The procedure of thoracoscopy was employed in adult patients for more than half a century before the first report evaluating its use in children was published in 1976. Initially thoracoscopy was proposed as a technique for obtaining pulmonary biopsy specimens in immunocompromised children when interstitial pneumonia developed, but, as more experience with the technique was gained, new indications for its use in children have arisen. A review of the published reports on the use of thoracoscopy in children has brought to light areas in which the procedure has been particularly useful as well as several limitations of the procedure. In properly selected patients, thoracoscopy is an extremely accurate method of tissue diagnosis for diffuse and localized pulmonary infiltrates. This technique may be the procedure of choice in the diagnosis of mediastinal lesions in children and in the surgical treatment of empyema and pneumothorax. Most of the morbidity and mortality reported for the procedure have been in patients with diffuse interstitial pneumonias. Such patients, who are on high-pressure ventilator support, are best managed by a standard open lung biopsy. Maintenance of a sufficient pneumothorax has proved difficult in very small infants and children, and the procedure may not be applicable in children who weigh under 8 kg. Refinements in thoracoscopy instrumentation will allow the performance of more complicated surgical dissections as pediatric surgeons acquire more familiarity with this technique.