Preoperative and intraoperative localization of small pulmonary nodules for thoracoscopic surgery: a contemporary narrative review.

For thoracoscopic resection to be successful, accurate preoperative and intraoperative localization is necessary due to the growing detection of small, non-palpable lung nodules using low-dose CT scanning. Accurate localization is required rather than optional in robot-assisted thoracic surgery (RATS) since the total lack of tactile feedback makes it extremely difficult to identify deep, tiny, and subsolid nodules. With a focus on RATS-specific criteria, this study offers a modern, clinically focused framework for technique selection. This is a narrative review of the current literature. A structured literature search was conducted in PubMed, Embase, and Web of Science from January 2015 to May 2026, and 116 relevant articles were included for qualitative synthesis. We summarized the principles, clinical efficacy, complications, and RATS‑specific adaptability of CT-guided percutaneous, bronchoscopy-assisted, and intraoperative localization techniques. No quantitative meta-analysis or bias risk assessment was performed in this study. Nodule traits, patient considerations, and institutional resources should all be taken into consideration when choosing a technique. Although percutaneous techniques have a high success rate (88-100%), there is a risk of bleeding and pneumothorax (up to 40%). First-line options for RATS are indocyanine green (ICG) fluorescence marking and microcoil localization. ICG uses robotic near-infrared channels to achieve 100% intraoperative identification and R0 resection rates, while microcoils allow sublobar resection in 90.6% of patients with 100% R0 resection. Transbronchial approaches (virtual bronchoscopic navigation [VBN], electromagnetic navigation bronchoscopy [ENB]) eliminate external marker interference and greatly lower the incidence of pneumothorax (88% reduction, 3.3% vs. 28.3% for CT-guided transthoracic aspiration, P < 0.001). Electromagnetic interference is completely avoided in next-generation shape-sensing robotic bronchoscopy. Single-stage hybrid operating room methods are favored by workflow integration. Resource-stratified approaches are suggested: low-resource settings may employ VBN/VAL-MAP or percutaneous methylene blue; mid-resource centers benefit from ENB/VBN with ICG; high-resource centers may use single-stage cone-beam CT or robotic bronchoscopy. The best RATS-compatible selection is guided by the "three-zero" approach (zero external indicators, zero transport danger, and zero electromagnetic interference). Nodule traits, patient considerations, and institutional resources must all be considered when choosing a localization technique. Precise localization is required in RATS in order to maintain negative margins, lower conversion rates, and make up for tactile deficiencies. The best balance is frequently achieved using multimodal techniques. Further increases in pulmonary nodule localization accuracy, safety, and workflow efficiency are anticipated due to ongoing advancements in robotic bronchoscopy, hybrid operating rooms, and artificial intelligence.