A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether video-assisted thoracoscopic surgery (VATS) was justifiable for first-episode primary spontaneous pneumothorax (PSP). Altogether 183 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS has superior outcomes in terms of recurrence rates of pneumothorax (from 0 to 13% according to several studies for VATS vs. 22.8 to 42% for tube thoracostomy alone), duration of chest tube drainage (CTD) (4.56 vs.7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for CTD) with first-episode PSP compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of $408, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to conservative approach. These findings were not replicated in an article considering primary VATS (PV) vs. secondary VATS (SV) as the best treatment modality for PSP in children. Although the total treatment length of stay was significantly shorter for PV vs. SV (7.1+/-0.96 vs. 10.5+/-1.2, P=0.04), morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). In this article the observed recurrence rate was 54%. Performing PV on all patients with PSP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach, therefore, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with spontaneous pneumothorax (SP). Instead, secondary treatment is recommended. Lastly, two articles also examined the rate of recurrence of VATS compared to open thoracotomy (OT). The range was from 0 to 7.7% for OT vs. 10.3 to 13% for VATS, a non-statistical difference.