Purpose Pulmonary co-morbidities are recognized risk factors in conventional colorectal surgery. The avoidance of an upper abdominal incision in patients with major pulmonary co-morbidities is appealing, but the effect of a carbon dioxide pneumoperitoneum on such patients has not been well documented. We examine here the feasibility and safety of laparoscopic colorectal surgery in this high-risk patient population, defined by need for home oxygen, history of severe obstructive pulmonary disease, or extensive smoking history. Methods Between January 1995 and June 2005, data from 1,602 consecutive patients undergoing laparoscopic colorectal surgery were prospectively recorded and serve as the basis for this retrospective case-matched analysis. 492 patients presented with a major pulmonary co-morbidity and were compared to a group of patients without pulmonary co-morbidities undergoing laparoscopic colorectal surgery and later to a case-matched group of patients undergoing open surgery during a similar time period. Results While patients with pulmonary co-morbidities were more likely to have diabetes and be on steroids, the overall morbidity was similar in the two laparoscopic groups (9.8% vs. 9.5%, p=0.90). This group was also more likely to have cardiac and renal co-morbidities. The effects of a carbon dioxide pneumoperitoneum on patients with pulmonary co-morbidities did not translate into an increased conversion rate in this high-risk patient subset (p=0.18). The rates of segmental atelectasis (6% vs. 7%) and pneumonia (6% vs. 2%) did not significantly differ between the two groups and compared quite favorably to the open group. Furthermore, length of stay was slightly decreased in the group with pulmonary co-morbidities (4.3 vs. 5.1 days, p=0.12). Conclusions Patients presenting with underlying pulmonary disease frequently have other co-morbidities as well. With proper patient selection and laparoscopic experience, advanced laparoscopic procedures can be performed in this complicated patient population without undue morbidity or mortality. A minimally invasive approach and avoidance of an upper abdominal incision is associated with improved postoperative recovery compared with conventional surgery.