Rectal cancer is a major killer. Most of those dying after curative surgery suffer from recurrent disease in the pelvis. Local recurrence is also the only site of failure in up to 50% of patients. A disturbing fact is that the local recurrence rate shows considerably surgeon-related variances. There is now strong evidence that optimizing surgical technique by adopting the principle of total mesorectal excision (TME) will reduce local failure rate, increase the use of sphincter-saving operations, and improve functional results. Surgeons applying this surgical principle will consistently achieve similarly low recurrence rates.