AIM: Breast-conserving surgery (BCS) has been increasingly favored by elderly breast cancer patients to preserve their quality of life. This study compares the efficacy and safety of endoscopic versus conventional BCS in elderly patients, focusing on operative and aesthetic outcomes. METHODS: A retrospective analysis was conducted on 261 elderly breast cancer patients (age ≥70) treated from January 2020 to January 2022. Patients were divided into endoscopic (n = 126) and conventional (n = 135) BCS groups. Surgical observations, complications, immune cell changes, adipokine levels, and survival rates were evaluated. Statistical analyses were performed using SPSS software. RESULTS: Compared to the conventional BCS group, the endoscopic BCS group had significantly lower intraoperative blood loss (12.82 vs. 128.29 mL; p < 0.001), reduced hospitalization costs (13,289.74 vs. 16,032.41 Yuan; 1 Chinese Yuan ≈ 0.1385 US Dollars, p < 0.001), and shorter drainage duration (p = 0.002). The endoscopic BCS group reported superior aesthetic outcomes (66.67% rated as excellent vs. 50.37%; p = 0.047) and fewer surgical complications compared to the conventional BCS group, including lower rates of axillary pain, numbness, and arm swelling (p = 0.002, p = 0.002, and p = 0.008, respectively). No significant differences were observed in perioperative immune cell markers, adipokine levels, or survival outcomes between the groups. CONCLUSIONS: Endoscopic BCS offers advantages in reducing operative morbidity and enhancing aesthetic outcomes without compromising oncological safety for elderly patients.