The past 2 years have witnessed the evolution of video-assisted thoracoscopy in the United States. Performance of the procedure has now moved from the university center to the community hospital. It is clear that thoracoscopy is the modality of choice for both the diagnosis and management of pleural disease (except mesothelioma); the identification of undiagnosed peripheral pulmonary nodules; the removal of simple mediastinal cysts; and the performance of wedge biopsy for interstitial lung disease and simple pericardial procedures. Its role in the management of primary lung cancer and esophageal disease remains to be defined. There are four areas that currently need to be addressed as the present role of therapeutic thoracoscopy evolves: (1) instrumentation, (2) economics, (3) a credentialing process, and (4) its application in certain procedures. All of these are addressed in this presentation.