Over the past decade, there has been significant success in operative intraluminal endoscopy due to technological progress and expansion of indications for endoscopy in various gastrointestinal diseases. To date, surgical endoscopy has gone beyond the mucosa of hollow organs and allows treating patients with neuromuscular diseases, removing myogenic submucosal neoplasms, and performing interventions on adjacent organs. We call these interventions third space endoscopy. The development third space endoscopy is associated with an increase in the aggressiveness of such interventions and imposes special requirements to ensure their safety. When planning an operative intervention, the surgeon should consider specifics of its implementation, as well as the possibility of intraoperative situations requiring coordinated actions of all participants in the intervention. Knowledge of these features allows to eliminate most situations with minimal consequences for the patient. To achieve the most effective and safe result, the teamwork of the surgical and anesthesiological teams is necessary. In this regard, the issues of anesthesiological support in operative endoscopy deserve special attention. This article highlights the general principles and recommendations when performing tunnel interventions in patients with gastrointestinal diseases which are related to anesthetic issues.