Notes: technical aspects - hype or hope?

Natural orifice transluminal endoscopic surgery (NOTES) is currently an intensely discussed topic. The debate is extremely controversial, ranging from euphoric visions to complete refusal, and the future clinical role of natural orifice surgery is difficult to describe. This chapter analyzes the current technological status, and addresses the question of whether to enrich the surgical procedures will become an option. A literature research was undertaken using Medline and Pubmed. Personal experiences and communications were also included in this state-of-the-art report. The individual barriers currently impeding the clinical use, as defined by the NOSCAR group, are addressed in detail. With the exception of the vaginal access, no natural orifice-entering technique is already clinically mature. The selective use-potentially in combination-in a more refined technique than currently, is likely to provide a breakthrough. Most of the remaining obstacles are just a matter of further progress in advanced medical engineering. However, it should not be forgotten that the problems to be solved are less than trivial, and close cooperation between engineers and surgeons is essential. NOTES is still in the early stages of development. Currently available tools and techniques remain in the pioneer stage. However, worldwide activities in research and development will lead to promising solutions, which certainly will help to overcome the existing barriers. Whether "pure NOTES" or hybrid procedures only, surgery will take another step forward toward a less-invasive discipline.