Endoscopic submucosal dissection (ESD) of the ileocecal valve and terminal ileum remains technically demanding due to poor scope stability and adipose tissue interference. The undersaline ESD technique combined with internal traction may enhance safety and efficiency in such complex cases. A 71-year-old patient was referred for ESD of a 4 cm non-granular flat adenoma involving the entire ileocecal valve and approximately two-thirds of the last 1 cm of the terminal ileum. Circumferential incision was performed under saline immersion using a tip-cutting knife with flushing capability. A mucosal flap was created at the anal side to allow clip and band countertraction. The lesion was removed en bloc, and the mucosal defect was partially closed with clips. Oral budesonide was given for two months to prevent ileal stricture. The patient has an uneventful recovery without relapse at 3 months of follow up.