The authors determine the success rate, safety, and potential complications of computed tomography-guided preoperative hookwire localization of small peripheral pulmonary nodules. One hundred one consecutive wire localizations with addition of methylene blue injection were performed in 94 patients immediately before thoracoscopic resection of small lung lesions. Sixty-two patients had a known primary malignancy, whereas 32 had an asymptomatic nodule. Eighty-eight patients underwent single lesion localization, five underwent double localization, and one underwent triple wire placement. Five patients had previously undergone percutaneous biopsy that was nondiagnostic. The nodule was within the first wedge biopsy of lung tissue in 95 of 97 specimens (98%). A second wedge and an open lobectomy were required in one patient each. Three additional biopsies were intraoperatively deferred after the histologic diagnosis was established after removal of another nodule. The procedure was terminated before wire placement in one patient who was unable to successfully hold his breath. The wire dislodged with the tip in the pleural space rather than in the lung parenchyma in 22 cases; however, methylene blue tattoo allowed localization in 13 of these (59%). In the other nine cases, extra portals, digital palpation, or expanded wedge resection was required. Complications included pneumothorax in 48 cases, moderate pleuritic pain in five cases, seven small intercostal hematomas, and a 7-mm wire fragment retained in one patient's lung along the suture line. No patient required a preoperative drain for treatment of pneumothorax. Wire dislodgement occurred in 6 of 52 (12%) cases without an initial pneumothorax and in 16 of 48 (33%) cases if a pneumothorax occurred. Wires dislodged less frequently if placed either directly into or through the nodule in 11 of 64 (17%) cases than if placed adjacent to the nodule in 11 of 36 (31%) cases. Average wire tip depth from the visceral pleura was significantly less when the wire dislodged (11 mm) than when the wire remained in place (25 mm). Wire localization of small peripheral pulmonary nodules is a safe and effective procedure to assist thoracoscopic sublobectomy resection.