The current status of video-assisted thoracoscopic surgery (VATS) of the lung has been reviewed. The published data support the view that VATS pulmonary surgery is feasible and safe. It is associated with decreased perioperative pain and opiate requirement, better postoperative pulmonary function, and probable overall neutral cost impact. A VATS approach is functionally superior to open thoracotomy for wedge resection, pneumothorax surgery and bullous lung disease and may allow surgical intervention in patients with pulmonary function which is in adequate for open resection. Major VATS pulmonary resection with lobectomy and pneumonectomy can be performed for early malignant disease without compromising established surgical principles. Specific training is needed in VATS surgery and background skills in general thoracic surgery are necessary to underwrite major interventions. Decreased cytokine activation and enhanced post surgical immune function may prove to be long-term benefits of VATS surgery.