The role of minimally invasive surgery (MIS) in paediatric pulmonary metastasectomy is evolving, reflecting advances in imaging, localisation and instrumentation. Compared with thoracotomy, thoracoscopy offers benefits of reduced postoperative pain, shorter recovery and easier reoperation. However, limitations include anaesthetic challenges in smaller children and lack of manual palpation, which may miss subpleural nodules, which is particularly important in chemoresistant tumours such as osteosarcoma and nonrhabdomyosarcoma soft tissue sarcoma. MIS is most suitable for limited disease, peripheral nodules and histologies where complete manual exploration is unnecessary. Indications depend on tumour type, number and location of lesions, as well as patient stability and institutional expertise. Advances in nodule localization—such as wire or coil marking, fluorescence imaging and radiotracers—have improved thoracoscopic precision. Wedge resection remains preferred for peripheral nodules, with anatomic resection reserved for central or larger lesions. MIS contraindications include extensive disease, inability to tolerate single-lung ventilation or lack of required resources. Optimal outcomes depend on experienced multidisciplinary teams and readiness to convert to open surgery when needed. Overall, thoracoscopy is a safe, effective option in selected paediatric patients, providing therapeutic benefit while minimising morbidity when applied judiciously to tumour biology and disease extent.