Surgical technique evolved from traditional open surgery to laparoscopic surgery, offering patients reduced pain and quick recovery. Recently, a new approach called natural orifice translumenal endoscopic surgery (NOTES) has emerged. In NOTES, procedures may be transvaginal, transgastric, or transrectal or transesophageal. NOTES procedures present new ergonomic challenges to surgeons due to visualization and tissue manipulation challenges. An ergonomic analysis of NOTES cholecystectomy was conducted. As there is currently no standardization for performing NOTES, this analysis presents the results as a case study. Results showed NOTES procedures impose unique limitations on the surgeon's ability to perform surgical tasks autonomously, requiring collaboration and coordination amongst the surgical team members.