The most common elective indications for total colectomy are ulcerative colitis and familial polyposis. However, sphincter-conserving procedures such as the ileoanal anastomosis (Chapter 64) should be considered in good-risk patients. In the very poor risk patient with ulcerative colitis, particularly with a complication such as a free perforation, it is judicious to perform the operation in two stages. The removal of the rectum is delayed until the patient’s condition is less critical. The possibility of malignancy in patients with ulcerative colitis of many years’ duration must be considered. Conservation of the anus and lower rectum by ileoproctostomy should be considered in congenital polyposis, where the polyps in the retained rectum that do not disappear spontaneously can be destroyed by repeated fulguration. Total colectomy is also performed for severe colitis of other etiologies, especially pseudomembranous colitis.
Unless total colectomy is done as an emergency procedure, efforts should be made to improve the patient’s nutritional status with a high-protein, high-calorie diet. Total parenteral nutrition may be used. The blood volume is restored and supplemental vitamins are provided. The surgeon must carefully evaluate the status of the steroid therapy. The patient requires special psychologic preparation for the ileostomy. This should include a visit by an enterostomal therapist who can demonstrate successful rehabilitation following this procedure. The patient should be shown the permanent type of ileostomy appliance and should be encouraged to read the literature available from an ileostomy club to prepare him or her for postoperative management. In addition, the site of the ileostomy should be selected away from bony prominences and previous scars as described in Chapter 51. A permanent type of appliance may be glued to the patient’s skin for 1 to 2 days to allow him or her to move about with it in place and make any final adjustments in its eventual location. This point is marked with indelible ink to assure accurate placement of the stoma. A liquid diet is given for 1 or 2 days, followed by laxative purging the afternoon and evening prior to surgery. The male patient should be informed of the possibility of postoperative impotence, retrograde ejaculation, and difficulty in voiding. Women of child-bearing age should be counseled regarding the risk of decreased fertility after pelvic dissection.
General endotracheal anesthesia is preferred.
The patient is placed in a moderate Trendelenburg position. For total proctocolectomy, during the perineal portion of the operation, the patient may be repositioned in the lithotomy position with the thighs widely extended. Alternatively, the legs may be placed in the modified lithotomy position using the Allen stirrups for support of the feet and knees. This allows a single positioning for preparation and draping but may compromise the perineal exposure. A large rectal tube is used to lavage out the rectosigmoid with a povidone–iodine solution. This ...