What is a Total Abdominal Colectomy
A total abdominal colectomy is the surgical removal of the entire colon (from cecum to rectosigmoid junction) while preserving the rectum, typically followed by an ileorectal anastomosis (connecting the small bowel to the remaining rectum) or creation of an end ileostomy. 1
Anatomic Definition and Surgical Extent
Total abdominal colectomy removes all intra-abdominal colon while leaving the rectum in place, with the bowel divided at the rectosigmoid junction 1
The procedure differs from subtotal colectomy (which anastomoses small bowel to sigmoid colon) and total proctocolectomy (which removes both colon and rectum) 1
When performed with ileorectal anastomosis, the terminal ileum is connected directly to the preserved rectum, maintaining anal sphincter function and avoiding a permanent stoma 1
Alternatively, the procedure can be completed with an end ileostomy when anastomosis is unsafe or undesirable, leaving the rectal stump in situ 1
Primary Clinical Indications
For Lynch Syndrome and hereditary colorectal cancer:
Total colectomy with ileorectal anastomosis is the primary treatment for Lynch Syndrome patients with colon cancer or non-resectable neoplasia, reducing 10-year metachronous cancer risk from 16-19% (after partial colectomy) to 3.4% 1
This approach provides a 2.3-year life expectancy gain in younger patients (age 27) compared to hemicolectomy, though benefit decreases with age (1 year at age 47, only 0.3 years at age 67) 1
For ulcerative colitis:
Total abdominal colectomy serves as the initial emergency operation for acute severe colitis, particularly in patients on high-dose steroids (≥20 mg prednisolone for >6 weeks) or anti-TNF therapy 1
Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis, coinciding with the biologic therapy era 2
A staged approach (initial total abdominal colectomy followed by later proctectomy and pouch construction) allows critically ill patients to recover, normalize nutrition, and clarify diagnosis before definitive reconstruction 1
For fulminant Clostridioides difficile colitis:
Total colectomy with end ileostomy is the procedure of choice for fulminant C. difficile infection requiring surgery, performed in 89% of cases (1,247/1,401 patients) 1
Emergency colectomy reduces mortality compared to medical management alone, particularly beneficial in patients ≥65 years, immunocompetent patients, and those with leukocytosis ≥20×10⁹/L 1
For Crohn's disease with extensive colonic involvement:
- Total abdominal colectomy is indicated when multiple colonic segments are affected, though segmental resection is preferred when feasible in the biologic era 1
Reconstruction Options and Their Implications
Ileorectal anastomosis (IRA):
Preserves anal sphincter function with better bowel function than proctocolectomy, but requires lifelong endoscopic surveillance of the retained rectum every 6-12 months 1
Appropriate for patients with minimal rectal involvement, younger age, and willingness to undergo surveillance 1
Contraindicated in patients >60-65 years with underlying sphincter dysfunction, where less extensive surgery should be considered 1
End ileostomy without anastomosis:
Indicated in emergency settings, severely ill patients, or when anastomosis carries excessive risk 1
When leaving a rectal remnant, divide at mid-rectum level (not at promontory) to facilitate future reconstruction, with transanal drainage for several days to prevent stump blowout 1
Functional outcomes show all surveyed ileostomy patients (14/14) were satisfied, compared to 90% (19/21) with ileorectal anastomosis, though the latter group averaged 6.85 daily bowel movements with 25% incontinence rate 3
Surgical Approach and Technical Considerations
Laparoscopic approach is preferred when appropriate skills are available, particularly in acute severe colitis, resulting in fewer wound infections, fewer intra-abdominal abscesses, and shorter hospital stays 1, 4
Single-incision laparoscopic technique through the ileostomy site offers a truly scarless approach with mean operative time of 139±24 minutes and faster resumption of solid diet 4, 5
The procedure involves clockwise mobilization starting with right colon, dividing ileocolic pedicle after visualizing right ureter and duodenum, taking down hepatocolic ligament, dividing transverse mesocolon, mobilizing descending colon with left ureter visualization, and dividing at rectosigmoid junction 5
Outcomes and Complications
Overall morbidity ranges from 7.7% in young patients to 38.8% in elderly, with surgical complications (anastomotic leak, wound infection, bleeding) occurring in 7.9% regardless of age 6
Mortality is higher in elderly patients (17% vs 5% in younger patients) and associated with high ASA score and emergency presentation 3, 6
Systemic complications are more frequent in elderly due to comorbidities, but surgical complication rates remain similar across age groups 6
When performed for Lynch Syndrome, functional outcomes (stool frequency, social impact) are worse after total colectomy than partial colectomy, though global quality of life remains comparable 1
Critical Clinical Caveats
Age is not an absolute contraindication to total abdominal colectomy when combined with careful preoperative evaluation, though less extensive surgery should be considered in patients >60-65 years 1, 6
For Lynch Syndrome patients with rectal cancer, consider total proctocolectomy with ileal pouch-anal anastomosis instead, as metachronous advanced neoplasia risk reaches 51% after anterior resection alone 1
In emergency settings with diffuse peritonitis, delay in surgery increases complications—joint care with senior surgeons and gastroenterologists is essential 1
The retained rectum after ileorectal anastomosis carries persistent cancer risk requiring indefinite surveillance, with cumulative colon cancer risk of 19%, 47%, and 69% at 10,20, and 30 years respectively in Lynch Syndrome patients 1