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INDICATIONS
The most common indications for total colectomy are ulcerative colitis and familial polyposis.
However, sphincter-conserving procedures such as the ileoanal anastomosis (see Ileoanal
Anastomosis) 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.
PREOPERATIVE PREPARATION
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. A permanent type of appliance should 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 and difficulty in voiding.
ANESTHESIA
General endotracheal anesthesia is preferred.

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POSITION
The patient is placed in a moderate Trendelenburg position near the left side of the table. For
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 povidine-iodine solution. This
tube is left to dependent drainage until the perineal resection begins.
OPERATIVE PREPARATION
The skin is prepared in the routine manner, and the ileostomy site just below the halfway
mark between the right anterior iliac spine and the umbilicus is re-marked.
INCISION AND EXPOSURE
The surgeon stands to the patient's left side. The incision must extend sufficiently high in the
epigastrium to provide an easy exposure of the colonic flexures, lest undue traction of the
friable bowel result in perforation and gross contamination (Figure 1).
After general exploration of the abdomen, the small bowel may be placed in a plastic bag.
The dissection is started in the region of the tip of the cecum (Figure 2). The right colon is
retracted medially as the peritoneum in the right lumbar gutter is incised with curved scissors
(Figure 2). Because of the tendency to increased vascularity, it may be necessary to ligate a
number of blood vessels in the free margin of the peritoneum along the right lumbar gutter.
The peritoneal attachments to the terminal ileum are divided and the cecum and terminal
ileum mobilized well outside the wound (Figure 3). The peritoneum is tented upward before it
is incised to avoid injuring the underlying right spermatic vessels and ureter. Blunt gauze
dissection is utilized to push these structures away from the adjacent mesentery. The right
ureter should be identified throughout its course up to the right kidney and down to the pelvic
brim. Any adhesions between gallbladder, liver, and hepatic flexure are divided. During the
mobilization of the ascending colon and hepatic flexure, care must be taken to identify the
retroperitoneal portion of the duodenum, which may come into view rather unexpectedly.
Blunt gauze is utilized to sweep away the duodenum from the overlying mesocolon. The
thickened, contracted, and highly vascular greater omentum is divided between curved
clamps and ligated (Figure 4). The greater omentum is retracted upward and the lesser
omental sac entered from the right side.
DETAILS OF PROCEDURE
The thickened and vascular greater omentum is retracted upward in preparation for its
separation from the transverse colon. An incision is made in the omental reflection along the
superior surface of the colon (Figure 5). Since the omentum may be quite adherent to the
colon, it may be easier to divide the gastrocolic omentum nearer the stomach than the
transverse colon. This can be facilitated if the surgeon places his or her left hand, palm
upward, in the lesser sac in order to better define the gastrocolic omentum. Most of the
dissection can be done with electrocautery, especially if the relatively avascular plane is
present where the omentum joins the transverse colon. If large vessels are encountered,
paired curved clamps are applied and their contents ligated.
Special attention is required during the division of the thickened splenocolic ligament to avoid
tearing the splenic capsule by undue tension (Figure 6). The splenocolic ligament is divided at
some distance, if possible, from the inferior pole of the spleen (Figure 7). When the splenic
flexure and descending colon have been partially freed down to the region of the sigmoid, the
surgeon may wish to return to the region of the right colon and control the blood supply to the
bowel before removing it in order to facilitate the eventual exposure of the pelvis for the
exploration of the rectum. The mobilized right colon is drawn outside the peritoneal cavity,
and the vessels in the mesentery can be identified easily (Figure 8). Enlarged lymph nodes
often fill in the arcades about the mesenteric border. Unless malignancy has been found, the
blood supply can be ligated near the bowel wall as shown in Figure 8. Before the blood
supply is ligated, the ureter is protected posteriorly by warm, moist packs.
After the blood supply to the region of the appendix and the right colon has been divided, the
terminal ileum may be further mobilized. An incision is made into the mesentery of the

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terminal ileum with a clear view of the ureter at all times to avoid its injury. It is often
necessary to remove a portion of the terminal ileum because of its possible involvement with
the inflammatory process (Figure 9).
Considerable time is required to separate the blood supply proximally from the site where the
ileum is to be divided. Several centimeters of ileum can be denuded of blood supply in
preparation for the development of an ileostomy (Figure 9). The blood supply to this portion of
the ileum should be divided very carefully, almost one vessel at a time, maintaining the large
vascular arcade at some distance from the mesenteric border. A noncrushing vascular-type
clamp is applied to the ileal side and a straight Kocher clamp to the cecal side in preparation
for the division of the intestine (Figure 10). Most commonly, however, the ileum is divided with
a GIA stapling instrument. The contents of the Kocher clamp can be ligated with heavy silk or
absorbable suture to facilitate handling of the right colon (Figure 11).
The colon is then retracted medially, and the mesentery is divided up to the region of the
middle colic vessel (Figure 12). Two half-length clamps should be applied proximally on the
middle colic vessels because of their size and the increased vascularity in ulcerative colitis.
The mesentery of the transverse colon is divided rather easily between pairs of clamps and
the contents carefully ligated. This can be done at some distance from the inferior surface of
the pancreas. As additional portions of colon are freed, they are incorporated in towels to
avoid tearing the bowel wall and possible gross contamination.
An incision is made down the left lumbar gutter, and because the thickened and vascular
peritoneum has a tendency to contract, all bleeding points should be carefully ligated (Figure
13). The peritoneum is lifted up until the left gonadal vessels and ureter are identified. Both
should be identified throughout most of their course down over the brim of the pelvis (Figure
14).
As shown in Figure 15, the mesentery is divided adjacent to the rectosigmoid rather than up
over the iliac artery bifurcation, as would be done in carcinoma. The peritoneum adjacent to
the bowel is divided after identification of the ureters on either side, and the peritoneum in the
pouch of Douglas between the rectum and bladder or cervix is incised. This flap is carefully
elevated. This dissection along with that into the presacral space is facilitated by using lighted
deep pelvic retractors, a focused headlight on the surgeon, and an extra-long insulated
electrocautery tip. The dissection proceeds into the same presacral space as the mesorectal
dissection, but the surgeon can stay closer to the rectum laterally and anteriorly, as this
operation does not require the wide margins necessary for a malignancy. At this point, the
rectum may be divided with a GIA stapler or it may be transected between clamps (Figure
16). The distal stump is then oversewn (Figure 17). At this time sharp dissection about the
rectum should be carried out to free it as low as possible in order to lessen the blood loss
during the subsequent perineal excision.
In the presence of multiple polyposis, a segment of rectum can be retained 5 to 8 cm above
the pouch of Douglas or at a distance that can be easily reached by the sigmoidoscope for
subsequent fulguration of the multiple polyps. When this is done, the terminal ileum is
anastomosed to the rectal pouch in a side-to-end manner.
Absorbable sutures are used to close the peritoneal floor. The location of the ureters should
be ascertained from time to time to avoid injury during the reconstruction of the pelvic floor.
After the pelvis has been reperitonealized, some of the raw surfaces in the left lumbar gutter
also can be covered if the tissues are sufficiently lax (Figure 18). Again, the sutures should be
placed so as to avoid injuring the underlying ureters and gonadal vessels.
The construction of the ileostomy is of major importance. The small intestine may be removed
from the plastic bag and the site selected for ileostomy exposed. The location of the
previously marked ileostomy site is evaluated. The midway point between the umbilicus and
anterior iliac spine is again verified by a sterilized ruler. The ileostomy site is placed a little
below the midway point (Figure 1, Total Colectomy). With Kocher clamps applied to the
fascial edge of the incision after removal of the self-retaining retractor, a 3-cm circle of skin is
excised. After the button of skin and the underlying fat have been removed, all bleeding
points are controlled. Then, while applying traction against the abdominal wall from
underneath with the left hand, the surgeon makes a stellate incision through the entire
thickness of the abdominal wall. Occasionally, a segment of fascia is removed and the rectus
muscle retracted laterally. Any bleeding that is encountered, especially in the rectus muscle,

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is clamped and ligated. An opening large enough to admit two fingers easily is usually
sufficient.
Noncrushing vascular-type forceps are inserted through the ileostomy site and applied just
proximal to the similar forceps on the terminal ileum (Figure 19). The original forceps are
removed, and the ileum is withdrawn through the abdominal wall with the mesentery
cephalad. At least 5 to 6 cm of mesentery-free ileum should be above the skin level so that an
ileostomy of adequate length can be constructed. It may be necessary, especially in the
obese patient, to undercut the terminal ileum under the mesenteric blood supply to attain this
essential length. The viability is then reevaluated after the ileum is pulled up through the
abdominal wall. The mesentery can be anchored to the abdominal wall or brought up into the
subcutaneous tissue (Figure 20). It may be advisable to anchor the mesentery of the ileum to
the parietes laterally before constructing the ileostomy, because of the possibility of interfering
with the blood supply to the terminal ileum. The right lumbar gutter should be closed off to
avoid the potential of a postoperative internal hernia. At times it may be difficult to
approximate the mesentery of the right colon and ileum to the right lumbar gutter and effect a
closure (Figures 20 and 21). The surgeon should palpate the right gutter repeatedly and place
whatever sutures are necessary to close it completely or else leave it completely open. A pair
of Babcock or Allis forceps is then inserted into the lumen of the ileum, and the ileum is
everted on itself. The completed ileostomy should extend upward from the skin level at least
2.5 to 3 cm. The mucosa is anchored with interrupted fine synthetic absorbable sutures to the
skin (Figure 21). Likewise, the mesentery may be anchored to the peritoneum, but no sutures
should be taken between the seromuscular coat of the terminal ileum and the peritoneum.
CLOSURE
A double-looped (0 or #1) delayed absorbable suture is used for running closure of the
midline linea alba incision. In very large patients, two sutures are used that begin at either
end of the incision. Interrupted fine absorbable sutures may be placed in Scarpa's fascia. The
skin is closed with staples, although some prefer to use absorbable subcutaneous sutures
followed by adhesive skin strips. At the end of the case, a dry sterile dressing covers the
abdominal incision and an ostomy appliance is put about the ileostomy. In the presence of
marked emaciation and prolonged steroid therapy, the use of retention sutures should be
considered.
The anus is excised as described in the perineal section of abdominoperineal resection (see
Abdominoperineal Resection and Abdominoperineal Resection, Total Mesorectal Excision).
The only exception is that it is not necessary to go wide on the levators when a simple
extirpation of the sphincter muscles and bowel wall itself is carried out. Primary closure with
catheter suction can be used (Figure 22).
POSTOPERATIVE CARE
Blood should be replaced as it is lost during the procedure. Additional blood or colloids may
be required on the afternoon of surgery and during the early postoperative period. Constant
bladder drainage is maintained for at least 4 or 5 days. If the patient has been on steroid
therapy, this is continued during the postoperative period. A transparent temporary-type
ileostomy appliance is placed over the ileostomy before moving the patient to the recovery
area. This permits frequent observations of the stoma to make sure it maintains a pink and
viable color. A strict intake and output chart must be maintained at all times following an
ileostomy. Likewise, daily electrolyte determinations are essential because of excessive
losses of electrolyte-rich fluid. Excessive amounts of fluid are occasionally lost, and large
amounts of intravenous fluids, electrolytes, and colloids will be required to maintain fluid
balance. Antibiotic therapy is continued for 5 to 7 days. The nasogastric tube is removed early
and oral intake of liquids advanced as tolerated. The drains should then be removed, with
serial observations as described in the discussion of abdominoperineal resection (see
Abdominoperineal ResectionPerineal Resection). These patients require frequent and
prolonged observation because of the tendency to a variety of complications ranging from
abscess formation to intestinal obstruction. They should be in contact with an enterostomal
therapist, who ideally may be available during office visits to the surgeon.

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