Restorative proctocolectomy may be performed as a 1-, 2- or 3-stage procedure (Fig. 14.3). A staged procedure is the procedure of choice in emergency, in acute severe colitis, when the patient is taking high dose of steroids (e.g. prednisolone >40 mg/day) or moderate steroid dose (20 mg/day) for more than 6 weeks, when differential diagnosis with CD is not established, when advanced CRC is present in the colon and in case of moderate to severe malnutrition [21]. Recent reports from Mayo Clinic and Cleveland Clinic have evidenced an increased risk of post-operative complications in patients undergoing restorative procedure under Infliximab therapy, suggesting a staged approach also for this setting [28, 29]. When appropriate skills are available, a laparoscopic approach is recommended [21]. A subtotal colectomy with end ileostomy, leaving in situ the rectum, is a relatively safe procedure even in critically ill patients, allowing patients to regain general health, normalize nutrition, interrupt any medical therapy (desaturating from steroids) and consider the option of an IPAA, an IRA or a permanent ileostomy [30, 31, 32]. There are specific recommendations on how to deal with the rectal stump, since these may have an impact on both complications and later proctectomy and IPAA. The whole rectum has to be preserved, with or without the distal part of the sigmoid colon, while dividing the rectum at the distal third is not recommended. In fact, pelvic dissection during the first procedure leads to high risk of nerves and sacral veins injury at the time of IPAA. Furthermore, post-operative pelvic fibrosis may impair ileo-anal anastomosis and jeopardize pouch function [21]. Blowout of the rectum in a very compromised bowel, due to a dehiscence of the closing suture, is the most common and dangerous complication of the staged procedure (Fig. 14.4). When necessary, a long rectal stump may allow performing a recto-cutaneous fistula, eliminating any sutured bowel from the abdominal cavity. Once again, the dehiscence of a too short rectal remnant in the pelvis should be impossible to be controlled and the consequent pelvic fibrotic reaction could lead to the impossibility of performing an IPAA.

Proctectomy, pouch formation and ileo-anal anastomosis are the most technically demanding phases of the whole procedure. In elective cases, both resective (total proctocolectomy) and restorative (IPAA) procedures may be performed during the same intervention. Most surgeons favour creation of a temporary defunctioning loop ileostomy after IPAA to avoid anastomotic dehiscence and pelvic contamination; this is the classical two-stage procedure, since a second operation is needed, after 8–10 weeks, for ileostomy closure. However, some authors advocate the single stage procedure in selected cases, mainly on the basis of an exercise in risk management. Anastomotic dehiscence is three times higher in one-stage versus two-stage procedures (5 vs. 15 %), but ileostomy closure has the considerable complication rate of 11–25 %. So, the final decision is a balance between these two aspects, taking into account patient’s specific risk factors (e.g. preoperative therapy, nutrition, age, BMI, technical difficulties encountered during surgery) [33].

Parks and Nicholls originally proposed a triple-limb S-shaped pouch, but several alternative designs have been described, including a high-capacity “W” pouch and an ease-to-perform “J” pouch [23, 34]. The evidence is that within 1 year after pouch construction, the pouch shape has no influence on functional results. However, different pouch designs have specific complications. The “S” pouch has an efferent limb that may suffer from kinking if it is longer than 1 cm, and a hand-sewn ileo-anal anastomosis with mucosectomy is necessary (see later). The “W” pouch avoids efferent limb complications, but is time-consuming with poor long-term benefits. The “J” pouch is favoured by most surgeons because of the ease of construction, allows both manual or stapled anastomosis and less intestine is used in the process [35, 36].

Dissection and removal of the columnar mucosa above the dentate line with trans-anal hand-sewn anastomosis was initially advocated in order to prevent UC recurrence and CRC. The main problem with mucosectomy is due to the removal of the anal transitional zone (ATZ), which is richly innervated by sensory nerve endings that mediate anal sampling reflexes, permitting discrimination of solids and liquids from gases and thus contributing to the whole continence mechanism (Fig. 14.5) [37]. Given that when performing an IPAA the maximum length of anorectal mucosa between the dentate line and the anastomosis should not exceed 2 cm (1–1.5 cm are better), a stapled IPAA is generally preferred since it improves continence through ATZ preservation and the cancer risk is equally low as in hand-sewn anastomosis (Figs. 14.6, 14.7) [21]. Even if the advent of reliable and ergonomic stapling instruments has greatly simplified the pouch-anal anastomosis, the surgical team performing an IPAA has to be able to perform a hand-sewn anastomosis in case the stapler fails [21].

In referral centres a minimally invasive approach has become the standard of care. Avoidance of wound pain and complications, reduction of blood loss and adverse surgical events, improvements of short-term and long-term morbidity, reduction of adhesion formation preserving the risk of obstruction and fecundity and a better cosmesis in a young population, are all strong points of laparoscopic surgery [22, 38–41]. Laparoscopy, together with the application of enhanced recovery programmes, designed for early post-operative mobilization and feeding, is the new gold standard of care for UC patients.

Rectal and pelvic dissection may result in damage of parasympathetic erigent nerves and sympathetic hypogastric plexus, regulating ejaculation in 1–4 % of the male patients. In women, sexual dysfunction may be much higher at 8–11 %, mainly due to vaginal dryness, dyspareunia, pain interfering with sexual pleasure and limiting of sexual activity because of concerns of stool leakage [42

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