Natural orifice transluminal endoscopic surgery: The true frontier of gastrointestinal endoscopy

Natural orifice transluminal endoscopic surgery (NOTES) remains a frontier that continues to blur the boundaries between surgery and interventional endoscopy.Since its inception as an idea, NOTES has witnessed remarkable progress, from early animal experiments to its gradual translation into human applications as a minimally invasive approach for various mediastinal, thoracic, peritoneal, retroperitoneal, and pelvic diseases.The initial phase of NOTES was met with significant technical and safety challenges, often requiring hybrid laparoscopic assistance.A decade later, the first pure NOTES procedure, a transvaginal cholecystectomy, marked a turning point that demonstrated the feasibility of a completely incisionless surgical concept.Over time, major barriers such as safe access, reliable closure, and effective hemostasis have been steadily addressed through advances in endoscopic tunneling, suturing platforms, hemostatic materials, and flexible endoscopic systems.The evolution of third space endoscopy, endobariatric procedures, and organ preserving transluminal interventions has further strengthened the translational foundation of NOTES.New robotic and magnetic platforms are now providing greater stability, precision, and triangulation, bringing NOTES closer to daily clinical use.Now more than two decades since its conception, NOTES stands on the verge of redefining minimally invasive therapy.This review revisits its journey, summarizes the present achievements, and highlights the innovations and global collaboration needed to guide the next era of scarless surgery.Recent advances in magnetic-assisted platforms have also played an important role in improving exposure, traction, and anastomotic creation within NOTES.