Thoracic empyema encompasses a spectrum of inflammatory manifestations ranging from thin parapneumonic pleural effusion to the formation of a thick, constricting rind. The aim of this study is to determine the applicability of thoracoscopically aided pleural debridement (TAPD) in children with complicated empyema and to assess its possible advantages. In the last 6 years, 26 children (ages 2 months-16 years; median, 7 years; mean, 7 years) were diagnosed with empyema (right, n = 15; left, n = 11). Their charts, radiographs, and follow-up courses were reviewed. All children had typical clinical and radiological findings of empyema; one also had necrotizing pneumonitis. Treatment modalities included antibiotics only (n = 3), antibiotics with tube thoracostomy (n = 11), open thoracotomy (n = 5), and TAPD (n = 7). Children treated with antibiotics alone had an average (avg) length of stay (LOS) of 31 days. Those managed with tube thoracostomy had an avg LOS of 13 days, and those who underwent thoracotomy had an avg LOS of 16 days. The seven children treated with TAPD had an avg LOS of 12 days, and their avg postoperative chest tube use was 6 days. Children with TAPD had considerable less pain and recovered faster. TAPD of empyema is promising for children whose lungs do not expand promptly after tube thoracostomy or who have a persistent loculated empyema.