Thoracic surgery is associated with a high morbidity and mortality rate in the elderly patient population. Appropriate management of thoracic diseases is often avoided because of the inherent risks associated with the access thoracotomy. The purpose of this study was to evaluate the perioperative outcomes of octogenarians who underwent video-assisted thoracic surgery (VATS) for a variety of thoracic conditions. A retrospective chart review was done on all patients who were between 80 and 90 years of age and underwent elective VATS between January 1995 and August 2001. A total of 162 consecutive VATS procedures were performed in 157 patients. Comorbid conditions consistent with their advanced age included chronic obstructive pulmonary disease, hypertension, coronary artery disease, and diabetes. The procedures included 96 lung resections (53 lobectomies, 42 wedge/segment resections), 46 pleurectomies, 8 decortications, 8 mediastinal biopsies, 3 pericardial windows, and 1 drainage of hemothorax. The pathology included 76 primary lung cancers, 35 metastatic diseases, 37 benign conditions, 9 nesotheliomas, and 3 carcinoid tumors. The average operative time and length of hospital stay after surgery were 51 min and 2.6 days, respectively. There were 3 (1.9%) mortalities, 2 from cardiac complications and 1 from pneumonia. Two (1.2%) patients required reexploration for bleeding. Four (2.5%) cases were converted to open thoracotomy thirteen (8.0%) cases had an air leak, of which 11 were managed on an outpatient basis with a Heimlich valve. They were discharged from the hospital an average of 3.3 days postoperatively. With VATS, surgical therapy can be offered to octogenarians with a low morbidity and mortality rate, as well as a short hospital stay.