Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.