The most important portion of preoperative planning is the consent process in patients with IBD. It is important to describe all of the risks and benefits and possible complications of the procedure. Consent requires mention of the possibility of a permanent stoma, subsequent diagnosis of Crohn’s disease, impotence, decreased fecundity, and pouchitis. It is also important to discuss the practical implications of living with a J-pouch. The average patient will have six to eight bowel movements per day, with good continence and decreased urgency. It is imperative to have trained stoma site marking and education, optimally with a stoma nurse. Nutrition is optimized as much as possible, although that can be very difficult with IBD. It is also helpful to have patients and their families speak with patients who have J-pouches.

Once the patient understands the ramifications of this procedure, the operative staging is decided and for patients with IBD the plan for the immunosuppressant medications is created. When patients are acutely ill in the hospital and the total colectomy is urgently performed, stress-dose intravenous (IV) steroids are given, which are then weaned down to the preoperative home dose at the time of discharge. When the patient presents on an elective basis, steroids can be weaned down by 5 mg/week until symptoms are intolerable. It is crucial that the patients understand that malnutrition is just as dangerous as the medications, so it is not beneficial to wean or stop immunosuppressant medications if symptoms are severe. Locally active medications are continued until the time of surgery. Biologics are stopped if symptoms are not improved with use. If symptoms are helped with biologics, it is beneficial to wait a minimum of four to five half-lives of the medication if possible to perform the operation. If patients are dependent on these medications, it is best to perform surgery at the time of the next scheduled dosing. 6-mercaptopurine, azathioprine, and methotrexate can be continued up to the time of surgery.

A complete comprehensive history and physical examination is performed with particular attention to the anal exam looking for signs of Crohn’s disease. Particular attention should be directed to the discussion of immunomodulator medications, nutritional issues, history of blood clots or anesthetic issues. Preoperative labs including complete metabolic panel (CMP), complete blood count, and type and screen should be checked. The CMP is important to evaluate liver function because UC can be linked to primary sclerosing cholangitis. If malnutrition is a concern, a prealbumin is a good measure of acute malnutrition. A chest X-ray, electrocardiogram, and/or pregnancy test should be performed in appropriate patients. For patients with cancer, appropriate preoperative staging and carcinoembryonic antigen test should be performed before any procedure. If radiation is being considered in patients with rectal cancer, it should be given before surgery.

The nontoxic patient is given an oral cathartic and oral antibiotic bowel preparation. If patients are having copious liquid bowel movements because of IBD, clear liquids the day before surgery will suffice. The patient is asked to perform a Hibiclens rinse the night before as well as the morning of the surgery. Prophylactic heparin or Lovenox is injected subcutaneously before the surgery. One dose of an antibiotic that covers gram-negative as well as gram-positive bacteria is given within 1 hour of the incision, and not continued postoperatively. If steroids were taken within 6 months of the operation, a stress dose of steroids is given before incision.