To investigate the safety and accuracy of robotassisted CTguided hookwire localization before videoassisted thoracoscopic surgery (VATS) for pulmonary groundglass nodules (GGNs), and to construct a decision tree algorithm (DTA) prediction model.

A total of 378 patients with GGNs who underwent robotassisted CTguided hookwire localization followed by VATS in our hospital from January 2022 to April 2025 were enrolled. Among them, 345 cases with successful localization were assigned as the control group, and 33 cases with unsuccessful localization as the observation group. The clinical data, localization accuracy, and puncturerelated complications were compared between the two groups. A DTA prediction model was constructed, and its predictive performance was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and 5fold crossvalidation.

Localization failed in 33 cases (8.73%), including 9 cases of hookwire dislodgement from lung tissue with ectopic placement into the pleural cavity and 24 cases of hookwire displacement. Localizationrelated complications included pneumothorax in 27 cases (7.14%), selflimiting pulmonary hemorrhage in 46 cases (12.17%), and mild pleural reactions in 2 cases. No critical complications such as hemothorax or air embolism occurred. The incidence of pulmonary hemorrhage in the observation group was significantly higher than that in the control group [10 cases (30.30%) vs. 36 cases (10.43%), P=0.001]. Univariate analysis showed that nodule size, distance from nodule to pleura, total depth, smoking history, and lesion location were associated with poor localization (P<0.05). In the DTA model, the feature weights were: distance from nodule to pleura 0.454, total depth 0.245, nodule size 0.217, smoking history 0.076, and lesion location 0.007. The ROC analysis yielded an area under the curve (AUC) of 0.909 (95%CI: 0.716~0.996) for the training set and 0.950 (95%CI: 0.901~1.000) for the validation set. After 5fold crossvalidation, the model accuracy was 83.2%. The calibration curve showed good consistency between the predicted probability and the actual incidence. During postoperative followup, tumor recurrence/metastasis occurred in 45 cases, and 19 patients died.

Robotassisted CTguided hookwire localization is safe and reliable for preoperative localization of GGNs. Distance from nodule to pleura, nodule size, total depth, smoking history, and lesion location are influencing factors for localization failure. The DTA model can effectively predict the risk of preoperative localization failure.