In the later part of the 21st century, the world witnessed a paradigm shift in the approach to abdominal surgery with the introduction and rapid worldwide adaptation of laparoscopic techniques to perform almost the entire range of procedures formerly performed through a laparotomy. The field of endoscopy also saw rapid progress with the development from flexible diagnostic endoscopy to various intraluminal interventional procedures. A totally new dimension was added to ‘minimally invasive surgery when the gastroenterologist went translumenal and entered the peritoneal cavity by perforating the viscera. The revelation of the feasibility of performance of procedures in the peritoneal cavity in the absence of skin incisions, resulted in wide spread interest in this new field of Natural Orifice Translumenal Endoscopic Surgery (NOTES). Kalloo et al are credited with the first NOTES procedure, where they entered the peritoneal cavity of a pig transgastrically in 2000. Reddy and Rao performed the first human NOTES procedure, a transgastric appendectomy in 2004. Ever since many procedures have been performed through the various natural orifices transvaginal, transrectal, transcolonic, transesophageal, transurethral and even transumbilical (the umbilicus being considered an embryological orifice). The feasibility and safety of performance of various abdominal and thoracic advanced surgeries has been reported in animal models. However, reports in humans have been just a few case reports and small series, limited to the basic and a few advanced surgeries performed via natural orifices. Ethical issues involved in the introduction of a new technique and the need for technological advancement for the adaptation of endoscopic instruments in the spacious abdominal cavity stand as the chief hurdles in the wide spread use of the NOTES approach in clinical practice.