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Recent progress in medical treatment for patients with ulcerative colitis (UC) has been remarkable and surgical indications are changing accordingly. While the number of conventional refractory cases is decreasing, the number of cases of surgery for cancer or dysplasia is markedly increasing. With similar sporadic cases, the recto-sigmoid colon is involved in approximately 75% of affected patients, for whom resection of anal canal mucosa with an ileal pouch anal anastomosis procedure is recommended.Another prominent change is the increasing age of patients undergoing surgery. We have reported that the prognosis of elderly patients undergoing emergency surgery is poor. Thus, in severe cases, if first-line therapy is ineffective, collaboration between the attending physician and surgeon is important to determine whether to perform surgery or second-line therapy.On the other hand, no major changes regarding surgical techniques for UC have been recently presented. The surgical procedure most often utilized for cases of open surgery is a small laparotomy, while robotic surgery using a da Vinci system is common for laparoscopic surgery cases. In the future, salvage surgery is also expected to become an important procedure.