The management of primary rectal cancer has evolved dramatically over the last 30 years, principally focused on the aim of reducing local recurrence. Clinical trials positioned local recurrence at the forefront for treatment outcomes, especially with the evolution of total mesorectal excision and neoadjuvant chemoradiotherapy. This has been achieved to a significant degree with isolated pelvic recurrence falling from 18%–30% to 2%–8%. For patients with local pelvic recurrence, death may be a painful process with the unpleasant prospect of the slow development of a malodorous, fungating, fistulating perineal mass. For patients with local recurrence, there is the possibility of further, albeit more radical, surgery, where excision for cure is a treatment option. The extensive nature of the operative techniques required to obtain clear resection margins carries some morbidity. Yet, concentration of cases in specialised centres along with improvements in perioperative intervention, extended radical resection has become the standard of care. The outcome of these patients is variably reported, often in small(ish) case series from low volume institutions with multiple surgeons. Nevertheless, appreciation of the need to employ appropriate surgical techniques with the aim of achieving an R0 resection has improved the outcome for patients with local recurrence of rectal cancer. The aim of this presentation is to address the surgical challenges, provide operative strategies and encourage a team-based approach to improve long term survival for this unfortunate group of patients.