A pull through or pull-through procedure refers to when a piece of intestine deep in the pelvis needs to be removed. The end above it, which is normally in the abdominal cavity, is ”pulled through” the pelvis and connected to the bottom.
When we need to bring a piece of intestine down to the bottom, we must ”pull” it there, but it is a very gentle and delicate pull that can only be done once the intestine has been completely separated from any structures that surround it. It must also be done without injuring any connected nerves and blood vessels. If things get pulled under significant tension, it could risk the blood flow to that area, which can lead to complications such as narrowing (stricture), or loss of the pull-through where the area scars shut. In short, we do ”pull” but it is a very gentle and controlled surgical type of pulling.
Pull-through is a very general term. It may be used to describe different surgeries for a variety of colorectal conditions. Each condition has its own type of pull-through surgery. The different pull-through procedures for the following conditions are reviewed below.
Children born with anorectal malformations that need surgery may have one of two kinds of pull-through procedures. The most common is referred to as a PSARP (pronounced ‘Pee-Sarp’), which stands for posterior sagittal anorectoplasty. This procedure was created by our center’s founding director, Dr. Alberto Pena, for children who are born missing a normal anal opening on their bottom. In this type of pull-through, the surgeon opens the middle of the bottom finds the rectum and separates it from whatever it connects to (sometimes the urinary tract, but in other situations it can be the vagina, or it can be blind ending). They will then bring it down to the bottom and sew it into place. There are several kinds of procedures:
Posterior Sagittal Anoplasty (PSAP) used for the mildest form of malformations where only the anus needs to be slightly moved or enlarged.
Posterior Sagittal Anorectoplasty (PSARP) for children with more complex malformations where the rectum is located higher in the pelvis and may connect to the urinary tract.
Posterior Sagittal Anorectovaginourethroplasty (PSARVUP) for females born with persistent cloaca. In this complex malformation where the urinary, genital and intestinal tracts all come together and make one common channel, when there needs to be three. The surgeon opens through the bottom and separates the rectum from the urinary and genital structures and reconstructs things in the way that works best for the patient. As every cloaca is different, there are many ways to perform that reconstruction.
This is a hybrid form of Posterior Sagittal Anorectoplasty (PSARP) in which the rectum is separated from the urinary tract through the abdomen by using laparoscopy (minimally invasive surgery using a camera and working through tiny incisions or cuts). The bottom is opened only where the anus should open. The rectum is then ”pulled through” and connected there.
This is another hybrid form of PSARP in which the rectum is separated from the urinary and genital structures, which can then be separated in laparoscopic or open fashion. Once the urinary and genital structures have been repaired and reconstructed, the rectum is then ”pulled through” and connected to the bottom.
Children born with Hirschsprung disease will usually need to have the lowest portion of the large intestine (rectum, and sometimes sigmoid colon) removed. The portion above must be pulled through the pelvis and connected to the anal canal. In rare cases, the entire colon is affected and must be removed. The small intestine would be connected to the anal canal at the time of the pull-through surgery. There are several ways to do these pull-through procedures. They are all named for the surgeon(s) who developed the technique. The Swenson pull-through was the first, and was followed by the Yancey-Soave and Duhamel procedures.
Children born with familial polyposis will at some point need to have their colons removed. This procedure usually happens with a pull-through of the small bowel above the colon. It may be pulled through in a straight fashion (direct connection to the anal canal). In many cases, a J-shaped pouch will be created from the end of the small bowel that gets pulled through and connected to the anal canal.
Children born with ulcerative colitis may need a colectomy, or removal of the entire colon or large intestines due to significant bleeding and symptoms that do not improve with medical therapy. When the colon is removed, either at the same time or during a later procedure a pull-through procedure may be done. A J-shaped pouch will be created from the end of the small bowel that gets pulled through and connected to the anal canal.
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Last Updated 06/2026
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