Background: Patients with recurrent, refractory hepatic hydrothorax from porous diaphragm syndrome represent a therapeutic challenge with few options. Methods: A retrospective review of an electronic prospective database of patients with cirrhosis and refractory hepatic hydrothorax. Patients underwent video-assisted thoracoscopic surgery (VATS) with talc pleurodesis insufflating 2.5 g of talc. Successful therapy was defined as relief of dyspnea and control of symptomatic hydrothorax for a minimum of 6 months after the procedure. Results: There were 41 patients (21 men, median age 55 years), 25 with Child-Pugh class C and 14 with class B, and 2 liver transplant patients. The etiology of the cirrhosis was hepatitis B in 4, hepatitis C in 20, alcohol in 4, cryptogenic cirrhosis in 11, and other in 2. Definitive openings in the diaphragm were seen in only 2 patients. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2. There was 1 operative death (coagulopathy). Conclusions: Patients with recurrent effusions from porous diaphragm syndrome have few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of patients, but repeat talc slurry through the chest tube or repeat VATS is often needed. Video-assisted thoracoscopic surgery provides an effective alternative to transjugular intrahepatic portosystemic shunt and is a bridge toward liver transplantation in patients with few other options. © 2006 The Society of Thoracic Surgeons.