Since its broad propagation in 2006/2007, the concept of natural orifice translumenal endoscopic surgery (NOTES) got widespread interest both in the surgical and gastroenterological communities. In a few years NOTES techniques, either transgastric, or transvaginal, or transrectal have been thoroughly described both in animals and in humans. These include appendectomy , cholecystectomy  and peritoneoscopy  mainly but even tubal ligation , oophorectomy , colectomy , nephrectomy  and gastric sleeve  although in a vast majority of cases this was done under hybrid conditions. Primary enthusiasm, however, was soon followed by frustration on both sides, since the technological barriers which had been precisely described in the so-called “white paper”  early in the development of NOTES turned out to be by far more difficult to overcome than expected.
To monitor clinical the clinical results and diffusion of Notes surgery in Europe, the European Association for Endoscopic Surgery (EAES) and the European Society of Gastroenterology (ESGE) decided gto merge their expertise to create a clinical Registry. The Euro-NOTES Clinical Registry aims at collecting all clinical cases done in Europe under true NOTES conditions.
The Registry was established about a year ago and collects almost 400 cases now. The vast majority of these cases are cholecystectomy procedures; but unlike other registries, clinical cases are distributed among several different techniques, all sufficiently represented. In fact we include 234 transvaginal procedures done by rigid instruments, 109 done by rigid and flexible instruments, 6 done by a modified Transanal Endoscopic Microsurgery (TEM) equipment, and 12 transgastric procedures. In truth those procedures performed by a modified TEM are the only real NOTES procedures, as no laparoscopic aid was employed. A ruff statistical analysis of data shows no statistical difference in overall, intra-operative and post-operative complications among groups, in all cases comparable to standard laparoscopy conditions. The analysis of duration of the procedure demonstrated a shorter time requirement for the use of rigid instruments inserted through the vagina, compared to all other groups. Except for transgastric approach only minimum differences in terms of hospital stay are observed. Finally, no patient reported persistent dyspareunia, whichever transvaginal technique had been used, allowing us to think that the problem had probably been overestimated in the past.
In addition the Registry includes several cases of colorectal resections performed transanally with different techniques for different indications such as diverticulitis, prolapse and neoplasms and upperGI tract wedge resections for Gastro-Intestinal Stromal Tumours.
We invite all surgeons and endoscopists who are clinical involved in Notes Surgery to join the registry in order to increase its clinical validity (www.euronotes.world.it).