Surgery was first introduced as a treatment for ulcerative colitis in the late 19th century with the use of appendicostomy or cecostomy as a conduit to irrigate the diseased colon with various solutions (1). This strategy continued until the 1940s when fecal diversion became popular. In the 1950s, advances in surgical technique greatly improved the construction of an end ileostomy, making colectomy the treatment of choice for medically refractory ulcerative colitis (2). Attempts to further improve patient’s quality of life resulted in the development of the marginally successful continent ileostomy (3). In the late 1970s, the ileal pouch-anal anastomosis (IPAA) was introduced (4). This procedure restored the intestinal continuity by creating a neorectum from the distal ileum and has become the preferred surgical treatment for patients with medically intractable ulcerative colitis.

Prior to surgery, it is imperative to confirm the original diagnosis of ulcerative colitis. Some patients, thought to have ulcerative colitis, will actually have Crohn’s colitis, which is a contraindication to the creation of an IPAA. Therefore, careful review of the clinical record and a thorough history and physical exam is critical to the preoperative management. Usually, ulcerative colitis can be distinguished from Crohn’s colitis on clinical criteria. However, in some instances, the etiology of the colitis will remain indeterminate. Under these circumstances, it may be appropriate to perform a total abdominal colectomy (TAC), leaving the rectum in situ, so that a definitive pathologic diagnosis can be done. If ulcerative colitis is then confirmed, a restorative completion proctectomy with an IPAA is performed.

Current surgical therapy can be divided into two subgroups: operations that restore intestinal continuity, utilizing the patient’s native sphincter mechanism, and those requiring a permanent ileostomy. Since patients will experience frequent loose stools following an IPAA, the decision to utilize a patient’s own sphincter should be made carefully. Postoperative functional outcomes correlate strongly with preoperative sphincter performance. Therefore, older patients (6, 7 and 8), women with a history of obstetrical trauma (9), or those with a preexisting history of fecal incontinence may warrant careful evaluation of anorectal function, which may include preoperative anal sphincter manometry and/or anal ultrasound. Patients with poor anorectal function should be counseled about the distinct possibility of incontinence after a sphincter saving procedure and a permanent ileostomy should be considered. Furthermore, since an IPAA is a complicated and formidable operation, patients must be medically fit and highly motivated. In patients with a poor functional status or who are ambivalent about restoring intestinal continuity, a permanent ileostomy should be considered. In patients who are debilitated by the ulcerative colitis itself a TAC with an end ileostomy can be done, leaving the rectum intact. Usually this is enough to restore the patient’s health, at which time the rectum can be removed and an IPAA performed.

Operative therapy for ulcerative colitis requires two elements. The first element is therapeutic and involves removal of the diseased tissue. In most cases, this involves the complete removal of the abdominal colon. Even in patients with isolated left-sided colitis, the complete removal of the colon is recommended because of the likelihood of disease progression and because of the increased risk of developing colon cancer. Removal of the rectum is usually indicated and done at the initial operation. However, in patients who are very ill, either from toxic colitis or from severe debilitation, it is advisable to remove the entire colon, leaving the rectum in situ. Usually, this will be enough to restore the health of the patient, at which time the rectum can be electively removed.

After completion of the therapeutic portion of the operation, the next element to accomplish is reconstruction. The descriptions and indications of common operations are listed here (Fig. 9.1).