Histologic diagnosis of suspicious small subpleural lung lesions is difficult and often impossible using existing image-guided needle biopsy techniques including video-assisted thoracoscopic wedge resection. Preoperative lung lesion localization provides a more obvious target to facilitate intraoperative resection. This study reviewed the indications, results and complications of CT-guided hook wire localization for subpleural lung lesions in video-assisted thoracoscopic surgery (VATS). Methods: Between February 2001 and January 2007, 41 patients (20 males, 21 females; mean age, 52.5 ± 5.1 years) with 43 subpleural pulmonary lesions underwent preoperative CT-guided double-thorn hook wire localization prior to video-assisted thoracoscopic wedge resection. Nodule diameters ranged from 2 mm to 26 mm (mean, 9.7 ± 1.6 mm). The distance of the lung lesions from the nearest pleural surfaces ranged from 2 mm to 30 mm (mean, 9.6 ± 2.0 mm). Patients then received VATS within 5 hours. The efficacy of preoperative localization was evaluated in terms of procedure time, VATS success rate and associated complications of localization. Results: Forty-three wedge resections of the lungs containing 43 subpleural lung lesions as guided or assisted by the inserted hook wires were successfully performed in 41 VATS procedures (41 of 43 procedures, 95.3%). The mean procedure time for preoperative CT-guided hook wire localization was 30.4 ± 2.8 minutes. Eight patients had asymptomatic minimal pneumothoraces (18.6%); six patients had minimal needle tract parenchymal hemorrhages (13.9%) and one patient (2.3%) had an estimated 100 mL of hemothorax due to a small intercostal artery bleed that was cauterized during operation. The mean procedure time for VATS was 103 ± 9.7 minutes (range, 44–198 minutes). Pathologic examination revealed seven primary lung cancers, 11 metastases, one hemangioma, 19 definite non-neoplastic pathologies, two nonspecific chronic inflammation, and three metallic foreign bodies. Diagnostic yield was 95%. No major complications related to the preoperative hook wire localization and VATS were noted. Conclusion: CT-guided hook wire fixation is useful, helps in precise lesion localization in VATS wedge resection, and has a low rate of minor complications.