Standard surgical treatment for low rectal cancer below 5 cm from the anal verge used to be abdominoperineal resection (APR). In recent years sphincter saving techniques, like intersphincteric resection (ISR) proved to be an ongologically accepted alternative. Operations for ultra low rectal cancer are challenging and coloanal anastomosis is probably the source of most postoperative complications. We present ISR with pull-through delayed anastomosis (PTDA) as a surgical option for the management of elective cases, when standard coloanal anastomosis (CAA) is at greater risk of dehiscence or a covering stoma is refused or dangerous.