We read with great interest Dr Rösch’s piercing analysis of the current reality of natural orifice transluminal endoscopic surgery (NOTES) (Gut 2008;57:1481–6) and agree that much regarding this experimental approach seems to belong more to the realm of Lewis Carroll fantasy than modern surgical science. All too often there are too few elements of real clinical applicability within many zealous technical reports and too much left in anticipation of “future technological innovation”.

We would, however, propose an extra facet to his critique in suggesting that NOTES may represent far more than minimally invasive access taken to an extreme conclusion if we choose to use it as a spur to reassess the actual operative blueprint. The “gold-standard” operation for colorectal malignancy has been unchanged now for decades. Even the advent and acceptance of laparoscopy only changed the access employed not the actual operative extent of the radical intra-abdominal procedure. Therefore, since subspecialisation, colorectal surgery has lagged …