The rst step is exploratory laparotomy or diagnostic laparoscopy to conrm the diagnosis and ensure that there is no colonic necrosis or perforation. A laparoscopic approach is preferable if the patient is a good candidate and if the surgeon is com­fortable with the procedure; otherwise it can be undertaken using an open approach. The second step involves the creation of a loop ileostomy. The loop ileostomy is ideally created 20 cm from the ileocecal valve so that an 18Fr Foley catheter, inserted into the distal limb of the ileostomy, can be positioned in the cecum. The Foley should be secured to the ileostomy at the end of the procedure using a 0-silk suture (Fig.10.2b). Lavage of the colon is then performed with 8L of polyethylene glycol (PEG) solution warmed to 37°C.The colonic lavage is performed with the use of the Foley catheter connected to a bag with the PEG solution using urological connection tubing, similar to the one used in cystoscopy. A rectal tube or manage­ment device should be inserted into the rectum and attached to a large drainage bag until the lavage is complete. The PEG solution is administered in increments, liter by liter, ensuring that efuent drainage is collected in the rectal tube. If the proce­dure is performed laparoscopically, pneumoperitoneum can be maintained at 7–10 mmHg during lavage. Laparoscopic bowel graspers may be used to aid in pushing the uid along the colon. If performed by a laparotomy, the abdomen is kept open, and the surgeon can manually aid the movement of the uid through the colon. If trouble is encountered getting uid through the colon, the patient may be moved into the Trendelenburg/reverse Trendelenburg positions as well as left side up/down and right side up/down to move the uid along the colon. Alternatively, though rarely required, the hepatic and/or splenic exures may be mobilized. Due to uid sequestration in the diseased and atonic colon, an ACS may occur during or after the operation. Although the authors do not recommend routinely monitoring for ACS, the surgeon should be aware of this possibility. The surgeon may choose to leave a drain in the paracolic gutters to drain excessive ascites and potentially reduce the risk of an ACS.Postoperatively, vancomycin ushes (500mg in 500mL of Lactated Ringers) are delivered to the diseased colon through the Foley catheter that was left in the efferent limb of the ileostomy. The rst vancomycin ush is given after completion of the PEG ushes, and administration should be continued every 8h for 10days or until the patient is clinically well.