Background: Colorectal cancer is a major malignant disease of the gastrointestinal tract, which is the third most common cancer and the second leading cause of death from cancer worldwide. The global burden of colorectal cancer is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030. A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer. The local transanal excision of rectal cancer is reserved for early-stage cancers in a select group of patients. The lesions amenable for local excision are small (< 3cm in size), occupying less than a third of a circumference of the rectum, preferably exophytic/polypoid, superficial and mobile (T1 and T2 lesions), low-grade tumors (well or moderately differentiated) that are located in low in the rectum (within 8 cm of the anal verge). There should also be no palpable or radiologic evidence of enlarged mesenteric lymph nodes. The likelihood of lymph node involvement in this type of lesion ranges from 0-12%. The choice of a low anterior resection (LAR) with colorectal stapled anastomosis, ultralow coloanal anastomosis, or abdominoperineal resection (APR) depends on tumor height, the extent of its local invasion, and the surgeon’s skills. Decision-making regarding those procedures takes place during multimodal treatment, or even at the time of the surgery. APR is performed in patients with lower-third rectal cancers. APR should be performed in patients in whom negative margin resection. The term total mesorectal excision (TME) was first introduced in a report by Heald in 1982. He described the “holy plane,” an avascular interface between the mesorectal fascia and the parietal dorsolateral pelvic fascia. He also stated that the rectum and mesorectum are an embryologically distinct lymphovascular entity. In TME surgery, dissection is along this “holy plane” through sharp dissection, in contrast to the more conventional blunt approach. Heald reported local recurrence rates well below 10% and survival rates of up to 87%. TME is the gold standard for the surgical treatment of rectal cancer involving the middle and lower third of the rectum. For the upper third of the rectum, TME is not considered obligatory (removal of the mesorectum to the level of the levator muscles); rather a more conservative resection called tumor-specific TME is preferred (removal of the mesorectum 5cm distal of the tumor).