosis, and adhesive obstruction. p t Results 1 Table 1. Patient characteristics  Open Duhamel Laparoscopic Duhamel Gender (m,f) 21, 4 23, 7 Age at diagnosis (months) 4.2 (0.13–72.4) 4.6 (0.7–67.8) Age at operation (months) 6.8 (1.2–74.9) 8 (0.9–72) Weight at operation (kg) 7.1 (4.5–18.5) 8 (3.2–22) Operation time (h) not available 4.5 (2.3–9) Data given as median (range) No intraoperative complications were recorded in both groups. The operative time for the open group could not be traced anymore. In the LD group the mean operative time was 4.8 h (range = 2.3–9 h). 2 p p Table 2. Postoperative events  n n Postoperative fever  3 1 Leakage of rectum stump 0 1 Abscesses 0 0 Start of oral feeding (days) 5.1 (4–8) 3.4 (2–9)  Hospital stay (days) 7.8 (6–13) 6 (3–15) Because of the study design the period of follow-up is different between the two groups. Two patients in the LD group were readmitted for dilatation of the anorectum for stenosis. In one of these patients a rectal spur needed to be transected; this was performed under laparoscopic control. In this patient initially only one cartridge had been used. Reoperation was carried out in one OD patient and in two LD patients. 3 Table 3. Results at follow-up  n n Follow-up (months) 87.8 (7–211) 39.5 (–113) Reoperation (Duhamel) 1 2 Stenosis 0 2 Obstructive ileus 3 0 Admission for enterocolitis 3 9 Admission for constipation 7 5 Incontinence 0 0 Enuresis  3 0 Discussion Hirschsprung’s disease is basically incurable. Even when the proximal transection plane of the bowel shows a normal plexus at pathologic examination, there is no guarantee of a good outcome because the distal rectum is and remains abnormal. The best that surgery can achieve is a delicate balance between constipation and incontinence. More often than not the balance tips in one direction. End points are difficult to set and final results are therefore difficult to evaluate. 8 Conclusion The laparoscopic variant of the Duhamel procedure is not simple, as reflected by its long operation time. There seems to be no essential difference between the open and the laparoscopic procedure with respect to postoperative complications or functional results at follow-up. Although there is a tendency for a higher enterocolitis rate in the LD group, lower adhesive obstruction and enuresis rates were encountered. There is no doubt that the LD is cosmetically superior. Despite the fact that the transanal approach is becoming more popular in recent years, there certainly remains a place for the laparoscopic Duhamel–Martin procedure, particularly when extended Hirschsprung’s disease is present.