Background Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. Summary After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes, nevertheless there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference and tumor characteristics such as stage and localization.