Spontaneous pneumothorax is a relatively common disease primarily affecting young and otherwise healthy individuals. Chest pain and dyspnea are the most common presenting symptoms and in majority of cases only a chest X-ray is needed to confirm the diagnosis. The initial treatment usually consist of a chest tube drainage, however, persistent airleakage and recurrent pneumothorax are frequent, these patients often requiring surgery. Open thoracotomy was the most common surgical approach with wedge resection of the leaking part of the lung. Today, video-assisted thoracoscopic surgery has in most centers replaced open surgery for spontaneous pneumothorax. In this article the presentation, diagnosis and treatment of spontaneous pneumothorax, including different surgical strategies, are reviewed in an evidence-based approach.