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Laparoscopic sphincterpreservation for low rectal cancer is challenging due to the risk of positive margins. We hypothesized that perineal approach first may improve quality of surgery, as compared to the conventional laparoscopic abdominal approach first.Sixty patients with a low rectal cancer were randomised to a conventional laparoscopic pelvic dissection followed perineal rectal transection and an initial perineal approach followed by the laparoscopic pelvic dissection. Theprimary end point was the rate of a positive circumferential margin.There were 30 patients in each group. There was no difference in operative mortality, morbidity (10% vs 10%) or distal margin positivity (3% vs 3%). The respective rates of circumferential margin positivity were 15% and 0% (P = 0.03).The perineal approach reduces the risk of a positive circumferential margin during laparoscopic TME with coloanal anastomosis.