Background: Spontaneous pneumothorax (SP) remains a significant health problem because of the high recurrence rate during thoracic drainage and conservative treatments. SP can appear under two forms: primary SP occurs in otherwise healthy patients, most commonly in tall, young, lean men, and particularly in those who smoke. Secondary SP occurs as a complication of an underlying lung disease, which most often is chronic obstructive pulmonary disease. Objective: The aim of the study was to compare outcome in patient who undergo thoracoscope and patients who undergo thoracotomy in primary spontaneous pneumothorax. Patients and Methods: This randomized clinical trial study was conducted at Cardiothoracic Surgery Department, Zagazig University Hospitals. We included 30 patients with primary spontaneous pneumothorax in a randomly selected (allocation sealed envelope). Patients were randomly divided into two groups; Group A: 15 cases were subjected to video-assisted thoracic surgery (VATS) Bullectomy in primary spontaneous pneumothorax. Group B: 15 cases were subjected to open thoracotomy in primary spontaneous pneumothorax. Results: This study showed that there was significant difference between both groups regarding to intraoperative blood loss, chest tube duration and hospital stay that was higher in thoracotomy group than VATS group. The complications were higher in open thoracotomy than VATS group but it did not reach significant difference. Also, there was no significant difference regarding to recurrence. Conclusion: VATS is associated with shorter length of hospital stay and less blood loss with no difference of recurrence, and postoperative outcome compared to open thoracotomy in primary spontaneous pneumothorax patients.