Rectal tumor surgery is currently at a critical stage of transformation from “organ resection” to “precision intervention”. Total mesorectal excision has significantly improved the local control of rectal cancer; however, defecatory, urinary, and sexual dysfunction, as well as low anterior resection syndrome after radical surgery, still profoundly affect patients’ long-term quality of life. With the development of early screening, precision imaging, total neoadjuvant therapy, immunotherapy, and organ preservation concepts, an increasing number of rectal lesions exhibit the characteristics of “being amenable to local intervention, requiring functional protection, and yet not compromising oncological safety”. Based on previous literature reports and our team’s practice, this article proposes the concept of a transanal minimally invasive surgery system: utilizing the transanal approach as a common pathway, and based on whether it relies on a transanal endoscopic platform, whether it involves direct-vision intersphincteric operation, and whether it requires extended mesorectal excision and reconstruction, the related procedures are classified into transanal minimally invasive surgery under transanal endoscopy, transanal intersphincteric resection, extended transanal minimally invasive surgery formed by combining the two, and transanal partial mesorectal excision. This system helps to integrate endoscopic therapy, transanal endoscopic local excision, direct-vision transanal intersphincteric resection, robot-assisted transanal surgery, and complex luminal reconstruction into the same decision-making framework, thereby more clearly defining the resection depth, operational boundaries, and reconstruction strategies for different lesions. Simultaneously, this article fully incorporates the concept of integrated minimally invasive approaches, interpreting transanal minimally invasive surgery as a multidimensional injury control and response-guided decision-making tool, rather than simply comparing incision size or the superiority and inferiority of technical platforms. Herein, the value of local excision can be summarized as resecting suspicious residual lesions under limited trauma and obtaining complete pathological information, thereby accomplishing risk re-stratification within the organ preservation strategy. On this basis, this article further emphasizes that local excision should not be positioned merely as a passive salvage option after neoadjuvant therapy or as a substitute for the watch-and-wait strategy following clinical complete response/near complete response. Instead, it can be shifted forward into the comprehensive treatment decision-making chain to become a key node for efficacy verification, pathological re-stratification, and determining whether to proceed with radical surgery; meanwhile, classic radical surgery should serve as the ultimate curative measure for situations such as high pathological risk, insufficient treatment response, local regrowth, and failure of salvage pathways after local excision.