OBJECTIVES: There are no guidelines regarding the surgical approach for spontaneous pneumothorax. It has been reported, however, that the risk of recurrence following video-assisted thoracic surgery is higher than that following open thoracotomy (OT). The objective of this study was to determine whether this higher risk of recurrence following video-assisted thoracic surgery could be attributable to differences in intraoperative parenchymal resection and the pleurodesis technique. METHODS: Data for 7647 patients operated on for primary or secondary spontaneous pneumothorax between 1 January 2005 and 31 December 2012 were extracted from Epithor(R), the French national database. The type of pleurodesis and parenchymal resection was collected. Outcomes were (i) bleeding, defined as postoperative pleural bleeding; (ii) pulmonary and pleural complications, defined as atelectasis, pneumonia, empyema, prolonged ventilation, acute respiratory distress syndrome and prolonged air leaks; (iii) in-hospital length of stay and (iv) recurrence, defined as chest drainage or surgery for a second pneumothorax. RESULTS: Of note, 6643 patients underwent videothoracoscopy and 1004 patients underwent OT. When compared with the thoracotomy group, the videothoracoscopy group was associated with more parenchymal resections (62.4 vs 80%, P = 0.01), fewer mechanical pleurodesis procedures (93 vs 77.5%, P < 10(-3)), fewer postoperative respiratory complications (12 vs 8.2%, P = 0.01), fewer cases of postoperative pleural bleeding (2.3 vs 1.4%, P = 0.04) and shorter hospital lengths of stay (16 vs 9 days, P = 0.01). The recurrence rate was 1.8% (n = 18) in the thoracotomy group versus 3.8% (n = 254) in the videothoracoscopy group (P = 0.01). The median time between surgery and recurrence was 3 months (range: 1-76 months). CONCLUSIONS: In the surgical management of spontaneous pneumothorax, videothoracoscopy is associated with a higher rate of recurrence than OT. This difference might be attributable to differences in the pleurodesis technique rather than differences in the parenchymal resection.