OBJECTIVE Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgery practice. This study discusses the clinical aspects and utility of VATS in spontaneous hemopneumothorax (SHP). METHODS Of 363 spontaneous pneumothorax (SP) cases, 24 patients presented with SHP (6.6%). The clinical features, surgical indications, emergency VATS technique, and patient outcomes are discussed. RESULTS All 24 patients were male (mean age, 25.3 years). Eleven patients were in hypovolemic shock, and their hemoglobin levels ranged from 6.7 to 12.7 g/dL; therefore, they received fluid resuscitation and blood transfusion. The amount of blood drained through the chest tube varied from 200 to 3,500 mL. Emergency VATS revealed that 5 cases were simple hemothoraces and 19 cases were associated with pneumothorax. The cause of bleeding was identified by thoracoscopy, as from an aberrant vessel (n = 11), torn parietal pleura (n = 4), ruptured vascularized bullae (n = 2), and lung parenchyma (n = 1). Six patients had no evidence of an obvious bleeding site. Bullous lesions were at the apex of the upper lobe in 14 patients, and multiple lobar involvement was seen in 2 patients. All the bullae were resected with endoscopic stapler in eight patients and ligated with a homemade endoloop in eight patients. The mean operation time was 42 min. The mean chest tube removal time was 3.5 days after insertion, and mean postoperative stay was 4.5 days. There is no recurrence of SHP or SP during the follow-up period. CONCLUSIONS SHP complicated by severe bleeding presents a potentially grave emergency. VATS may be considered as feasible treatment for patients with SHP.