Operative fetoscopy is a surgical approach to the in utero treatment of fetal or placental abnormalities. The approach is on the basis of combined use of ultrasound and endoscopy and minimally invasive access into the womb. Operative fetoscopy is associated with significantly less risk of preterm birth, neonatal morbidity, and maternal morbidity as compared with open fetal surgery. A wide variety of fetal conditions have been surgically managed via operative fetoscopy, particularly complicated monochorionic twin gestations. The aim of this chapter is to review the current status and future direction of operative fetoscopy for the treatment of complicated monochorionic twin pregnancies.