Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that enables en bloc resection of even large superficial tumors in the upper and lower gastrointestinal tract. It provides a high accuracy of histological analysis and a reduced recurrence rate. It was initially developed in Japan and then popularized throughout Asia. Experience in the Western World, however, is still limited, and ESD is performed in only a few select centers. Current issues are low volume of cases to start the ESD program, no description of ideal training programs, and a few published reports from the West proving its superiority over the conventional endoscopic mucosal resection (EMR) or piecemeal EMR. Here, the authors discuss the clinical indications and proposed benefit, the training required to perform ESD, the equipment and techniques required for successful ESD, and finally, the future directions of ESD.