We investigated the role of routine video-assisted thoracoscopy (VAT) prior to thoracotomy. From June 1993 to May 1995, we routinely performed VAT prior to all our elective thoracotomies in adults. Patients who planned to have video-assisted thoracic surgery (VATS), those who underwent emergency thoracotomy, and patients younger than 10 years old were excluded from this study. There were 63 patients (47 men and 16 women; age range, 16 to 84 years), of whom 39 (62%) had malignant disease and 24 (38%) had benign disease. In four cases, VAT could not be performed because of either pleural symphysis or inability to adequately collapse the upper lung. In six cases, thoracoscopic findings influenced subsequent management. Pleural metastases were found in two cases that led to abandonment of thoracotomy; in four cases, identification of chest wall involvement by a malignant or benign process led to proper planning of subsequent thoracotomy. There was no added morbidity from this procedure which took, on average, 6.2 min to complete (range, 3 to 17 min). There was no added cost for consumables. We concluded that: (1) routine VAT is a safe procedure; (2) it adds little to the overall cost or operating time; (3) it can provide useful information that could alter subsequent operative strategy. We recommend routine VAT prior to thoracotomy in patients with known or suspected intrathoracic malignancy and those suspected of having chest wall involvement on CT scans.