The role of local excision (LE) in the treatment of rectal cancer is ever-evolving. Over the past 125 years, its use has varied widely, depending on the intent of therapy (curative, palliative or compromised); specific treatment goals; the safety, effectiveness and local availability of alternative forms of therapy for rectal cancer; and the decision-making process and treatment philosophy of those involved in choosing an optimal treatment plan, including the patient and the surgeon. At one time, LE through a posterior approach was the most common method used to treat patients with rectal cancer, for both curative and palliative intent. At other times in the twentieth century, LE was rarely used for curative-intent treatment of rectal cancer in normal-risk patients, who instead were treated by standard anterior resection or abdominoperineal excision (APE). Local excision was used primarily for palliation or in compromise situations, such as when a patient’s operative risks and comorbidities made it too dangerous to undergo standard radical resection or because the patient refused the recommended anterior resection or APE.