The United States had a scarcity of large data sets to contribute to the ongoing international debate. For a study, researchers sought to determine the local recurrence rate and other oncologic outcomes in patients with transanal total mesorectal excision for rectal adenocarcinoma. This retrospective study of patients with transanal total mesorectal excision for primary rectal cancer between January 2014 and December 2019. This research was carried out at a single academic tertiary care medical center in the United States. The study included more than or equal to 18-year-old patients undergoing surgical resection for primary rectal cancer. A 2-person team performed the transanal total mesorectal excision procedures. The primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall and cancer-specific survival. A total of 79 patients were included in the study. The median age was 58 years old (interquartile range, 50–64 years), and the median BMI was 28 kg/m2 (interquartile range, 24.6–32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 patient (1.3%). Circumferential resection margin involvement (<one millimeter) occurred in 4 patients (5.1%), and no patients had a positive distal margin (<one millimeter) or intraoperative rectal perforation. About 94.9% of specimens had optimal composite pathology. The median duration of follow-up was 29 months (range, 6–68). There were no recurrences on a local level. Distant metastases were discovered in 10 (13.5%) of the patients and were diagnosed after 14 months (range, 0.6–53). At 2 years, disease-free survival was 91.2%, and overall survival was 94.7%. The study’s limitations included a retrospective design, a single-center, and a relatively short follow-up period. This cohort’s oncologic outcomes support transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise.