Objectives Empyema is a severe condition, which needs adequate and expeditious treatment. Different modalities can be considered, from single drainage placement to open window thoracostomy. Videothoracoscopic decortication unites the goals of good lung re-expansion with minimally invasive surgery, but ocassionally in chronic pleural empyema, this procedure is not easy and requires conversion to open surgery. The aim of this paper is to evaluate the feasibility of this approach in such cases and to perform a comparative study with open decortication. Methods We have performed a retrospective comparative analysis of a prospective database. From 2000 to 2011, 186 patients suffering from empyema were admitted in our Department. Sixty (32.8%) of them needed decortication, 27 by videothoracoscopy (Group A) and 34 by thoracotomy (Group B). Variables: operative time, complications, days of drainage, postoperative length of stay (LOS) and mortality. Statistical analysis: homogeneity between videothoracoscopic and thoracotomy groups was evaluated. Student's t-test was used for continuous variable, unpaired t-test was used for operative time, LOS and days of drainage. Chi2-test was used for categorical data. Significance level P = 0.05 (SSPS 17 Software). Results Pleural decortication was performed in stage III chronic empyema with excellent results and only 3 patients needed conversion (11.1%). Comparison: Operative time: Group A 135 min (65-175), Group B 160 min (90-240). No significative. Complications: Group A 8.2%, Group B 14.7%, P < 0.05. Days of drainage: Group A 5.9 ± 2 days, Group B 9.3% ± 2 days, P < 0.05. LOS: Group A 7.8 days, Group B 11.4 days, P < 0.05. Mortality: Group A 1 (1.6%), Group B 3 (4.9%) No significative. Conclusions Videothoracoscopic decortication is a feasible procedure in stage III empyema with equally effective resolution as thoracotomy. Furthermore in our series it has better results in operative time, postoperative morbidity and length of stay. Multicentric-randomized trial should be performed to suggest this approach as gold standard of pleural empyema. Disclosure All authors have declared no conflicts of interest.