Many pediatric surgeons advocate early open drainage or decortication for children with acute empyema. Unfortunately, such procedures can be associated with significant morbidity. Since 1981, we have used early thoracoscopic adhesiolysis and pleural debridement as an alternative to open thoracotomy in 9 children with acute empyema. The average age was 7.8 +/- 1.8 years (range, 2 to 16). All patients had failed initial treatment, which included antibiotics and chest tube drainage. All procedures were performed under general anesthesia. Following thoracoscopy, 8 of the 9 patients were managed with a single drainage tube and the average duration of tube drainage was 8.4 +/- 1.4 days. One patient died of underlying leukemia. Of the 8 patients who recovered, the average postoperative hospital stay was 13.4 +/- 2.9 days. No complications resulted from the thoracoscopies and there was no need for further surgical intervention in any of these patients. We conclude that thoracoscopy allows for minimally invasive, yet effective treatment of acute empyema with loculated collections. Thoracoscopic visualization of the pleural cavity permits efficient debridement, thorough adhesiolysis, and optimal placement of drainage tubes. Since we have begun using early thoracoscopy in the treatment of pediatric empyema, open drainage or decortication has not been required in any of these patients. Thoracoscopy is a useful adjunct in the treatment of empyema in children and its early application may eliminate the need for decortication.