OBJECTIVE To determine the indications and limitations of surgical videothoracoscopy for management of pleural effusion, an infrequent and often recurring complication of cirrhotic ascites whose pathogenesis involves direct passage of ascitic fluid into the pleural space through minute defects in the diaphragm. DESIGN/SETTING/PATIENTS/INTERVENTIONS: Eight cirrhotic patients with ascites and recurrent pleural effusion underwent surgical videothoracoscopy to localize and close any diaphragmatic defects and to achieve pleurodesis by application of talc. RESULTS Diaphragmatic defects were localized and closed in six patients; postoperative mean volume and duration of drainage were, respectively, 0.408 +/- 0.157 mL and 7.6 +/- 1.75 days. None of these six patients developed recurrent pleural effusion (follow-up, 7 to 36 months). In the 2 patients in whom no defect was found, drainage had to be maintained for 15 days and 18 days (drainage volumes, 3 and 4 L). At hospital discharge, both patients had a stable recurrent effusion occupying the lower third of the cavity. CONCLUSIONS Utilization of videothoracoscopy appears particularly indicated for these fragile patients when medical therapy fails. The procedure's efficacy is immediate and durable once defects are identified and closed. If the technique proves unsuccessful, it does not hinder subsequent use of other methods.