AimOrgan‐preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6‐year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK.MethodData were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6‐year period.ResultsOne hundred and forty‐one patients who underwent full‐thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty‐eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty‐three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty‐three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow‐up of 28.7 months (12.1–66.5 months). The overall estimated 5‐year overall survival rate was 87.9% and the disease‐free survival rate was 82.9%.ConclusionAcceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow‐up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.