The first consists in what we would call Endoscopical Access Natural Orifice Surgery (EA-NOS) which includes all procedures truly performed through natural orifices, having the goal to design new platforms for surgery to be brought within the human body to recreate surgical conditions under safety. The evident difficulties to obtain such an environment with guaranteed ease of use, safety and efficacy, reduced to a mere research activity the interest in this field, with few clinical applications described consisting of hybrid procedures, i.e. procedures which were performed basically under laparoscopic conditions with the help of flexible instruments inserted through natural orifices. In fact, a recent large metanalysis of NOTES literature3 focusing on various surgical intra-abdominal procedures, all ascribable to EA-NOS, concluded that no human studies were found satisfactory for the inclusion criteria, for scarce disposable evidence, minor safety and efficacy compared to laparotomic and laparoscopic alternatives. The recommendation that human procedures should first pass through hybrid NOTES surgery, under strict guidelines, and in apposite controlled registers was later supported, as known, by the revision of NOSCAR "white paper" 4 . In fact, it is out of discussion that there is a need for a worldwide register, a standardization of the nomenclature, safety data to be used by ethical committees in order to authorize human trials, and implementation of the interface between medical societies, industry and regulatory offices. In this field, on behalf of the EURONOTES Foundation, we have promoted an european registry of NOTES procedures (www.euronotes.world.it) which preliminary results are now awaited.