Associated with an increase of small-sized lung cancer or metachronous second primary lung cancer, we have more opportunities to perform sublobar resection. Difficulties of identifying tumor location and appropriate surgical margin for small-sized ground-glass opacity （GGO） dominant lesions in thoracoscopic surgery is the big issue of sublobar resection. Virtual-assisted lung mapping （VAL-MAP） that makes markings on the lung surface through some peripheral bronchi by bronchoscopically projects intrapulmonary anatomy on the lung surface and literally draw a map. We report a case of thoracoscopic left upper division segmentectomy for multiple ground-glass nodules （GGNs） using preoperative VAL-MAP. A 65-year-old women who had undergone right upper lobectomy for primary lung cancer, and had multiple GGNs in the bilateral lungs was followed up as an outpatient. Eleven years after initial pulmonary resection, 2 lesions in the left upper division became bigger, and we decided to perform surgery for 4 GGNs in the left upper division including these 2 lesions. We preoperatively made bronchoscopic dye markings through B1＋2c, B3a and B4a for in the left upper lobe. The 3 markings were intraoperatively identified. We decided the resection line based on the markings and performed thoracoscopic left upper division segmentectomy. The pathological diagnosis was minimally invasive adenocarcinoma, adenocarcinoma in situ and pneumonitis. Surgical margins were negative. VAL-MAP will assume an important role as an intraoperative navigation system for sublobar resection.

For general thoracic surgeons, perioperative management for prevention of cardiac complications is important because patients undergoing general thoracic surgery often have risk factors for cardiac disease. Sever cardiac failure should be detected and treated prior to surgery, and coronary artery may be examined in patients with risk factors for ischemic heart disease. Pulmonary resection sometimes causes right-sided heart failure due to reducing pulmonary vascular bed. In high-risk patients for rightsided heart failure, pulmonary artery pressure monitoring by right heart catheterization should be considered in addition to blood pressure and central venous pressure monitoring, and precise fluid management is required. Because perioperatively occurred myocardial infarction is sometimes lethal, patients with preoperatively identified significant coronary artery stenosis, percutaneous coronary intervention or coronary artery bypass grafting should be considered although surgeons need to be careful for the timing of surgery and anticoagulant therapy. Even if patients have no typical symptoms, perioperative myocardial infarction can be diagnosed 12-lead electrocardiogram and serum biomarkers. Cooperation with cardiologists is necessary for the treatment of perioperative myocardial infarction. Although arrhythmia is one of the major complications after general thoracic surgery, arrhythmia with hemodynamic instability should be immediately treated. Early diagnosis and management of cardiovascular events can minimize the consequences of these complications.