The most common elective indications for total colectomy are ulcerative colitis and familial polyposis. However, sphincter-conserving procedures such as the ileoanal anastomosis (see Chapter 68) should be considered in good-risk patients. In very poor-risk patients with ulcerative colitis, particularly with a complication such as a free perforation, it is judicious to perform the proctocolectomy in two stages. 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 can be considered in selected patients with familial polyposis with limited rectal involvement, 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, effort should be made to improve the patient’s nutritional status with a high-protein, high-calorie diet. Total parenteral nutrition may be used. Preoperative blood transfusion is considered in severely anemic patients. The surgeon must carefully evaluate the status of the steroid therapy. Patients require special psychological preparation for the ileostomy. This should include a visit by an enterostomal therapist, who can demonstrate successful rehabilitation following this procedure. Patients should be shown the permanent type of ileostomy appliance and should be encouraged to browse educational material to prepare them for postoperative management. In addition, the site of the ileostomy should be selected away from bony prominences and previous scars, as described in Chapter 55. Although not done frequently, it has been found it helpful in some cases for a permanent type of appliance to be glued to the patient’s skin for 1–2 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 ensure accurate placement of the stoma. A liquid diet is given for 1–2 days, followed by antibiotic and mechanical bowel prep a day prior to surgery. Male patients should be informed of the possibility of postoperative impotence, retrograde ejaculation, and difficulty in voiding. Women of childbearing 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 Allen stirrups for support of the feet and knees. This allows a single positioning for preparation and draping. Preoperative povidone-iodine enemas are optional. A large rectal tube is used for this purpose and ...