Background: The role of laparoscopic resection in the management of rectal cancer is still controversial. There are few reports demonstrating feasibility and efficacy of laparoscopic rectal resection for rectal cancer. Aim of this study is a prospective evaluation of the perioperative outcome and long-term results of laparoscopic rectal resection for rectal cancer in a single institution. Methods: From November 1999 to November 2005 one-hundred and seven consecutive patients with rectal cancer were treated by laparoscopy. Patients with locally advanced disease and no evidence of distant metastases were candidates for neoadjuvant chemo-radiotherapy. All patients were followed up prospectively to evaluate complications and late outcomes. The survival rates were calculated with the Kaplan-Meier method. Results: A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation and one a laparoscopic Hartmann procedure. The tumor location was: upper third 43.9%, middle third 43.0% and lower third of the rectum 13.1%. Mean operative time was 278 min (range 135/430). Conversion rate was 18.7% (20/107). A protective ileostomy was performed in 21/104 patients (20.2%). The overall morbidity rate was 29%, with an overall anastomotic leak rate of 13.4% (14/104). There was no postoperative mortality. UICC tumor stages were as follow: stage I: 48.7%, stage II: 19.6%, stage III: 26.2%, stage IV: 7.5%. Average number of lymph nodes removed was 18 (range 1/49). The mean distance of the distal margin from the tumor was 2.6 cm (range 0-10), in two cases (1.9%) a microscopically invasion of the distal margin was registered (2T3 stage, one converted for technical reasons). Mean hospital stay was 9 days (range 4-43). The mean follow-up period was 35.8 months and 88patients (82.2%) have a follow-up superior to 12 months. The local recurrence rate was 0.95% (1/105), there was no port site metastases. The cumulative survival rate at 5 years was 75.3%. Conclusions: This prospective study demonstrates that laparoscopic rectal surgery is feasible but technical demanding (conversion rate 18.7%) and time consuming (mean operative time 278 min.). Laparoscopic rectal surgery is not associated with higher morbidity and mortality than open surgery. Oncological and surgical principles are respected and long-term outcomes are at least comparable to the open published series. Further randomized studies will be necessary to confirm long-term clinical outcome in cancer patients and to evaluate the true benefits of this technique.