Patients with familial adenomatous polyposis are usually diagnosed early as a family history of this condition warrants early screening with colonoscopy. Although a total proctocolectomy is the required extent of resection, an ileal pouch anal anastomosis is the preferred surgical option in the absence of concomitant advanced rectal cancer.

Surgery is indicated for ulcerative colitis in the following situations:

Although a restorative proctocolectomy with ileal pouch anal anastomosis has become the preferred option for most patients with ulcerative colitis, a permanent end
ileostomy is still indicated in selected individuals. Elderly patients are often unable to cope with the relatively high frequency of liquid bowel movements after an ileal pouch. These patients also have multiple medical comorbidities, putting them at high risk for complications following a lengthy operation and a difficult pouch anal anastomosis. An end ileostomy is a good option and is often well accepted in this patient population.

Documentation of good sphincter tone is a prerequisite before an ileal pouch procedure. Sphincter tone is often suboptimal in patients who have had prior obstetric injury or a fistulotomy for anorectal fistulae. Long-term quality of life is better with an ileostomy in patients with poor sphincter tone.

Restoration of intestinal continuity with an ileal pouch has the advantage of avoiding a permanent stoma but is not entirely without complications. The associated risks of anastomotic leakage, pouchitis, and pouch failure should be appreciated by the patient when consenting for the procedure. In view of the higher incidence of long-term complications, the need for pouch surveillance and an additional procedure to close the temporary diverting stoma, medically fit patients with good sphincter tone may still opt for a permanent ileostomy. The choice between a permanent stoma and a restorative procedure is therefore influenced by a number of factors with the patient having to make the final decision.

Ulcerative colitis presenting as an acute severe attack with significant colonic dilatation (toxic megacolon) and signs of impending perforation, requires urgent surgical intervention. In this setting, the patient is often hemodynamically unstable and unable to withstand a prolonged procedure. In addition, an acutely inflamed colon may also be extremely friable and can perforate with the least manipulation. A total abdominal colectomy with ileostomy is therefore the preferred option in the emergent setting. A completion proctectomy with or without an ileal pouch can be performed at a later stage after resolution of the acute attack.

The incidence of synchronous large bowel adenocarcinoma varies from 1.5–7.6%. A synchronous rectal and sigmoid lesion can most often be resected en block, with a colorectal anastomosis to restore intestinal continuity. However, for a synchronous rectal and right colon lesion, a total proctocolectomy with ileostomy is sometimes required. Although not contraindicated, an ileal pouch is best avoided in the setting of synchronous colorectal cancers and patients are usually offered an end ileostomy with a low Hartmann’s procedure. Following adjuvant therapy, the option of a pouch procedure can be considered in patients showing good control of the primary malignancy.

The presence of a single malignancy in the colon or rectum puts the rest of the large bowel at a 12–62% risk of harboring polyps. If the polyps are too numerous to be removed endoscopically, or a number of polyps show malignant/premalignant changes, a total proctocolectomy with ileostomy should be considered especially in elderly patients.

Crohn’s disease with pancolitis, poorly responsive to medical management is a definite indication for a total proctocolectomy with ileostomy because an ileal pouch is an absolute contraindication in Crohn’s disease. However, the procedure may have to be performed in two stages if there is severe perianal Crohn’s disease. Performing a proctectomy in the presence of active perianal Crohn’s with abscesses and draining fistulae significantly increases the incidence of perineal wound sepsis and nonhealing. An abdominal colectomy and ileostomy together with unroofing of the perianal fistulae is done at the first stage. Once the infection and inflammation abates, the patient may be scheduled for completion proctectomy. A number of local pedicle flaps to cover the perineum have been described but are best avoided in the presence of active infection. Fecal diversion with ileostomy together with laying open all fistulous tracts and ultimately an intersphincteric proctectomy, often results in healing in a significant number of patients, decreasing the need for flap procedures.

Although laparoscopic colorectal resections are becoming increasingly commonplace, the majority of rectal resections in the United States are still accomplished by a laparotomy. Laparoscopy has its own learning curve, limitations, and technical challenges. While a limited colon or rectal resection could be completed safely and effectively within a reasonable time period, a total proctocolectomy may prove to be time consuming using a pure laparoscopic technique. Additionally inflammatory bowel disease is often associated with extensive bowel adhesions and complex fistulization, which when present add significantly to the technical difficulty of the procedure.

The benefits of laparoscopy should be prudently weighed against the technical ability of the operating surgeon, the complexity of each individual case, and the surgical risk of the patient. A decision to convert to the open approach is not a sign of failure but rather a reflection of a mature judgment and should be made early if needed.

This chapter emphasizes the surgical technique of an open total proctocolectomy with end ileostomy.