Anesthesia for endoscopic surgery can be challenging depending on surgical manipulations and patient comorbidity. Anesthetists must understand the possible systemic changes and complications that are associated with endoscopic surgery. Pneumoperitoneum induces vasoconstriction, reduces cardiac output, and decreases functional residual capacity in the cardiopulmonary system. Both hypoventilation caused by the thoracoscopic procedure and CO₂ insufflation increase Paco₂. To prevent the problems associated with high Paco₂, monitoring of end-tidal CO₂ (ETco₂) and capability of positive pressure ventilation are crucial. Sudden changes of ETco₂ should be monitored closely. Endoscopic surgery should be a less invasive procedure; however, appropriate analgesia remains necessary.