In 1982, Heald et al. [24] published the results of the technique of total mesorectal excision (TME) for the management of rectal cancer. They reported a 4 % rate of local recurrence. Afterward, different multicentre studies showed that the implementation of the TME decreased the rate of local recurrence and improved survival. In short, TME became the gold standard surgical technique for tumours located in the middle and lower rectum. Currently, rectal cancer should be managed by a multidisciplinary team where each case is treated individually.

One of the problems that arises after total mesorectal excision is determining what type of reconstruction should be carried out [25]. Over the years, anastomotic techniques have been refined. Keeping in mind that most of us are using primarily mechanical stapled colorectal anastomosis, the so-called Colon Ring, a staple-free technique based on a ring of titanium and nickel that produces compression with a consistent force at the end-to-end anastomosis, was marketed a few months ago.

First studies [26] on the subject show that the compression technique is surgically feasible, easy to use, and without significant complication rates; however, a large randomized controlled trial is needed in order to determine the actual benefits of the Colon Ring over traditional stapling techniques.

Other important technical advances in rectal surgery thanks to the improvement of the anastomotic technique are the sphincter-saving procedures that have become the standard treatment in the surgical approach to most cancers of the middle and lower third of the rectum. When the total rectum is removed, straight colo-anal anastomosis is related to the well-known anterior resection syndrome characterized by increased stool frequency, urgency, and incontinence mostly due to loss of the reservoir function. In order to improve functional outcome, the construction of a colonic J-pouch from the distal colon was proposed. The distal section of the colon is formed into a J-shaped pouch in order to replace the function of the rectum and store stool until it can be eliminated. A significant number of studies [27] that compared the J-pouch with straight end-to-end colo-anal anastomosis have shown functional superiority of the pouch, especially in the first 2 years after surgery, with similar morbidity. However, up to one out of four patients complains of evacuator dysfunction which is related to an oversized reservoir. Currently, it is recommended that the reservoir be fashioned no larger than 5–6 cm. From a technical point of view, it is not difficult to make a colonic J-Pouch; what is sometimes a challenge is to down it through a narrow pelvis, which is the norm in obese male patients.

As seen before, while colonic J-pouch anastomosis is able to eliminate some of the functional problems of straight colo-anal anastomosis, it comes with the problem of pouch evacuation. Hence, in an attempt to improve functional results, alternative techniques, such as transverse coloplasty pouch and side-to-end colo-anal anastomosis, have been suggested.

In a randomized controlled study [28], transverse coloplasty reconstruction after rectal cancer resection and colo-anal anastomosis is functionally similar to colonic J-pouch both in short- and long-term outcomes. The coloplasty technique does not seem to improve significantly the incomplete defecation symptom with respect to the J-pouch. The same outcomes are reported when compared to side-to-end anastomosis. This last technique has as a major advantage in that it is the easiest and fastest to perform.

With reference to quality of life issues, it is very difficult to extract any conclusion. There are few studies, most of them based on a smaller number of patients. Studies such as that of Hallbook and Furst [29], using the NHP and EORTC questionnaires, respectively, found no differences when straight anastomosis was compared to colo-anal reservoir. On the contrary, more recent papers, such as the one by Sailer [30], that use the GIQL, C30, and CR38 questionnaires, found that patients with a reservoir presented with a better quality of life.

In any case, and keeping in mind the lack of proper evidence, it seems that those reconstructive techniques that offer a “neo-rectum” are associated with a better quality of life.

If there is a major postoperative issue that all colorectal surgeons are afraid of, it is anastomotic dehiscence. It is very well known that the anastomotic leakage rate rises as it comes close to the pelvic floor. In order to minimize the morbidity, a protective ostomy is recommended for many. This preventive manoeuvre, however, is not free of morbidity by itself: in some studies nearly 50 % [31] of cases present a complication related to the protective ostomy. Hence, an ostomy should be performed when the risk of dehiscence is high enough to justify it. In this context, it seems reasonable to add a protective ostomy to the low anterior rectal resection if the patient has received neo-adjuvant treatment.

Whether to use a colostomy or an ileostomy to protect the anastomosis could be left to the surgeon’s preferences. However, there are some RCT that point out that the ileostomy is linked to a lower morbidity rate in terms of prolapse and sepsis.

Lastly, some authors perform [32] the so-called ghost-ileostomy. It is done by placing a removable Silastic band (vascular loop) around the ileum which is exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. In case of an anastomotic complication, the ileostomy is performed under local anaesthesia. Ghost-ileostomy allows selective ileostomy formation; however, current evidence tells us that this kind of ileostomy should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neo-adjuvant therapy.