For many patients with inflammatory bowel disease (IBD) proctocolitis, proctectomy offers symptom and disease control, albeit at the expense of a potentially morbid proctectomy. There are select situations, however, where definitively leaving an IBD rectum in situ, either in or out of intestinal continuity, may be a suitable alternative to proctectomy. This review explores the rare occasions where leaving the rectum in situ may be advisable and discusses the subsequent implications.