Colorectal adenocarcinoma is the second leading cause of cancer deaths in Western countries. Rectal cancer comprises approximately 25% of the malignancies arising in the large bowel. However, the past two decades have seen many major advances in the diagnosis and treatment of this disease. While surgery is still the cornerstone of curative therapy, a multidisciplinary approach including neoadjuvant chemoradiotherapy has resulted in significantly improved outcomes. Information concerning the T, N, M stage and the exact location of tumor in relation to the anal verge are of crucial importance when planning a curative rectal cancer resection. Preoperative staging, utilizing a combination of diagnostic modalities, must be undertaken to determine whether or not neoadjuvant therapy is indicated. In radical resection of locally advanced low rectal cancer, several unique surgical management issues should be considered: 1) total mesorectal excision (TME); 2) longitudinal and circumferential resection margins; 3) autonomic nerve preservation (ANP); 4) sphincter preservation versus abdominoperineal resection (APR); 5) restoration of bowel continuity; and 6) laparoscopic versus open resection. The surgeon must first strive to achieve an oncologic cure, but whenever possible this should be undertaken with the goal of maintaining the patient's quality of life. The purpose of this review is to outline the critical surgical issues involved in management of locally advanced low rectal cancer.