Colo-anal anastomosis represents the only surgical method allowing both resection of the distal third of the rectum and re-establishment of intestinal continuity. Technically similar to a low anterior resection, a transanal approach is used for the distal dissection as this is the only way to ensure that the mucosal excision continues as far as the dentate line. Intestinal continuity is then restored by fashioning a colo-anal anastomosis under direct vision. Alternatively, a colonic reservoir can be created in the form of a J and a pouchanal anastomosis fashioned. A proven technique for this surgical procedure is discussed.