Ullah S, Ali FS, Han YL, Liu BR, Thosani N, Liao Z. Natural orifice transluminal endoscopic surgery: The true frontier of gastrointestinal endoscopy. World J Gastroenterol 2026; 32(43): 123529 [DOI: 10.3748/wjg.123529]
Corresponding Author of This Article
Zhuan Liao, MD, PhD, Department of Gastroenterology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai 200433, China. liaozhuan@smmu.edu.cn
Research Domain of This Article
Gastroenterology & Hepatology
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review-article
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Ullah S, Ali FS, Han YL, Liu BR, Thosani N, Liao Z. Natural orifice transluminal endoscopic surgery: The true frontier of gastrointestinal endoscopy. World J Gastroenterol 2026; 32(43): 123529 [DOI: 10.3748/wjg.123529]
World J Gastroenterol. Nov 21, 2026; 32(43): 123529 Published online Nov 21, 2026. doi: 10.3748/wjg.123529
Natural orifice transluminal endoscopic surgery: The true frontier of gastrointestinal endoscopy
Saif Ullah, Faisal S Ali, Yi-Lin Han, Bing-Rong Liu, Nirav Thosani, Zhuan Liao
Saif Ullah, Yi-Lin Han, Zhuan Liao, Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai 200433, China
Faisal S Ali, Division of Gastroenterology, University of New Mexico, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 87108, United States
Bing-Rong Liu, Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Nirav Thosani, Department of Surgery, The University of Texas Health Science Center, Houston, TX 77030, United States
Co-first authors: Saif Ullah and Faisal S Ali.
Co-corresponding authors: Nirav Thosani and Zhuan Liao.
Author contributions: Ullah S and Ali FS participated in the conception and design of the study, performed the literature review, drafted the manuscript, and revised the manuscript for important intellectual content, contributed equally to this work as co-first authors; Han YL and Liu BR provided expert input on natural orifice transluminal endoscopic surgery techniques, clinical applications, and historical development of the field, and critically revised the manuscript; Thosani N and Liao Z conceived and supervised the review, provided overall guidance, reviewed the manuscript critically for important intellectual content, and approved the final version as co-corresponding authors; all authors contributed to manuscript revision, read and approved the final manuscript, and agree to be accountable for all aspects of the work.
AI contribution statement: During the preparation of this manuscript, AI tool (ChatGPT) was used only for language refinement, grammar correction, and readability improvement. The authors carefully reviewed, verified, and edited all AI-assisted outputs.
Supported by the China Postdoctoral Science Foundation, No. 2025M784485.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
Corresponding author: Zhuan Liao, MD, PhD, Department of Gastroenterology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai 200433, China. liaozhuan@smmu.edu.cn
Received: May 21, 2026 Revised: July 3, 2026 Accepted: July 31, 2026 Published online: November 21, 2026 Processing time: 125 Days and 19.5 Hours
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) remains a frontier that continues to blur the boundaries between surgery and interventional endoscopy. Since its inception as an idea, NOTES has witnessed remarkable progress, from early animal experiments to its gradual translation into human applications as a minimally invasive approach for various mediastinal, thoracic, peritoneal, retroperitoneal, and pelvic diseases. The initial phase of NOTES was met with significant technical and safety challenges, often requiring hybrid laparoscopic assistance. A decade after inception of the idea of NOTES, the first pure NOTES procedure, a transvaginal cholecystectomy, marked a turning point that demonstrated the feasibility of a completely incisionless surgical concept. Over time, major barriers such as safe access, reliable closure, and effective hemostasis have been steadily addressed through advances in endoscopic tunneling, suturing platforms, hemostatic materials, and flexible endoscopic systems. The evolution of third space endoscopy, endobariatric procedures, and organ preserving transluminal interventions has further strengthened the translational foundation of NOTES. Robotic are now providing greater stability, precision, and triangulation, bringing NOTES closer to daily clinical use. Now more than two decades since its conception, NOTES stands on the verge of redefining minimally invasive therapy. This review revisits its journey, summarizes the present achievements, and highlights the innovations and global collaboration needed to guide the next era of scarless surgery. Recent advances in magnetic-assisted platforms have also played an important role in improving exposure, traction, and anastomosis creation within NOTES.
Core Tip: Natural orifice transluminal endoscopic surgery (NOTES) represents a major frontier in gastrointestinal endoscopy by extending minimally invasive therapy toward truly incisionless intervention. Although early clinical translation was limited by concerns regarding access, closure, infection, hemostasis, spatial orientation, and training, many of these barriers have been progressively addressed through advances in third-space endoscopy, endoscopic suturing, closure devices, hemostatic materials, robotic systems, and magnetic platforms. This opinion review highlights the evolution of NOTES, its current clinical and experimental applications, and the collaborative innovation needed to transform NOTES from a pioneering concept into a safe and practical therapeutic platform.
