Interest in natural orifice translumenal endoscopic surgery (NOTES) has blossomed since the publication of transgastric peritoneoscopy in animals in 2004. Laboratory research has demonstrated the feasibility of natural orifice surgery and provided insight into the technical innovations necessary to advance the field. Today, natural orifice surgery is entering the clinical realm, both in hybrid laparoscopic-endoscopic cases and a few pure natural orifice procedures. Although the promise of "scarless" surgery entices clinicians and the public alike, care must be taken to introduce novel techniques as safely as possible with critical evaluation of outcomes.