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Aim: Transanal endoscopic microsurgery (TEM) was originally invented by Buess et al. (Chirurg, 1984, 55, 677-80) for the treatment of infraperitoneal rectal adenomas. Its indications have progressively expanded to include larger and more advanced lesions. The aim of the study was to report the results of TEM used for the treatment of circumferential rectal lesions., Method: We retrospectively reviewed the medical records of 17 consecutive patients [median age 69 (32-89) years; nine men] who underwent TEM for a circumferential rectal lesion in our department between September 2010 and January 2015., Results: The median distance from the anal verge was 4 (3-11) cm, the median longitudinal extent was 7 (3-10) cm and the median surface area was 75 (40-255) cm(2) . An end-to-end anastomosis without proximal bowel mobilization was completed endoscopically in all cases. The median operating time was 120 (40-240) min. Persistent, endoscopically uncontrollable endoluminal bleeding in one patient was successfully treated with a second TEM procedure. One patient underwent preoperative radiotherapy for adenocarcinoma detected at the preoperative assessment. Surgical histology showed a pT3 cancer in one patient who refused further surgery, a pT2 cancer in two who subsequently underwent abdominoperineal resection, a pT1 cancer in four and a ypT0 in one patient. All are at present free of disease. No patients developed faecal incontinence or urinary or sexual dysfunction. Four patients required endoscopic balloon dilatation for stenosis., Conclusion: Transanal endoscopic microsurgery is a feasible and safe technique for large circumferential lesions with a satisfactory outcome. Preoperative staging may be inaccurate., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)