Abdominoperineal Resection with Total Colectomy and End-Ileostomy

• Ulcerative colitis refractory to medical therapy (pancolitis)
• Crohn's disease refractory to medical therapy involving the colon and rectum
• Familial adenomatous polyposis

• Poor cardiopulmonary reserve
• Inability to tolerate general anesthesia

• Operating room/general anesthesia
• Stirrups for lithotomy positioning
• Conventional laparotomy instrument tray (including long instruments) and retractors
• Lighted retractor for pelvic dissection
• Lighted Hill-Ferguson retractor
• Lone Star retractor for perineal dissection

• Anatomically, the colon is divided into the ascending (right), transverse, descending (left), and sigmoid colon.
• The duodenum lies posterior to the right colon in the retroperitoneum and must be identified during the dissection.
• The white line of Toldt on both the right and left is an important surgical landmark for mobilizing the right and left colon, respectively. It represents the fusion between the colonic mesentery and the peritoneum.
• The rectum is 12 to 15 cm in length and follows the curve of the sacrum in the pelvis. The anterior third of the rectum is intraperitoneal, but the remainder is extraperitoneal.
• The posterior rectum is attached to the mesorectum, which contains the rectal lymphatics. The mesorectum is enveloped by the fascia propria.
• The total mesorectal excision (TME) technique of proctectomy involves dissection of the rectum between the fascia propria enveloping the mesorectum and the presacral fascia investing the sacrum. Typically this is a bloodless dissection that facilitates complete removal of the mesorectum, an important oncologic principle.
• Blood supply to the colon consists of the ileocolic, right colic, middle colic, left colic, and sigmoidal arteries. The ileocolic, right colic, and middle colic are branches of the superior mesenteric artery. The left colic and sigmoidal arteries are branches of the inferior mesenteric artery.
• Blood supply to the rectum consists of the superior, middle, and inferior hemorrhoidal arteries. The superior rectal (hemorrhoidal) artery is a branch of the inferior mesenteric artery. The middle rectal artery is a branch of the internal iliac artery. The inferior rectal artery is a branch of the pudendal artery.
• The ureter normally crosses the common iliac artery just proximal to the bifurcation of the external and internal iliac arteries.

• The nasogastric tube is removed on postoperative day 1.
• The Foley catheter is removed on postoperative day 3 to 5 given the extensive pelvic dissection.
• Oral intake is initiated when there is evidence of ileostomy function. The diet initially consists of clear liquids and is advanced as tolerated to a regular diet. IV fluids are set at maintenance rate while patient is NPO.
• An enterostomal therapist/nurse is consulted to instruct and assist patient with stoma care.

• Intraoperative:
• Ureteral injury
• Injury to hypogastric nerves
• Injury to presacral nerve plexus
• Bleeding from presacral venous plexus
• Peroneal nerve palsy from excess pressure over fibular head due to poor positioning in stirrups
• Transection of the male urethra
• Postoperative:
• Wound infection of abdominal or perineal incision
• Intra-abdominal abscess
• Urinary retention
• Sexual dysfunction

Total proctocolectomy with end ileostomy remains a reliable method for removing the diseased colon, rectum, and anus in entirety. Although historically this was one of the first procedures performed for pathologic conditions of both the colon and rectum, it continues to have a role in surgical management today. Patients best served by this approach are those with poor preoperative sphincter function (commonly elderly patients), in which preservation of the sphincter complex is less critical.