Preoperative planning is twofold: (1) to make sure that total abdominal colectomy is needed and is the best option for the patient’s condition and (2) to make sure that the patient can tolerate major abdominal surgery. Planning is based on the indications and contraindications as noted. Preoperative counseling is crucial so that patients understand the implications of this surgery. Patients need to understand that removal of the entire colon will impact their GI function. Ideally, postoperative function is adequate with about 4-5 loose bowel movements per day with acceptable continence. However, functional outcomes can be highly variable and some patients may experience more frequent bowel activity and even incontinence. Assessment of the overall functional status of the patient with a focus on anal incontinence is essential. Elderly or frail patients with poor anal continence before
surgery are likely to have debilitating diarrhea and may be better served with a permanent ileostomy. Having these conversations preoperatively will help set patient expectations and will clarify the best option for each patient.

FAP and MAP are uncommon genetic polyposis disorders that if left untreated will progress to colorectal cancer. In patients with FAP or MAP, careful endoscopic evaluation must be performed to determine the degree of rectal involvement. If there are <20 polyps in the rectum, it may be possible to endoscopically resect all lesions to preserve the rectum. Postoperatively, the rectum will need frequent surveillance with flexible sigmoidoscopy every 3-12 months, depending on the number of rectal polyps detected on future examinations. Total abdominal colectomy is particularly applicable to patients with attenuated FAP and MAP, when there are usually <100 polyps (instead of thousands) and the polyps are often proximal to the rectum. Upper endoscopy is also needed to evaluate for gastric and duodenal lesions. A positive family history of desmoid tumors should prompt a computed tomography (CT) scan of the abdomen and pelvis to evaluate for possible intra-abdominal desmoids that would affect the surgical approach to colectomy.

Lynch syndrome accounts for 2-4% of all colon cancers. Although there is up to a 70% lifetime risk of colon cancer, prophylactic total abdominal colectomy is not currently the standard of care. Once diagnosed with Lynch syndrome, colonoscopy every 1-2 years is recommended. When a colon malignancy is detected, a total abdominal colectomy should be considered given the increased risk of metachronous disease. The recommendation of a total colectomy or segmental resection is a complicated decision that involves balancing the risk of future cancer with diminished GI function. The choice of procedure requires extensive patient discussion. A total abdominal colectomy should be encouraged in younger patients given the increased risk of malignancy over time. However, older patients may opt for a segmental resection to preserve GI function with a focus on quality of life. There is also a 30-45% risk of endometrial cancer and 6-14% risk of ovarian cancer, so that prophylactic total abdominal hysterectomy and bilateral salpingo-oophorectomy may be often done at the time of colectomy in women who have completed childbearing. Historically, the diagnosis of Lynch syndrome has been determined on clinical grounds using family and personal history. Molecular testing has become more available, and current National Comprehensive Cancer Network guidelines advocate universal molecular testing of all newly diagnosed colon cancer. Immunohistochemistry for mismatch repair genes or polymerase chain reaction testing for microsatellite instability can identify patients at high risk for Lynch syndrome, which may prompt genetic testing and discussions about optimal surgical management when appropriate. Ideally, this testing can be performed on preoperative tumor biopsies before any surgical intervention. If Lynch syndrome is diagnosed after surgical resection, colonoscopy is needed every 1-2 years for surveillance of the remainder of the colon given the risk of metachronous tumors.

Patients with inflammatory bowel disease need colonoscopy, endoscopy, small bowel imaging (capsule or enterography), and pathology to determine the extent of disease. Total abdominal colectomy with ileorectal anastomosis is best for patients with minimal small bowel, rectal, and perianal disease and who have excellent anorectal continence. In addition, consideration of their medical management is required because many of the patients utilize long-term steroids and/or anti-tumor necrosis factor (TNF) agents. We typically wait 6 weeks after the last dose of anti-TNF medication and work closely with gastroenterology specialists regarding newer medications. If a patient is unable to wean from steroids, was given recent anti-TNF agents, or has malnutrition, consideration should be given to performing an end ileostomy rather than an anastomosis with the plan to restore intestinal continuity once the patient’s medical condition improves. This operation is best for patients with known Crohn’s disease or indeterminate colitis with rectal sparing and who would prefer to avoid a permanent stoma. Because ulcerative colitis always involves the rectum, it is unusual to preserve the rectum once there are indications for surgery. However, if surgery is necessary and the disease in the rectum is quiescent, an ileorectal anastomosis can be an option. Special circumstances may include female patients who are concerned about the risk of infertility associated with a pelvic dissection and obese patients when construction of an ileal J-pouch may not be feasible. Given the risk of dysplasia subsequently developing in the rectum, frequent surveillance is mandatory for these patients. An ileorectal anastomosis can be converted to an ileal J-pouch or a permanent ileostomy if the clinical parameters were to change.

Severe constipation is defined as infrequent (≤3) bowel movements per week associated with straining (>25% bowel movements with straining or patient sensation of hard stool). If dietary modification and medical management cannot bring relief, mechanical causes should be excluded with colonoscopy or barium enema. After excluding a mechanical cause, colonic transit study (Sitz
markers) and defecography can be useful to find the rare patient with slow colonic transit and a normal functioning rectum. Under these conditions, a total abdominal colectomy with an ileorectal anastomosis can be performed. This procedure will usually successfully increase the frequency of bowel movements. However, only about 50% of patients will have relief of their associated abdominal pain. Furthermore, because some patients will experience difficulty with diarrhea and incontinence, preoperative counseling is critical.

On rare occasions, a total abdominal colectomy may be necessary for massive lower GI bleeding. The most common causes of massive lower GI bleeding are diverticulosis or arteriovenous malformation. The majority of lower GI bleeding will spontaneously cease. Patients who continue to bleed should have attempts at radiographic localization with CT angiography, tagged red blood cell scans, or arteriography. If the bleeding is localized, endovascular embolization can often control it. The threshold for total abdominal colectomy has historically been >6 packed red blood cell transfusions. However, provocative angiography with instillation of dilute tissue plasminogen activator or heparin is an additional consideration before colectomy and can frequently unmask the source of bleeding to allow targeted treatment. Once adequately localized, a segmental resection can be done for those patients who either continue to bleed or rebleed. Rarely, patients will continue to bleed and despite several attempts cannot be adequately localized. In patients who are either hemodynamically unstable or have ongoing transfusion requirements, a total abdominal colectomy is a reasonable operative solution. Before surgery, an upper GI source should be excluded with either upper endoscopy or, possibly, a well-placed nasogastric tube with gastric lavage. Because significant lower GI bleeding can be due to hemorrhoids, a detailed anorectal examination must be performed. If possible, small bowel imaging should also be done before surgery. However, if emergent surgery is necessary, the surgeon should carefully examine the small bowel for any evidence that the small bowel may be the source. If nothing is found in the small bowel, the bleeding is likely from the colon, necessitating a “blind” total colectomy. For high-risk patients with hemodynamic instability, an ileostomy should be created with a plan for an ileorectal anastomosis at a later date. For lower risk patients, a primary anastomosis may be reasonable.