The recent advances in technology and technique in endoscopic surgery have dramatically altered the approach to intrathoracic lesions in the pediatric patient. Now most operations can be performed using a video-assisted approach, which has markedly decreased the associated morbidity for the patient. This has allowed for an aggressive approach in obtaining tissue for diagnostic purposes in cases of interstitial lung disease or questionable focal lesions in immunocompromised patients, without fear of the significant pulmonary complications previously associated with standard thoracotomy. In general, a lung biopsy now can be performed with little more morbidity than that of a transbronchial biopsy yet the tissue obtained is far superior. The same is true for mediastinal masses or foregut abnormalities. Patients who undergo a limited biopsy procedure can be released on the day of surgery. Lesions such as esophageal duplications can be excised thoracoscopically, with the patient ready for discharge the following day. Even closure of patent ductus arteriosus is now performed safely thoracoscopically, with a hospitalization period of less than 24 hours. Although a thoracoscopic approach may not always result in a significant decrease in the length of hospital stay, it may be associated with a significant decrease in morbidity for the patient. For example, in cases of severe scoliosis, thoracoscopic anterior spinal fusion results in earlier extubation, a stay in the intensive care unit, and earlier mobilization. It is clear that thoracoscopic surgery has significant advantages over the standard open thoracotomy in many cases. With continued improvement and miniaturization of the equipment, the procedures we can perform and the advantages to the patient should continue to grow.