Video-assisted thoracic surgery (VATS) is the treatment of choice for uncomplicated primary spontaneous pneumothorax (PSP). In this study, we design a modified thoracoscopic procedure and compare it with the standard VATS. Between January 2001 and July 2003, fifty-two consecutive patients with PSP were managed with the modified procedure, called video-assisted extrathoracic bleb excision (VAEB). Simultaneously, we reviewed and recorded the same data of another consecutive 52 patients who underwent standard VATS between April 1997 and December 2000. The two groups were compared regarding operative time, intraoperative blood loss, postoperative pain by visual analog scale (VAS), amount of chest tube drainage, length of hospital stay (LOS), and hospital cost. The age, gender, amount of chest tube drainage, and LOS were not significantly different (P = 0.787, 0.727, 0.660, and 0.602, respectively). The operative time was shorter (VAEB 43+/-6 min; VATS 63+/-5 min), pain was less (VAS: VAEB 6+/-1; VATS 7+/-1) and hospital cost was lower (VAEB dollars 1429+/-37; VATS dollars 2035+/-93) in the VAEB group. VAEB is an effective alternative procedure to standard VATS for PSP. It has the same effectiveness as VATS and catches the advantages of transaxillary minithoracotomy. In addition, it is an easier, quicker, less traumatic and more economical approach.