Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contra-indications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.