Background: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. Methods: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. Results: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital <24 h for needlescopic splenectomies (40% vs 0%, p = 0.087), fundoplications (68% vs 42%, p = 0.107), and myotomies (90% vs 30%, p = 0.022) than for conventional laparoscopic surgery. Operative times were significantly shorter for needlescopic sympathectomy than for laparoscopic sympathectomy and Heller myotomy (p = 0.004 and 0.013, respectively), and they were equivalent for other procedures. Conclusion: Needlescopic surgery can be performed in a variety of procedures with no apparent increase in conversions, operative time, morbidity, or mortality. There is a trend toward reduced hospital stays for certain procedures. Randomized prospective trials comparing needlescopic to conventional laparoscopic surgery are still needed to confirm and/or extend our findings.