Patients with medically refractory disease or dysplasia from ulcerative colitis, as well as some patients with IBD not otherwise classified or Crohn’s disease, are good candidates for a restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA). The transanal IPAA is just 1 of many minimally invasive procedures that have gained popularity in recent years. Although the transanal approach is gaining in popularity, there is a dearth of high-quality data to support it at this time. The purpose of this study was to analyze the initial transanal experience in terms of clinical outcomes, such as complication rates. A prospective case series with a single research site was used for this study. This research was carried out at a major university hospital. Study participants had either a 2- or 3-stage restorative proctocolectomy with IPAA for ulcerative colitis, IBD not otherwise specified, or Crohn’s disease. The outcomes of consecutive patients undergoing a transanal approach for restorative proctocolectomy after November 2016 were compared to those of a historical cohort of patients undergoing an open approach for proctocolectomy prior to October 2016. The rates of early and late anastomotic leakage were the primary indicators of progress along the learning curve. Clinical measurements taken after surgery were considered secondary outcomes. The patients in the study included 100 people who had an open procedure and 65 people who had a transanal procedure. Blood loss was estimated to be lower with the transanal approach (100 [50-150] vs. 150 [100-250] mL; P=0.007), and the transanal group had a shorter hospital stay by 2 days (P<0.001). With the transanal approach, the rate of anastomotic leaks was higher than with the open approach (n=7 [11%] vs n = 2 [2%] respectively; P=0.03). The 3rd tertile, which was later in the learning curve, had the fewest anastomotic complications, but this was not statistically significant. Potential selection and timing biases were introduced due to the study’s nonrandomized sequential assignment design. While the transanal approach to restorative proctocolectomy reduced blood loss and reduced hospital stays, the anastomotic leak rate was significantly higher. There are benefits to performing pouch surgery via the transanal minimally invasive approach, but there is also a significant learning curve.