In recent years, as the concept of total mesenteric resection for rectal cancer has become more popular and neoadjuvant radiotherapy has been promoted, it has improved the treatment outcome and increased the rate of anus preservation for low to intermediate rectal cancer, while increasing the risk of postoperative anastomotic leak due to the impact of surgery and radiotherapy on the anastomotic blood supply and tissue healing ability. In clinical practice, the risk of postoperative anastomotic leak is reduced by performing prophylactic terminal ileostomy. Postoperative anastomotic leak after rectal cancer occurs clinically, and once it occurs, without prophylactic ileostomy, stool will continue to leak from the leaky button into the pelvis, leading to pelvic infection, pelvic abscess, and difficult healing of the anastomosis. The patient will have high fever and significant unbearable pain in the perineal area, which is very painful. Then, the treatment given is pelvic tube drainage, flushing, and ileostomy to divert intestinal contents, along with anti-infection and intravenous nutrition therapy. The recovery time is slow. For this reason, prophylactic ileostomy is usually performed after low rectal preservation. Let’s talk about: pros and cons of ileostomy Pros: Significantly reduces the incidence of anastomotic leak. Disadvantages: Patients will have an ileostomy for 3-6 months and will have to clean the stoma bag several times a day because the small intestine will have bowel contents at all times. There are several stoma complications that can occur if the stoma is not properly cared for. For example, parastomal hernia, stoma prolapse, peristoma skin infection, and stoma depression. Also, one has to face another surgery to return the stoma back 3-6 months after the surgery. Whether to do a prophylactic ileostomy or not is a difficult choice, both for the patient and for the specialist. As to how to choose, try to follow the specialist’s advice. Sometimes it is difficult to make a clear choice preoperatively, and the surgeon needs to decide intraoperatively on a case-by-case basis. The surgeon should consider the location of the tumor, the size of the tumor and the depth of infiltration of the intestinal wall, the metastasis of the peri-intestinal lymph nodes and the preoperative bowel preparation. Trust the surgeon, no matter to do or not to do, the consideration must be from the standpoint of maximizing the patient’s benefit.