OBJECTIVE The aim of this study was to review the treatment options for spontaneous haemopneumothorax (SHP) by video-assisted thoracoscopic surgery (VATS). METHODS Records from 16 patients (14 male, age 16-38 years, mean age 26.1 years) with prominent SHP (blood loss over 400 cc in the first 24 h) undergoing VATS from July 1994 to December 2005 and treated by one thoracic surgeon in four medical centres or community hospitals of North and Mid-Taiwan were reviewed retrospectively. RESULTS Thirteen patients (81.3%) were identified to have a prominent bleeding source intraoperatively. Torn engorged vessels from the parietal pleura to adjacent bullae were found in nine patients, and bleeders adjacent or over the parietal part of the adhered pleura were found in the other four. Ruptured bullae/blebs or air leakage were found in 14 (87.5%). All underwent removal of intrapleural blood clot, control of bleeders and their bullae/blebs were resected through three-port VATS (n = 13, 81.2%) or mini-thoracotomy and VATS (n = 3, because of unstable vital signs or conversion because of dense adhesion). Mechanical or chemical pleurodesis was carried out in all patients. The mean operative time was 53.8 +/- 21.7 min. There was no postoperative mortality. However, recurrent bleeding requiring reoperation occurred in one patient, and one other patient had a prolonged air leakage (>7 days) postoperatively and recovered spontaneously. The mean duration of chest tube drainage was 3.8 days and the median follow-up period was 3.2 years. CONCLUSIONS SHP complicated by severe bleeding is a surgical emergency. VATS is a reasonable treatment for patients with SHP.