Background Video-assisted thoracoscopic surgery (VATS) is effective for fibropurulent thoracic empyema and less invasive, and it may be important as a bridge between minimally invasive and conventional open thoracic surgical management. Aim The aim of this study was to determine the optimal treatment of parapneumonic effusion in the fibrinopurulent stage comparing blind thoracostomy versus VATS with regard to efficacy, duration of hospitalization and intercostal tube (ICT) insertion, and need for further surgery or not. Patients and methods This study was a prospective comparative randomized study conducted on 60 patients with confirmed parapneumonic effusion where they were classified into two groups. The blind thoracostomy group: 30 patients underwent blind thoracostomy and the VATS group: 30 patients underwent VATS. Results The incidence of clinical improvement was more in the VATS group when compared to the blind thoracostomy group. The hospital outcome in the VATS group was much better than in the blind group, where in the VATS group, the postoperative length of hospital stay was around 4.8 days and the time of ICT removal was after 5 days from insertion, whereas in the blind group, the length of hospital stay was around 9.7 days and the time of ICT removal was after about 6 days of insertion. The incidence of postoperative complications was higher in the blind group than in the VATS group. Conclusion VATS provides more accurate staging for parapneumonic effusion, an excellent surgical view for a complicated empyema cavity, thus making it possible to perform a sufficient evacuation of all empyema membranes.