Low anterior resection (LAR), with its numerous technical modifications, is one of the most commonly performed operations for rectal cancer. In the past, patients with locally advanced distal rectal cancer were most frequently treated by abdominoperineal resection and permanent colostomy. However, over the past two decades and with improved understanding of tumor biology and refinement in technique, use of LAR to treat rectal cancer has increased substantially. Yet, despite the significant increase in LAR and sphincter preservation, patients in many areas of the country have little access to these techniques and continue to commonly be treated with abdominoperineal resection. This article examines the surgeon's unique and critical role in the pretreatment evaluation and decisions leading to choice of surgical therapy for locally invasive distal rectal cancer. In particular, the authors focus on technical aspects to preserve the anal sphincter, and review methods to optimize functional outcomes in the setting of low pelvic anastomosis.