Over 42,000 patients each year are diagnosed with rectal cancer in the United States. There have been recent advances in the oncologic treatment of colon and rectal cancer; however, cure depends on surgical resection. The combined abdominoperineal resection of the rectum (APR) first described by Mayo and popularized by Miles remained the gold standard for cancers of the distal rectum for most of the last century (1). The operation involves removing the rectum, anus, sphincter complex, and a portion of the levator ani and is concluded with the construction of a permanent colostomy. The more recently appreciated efficacy of a much narrower distal margin of resection compared with the heretofore required 5-cm distal margin, the newer technique of total mesorectal excision (TME), and the development and ongoing improvement in stapler technology are the major factors that have resulted in the applicability of sphincter-saving procedures for the majority of patients with distal rectal cancers, usually employing rectosigmoid resection with low rectal anastomosis (low anterior resection) or ultralow coloanal anastomosis (2,3).

In this chapter, we discuss the various factors that must be considered in the preoperative evaluation and staging that would indicate the appropriateness of a sphincter-preserving operation. We outline our technique in the conduct of such operations keeping in mind that performing such an operation simply because it is technically feasible to do so is not always in the patient's best interest. It our goal ...