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Objective: To evaluate the short and long term results of video-assisted thoracoscopic surgery for complicated pneumothorax. Design: Retrospective study. Setting: General hospital, Linz, Austria. Subjects: 76 consecutive patients with complicated pneumothorax. Interventions: 57 patients with primary and 19 with secondary spontaneous pneumothorax underwent video-assisted thoracoscopic surgery. Depending on the findings at thoracoscopy, patients were allocated to have stapled bleb resection (n = 29), multiple bleb resection combined with apical pleurectomy (n = 40), or apical segmental resection combined with apical pleurectomy (no visible disease on the lung surface, n = 7). Main outcome measures: Efficacy, morbidity, mortality, and late recurrence rate. Results: No conversions to open thoracotomy were necessary and early lung reexpansion was achieved in all but one patient (99%). There was one postoperative death (1%) and morbidity was 7%, including one persistent air leak and one early recurrence, both of which required thoracotomy. All postoperative complications developed in patients with spontaneous pneumothorax secondary to diffuse bullous emphysema. At a median follow up of 34 months there were 4 ipsilateral pneumothorax recurrences (5%), two of which developed after bleb resection combined with pleurectomy and two after bleb resection alone. Conclusion: Video-assisted thoracoscopic surgery was safe and effective for the treatment of complicated spontaneous pneumothorax. It is our procedure of choice for complicated primary spontaneous pneumothorax and is a valuable alternative to open thoracotomy for patients with secondary spontaneous pneumothorax. [ABSTRACT FROM AUTHOR]