Purpose: To assess the feasibility of computed tomography (CT)-guided localization using a specific long dual-barbed hookwire in resection of pulmonary nodules with the size of 20mm or less by video-assisted thoracoscopic surgery (VATS) and to discuss the necessity of early treatment of small pulmonary nodules by VATS. Results: All the nodules were successfully localized with hook wire under CT guidance. The 34 nodules had a mean diameter of 8.9 +/- 3.8 mm and a mean distance from the most superficial edge of the nodules to the visceral pleura of 21.4 +/- 12.4 mm. The mean length of time for CT-guided percutaneous localization was 9.0 +/- 3.8 minutes. Asymptomatic pneumothorax and parenchyma hemorrhage were observed in 1 patient (3.2%) and 5 patients (16.1%), respectively. VATS successfully resected all the lesions after localization. The mean VATS operation time was 2.6 +/- 1.2 hours (range, 0.8-5.2 hours). 24 (70.6%) malignant nodules and 10 benign nodules were discovered after surgery. Materials and Methods: Between March 2012 and August 2014, 31 patients with 34 small pulmonary lesions underwent CT-guided hook wire localization and VATS resection. The efficacy of preoperative localization was evaluated in terms of procedure time, VATS success rate and associated complications of localization. And the pathology and imaging diagnosis of all nodules were recorded. Conclusions: The CT-guided Hook-wire localization for pulmonary nodules with the size of 20 mm or less is an effective and safe technique to assist VATS. Once small pulmonary nodules change in size or number, it is necessary to treat in an early and aggressive way with minimally invasive surgery.