VATS allows for thoracoscopic debridement of the infected fibrinous peel that encases the lung and prevents its full expansion Under a general anesthetic, a high-resolution camera placed within the pleural space via a small (1-cm) incision between the ribs allows the removal of the purulent debris The peel may be removed under direct visualization with the aid of thoracoscopic instruments placed through additional thoracoscopic incisions A chest tube is then placed to drain the pleural cavity and left in place for a period of days Because sedation approaching the depth of general anesthesia is needed for the placement of a chest tube, many surgeons and infectious disease consultants recommend thoracoscopy as the initial approach to a child with empyema Studies suggest that while outcomes may not vary significantly, early surgical intervention likely decreases duration of IV antibiotics, days with a chest tube, and hospitalization In centers where a chest tube and fibrinolytic therapy is the initial treatment of choice, patients who fail to improve clinically after a few days should progress to VATS Seldom is open thoracotomy now necessary to resolve empyema It should be remembered that VATS will aid in the resolution of the pleural space disease but not necessarily the parenchymal disease which will need ongoing therapy Solid Lung and Pleural Lesions A number of solitary lesions are benign, with the most common being inflammatory pseudotumor and hamartoma, both of which may become quite large and cause symptoms of respiratory distress, cough, airway obstruction, or mediastinal compression Solid lesions in the pleural space occur uncommonly in children A localized, pleural-based mass should suggest neoplasm, which may be primary or metastatic The most common primary lung tumors are bronchial adenomas, and the most common metastatic lesions are Wilms tumor and osteogenic sarcoma They may encase the lung and produce restrictive lung disease It is impossible to generalize the mode of presentation of such rare processes Focal lesions may be expected to be found in the investigation of symptoms caused by local compression or erosion; because of the large functional pulmonary reserve of children, restrictive lung disease caused by a diffuse process is distinctly uncommon; or by serendipity A full radiographic evaluation, including a CT scan, should be obtained, admission to the hospital strongly considered, and appropriate consultation sought Focal lesions should be considered malignant until proven otherwise; thus, operation for biopsy or excision will likely be required LUNG LESIONS