Since its birth, already 5 years ago, the interest for NOTES is still growing among surgeons and gastroenterologists. From the first report of transgastric peritoneoscopy, many interventions have been achieved in experimental animal models. Technical progress is mandatory to allow more complex interventions for the development of this new field of surgery and interventional gastroenterology. This paper aims to summarize the achievements made so far and set the ground for future directions of improvement.