Lung nodule localization techniques in minimally invasive and video-assisted thoracoscopic surgery: a literature review

Advancement in low-dose computed tomography (LDCT) leads to an increased detection rate of small and subsolid lung nodules. With video-assisted thoracoscopic surgery (VATS) being the standard surgical approach in lung lesions resection in recent decades, these lung nodules pose a great challenge for surgeons to localize the nodule accurately and to ensure successful resection due to their subsolid consistency and small size. Henceforth, various localization techniques emerged to aid pre-operative localization, aiming for a high localization accuracy and a low complication rate. Throughout the development of thoracic surgery, traditional localization methods such as manual palpation and intra-operative lung ultrasonography (ILU) were incorporated to aid the localization of small lung nodules. However, these methods became more technically demanding after minimally invasive surgery (MIS) was developed due to the minimal wound size. Consequently, more creative techniques were explicitly developed for localization in MIS. Although conventional techniques like hookwire and liquid agent localization offer simple but effective localization, innovative techniques such as robotic-assisted bronchoscopy (RAB) and co-localization using a hybrid operating room (HOR) can further optimize localization success and minimize peri-procedural complication rates. The trend of co-localization will likely become a mainstream technique due to its effectiveness. We conducted a literature review of the existing literature in PubMed from 1990 to 2023. In this review article, we review various localization techniques currently used in VATS and illustrate their advantages and limitations in different situations.