For resectable rectal cancer, surgical treatment must safely meet two objectives. The most important goal is to achieve an R0 tumour resection with adequate circumferential margins and a complete regional lymphadenectomy. A secondary objective is to optimise post-surgical quality of life by preserving anal sphincter function. Surgery for rectal cancer is technically demanding and requires sophisticated decision-making to achieve optimal results. How do we as a healthcare community achieve excellence in the performance of surgery for localised rectal cancer? Do quality indicators help achieve excellence, and if so, is the type of operation performed an effective quality indicator for surgery of localised rectal cancer?

Four operations encompass the majority of surgery for rectal cancer. Transanal excision is reserved for small, early stage distal tumours and is not the subject of this discussion. Anterior resection (AR) and Hartmann’s resection both involve excision of the tumour and entire mesorectum from an abdominal approach. Abdominoperineal excision (APE), which is utilised for the most distal tumours, requires removal of soft tissues below the levator muscles, an anatomical space also bounded by the fatty tissues of the ischiorectal fossae and the bony pelvis. Complete excision of the mesorectum should also be performed during an APE, although for a minority of cases the nodal drainage may also involve the lateral pelvis. The extent of APR must be broadened if necessary to obtain negative margins, which are defined by the absence of tumour for a distance of 1 mm or more from the resection plane.1 This may require complete resection of the levator muscles, partial resection of sacrum and/or ileum and, when required, reconstruction of the pelvic floor with autologous tissue.

A major contribution to improving surgical quality is the careful work of Dr Quirke and colleagues,1 who demonstrated the importance of technique and surgeon–pathologist …