Background: Minimally invasive surgeries, laparoscopic and robotic-assisted procedures challenge intraoperative pulmonary function due to pneumoperitoneum and patient positioning. Ventilation strategies that optimize respiratory mechanics are important for reducing complications and ensuring adequate gas exchange. Pressure-guided ventilation modes, including pressure-controlled ventilation (PCV) and PCV with volume guarantee (PCV-VG), is a potential alternative to traditional volume-controlled ventilation (VCV). We aimed to evaluate the impact of pressure-guided ventilation approaches (PCV and PCV-VG) versus VCV on intraoperative respiratory function and postoperative outcomes in patients undergoing minimally invasive surgeries. Methods: A systematic review was conducted following PRISMA guidelines. Databases were searched for randomized controlled trials comparing PCV or PCV-VG to VCV in adult patients undergoing laparoscopic or robotic surgery. Inclusion criteria focused on studies reporting respiratory mechanics, gas exchange, inflammatory markers, or clinical outcomes. Ten RCTs with a total of 810 patients were included. Results: Pressure-guided ventilation was associated with lower peak airway pressure (Ppeak), improved dynamic compliance (Cdyn), and better oxygenation. PCV-VG showed advantages in maintaining tidal volume while reducing pulmonary stress. Several studies reported reductions in inflammatory biomarkers (sRAGE, S100A12) and postoperative pulmonary complications. Individualized PEEP further enhanced outcomes in some protocols. Conclusion: Pressure-guided ventilation strategies, PCV-VG, improve intraoperative pulmonary mechanics and reduce inflammatory responses compared to VCV during minimally invasive surgeries. These approaches offer lung-protective benefits and support safer anesthetic management.