We would like to express our opinion on the article by\ud Ciriaco and associates ; first of all we congratulate them\ud for the results obtained in their study.\ud We know that for small and deep pulmonary nodules the\ud localization techniques are necessary, and in 1999 Susuki\ud et al.  established dimensions and depth of the nodules for\ud which it is necessary for a localization’s technique. We\ud think that preoperative localization techniques have some negative aspects. First of all, the use of needle wire can\ud provoke pneumothorax, haemorrhages into the lung, parenchimal\ud damage or peri-nodule inflammation in a high\ud number of patients [1,3]. We are sure that in the major\ud number of cases these complications are non-symptomatic,\ud but they can influence negatively the state of health of a\ud patient and surgical approach, for example the peri-nodule\ud inflammation can influence resection’s margins. Second,\ud based on the international literature, the needle wire and the\ud other preoperative techniques (vital dye and radio-guided)\ud do not have a high percentage of localization, and there is no\ud statistical difference in time between thoracoscopy more\ud hook wire placement and thoracotomy . Therefore, we\ud never perform a pre-operative localization technique, like\ud needle wire, and we prefer intra-thoracoscopic ultrasound\ud . For us, ultrasound is the most effective method to\ud localize pulmonary nodules without side effects. Intrathoracoscopic\ud ultrasound is useful and has a great\ud percentage of 100% of localization in our record of cases\ud (13 cases) and also in other record of cases . With intrathoracoscopic\ud ultrasound we can study the structures\ud surrounding the nodule, like vessels, bronchi and lymphnodes\ud and the intra-thoracoscopic ultrasound help to choose\ud resection’s margins. Finally, the intra-thoracoscopic ultrasound\ud can give a histological finding of nodule, thanks to the\ud different ultrasound pattern of the pulmonary nodules .\ud The incomplete pulmonary exclusion and the presence of a\ud less quantity of air in pulmonary parenchyma help to\ud localize the nodules, because the nodules have hypoechoic\ud ultrasound pattern, however, the surrounding pulmonary\ud parenchyma is hyperechoic . The presence of a small\ud amount of air in pulmonary parenchyma is useful to localize\ud the pulmonary nodules. In experienced hands the localization\ud with intra-thoracoscopcic ultrasound is quick (12 min\ud in our record of case) and less risk, without side effects\ud related to this technique. The second positive aspect of\ud ultrasound is the possibility to make an intra-operative scan\ud of the lung, to find other nodules are not shown by\ud thorax CT. Visualizing pulmonary lesions at ultrasound\ud does not require complete collapse of the lung. Moreover,\ud the ultrasound is applicable in patients with more than one\ud nodule, while is difficult to position two or three needles.\ud Finally, we would like to know what the authors of this work\ud  think about suture system and hook wire
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