Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.