Pediatric surgical experience with video-assisted thoracoscopy is limited. The authors report their experience with 27 thoracoscopies in 22 children. The median age was 6.1 years (range, 1 day to 16 years). The two primary indications for thoracoscopy were management of pneumothorax and mediastinal cysts. Fifteen thoracoscopies accomplished their purpose without complications. Intraoperative complications required conversion to an open operation in three patients. One bronchogenic cyst and four pneumothoraces recurred. The main complications were poor visualization, bleeding from an intercostal artery, and difficulty with suturing. Compared with open thoracotomy, anesthesia time did not differ significantly, and less pain medication was required postoperatively.