The adhesion between the visceral and parietal pleura makes video-assisted thoracoscopic surgery (VATS) difficult or impossible. When performing VATS without conversion to thoracotomy due to pleural adhesion, it is important to( ⅰ) evaluate the presence and extent of the adhesion preoperatively, (ⅱ) carefully perform detachment, and( ⅲ) adequately repair the injured visceral pleura. We evaluate visceral sliding with the help of chest ultrasonography and plan the best approach to make utility inci-sions, camera port, and third-port incisions. Considering the difficulty in repairing the injured visceral pleura under VATS, we perform extra-pleural detachment of adhesions around the injured visceral pleura, which can facilitate the repair of the pleural injury. For repairing pleural injury, we use free mediastinal fat tissue as biological pledgets to support suturing. In this report, we present the approaches and techniques we follow to perform VATS for patients with pleural adhesion.