On the verge of something new and exciting, it is always difficult to make predictions: this may be especially true for NOTES which stands for natural orifice transluminal endoscopic surgery, and is represented by societies and initiatives with similarly ingeniously invented acronyms (NOSCAR = Natural Orifice Surgery Consortium for Assessment and Research).1 Perhaps for fear of being left behind, societies are formed on a national and international basis. Training courses are held on something which—frankly speaking—does not exist yet. At least not in humans outside of a few transvaginal cholecystectomy and appendectomy case reports and series.2^–9 Recently, in addition, a first series on transumbilical flexible endoscopic cholecystectomy has been reported with somewhat disappointing results10; transgastric cholecystectomy appears to be on the way.

NOTES raises a number of questions, both fundamental ones with regards to indications and risk assessment as well as those related to technical issues. These will be outlined and discussed in the following.

LAPAROSCOPIC SURGERY AS BENCHMARK

Many think that the greatly reduced invasivensss of laparoscopic as compared with open surgery will be further diminished by NOTES and serve as one of its justifications. At the time when laparoscopic cholecystectomy was invented, there was probably almost no perceived need at all, since almost everybody was convinced that the open procedure was perfect. Indeed, it took some time till the higher complication rate of the laparoscopic as compared with the open approach levelled off. Finally, less invasiveness, less pain and better patient comfort with laparoscopic surgery were also proven in comparative trials, mostly for benign disease.11

The degree of use of the laparoscopic approach varies between countries because environmental factors play a role, independently of the intrinsic value of the procedure. Figures from worldwide surveys, however, confirm a predominance of laparoscopic cholecystectomy12 and also a sharply increasing …