Our aim is to assess the results of surgical treatment for spontaneous pneumothorax (SP) using video-assisted thoracoscopic surgery (VATS) and to determine whether this technique is equally effective for primary SP (PSP) and secondary SP (SSP). A prospective study was performed on 54 patients with persistent and recurrent SP (42 PSPs and 12 SSPs). Mean operating time, time before drainage removal, and hospital stay were significantly longer with SSP (67.1 vs. 48.1 minutes; 5.4 vs. 3.6 days; and 7.7 vs. 5.3 days; p < 0.01, respectively). There was one conversion due to bleeding (PSP). Postoperative complications were greater with SSP (33% vs. 12%; p = 0.09). Although these were mild in all cases, the most common was air leak (25 vs. 5%; p = 0.06). The SP persisted in three cases [2 (5%) with PSP, and 1 (8%) with SSP] and recurred in 2 (1 in each group; 2% and 8%, respectively). Follow-up averaged 24 months. VATS is effective in the surgical treatment of PSP and SSP, although the technical difficulty, morbidity rate, hospital stay, and incidence of persistences and recurrences are greater in the latter than in the former.