The TME project (TME = total mesorectal excision) demonstrated and probably enhanced a major shift in rectal cancer surgical practice in Stockholm with an increased centralisation and specialisation. As a result, local control and cancer-specific survival has been significantly improved. In addition, the frequency of APR (APR = abdominoperineal resection) declined. TME based surgery demands surgical skill, which can be achieved by participation in education programmes and increased by personal training and experience. Variability in patient outcome is seen also with TME based surgery and is mainly related to case volume, with better results obtained in patients treated by high-volume surgeons. A combined treatment modality approach, integrating the colorectalsurgeon, diagnostic radiologist, pathologist, medical and radiation oncologist is necessary to achieve optimal outcome.