Natural orifice transluminal endoscopic surgery (NOTES) changes the paradigm of endoscopy and even surgery. The artificial perforation of abdominal hollow organs is now welcome and no longer avoided under all circumstances. Surgeons as well as gastroenterologists face a lot of problems, barriers and integration obstacles. The interdisciplinary approach for the introduction of a new technique appears promising and opens a lot of perspectives. This paper illustrates and discusses medical, technical, financial and professional barriers and integration obstacles for the introduction of NOTES into clinical practice.