Precise localization techniques for small pulmonary nodules: what is next?

With the widespread adoption of low-dose computed tomography (LDCT) screening, the detection rate of small pulmonary nodules has surged, necessitating precise localization for minimally invasive resection. Video-assisted thoracoscopic surgery (VATS), being the gold standard for diagnosis and treatment, faces significant challenges in localizing nodules <1 or >1.5 cm from the pleural surface, particularly ground-glass nodules, due to limited tactile feedback. This review systematically evaluates advancements in preoperative and intraoperative localization techniques, focusing on four domains: computed tomography (CT)-guided methods (e.g., liquid agents like indocyanine green, metallic markers, and robotic-assisted puncture), bronchoscopy-guided approaches [electromagnetic navigation, radial endobronchial ultrasound (EBUS), and robotic bronchoscopy], three-dimensional (3D) printing navigation, and emerging technologies (augmented reality and real-time noninvasive systems). Despite progress, limitations persist: CT-guided methods face complications like pneumothorax (20%) and operator dependency, while bronchoscopic techniques exhibit lower diagnostic yields (18-60% vs. 70-90% for percutaneous biopsy). Innovations such as four-hook anchor devices and hybrid robotic systems demonstrated promise in improving localization accuracy and patient outcomes in reducing learning curves and improving precision. Future directions emphasize integrating artificial intelligence with multi-modal platforms to optimize accuracy and accessibility. This synthesis underscores the imperative for tailored strategies in nodule management, balancing efficacy, safety, and technological feasibility.