Endoluminal surgery represents the ultimate in minimally invasive approaches. Transanal Endoscopic Microsurgery (TEM) allows access to rectal lesions up to the rectosigmoid that would otherwise require a major abdominal operation. This is an especially attractive approach for patients with significant comorbidities. This video demonstrates a full thickness TEM excision of a uT0 rectal mass at the 10cm level. This is carried out in a 78 y.o. medically compromised man unsuitable for a major abdominal operation. Demonstrated is the superior optics and reach available with the TEM approach. This video highlights the technical aspects of the procedure.