Small pulmonary nodules (SPN) are isolated, nodular lesions located in the lung parenchyma, ≤3 cm in diameter, without pulmonary atelectasis and lymph node enlargement, and without typical imaging features. With the increase of public health awareness and the development and application of imaging technologies such as multilayer spiral CT and PET-CT, the detection rate of small pulmonary nodules in clinical practice has increased year by year. Their causes are diverse, making early qualitative diagnosis difficult and diagnostic decisions difficult. With the increasing maturity of televised thoracoscopic surgery, it is playing an increasingly prominent role in the diagnosis and treatment of small pulmonary nodules. Nowadays, people are more concerned about their health, routine medical checkups are becoming popular, and the development of medical imaging has led to an increase in the number of clinical cases of isolated pulmonary nodules. The literature reports that malignant tumors account for 33%-60% of isolated small pulmonary nodules, and the early qualitative diagnosis of small pulmonary nodules is still a major clinical challenge. Chest X-ray and chest CT remain the routine tests for the diagnosis of isolated pulmonary nodules. A single nodule with blurred margins and lobar, burr, pleural depression, or hairy glass-like changes can be used as a basis for determining malignant lesions. In contrast, smooth margins with calcified foci and surrounding satellite foci tend to be benign lesions. However, the characterization of small pulmonary nodules based simply on imaging signs has a certain rate of misdiagnosis. It was found that there is a high rate of misdiagnosis based solely on imaging findings, indicating the limitations of imaging in the qualitative diagnosis of pulmonary nodules. Fiberoptic bronchoscopy and CT-located lung aspiration biopsy are important methods to obtain a preoperative pathological diagnosis. Fibrobronchoscopy can biopsy endobronchial tumors under the microscope for central type lung cancer, and the diagnostic rate is higher. All four patients with central type in our group were clearly diagnosed by bronchoscopy before surgery. For peripheral pulmonary nodules, it is difficult to reach the lesion site by fibronectomy, so it is not used as a routine diagnostic test. percutaneous pulmonary puncture biopsy under CT is a common test method for peripheral pulmonary nodules, but it is difficult to operate, and it is more difficult to obtain a definite diagnosis by preoperative pathology, and as an invasive test, it may induce pneumothorax, hemothorax, hemoptysis, etc., and has the risk of causing malignant tumor implantation and metastasis. Clinically, for patients with small pulmonary nodules that are difficult to diagnose clearly, the traditional diagnosis and treatment method in thoracic surgery is dissection and exploration, but because of its large trauma and the positive rate of malignancy of such lesions is not high, the clinical application is mostly negative. Generally, diagnostic anti-infection, diagnostic anti-tuberculosis or follow-up observation are chosen. This undoubtedly increases the risk of delayed diagnosis and treatment of some malignant lesions, and even leads to tumor metastasis and loss of the best time for surgical treatment. Television thoracoscopic technique (VATS) has many advantages such as small trauma, fast recovery and meeting the requirements of medical aesthetics, which overcomes many shortcomings of traditional diagnosis and treatment methods and is easily accepted by patients. After complete excision of the lesion during surgery, it is sent for intraoperative rapid frozen pathology examination. For benign lesions, the diagnosis and treatment can be completed at one time; for malignant lesions, radical surgery is performed to achieve early diagnosis and early treatment. The key to the application of TV thoracoscopy in the diagnosis and treatment of small pulmonary nodules is the intraoperative localization of small nodules. Especially for small “hairy glass-like” lesions (fGGO) and small nodules deeper than the lung surface, effective localization is the key to achieve the expected treatment results. High resolution multi-layer spiral CT, 3D reconstruction and high level of film reading are the basis for preoperative localization of lesions. Intraoperatively, double-lumen tube tracheal intubation was used to control the expansion and atrophy of the affected lung, and the pleural surface of the nodule was visible under thoracoscopy as pleural bulge or pleural crinkle depression, and the lung surface was touched by oval clamp, and the local lung tissue of the nodule was hard in texture, which was generally not difficult to locate. Intraoperative application of suture marking method to locate small pulmonary nodules has been reported with good results. In cases of difficult localization, the affected lung can be controlled for low-pressure ventilation, and the operating hole can be probed for localization by finger touch. Before thoracoscopic surgery, CT-guided Hookwire can precisely locate small pulmonary lesions, and localize them by inserting a special probe into the lesion and placing hooked wire (Hookwire), metal spring ring or local injection of methylene blue to improve the efficiency of intraoperative search for small pulmonary nodules. In our group, Hookwire localization has been successfully performed preoperatively in cases of “ground glass lesions” with satisfactory results, and we will further investigate this aspect. For deeper pulmonary nodules that cannot be localized by the above methods and are close to the great vessels in the hilum, or for those who fail to localize intraoperatively and whose lesions are highly suspicious of malignant nature, direct lobectomy may be considered. Clinical attention should be paid to the standardized diagnosis and treatment of small pulmonary nodules, which requires comprehensive judgment and decision-making by clinicians in conjunction with patient history and imaging performance. If necessary, multidisciplinary collaboration is needed to develop a more reasonable, optimal and personalized treatment plan. As an important part of the diagnosis and treatment of small pulmonary nodules, TV thoracoscopy technology has a good prospect of application because of its unique advantages.