Standardization of surgical techniques according to the TME (total mesorectal excision) principles is the most important single factor in improving treatment outcome in rectal cancer. In skilled hands surgical specimens are of equal quality both in open and laparoscopic surgery. In selected patient groups, cancer of the middle or low rectum can also be managed laparoscopically by an experienced surgeon and under good circumstances. Since both immediate and long-term results from large international randomized multicenter studies are lacking so far, open surgery should still be considered as the standard method for rectal cancer.