Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess from Tübingen, Germany and it became available for widespread use in 1983 (Fig. 1). A surgeon’s ability to remove rectal lesions transanally is limited by access and exposure with conventional instruments usually restricting the surgeon to the distal 6–7 cm of rectum. When transanal excision is not possible, the traditional transabdominal approach, a major surgical procedure, is necessary. TEM, with its longer reach and enhanced visibility of the entire rectum, extends the boundaries of transanal surgery, giving appropriately selected patients a minimally invasive surgical option with a faster and virtually pain-free recovery.