The growing capabilities of therapeutic flexible endoscopy have led to a new era in the treatment of gastrointestinal conditions. Laparoscopic surgery has advanced to the point where complex procedures like gastric bypass can be performed minimally invasively. This has paved the way for even less invasive methods to treat conditions in the gut lumen and peritoneal cavity. The natural orifices may provide entry points for peritoneal surgery, avoiding abdominal wall incisions. Initial studies have demonstrated the feasibility and safety of per-oral transgastric endoscopic approaches. Other procedures, such as tubal ligation, cholecystectomy, and splenectomy, have also been performed in porcine models. Rao et al. have described transgastric appendectomy in humans. The ASGE and SAGES working groups met to discuss the potential of transluminal endoscopic surgery (NOTES), identifying barriers and next steps. They agreed that NOTES could offer benefits like less pain, faster recovery, and better cosmesis. The group defined NOTES as natural orifice transluminal endoscopic surgery, emphasizing the need for tissue resection and repair. They established the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) to promote research and development. Key criteria for participation included multidisciplinary teams, membership in ASGE/SAGES, animal facilities, sharing of results, IRB approval, and submission to an outcomes registry. The group identified significant barriers, including intraperitoneal infection, spatial orientation, and gastric closure. While access to the peritoneal cavity was not a barrier, optimal techniques and sites were unknown. Gastric closure was a critical challenge, requiring reliable methods to prevent leaks. Prevention of infection was also a concern, but early studies suggested that sterilization and secure closure could reduce risks. Suturing and anastomotic devices were a topic of debate, with diverse opinions among the group. Overall, the group recognized the potential of NOTES but acknowledged the need for further research and development.The growing capabilities of therapeutic flexible endoscopy have led to a new era in the treatment of gastrointestinal conditions. Laparoscopic surgery has advanced to the point where complex procedures like gastric bypass can be performed minimally invasively. This has paved the way for even less invasive methods to treat conditions in the gut lumen and peritoneal cavity. The natural orifices may provide entry points for peritoneal surgery, avoiding abdominal wall incisions. Initial studies have demonstrated the feasibility and safety of per-oral transgastric endoscopic approaches. Other procedures, such as tubal ligation, cholecystectomy, and splenectomy, have also been performed in porcine models. Rao et al. have described transgastric appendectomy in humans. The ASGE and SAGES working groups met to discuss the potential of transluminal endoscopic surgery (NOTES), identifying barriers and next steps. They agreed that NOTES could offer benefits like less pain, faster recovery, and better cosmesis. The group defined NOTES as natural orifice transluminal endoscopic surgery, emphasizing the need for tissue resection and repair. They established the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) to promote research and development. Key criteria for participation included multidisciplinary teams, membership in ASGE/SAGES, animal facilities, sharing of results, IRB approval, and submission to an outcomes registry. The group identified significant barriers, including intraperitoneal infection, spatial orientation, and gastric closure. While access to the peritoneal cavity was not a barrier, optimal techniques and sites were unknown. Gastric closure was a critical challenge, requiring reliable methods to prevent leaks. Prevention of infection was also a concern, but early studies suggested that sterilization and secure closure could reduce risks. Suturing and anastomotic devices were a topic of debate, with diverse opinions among the group. Overall, the group recognized the potential of NOTES but acknowledged the need for further research and development.