Older patients undergoing colorectal surgery face unique challenges that impact both short- and long-term outcomes. Frailty, sarcopenia, and multiple comorbidities increase surgical risks and complicate recovery, necessitating a tailored approach to perioperative care. A transdisciplinary strategy—incorporating prehabilitation, risk stratification, and patient-centered decision-making—is essential to optimize outcomes in this vulnerable population. Surgical considerations must be individualized, with minimally invasive techniques favored when feasible, staged approaches prioritized in high-risk or emergency cases, and surgical palliation employed to enhance symptom control and functional preservation. Despite the growing recognition of these challenges, older adults remain under-represented in clinical trials guiding rectal cancer management, leaving the effects of surgery and treatment toxicity insufficiently explored. A multimodal treatment strategy is crucial, balancing oncological control with functional outcomes and quality of life.