Background: Pleural effusion is a common clinical disease characterized by pathological fluid accumulation in the pleural cavity. There are many possible causes of pleural effusion, with congestive heart failure, pneumonia, and malignancy being the most prevalent in adults. Aim of the work: This research aimedto study the effect of enhancing the accuracy of diagnosis and decreasing post-operative complications on patients with recurrent pleural effusion. Patients and methods: This randomized controlled clinical trial study was conducted at Suez Canal University Hospitals, Cardiothoracic Surgery Department through the period from August 2021 to March 2023. The study included 100 cases who presented with recurrent pleural effusion of unknown origin. Patients were allocated into two groups. Patients who underwent intubated VATS were in group (A), and those who underwent awake VATS were in group (B). Results: The intraoperative complications of cardiac arrhythmia and self-limiting subcutaneous emphysema were insignificantly less frequent in awake VATS group. The postoperative complications including loculated effusion, prolonged air leakage and expansion defect, empyema and long pleural drainage were non-significantly less frequent in awake VATS group. Conclusion: In terms of operative complications and pain after surgery, awake video-assisted thoracoscopic operation was safer, more accurate, and more effective than video-assisted thoracoscopic operation conducted under general anesthesia. Additionally, the duration of the operation was shorter. Consequently, it may be the treatment of choice for all cases, not just those with comorbidities.