Despite the obvious benefits of minimally invasive surgery, the physiologic changes associated with thoracoscopic procedures present multiple challenges. The lung is the site of gaseous exchange, but during thoracoscopic surgery it is simultaneously either the surgical target organ or responsible for obscuring surgical exposure. Thus, there is a conflict of interests between the need to provide ideal surgical conditions and the need to maintain normal pulmonary, and cardiovascular physiology. In an attempt to minimize the physiologic insult associated with thoracoscopic surgery, multiple anesthetic and surgical techniques have therefore been developed. None are entirely problem free, however. Because the physiologic changes are technique specific, a clear understanding of the dynamic interaction between the anesthetic-surgical technique and patient physiology is essential.