To analyse the efficacy of video-assisted thoracoscopy (VAT) in patients with spontaneous pneumothorax (SP) and to identify clinical factors associated with outcome after VAT, one hundred and one VATs were performed in 97 patients in this prospective study. Based on thoracoscopic appearance of the visceral pleura three groups were identified, group 1 (n = 23) showing no abnormalities treated with talcage, group 2 (n = 23) showing bullae less than 2 cm treated with talcage and coagulation, and group 3 (n = 51) showing bullae larger than 2 cm treated with bullectomy by staplers, coagulation and pleural scarification. Data were analyzed with regard to clinical factors such as age, smoking behavior, pulmonary function and recurrent pneumothorax at presentation. No perioperative deaths occurred. Overall relapse rate was 4.0% during a follow-up period of 3 to 38 months (median 27.2). Univariate analysis did not show any association of clinical factors with postoperative complications (n = 19). Patients with extensive pulmonary lesions had longer drainage and hospitalization time, probably due to insufficient sealing effects of stapler devices and/or pleural scarification. Using multivariate analysis, none of the clinical factors had any association with complication rate, drainage/hospitalization time or relapses after VAT. Only patients with bullae larger than 2 cm treated with bullectomy by stapler devices were associated with longer drainage and hospitalization time. This study suggests that VAT is effective in the treatment of spontaneous pneumothorax, although the use of stapler devices and/or pleural scarification was associated with longer drainage and hospitalization time, however, none of the clinical factors were associated with the outcome after VAT.