There are several considerations when performing this combined procedure. First, use of DynaCT to perform hookwire localization of lung nodules requires additional training and familiarization with the Artis Zeego system by the surgeon, radiographer, and radiologist. Training using a mannequin with the DynaCT program for the hookwire placement prior to performing the procedure on the patient can greatly improve accuracy and safety. Prior training can also improve efficiency, thereby significantly reduce the dose of radiation administered to the patient. Second, the current generation of hybrid operating room tables is not designed for thoracic surgery and does not have a hinge joint for bridging. Therefore, bridging needs to be substituted by placing a rolled up pillow under the patient’s mid thorax region to open up the intercostal spaces.4 However, unbridging of the patient during the thoracic procedure may be difficult. An additional problem we noticed is that the operating table stands quite high, with limited lowering capability. Third, to optimize the DynaCT images and avoid collision from the rotating Artis Zeego arm, the anesthetic machine needs to be further away from the patient than usual, possibly requiring extension tubing. Also, any metal object surrounding the patient should be avoided, such as towel clips, which are substituted by adhesive disposable drapes. Furthermore, drip stands and metal bed bars can be substituted by radiolucent bars available from Siemens.