That's a transgastric cholecystectomy on our cover, which is a fancy way of saying that they (gulp!) removed the young man's gallbladder through his mouth. It's one of three natural orifice translumenal endoscopic surgeries (NOTES) that Legacy Good Samaritan Hospital in Portland, Ore., has hosted. It's also the climactic grand finale of abdominal surgery's great disappearing act. Right before your very eyes, it's gone from bigger-is-better incisions to keyhole incisions to no incisions.

"Natural orifice surgery ... who would have thought it possible?" writes internist Patricia Salber, MD, MBA, on www.thedoctorweighsin.com.

Put simply, natural orifice surgery is incision-free surgery. It involves a port of entry through a natural orifice (mouth, vagina, anus) to the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. It requires a single, small umbilical incision rather than the traditional three ports.

Not only could the procedure hold great appeal to patients who anticipate less pain and more rapid recovery, but some say that natural orifice surgery might be superior to laparoscopic surgery in reducing post-op abdominal wall pain, wound infection, hernia formation and adhesions.

"Weird, yes," writes Dr. Salber. "I am sure I wouldn't want to see pictures of my appendix being delivered through my mouth or my gallbladder through my vagina. But if these procedures not only eliminate a belly scar, but also reduce the serious complications of abdominal surgery, such as prolonged hospitalizations, post-operative bowel obstructions and post-op pain, then so be it."

NOTES appears to be a ways away from becoming surgery's next big thing. It must overcome several obstacles to supplant endoscopic surgery. Besides still being developmental, it's lacking the backing of third-party payors and what Lee Ponksy, MD, a urologic oncologist at Case Medical Center, calls "purpose-designed instrumentation" — endoscopic instruments that can grasp and retract well enough to be used in natural orifice surgery.

Then there's the potential catastrophic problem of a leak from the intentional puncture wound in the peritoneum. And who'll perform the surgery — surgeons who aren't trained in sophisticated endoscopic procedures or gastroenterologists who aren't prepared to perform intraoperative procedures? Perhaps NOTES will spawn a new specialist, "the orificionado," who has both skill sets.

"This is not ready for prime-time yet," says Dr. Ponsky, who has removed a pig cadaver's kidneys through its vagina. "It's still very early in its evaluation. Is it safe? Is it effective? ???Cautiously optimistic' is a term I like to use."

Be sure to read surgeon Christopher J. Gostout's balanced account on page 26.