Patients who were scheduled to undergo VATS wedge resection of a non-solid, partly solid, or solid pulmonary nodule with a maximum nodule diameter of less than 20 mm and without radiological changes in the visceral pleura on CT located in the peripheral lung (outer 1/3 side of the lung) were included in this study. The study period was from January 2013 to December 2014 for CT-guided percutaneous marking, January 2015 to December 2016 for navigation bronchoscopic marking, and January 2017 to December 2018 for CBCT and augmented fluoroscopy-guided bronchoscopic marking in the hybrid OR. The study design for all periods is illustrated in Figure 1.

The flow of video-assisted thoracic surgery (VATS) marking procedures in each group. In group A, CT-guided percutaneous VATS markings are performed on the morning of surgery. The patients are moved from the CT room to the operating room (OR) for VATS. In group B, bronchoscopic VATS markings are performed in the endoscopy room on the day prior to surgery using X-ray fluoroscopy and virtual bronchoscopic navigation. After the procedure, the patient is moved to the CT room, and a CT scan is performed to confirm the VATS marker placement. In group C, patients are given general anesthesia in the hybrid OR; all subsequent procedures, including cone-beam computed tomography (CBCT) (registration of the target lesion), bronchoscopic VATS markings with imaging guidance by augmented X-ray fluoroscopy, and another CBCT to confirm the successful VATS marking, are performed simultaneously.

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