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INDICATIONS

Total abdominal colectomy is most commonly performed in the setting of prophylactic cancer prevention (FAP), unidentified bleeding from the lower GI tract, or fulminant ulcerative or Clostridium difficile–associated colitis. The stepwise mobilization of the sigmoid colon, cecum, and finally the transverse colon facilitates the greatest control of this large amount of intra-abdominal tissue. Depending on the clinical situation, a hand port can be used to assist in the complete mobilization of the tissue. At the completion of the resection an end ileostomy or ileorectal anastomosis may be performed.

PREOPERATIVE PREPARATION

In urgent or emergency circumstances, bowel preparation is not possible and creation of an end ileostomy or ileorectal anastomosis with protective loop ileostomy must be considered at the outset. A Foley catheter is placed in the bladder. An orogastric tube is beneficial to decompress the stomach. The rectum is irrigated with saline and either Betadine or another cytocidal agent. A 34 French mushroom catheter can be left in the rectum to provide intraoperative drainage of the rectal cavity as well as tactile guidance to the anal canal.

ANESTHESIA

Thromboembolism prophylaxis, either pharmacologic or mechanical, is started prior to induction of general anesthesia. Prophylactic antibiotics that cover intestinal flora are given within 1 hour prior to skin incision. After induction of general anesthesia, an orogastric tube and urinary catheter are placed. Ureteral stents may be considered in the context of severe intraabdominal inflammation, fibrosis, or retroperitoneal infection.

POSITIONING

A beanbag should be placed under the patient to prevent sliding during extremes of positioning. The patient should be placed into a low lithotomy position with Allen stirrups. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the thigh and the plane of the bed should be between 0 and 10 degrees. Any more flexion will limit range of motion for the instruments. Any more extension may lead to an anterior dislocation of the hip.

Each elbow (ulnar nerve) is covered with a gel pad, and both arms are carefully tucked at the patient’s side. Care must be taken to avoid compromising or kinking the intravenous lines. The beanbag is carefully cradled above both shoulders and around the arms to prevent the patient from falling while in extreme positioning. The air is suctioned from the beanbag so that it retains its shape. A gel pad covered by a towel is placed on the upper chest. Tape is placed under the bed, over each shoulder, and across to the other side of the bed. If the peak airway pressures become elevated, the tape should be loosened. Security of the patient on the table should be confirmed by testing maximal Trendelenburg and left-side-down positioning prior to prepping and draping. The entire abdomen is prepped from nipples to upper thighs, ...

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