Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a recently introduced minimal invasive surgical technique using the natural openings of the human body. The Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) has identified a number of areas that require further investigation before NOTES can be implemented in daily clinical practice. The past years have shown extensive progress within research and development of NOTES, but randomized controlled trials are still lacking. These are essential to determine whether NOTES will benefit patients and the health care sector in general.