<p>Large bowel obstruction (LBO) is considered to be one of the most important surgical emergencies, and in the case of perforation, one of the most threatening. The predominant cause of LBO is a malignancy, followed by stenosing sigmoid diverticulitis and volvulus. The control of sepsis is of paramount importance, with the primary surgical approach being tailored to the presence or absence of a perforation and the patient’s overall condition. The surgical approach for carcinoma and diverticular stenosis often is the same, as in the latter case a carcinoma can only be ruled out in the resected tissue. In the event of perforation it’s imperative to differentiate between contained perforation (typically in the vicinity of the tumor) and free perforation (typically clearly proximal to the tumor) perforations. In cases of obstruction in the right hemicolon, whether with or without contained perforation, oncological resection with primary anastomosis can generally be performed, even in emergency circumstances. The decision regarding the placement of a stoma must take consideration of the patient’s general condition. Conversely, a left-sided resection in an emergency is associated with a greatly increased rate of anastomotic leakage and stoma placement should be more liberal. In the case of free perforation, maintaining continuity is less important than controlling sepsis, so that discontinuity resections are more often indicated. In a palliative situation without free perforation, surgical restraint is advisable even in emergencies, where alternatives include endoscopic stent placement or surgical stoma creation. In the event of a volvulus, the primary treatment modality should be an endoscopic decompression and detorsion, with subsequent elective resection performed during the same admission.</p>