- Total proctocolectomy involves removal of the entire colon and rectum, commonly performed for ulcerative colitis, familial adenomatous polyposis, colorectal cancer, or fulminant colitis
- Preoperative planning includes full colonic assessment, pelvic imaging if rectal disease is present, and discussions regarding reconstruction versus permanent stoma
- Marking of a stoma site should be done preoperatively if ileostomy is anticipated
- Dissection begins with full mobilization of the colon
- The lateral peritoneal attachments are divided along the white line of Toldt to mobilise the right and left colon
- The hepatic and splenic flexures are mobilized to free the transverse colon
- The sigmoid colon is mobilized down to the pelvic brim
- Vascular pedicles are ligated at their origins to ensure hemostasis and adequate mesenteric clearance
- Includes the ileocolic, right colic, middle colic, left colic, sigmoid, and superior rectal arteries
- Ensures devascularisation of the colon and rectum while preserving the terminal ileal supply
- The rectum is dissected down to the pelvic floor
- For cancer, total mesorectal excision is performed to ensure radial and distal clearance
- Dissect between the mesorectal fascia and the parietal pelvic fascia
- For benign disease, dissection may be close to the rectal wall to preserve pelvic nerves
- The rectum is divided at the anorectal junction or leaving a small rectal cuff
- Reconstruction
- Options
- A J-pouch is constructed from the terminal ileum and anastomosed to the anal canal
- A diverting loop ileostomy is often used to protect the anastomosis
- Permanent end ileostomy is formed with closure of the anus
- Critical structures must be identified and preserved
- Ureters should be identified early and protected during medial dissection
- Hypogastric nerves and pelvic splanchnic nerves should be preserved to reduce risk of bladder and sexual dysfunction
- In females, avoid injury to the posterior vaginal wall; in males, keep dissection clear of the prostate