The preoperative planning for patients undergoing a total abdominal colectomy with a planned ileorectal anastomosis can be extensive depending on the indication for the procedure; some of the requisites have been mentioned above in the indications section. However, numerous other evaluations may be required in order to ensure that a total colectomy as opposed to a smaller or segmental resection should not be performed.

Given the magnitude of the operation adequate preoperative and perioperative evaluation and management should be undertaken. Based on age, comorbidites, and the underlying condition evaluation and maximization prior to surgery should be performed. This assessment includes adequate medical clearance, appropriate prophylactic measures according to surgical care and improvement project guidelines, and good informed consent. Further specific evaluation based on the specific conditions or indications should also be performed.

Patients with familial adenomatous polyposis should undergo endoscopic evaluation of both the upper and lower GI tracts. Colonoscopy should be performed with particular attention to the rectum. Ileorectal anastomosis can be performed when there are less than 20 polyps in the rectum that can be removed thus “clearing the rectum.” Upper endoscopy with both forward and side viewing endoscopes is required to rule out gastric and periampullary lesions. A detailed family history should be obtained with particular attention being paid to a family history of desmoid tumors. A positive history of desmoid tumor should prompt a CT scan of the abdomen and pelvis to be done preoperatively to identify patients with intra-abdominal desmoids that may change the planned approach to surgery. Consideration for genetic testing should also be discussed with the patient.

Patients with Crohn’s colitis, mucosal ulcerative colitis, or indeterminate colitis require complete GI tract evaluations with colonoscopy, upper GI radiography or endoscopy, small bowel imaging, and possibly CT scan of the abdomen and pelvis. The outcomes of total abdominal colectomy with ileorectal anastomosis will in part depend on whether there is any small bowel disease, rectal disease, and perianal disease. In addition, assurance of adequate preoperative nutritional status with an albumin of >2.5–3.0 and no active infections at the time of surgery will diminish the risk of anastomotic leak. Moreover, many patients with colitis receive high dose steroids and/or antitumor necrosis factor (TNF) medications. Depending on the doses and timing of medications an anastomosis may be contraindicated and an initial total colectomy with ileostomy rather than ileorectal anastomosis may be the preferred procedure.

Patients with lower GI bleeding are typically hospitalized due to ongoing GI bleeding when evaluation fails to identify a specific bleeding site within the colon. However, evaluation should be undertaken to exclude an upper GI source with upper endoscopy and an anorectal. Other diagnostic studies such as tagged red blood scan and/or angiography may not localize the site of bleeding. If blood loss persists, such that greater than 6 units of PRBCs are transfused or bleeding recurs, a total abdominal colectomy with ileorectal anastomosis may be indicated. Patients, who recover from a first bleed, are not operated on due to failure of localization and minimal risk of rebleeding. These patients should undergo small bowel imaging with radiography and capsule endoscopy to clearly exclude primary small bowel pathology.

Patients with severe constipation defined as less than three bowel movements per week or straining greater than 25% of the time who have failed conservative therapy including dietary manipulations, fiber and laxative therapy, and prokinetic medications may be candidates for surgical management of their constipation. Patients with the above history should undergo a series of anatomic and functional studies. First and foremost colonoscopy should be undertaken to exclude a mechanical cause for constipation.
A colonic transit study and defacography should be performed to find the rare patient with colonic intertia and normal rectal emptying who might potentially be a candidate for this operation. Any other indication or combination of test outcomes leads to poor postoperative results.

HNPCC patients are identified thorough family histories with patients meeting the requirements by Amsterdam or Bethesda to have HNPCC should be considered for total colectomy if a colon cancer is present in the colon with a normal appearing rectum. Genetic testing, microsatellite instability (MSI), and other tests may also be useful in helping to determine those patients with HNPCC as opposed to those with sporadic colorectal cancer. Evaluation for noncolorectal-associated malignancies such as thyroid and uterine should be performed.

Patients who present with colonic obstructions most commonly due to distal colonic malignancies have the option of three procedures: resection and stoma, resection and anastomosis or on-table lavage, resection and anastomosis. The outcomes are similar from the standpoint of anastomotic leaks but the functional outcomes are slightly worse when a total colectomy is performed but this avoids a stoma, even if temporary and is technically easier than on-table lavage.