The hallmark radiological feature of HD is the presence of a transition zone on a contrast enema (CETZ) [
2]. One of the requisites for successful pullthrough surgery for Hirschsprung's disease is identification of the transition zone, for which a contrast enema is relied upon. Although CETZ remains the most accurate diagnostic sign for Hirschsprung's disease, it is not specific enough to delineate the transition zone in neonates and infants [
7,
8,
11]. Other radiographic signs to improve the diagnostic yield, including delayed and abnormal contractions of distal aganglionic segment also appear to be of limited value [
2,
12]. There has been a recent trend in the use of preoperative endoscopic marking of the transition zone, and laparoscopy-assisted suction colonic biopsy (SCBx) to provide accurate identification of the transition zone[
13,
14]. However, these investigations are not available in most developing countries. A plain abdominal radiograph, which is routinely done to evaluate any intestinal obstruction including HD, may provide more information than just the diagnosis. Its utility to locate a plain abdominal radiograph transition zone (PARTZ), especially when CETZ is inconclusive, has not been previously studied. In this study, PARTZ was clearly seen in 89% of the patients, which accurately corresponded with the pathological level of aganglionosis in 92% of the patients undergoing a pull through procedure. A CETZ on the other hand was conclusive in only 67% of the patients. Importantly, for this subset of patients with inconclusive CETZ (9 patients), a PARTZ accurately correlated with the pathological level of aganglionosis in 4(67%) patients. A false negative or inconclusive CE may be attributable to technical factors, too much or forceful instillation of contrast, a small caliber of neonatal bowel, prior colonic washouts or a long segment disease[
15,
14]. These factors may obliterate the transition zone. On the other hand, visualization of PARTZ relies on the physiological tapering of bowel gas in the transition zone above the distal collapsed gasless aganglionic segment, which is left undisturbed by avoiding instillation of any contrast in the rectum. Although in cases with inconclusive CE studies, retention of barium seen on radiographs obtained 24 hours after a barium enema is considered suggestive of Hirschsprung's disease [
2], the level of transition zone remains uncertain unless laparoscopy is employed [
14]. If facilities of laparoscopy are not available, an umbilical incision provides an excellent, safe, and versatile alternative to laparoscopy or other abdominal incisions [
17]. In conclusion, our study underscores the importance of combining the information of a transition zone on a plain abdominal radiograph and contrast enema to decide the surgical approach for the correction of Hirschsprung's in developing countries where laparoscopic facilities are not available. The small incidence of discordance between anticipated level of aganglionosis and operative findings should be recognized, particularly when planning a one-stage transanal pull-through.