This chapter reviews the current practice of minimally invasive neonatal surgery and reflects on potential future developments in this field. Compared to open thoracotomy, the potential advantages of a thoracoscopic approach are the muscle-sparing nature of the procedure, decreased the risk of nerve injury, and less secondary scoliosis in the long-term. The introduction of automatic carbon dioxide (CO₂) insufflation in the early 1960s created the necessary working domain to facilitate endoscopic surgical procedures. The development of CO₂ embolism is exceedingly rare in the pediatric population. Thoracoscopic lung biopsy and the resection of pulmonary lesions are the most commonly performed thoracoscopic operations in neonates. Potential complications with the thoracoscopic approach and the safety and excellent outcome of open patent ductus arteriosus (PDA) ligation have prevented both the thoracoscopic and interventional approaches from being universally accepted. Abdominal access for laparoscopic procedures in newborns is usually obtained through the umbilicus.