This chapter describes the Sphincter-saving procedures for low rectal cancer. Over the last century, management of rectal cancer has achieved significant advancement. Multidisciplinary management is now standard of care for rectal cancer at most of the colorectal center. Surgical treatment of rectal cancer has also evolved over a period, starting from perineal excision to abdominoperineal resection (APR) to various sphincter-saving procedures. Sphincter-saving procedures are the choice today both by the patients and the surgeon wherever possible, provided the oncological goals are achieved. This chapter covers the perineal approach, abdominoperineal resection, rationale for sphincter-sparing technique, factors affecting decision for sphincter-saving surgery, optimal margin for sphinctersparing techniques, preoperative workup, sphincter-saving procedures, local excision, transanal minimally invasive surgery, multimodality therapy and sphincter preservation, and role of the abdominoperineal resection in the era of sphincter-saving techniques.