Background: Penetrating neck trauma (PNT) represents a surgical emergency due to the potential for life-threatening vascular and aerodigestive injuries. Traditional management relies on physical examination, advanced imaging (e.g., CT angiography), and mandatory surgical exploration in selected cases. Video-assisted thoracoscopic surgery (VATS), while established in elective thoracic surgery, has been proposed as a potential tool for rapid assessment in the emergency department (ED) or trauma bay setting for injuries with suspected intrathoracic extension. However, its utility, feasibility, and impact on outcomes in the acute management of PNT remain poorly defined and potentially limited. Objective: This study aimed to critically evaluate the role, diagnostic yield, and therapeutic impact of emergency department thoracoscopy (ED-VATS) in the management of hemodynamically stable patients with penetrating neck trauma, and to compare outcomes with a standard management protocol. Methods: A retrospective cohort study was conducted at a Level I trauma center over a 5-year period. Patients with PNT (zones I-III) who were hemodynamically stable on presentation were included. Two groups were compared: 1) The ED-VATS Group: patients who underwent thoracoscopy in the ED or trauma resuscitation room for suspected intrathoracic injury (e.g., based on wound trajectory, chest X-ray findings, or ultrasound). 2) The Standard Management Group: patients managed per protocol with a combination of physical exam, multi-detector computed tomography angiography (MDCTA), endoscopic evaluation, and observation or operative exploration as indicated. Primary outcomes were diagnostic accuracy of ED-VATS for thoracic injuries, rates of negative/non-therapeutic procedures, time to definitive management, and in-hospital complications. Results: Of 347 patients with PNT, 28 (8.1%) underwent ED-VATS, while 319 were managed with the standard protocol. The diagnostic yield of ED-VATS for a clinically significant intrathoracic injury (requiring intervention) was only 39.3% (11/28). In 17 patients (60.7%), ED-VATS was non-diagnostic or identified minor injuries not requiring intervention. The median time from ED arrival to incision for ED-VATS was 42 minutes, but 9 patients (32.1%) in this group subsequently required a formal operative intervention (thoracotomy or neck exploration) based on VATS findings or clinical progression, effectively adding a procedural step. Compared to the standard group, the ED-VATS group had no significant difference in mortality (3.6% vs. 2.5%, p=0.6) or major complication rates (14.3% vs. 11.9%, p=0.7), but had a significantly higher rate of minor complications related to the procedure (e.g., port-site issues, prolonged air leak) (21.4% vs. 3.1%, p<0.001). MDCTA demonstrated a sensitivity of 98% and specificity of 95% for detecting injuries requiring intervention. Conclusion: In hemodynamically stable patients with penetrating neck trauma, emergency department thoracoscopy has a limited and highly selective role. It carries a high rate of non-therapeutic procedures, adds minimal therapeutic benefit over modern imaging-guided selective management, and introduces procedure-specific morbidity. Its use should be restricted to rare, specific scenarios where immediate thoracic visualization is deemed critical and CT is contraindicated or unavailable, rather than as a routine diagnostic tool. Standardized protocols utilizing clinical examination and MDCTA remain the cornerstone of safe and