Abstract Purpose The objective of this study is to describe the surgical technique and clinical results of a modified Soave procedure through the posterior sagittal approach (PSAP) for Hirschsprung's disease. Methods The patient was placed in a prone jackknife position. The rectum was approached via PSAP keeping the external sphincter intact. The rectum was isolated and then divided approximately 2 cm from the dentate line. The rectum and sigmoid were freed up to the normal segment. The aganglionic and ganglionic segments were confirmed intraoperatively by frozen biopsy. The rectal mucosectomy was started 0.5 to 1 cm proximal to the dentate line, leaving 1 cm of the muscular cuff. The colon was then pulled through the anus. The aganglionic segment and transitional zone were removed. Coloanal anastomosis was fashioned 0.5 to 1 cm proximal to the dentate line. Results Ninety-six patients were operated on from January 2000 to July 2002, using the described technique. Patient ages ranged from 2 to 36 months (median age, 8½ months). The aganglionic segment was located in the rectum in 56 patients and in the sigmoid colon in 40 patients. The average length of bowel resected was 20 cm (range, 10-35 cm). Combined laparotomy was performed in 2 patients and combined laparoscopy surgery in 1 infant. There were no operative or postoperative deaths. Anastomotic leakage occurred in 2 patients. Spontaneous defecation occurred in all patients. Conclusions Posterior sagittal approach provides excellent exposure of the operative field and decreases the major complications seen with the abdominal approach. The modified Soave procedure can easily be performed with PSAP.