Rectal adenocarcinoma located less than 6cm from the pectineate line raise the issue of sphincter preservation. Preoperative treatment response can modify the initial indication of surgery. With good response, conservative surgery can be performed with a distal margin less than 2 cm. Conversely a lack of response requires an abdominoperineal resection. Removal technique must emphasize a total mesorectal excision and a prevention of urosexual complications. Intersphincteric resection allows to increase distal margin without continence dysfunction. Regional lymphadenectomy doesn’t increase regional control. Digestive tract reconstruction combines coloanal anastomosis and J colonic pouch whenever anatomical conditions are favorable. Long-term follow up should validate this therapeutic approach.