The surgeon plays a major role in rectal cancer treatment concerning local recurrence and long-time survival. Thus, the rate of locally recurrent disease ranges from 4 to 55%. This state-of-the-art article points out the latest findings of surgical therapy, such as the total mesorectal excision, the limits of sphincter-preserving resection, the minimally invasive procedures and others, and reveals their impact on the patients outcome. Hence, oncologically adequate surgery allows to reduce the rate of local recurrence to 5 to 10% and to reach a 5-year survival rate of 70 to 80%.