Efforts to reduce the trauma and discomfort associated with thoracic and cardiac procedures in children have a long and complex history. While much of the early focus has been on smaller incisions, efforts to reduce the adverse effects of cardiopulmonary bypass, reduce pain associated with the incisions, and more recently, ameliorate the impact of the whole in-hospital experience have evolved as new technology and techniques have been developed. Many of the concepts follow the principles used in adult minimally invasive procedures, however, modified for the available instruments for pediatric surgery and take advantage of the more flexible chest wall structures in young children. In this summary we will review the approaches that have been described and comment on the evidence that they achieve the desired goal of minimizing the trauma of the surgical procedure and enhancing recovery.