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ORIGINAL ARTICLEGlobal Surgical Education - Journal of the Association for Surgical Education (2026) 5:129 https://doi.org/10.1007/s44186-026-00530-6 Edward J. Doolindoolin@chop.edu1 Department of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 3500 Civic Center BLVD, Philadelphia, PA 19104, USA2 Department of Surgery Perelman, School of Medicine, Philadelphia, PA 19104, USAAbstractPurpose Recently, poor function and incontinence after Hirschsprung Disease Surgery has been reported more frequently. Reports listing the causes and recommending how to manage incontinence are published, but no review identif i es operative steps which avoid this problem initially. We hypothesized that specif i c techniques in the operation, which would ensure preservation of the anal sphincter with improved function, can be identif i ed with content analysis.Methods This is a review of patients that underwent “proctectomy and pull-through surgery” for Hirschsprung disease. Text phrases considered signif i cant components of the operation were abstracted from the original published description and identif i ed in unstructured operative reports using content analysis. The outcome of bowel function was documented as a function of the inclusion of each text phrase.Results Eighty four charts were chosen for analysis. The average age at the procedure was 7 months (1–36). 47 of 84 (55%) of patients had a functionally successful pull through recorded as “normal bowel function” (NBF), 12 (14%) were classif i ed as “constipated” and 25(29%) were classif i ed as “incontinent”. Each of fi ve text phrases, when documented in the record, was associated with outcome improvement where NBF was reported in 80–90%.Conclusion It is important to assess procedures and understand what methods lead to a desired result. Complex operations can have many variations not identif i ed by CPT code or templated reports. Using content analysis, specif i c nuances can be identif i ed which lead to improvement of outcome. It is felt that creating unstructured reports is also a valuable educational exercise.Keywords Content analysis · Natural language processing · Unstructured records · Surgical education · Hirschsprung diseaseReceived: 26 November 2025 / Revised: 24 March 2026 / Accepted: 19 April 2026© The Author(s) 2026Content analysis of unstructured operative records can evaluate nuanced techniques in complex operationsEdward J. Doolin 1,2content has been employed when standardizing codes [4]. Reviewing medical records for identif i able phrases has been used to note risk factors for retained surgical items [5] The analysis of text is recommended for both learning and qual-ity measurement [6] This applies to surgical procedures as well. Here it is being used to associate elements of unstruc-tured operative notes with outcome.Often a procedure is clearly identif i ed by its name or CPT code. More complex operations do not lend themselves to such simple comparison. Multiple steps and subtle nuance in method create a variability not identif i ed. Comparisons based on name or CPT code are susceptible to undetected error. One such procedure is pull-through surgery for Hirschsprung disease, the subject of this review. Although this treatment is done safely using one of many dif f erent procedures, there is a wide spectrum of long-term func-tional outcomes reported. A description of the pull-through IntroductionIt is the premise of this review that analysis of unstructured operative reports identif i es detail which allows the study of complex operations [1, 2]. Authors point out that the vari-ability of the free text report is actually a wealth of informa-tion since it reveals nuance in a way that structured data does not [3]. Assessing unstructured operative reports for