Background: Although the majority of patients with low rectal tumours can now be offered restorative surgery, a subset of patients with very distal, locally extensive tumours, or excessive comorbidity, continue to require abdominoperineal resection or a Hartmann's procedure. The Clinical Standards Board for Scotland (CSBS) recommends that the permanent stoma rate for patients with rectal cancer should be no more than 40%. The aim of this study was to determine the proportion of patients not suitable for restorative surgery and to explore the remaining indications for non-restorative surgery. Materials and Methods: Data pertaining to the management of 100 consecutive patients treated for a rectal adenocarcinoma were extracted from a prospective database. Results: Eighty-one patients underwent primary restorative surgery; 12 patients, 9 of whom had received neoadjuvant therapy, had abdominoperineal excision for low rectal or anorectal tumours. Seven patients with locally extensive disease underwent an unplanned Hartmann's procedure rather than high anterior resection. Two of these resections were incomplete and two patients had metastatic disease not detected on staging. Conclusion: Not all patients with rectal cancer can avoid the formation of a stoma, but our results show that more than 80% of patients can be offered primary restorative surgery. The CSBS guidelines do not reflect acceptable contemporary practice and should be revised. This is particularly pertinent with the likely introduction of population screening for colorectal cancer.