Resection of large bullae to decompress adjacent lung tissue with the goal of improving pulmonary function has been an accepted surgical approach for many years. However, the indication for lung volume reduction is not bullous disease but diffuse emphysema and the surgical approach is based on an entirely different concept. The resection of the most affected parts of the emphysematous parenchyma aims at a reduction of the over expansion of the chest with the goal of improving respiratory mechanics. This concept was introduced by Brantigan in 1959, but has failed to gain widespread acceptance until recently. Based on the extensive experience in lung transplantation for patients with end stage emphysema J. D. Cooper reevaluated the idea successfully. He reported remarkable improvements in FEV1 and a reduction in hyperinflation after performing bilateral lung volume reduction through a median sternotomy. During the last 2 years we performed bilateral lung volume reduction in more than 30 patients with diffuse emphysema using video assisted thoracoscopy (VAT) and studied the results prospectively. In the first 20 patients preoperative mean forced expiratory volume in 1 second (FEV1) was 765 ml/sec and improved by a mean of 42% (0-100%) three months postoperatively. This gain in FEV1 was already observed at the end of hospitalisation approximately two weeks after surgery. The 12 minute walking distance improved over 40%. In our highly selected study population we had no perioperative mortality. Lung volume reduction is a palliative treatment of severe pulmonary emphysema. Currently no data is available on the duration of the improvement. In this selected group of patients dyspnea is reduced and pulmonary mechanics are improved, with a resulting increase in quality of life.