Rectal cancer is an increasing problem in the developing world. There is little written on how to manage this problem outside the confines of major teaching hospitals in Western Countries. In these centres debate surrounds preoperative staging, the use of preoperative radiotherapy and sophisticated sphincter preserving procedures. The literature is complex and of little relevance to those faced with a patient with rectal cancer in rural Africa or Asia far from the ivory towers. This review aims to combine the best of evidence based medical practice related to the management of rectal cancer with the practical realities of operating in resource poor environments. In this situation staging is by means of simple radiology and a clinical examination supplemented by an examination under anaesthetic. If there are no distant metastases and the tumour is freely mobile a resection can be attempted. An abdominoperineal resection is a good operation with a proven track record. If an anastomosis can be fashioned then an anterior resection is an excellent operation and should be performed extrafascially to avoid local recurrence. It is vital to counsel the patient preoperatively. The pros and cons of referral to a centre of excellence need to be discussed with the patient prior to any intervention.