Intestinal transplantation is the rarest abdominal organ transplant, performed in patients with end-stage intestinal failure (IF), most commonly due to short bowel syndrome and parenteral nutrition-related complications. As medical management of IF has improved, the number of transplants performed annually has declined, with only 95 procedures reported in the United States in 2023. This chapter provides a comprehensive review of the anesthetic management of this transplant, encompassing preoperative evaluation, intraoperative considerations, and postoperative care. Preoperative assessment must address the multisystem consequences of chronic IF, including malnutrition, coagulopathy, hepatic dysfunction, renal insufficiency, metabolic derangements, and severely limited vascular access. Intraoperatively, these lengthy procedures—often 10–15 h—demand meticulous hemodynamic monitoring, goal-directed fluid management, and anticipation of physiologic perturbations during vascular clamping and graft reperfusion. Multimodal analgesia, including neuraxial techniques when feasible, is an important component of perioperative care. Postoperatively, patients face significant risks of graft rejection, infection, renal failure, and surgical complications. One-year patient survival is approximately 90% for isolated intestine recipients. A thorough understanding of the unique physiology and surgical complexity of intestinal transplantation is essential for the anesthesiologist managing these high-acuity patients.