Background Video-assisted thoracoscopic surgery (VATS) has been considered an effective diagnostic modality for pulmonary tuberculosis. Its feasibility in therapeutic lung resection, however, has not been validated. Methods The medical records of patients who underwent VATS or a thoracotomy for therapeutic resection of pulmonary tuberculosis between January 2007 and March 2011 were reviewed for age, sex, indications for surgery, approach and procedures, preoperative sputum culture status, operative time, blood loss, hospital stay, and complications. Results One hundred twenty-three patients were enrolled. Sixty-three were successfully treated using VATS and 60 were converted to thoracotomy. The number of VATS wedge resections was significantly higher ( p = 0.004). Patients who underwent VATS had significantly less blood loss, shorter hospital stays, and fewer complications ( p = 0.031, 0.000, and 0.022, respectively). Lesions treated with a pneumonectomy or that required thoracoplasty failed to be done using VATS ( p = 0.054 and 0.002, respectively). Patients who underwent VATS had slightly more isolated lobectomies and significantly ( p = 0.005) shorter hospital stays than did thoracotomy patients. Concomitant and isolated segmentectomies were done using VATS, but there were significantly fewer than for thoracotomy patients ( p = 0.033). Conclusions Video-assisted thoracoscopic surgery is effective for therapeutic wedge resections, isolated lobectomies, and simple segmentectomies and lobectomies combined with wedge resections or segmentectomies for pulmonary tuberculosis. Tuberculosis lesions that require a pneumonectomy or thoracoplasty are still major challenges for VATS.