In 1908, William Ernest Miles published his article in the Lancet, introducing the basis of modern rectal cancer surgery. He established the basis for curative cancer treatment by combining the knowledge of anatomy and biological behaviour with improved surgical options as a result of better anaesthesiological techniques. Miles' contribution comprised the introduction of the concept of lymphatic spread of cancer cells and his consequent radical surgical resection, removing all primary lymph nodes en bloc. Miles' concept has dominated the minds of surgeons throughout the 20th century and his abdominoperineal resection has been the golden standard for several decades. However, his concept of downward spread of rectal cancer was proven wrong, which initiated the historical shift from radical abdominoperineal resection to the use of sphincter-saving surgery. Since the introduction of total mesorectal excision, abdominoperineal excision has been performed in only a minority of patients. Further improvement in surgical technique consisted of autonomic nerve preservation, improving functional outcome. From a historical overview, it can be concluded that the management of rectal cancer has been progressed tremendously over the past 100 years, mainly because of an increased understanding of the pathology and natural history of the disease, which has been initiated by Miles.