In this report, we will describe the treatment of a 38-year-old man with severe descending necrotizing mediastinitis (DNM) with bilateral empyema. DNM is a rare disease with a high mortality rate, and when accompanied by bilateral empyema, this is particularly serious and potentially fatal. To improve the prognosis of such patients, the establishment of an adequate surgical procedure for satisfactory debridement and drainage is essential. This is the first report on a new combined surgical procedure consisting of right standard posterolateral thoracotomy and left video-assisted thoracoscopic surgery (VATS) for severe DNM with bilateral empyema.