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To retrospectively compare needle video-thoracoscopic surgery (NVTS) with conventional video-thoracoscopic surgery (CVTS) for the treatment of primary spontaneous pneumothorax.The charts of 9 female and 66 male patients with onset of primary spontaneous pneumothorax between July 1999 and December 2005 were reviewed. Twenty-two patients in the NVTS group were treated with NVTS, using a needle-shaped thoracoscope and instruments (3-mm in diameter), and assisted by one 10-mm standard port, whereas 53 patients in the CVTS group were treated using conventional endoscopic devices with a 10-mm thoracoscope. All patients underwent endoscopic stapling to excise blebs if identified. Postoperative wound pain was scored using a numerical pain scale.Neither group experienced mortality or any major morbidity during mean follow-up of 80.5 months. In the NVTS and CVTS groups, intraoperative blood loss (11.4±14.8 and 17.4±18.1 mL respectively, P=0.174), and mean operative times (75.5±38.5 and 92.2±33.1 min, respectively, P=0.062) did not differ significantly. Mean durations of pleural drainage (0.6±1.0 and 2.6±2.3 d, respectively, P<0.01), and postoperative hospital stay (2.3±1.4 and 4.4±2.5 d, respectively, P<0.01) were less in the needle video-thorascopic surgery group. The degree of postoperative wound pain did not differ significantly between the 2 groups. There were 3 cases of persistent postoperative air leakage in both groups, which required further approaches to check for unrecognized blebs. There was no recurrence of pneumothorax in the NVTS group, and 3.6% recurrence rate in the CVTS group.Needle thoracoscopy seems to be a safe alternative to treat primary spontaneous pneumothorax.