With the national news events of the last two years, many parents know that some constipation also requires surgery, but what kind of cases require surgery? A search of the almighty “doujinshi” revealed many errors, so how do we, as doctors who were involved in the whole incident, consider this matter and decide which children can be operated on? When surgery is needed, is it okay to not do it? The current “gold standard” for diagnosing congenital megacolon and homozygosity is a biopsy of the entire intestinal wall. However, this test is also a surgical procedure, which is risky and expensive. Therefore, the preoperative diagnosis of megacolon or megacolon homozygosity is based on medical history (i.e., time of onset, degree of constipation, etc.), physical examination (including degree of abdominal distention, anal finger examination, etc.), and the classic “triple test” (barium enema + 24-hour review, histochemical examination, and rectal and anal canal manometry). If all of them have a very typical positive result, surgery can be considered. However, many children do not have typical symptoms or significant positive results. For these children, how can we determine whether surgery is needed or when to perform it? Simply put, this question depends on the degree of symptoms and the effectiveness of conservative treatment. If the symptoms of constipation are not very severe and the test results are not typical, conservative treatment can be given first. Some children with megacolon homozygosity can be cured by conservative treatment, allowing the immature nerve cells to gradually develop normally and establishing a normal defecation reflex. If the symptoms improve after a period of conservative treatment, the treatment can be continued until recovery. If the child still has no significant effect after 3 months to 6 months of regular conservative treatment, it may be congenital megacolon or more serious megacolon homozygosity, and surgery should be considered. Of course, the “triple test” such as barium colon irrigation can be reviewed before surgery, and other tests such as colon transfer test and fecal imaging can also be considered for comprehensive evaluation. In addition, the support of the family is also important. Although surgery carries certain risks, ranging from anesthetic accidents and wound infection to recurrent constipation or fecal incontinence, the vast majority of children with constipation can be treated. Families should also recognize that persistent constipation that does not respond to conservative treatment only exacerbates the damage to the bowel, causing the normal bowel to become dilated and dysfunctional, resulting in more bowel removal and more complications during surgery. Some children with untreated constipation come to the hospital in adulthood, at which time they solve their stools once a month. Moreover, we have observed that younger children are more compensated to re-establish normal bowel function. Therefore, the family should actively cooperate with the doctor’s treatment, preferably in the preschool years to solve the problem so as not to delay the disease.