Natural orifice transluminal endoscopic surgery--here and now.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) has captured the attention of physicians and patients alike. Although clinical experience remains limited as technological capacity lags someway behind concept, this revolutionary approach is already prompting reassessment of conventional surgical dogma. Indeed, this very aspect may in fact represent the greatest legacy of current endeavour aimed at progressing natural orifice intervention as the biological insights so gleaned may then be used to help hone standard operations further towards perfection. As a corollary, rather than viewing it as a mere means of reformatting laparoscopic operation without the abdominal wall access component, NOTES should be investigated fully from the perspective of how it may complement (rather than compete with) current conventional techniques. In this way patients may in due course be allowed benefit by selection of the procedure of 'best fit' from an expanded array of surgical interventions. A clear focus on identifying specific clinical niches that are currently imperfectly addressed would also considerably advance the rationale for new surgical innovations such as NOTES and allow them to be engineered in the directions most likely to result in therapeutic advance. Thus while NOTES approaches for operations for neoplasia of the colon and even rectum clearly require more nuanced deliberation and care than does for example cholecystectomy for uncomplicated cholelithiasis, the gain from such investment seems likely to more considerably aid both the development and stature of NOTES as well as providing the greater likelihood of clinical progress for our patients.