<p>Pulmonary complications remain a major cause of morbidity after Ivor Lewis esophagectomy, with acute respiratory distress syndrome (ARDS) representing the most severe form. The impact of a thoracoscopic thoracic phase combined with a mini-thoracotomy for hand-sewn anastomosis on postoperative ARDS remains insufficiently documented. Consecutive patients undergoing curative Ivor Lewis esophagectomy for esophageal or esophagogastric junction cancer between 2010 and 2021 were included. All patients underwent laparoscopic gastric mobilization. The thoracic phase was performed either by conventional thoracotomy or by thoracoscopy in left lateral decubitus with a mini-axillary thoracotomy for hand-sewn intrathoracic anastomosis. Postoperative outcomes were compared, with a particular focus on postoperative ARDS. Multivariable logistic regression was performed to identify factors associated with ARDS. A total of 407 patients were analyzed (thoracotomy: <i>n</i> = 105; thoracoscopy: <i>n</i> = 302). Oncologic outcomes, including R0 resection rate and lymph node yield, were similar. Overall postoperative morbidity and anastomotic leak rates did not differ significantly. The incidence of ARDS was significantly lower in the thoracoscopy group (3.0% vs. 7.6%, <i>p</i> = 0.041). On multivariable analysis, thoracoscopic approach was independently associated with a lower risk of ARDS (OR 0.25, 95% CI 0.07–0.94; <i>p</i> = 0.04). In this single-center cohort, a thoracoscopic thoracic phase combined with mini-thoracotomy during laparoscopic Ivor Lewis esophagectomy was feasible, preserved oncologic quality, and was associated with a lower risk of postoperative ARDS. These findings support the safety of this hybrid minimally invasive approach in high-volume centers.</p>