Presacral bleeding is a challenging situation that all colorectal surgeons must be able to manage. The algorithms are well-established and focus on initial control with pack­ing, resuscitation, and then further action if bleeding persists. These additional actions include suture ligation, sterile thumbtacks, rectus muscle welding, and hemostatic agents [78]. The principles of damage control surgery are also rele­vant to massive presacral bleeding. In the situation where bleeding control cannot be established, patients should be temporized, packed, and taken back to the ICU to correct acidosis, coagulopathies, and hypothermia. A second opera­tion is usually performed in 24–48 hours with the goal of restoring intestinal continuity, removing packing, and achieving nal closure [78]. A related complication is abdominal compartment syndrome, a life-threatening condi­tion that results from massive uncontrolled hemorrhage and/ or aggressive resuscitation leading to increased abdominal pressure [80]. When pressures exceed 20mmHg [78], the compartment must be rapidly decompressed to reestablish ow to the viscera, usually via an abdominal laparotomy. With decompression, symptoms tend to resolve. Complications are high, however, with multi-organ dysfunc­tion and mortality rates approaching 50% [81].