In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.