We reviewed empyema management at our center since video-assisted thoracoscopic surgery (VATS) was introduced. Between 1991 and 2003, 58 patients (34 male, 24 female) ages 1 day to 17 years (median, 6 years) were identified. The median interval from the onset of symptoms to presentation was 7 days; 31% of patients received inpatient care at another hospital, and 24% were from northern communities, including the Arctic. Symptoms included fever (100%), cough (66%), shortness of breath (46%), chest pain (38%), and abdominal pain (17%). Most patients (96%) had pneumonia. The most common organisms were Streptococcus pneumoniae (22%), group A streptococcus (8%), and Mycobacterium tuberculosis (3%). No organisms were identified in 31% of patients. One empyema was trauma-related and one was due to complications of esophageal stricturoplasty. All patients received intravenous antibiotics (median, 17 days). Three patients had thoracentesis, 17 had chest tubes, 3 had thoracentesis and chest tubes, 26 had VATS, 6 had thoracotomy, and 3 had minithoracotomy. Median operative times were 86 minutes for VATS, 90 minutes for thoracotomy, and 75 minutes for minithoracotomy. Median total length of stay (LOS) was 15 days for VATS, 20.5 days for thoracotomy, and 21 days for minithoracotomy. The median preoperative LOS was longer for thoracotomy (10 days) than for VATS (5 days) or minithoracotomy (1 day). The median postoperative LOS was 14 days for VATS, 9.5 days for thoracotomy, and 8 days for minithoracotomy. Our experience shows that VATS is a safe and effective approach to managing children with empyema. The shorter preoperative LOS for VATS is likely due to earlier surgical referral and intervention using less invasive surgical procedures.