Total colectomy may be indicated to treat diseases that either diffusely affect the colon but spare the rectum or in conditions affecting multiple segments of the colon making it necessary to remove the entire colon. Reestablishing gastrointestinal continuity is desirable in many of these conditions; however, the indication for surgery must be taken into consideration along with the patient’s overall condition and current ability to maintain fecal control.

Indications for the operation (Table 23-1) can be separated into infectious, inflammatory, malignant, and functional.

Contraindications may include those similar to any laparoscopic procedure such as multiple prior laparotomies with severe adhesions. The operation with an anastomosis is contraindicated in patients with severe malnutrition, sepsis, and disease processes involving the rectum. In the case of patients with sepsis, such as toxic C. diff colitis, the mortality from the disease process is high, let alone with emergency surgery. An anastomosis should not be entertained in these circumstances. Significant rectal involvement, be it polyps in patients with familial adenomatous polyposis or inflammation in patients with ulcerative colitis, precludes the patient as a candidate for this procedure. Patients with inadequate anal function and baseline incontinence should not be considered for this procedure. Similarly, patients with limited mobility, unable to tolerate urgency and frequency of stool, should avoid an ileorectal anastomosis because of the multiple bowel movements a day that are expected from the procedure. A patient with a high-grade large bowel obstruction that results in inability to handle the colon and risks intraoperative perforation may be better served by a decompressing and diverting loop colostomy or a “blow hole” transverse colostomy to release pressure and allow preparation, imaging, and endoscopy.