Spontaneous pneumothorax is a common problem and in patients at risk of recurrence, excision of the source of the air leak and pleurodesis is very effective in reducing further episodes. In the 15 years since the introduction of video assisted thoracic surgery (VATS), practice has changed towards this much less invasive procedure and away from thoracotomy. The evidence from randomized trials, non-randomized comparative studies, the consensus of surgeons and the documented change in practice from registry data are concordant. Unless there are specific clinical indications for more invasive surgery, it would seem reasonable for VATS to become the recommended approach.