BACKGROUND: Video-assisted thoracic surgery (VATS) resection of pulmonary metastases has long been questioned because radiologically undetected parenchymal lesions may be missed when bimanual palpation is restricted to the portholes. Technology, however, has improved and advanced VATS resections are now performed routinely worldwide. This prompted us to conduct a prospective observer-blinded study on pulmonary metastasectomy. METHODS: Eligible patients with oligometastatic pulmonary disease on computed tomography (CT) underwent high-definition VATS, with digital palpation by 1 surgical team and subsequent immediate thoracotomy during the same anesthesia by a different surgical team, with bimanual palpation and resection of all palpable nodules. Preoperative CT evaluations and surgical results were blinded. Primary endpoints were number and histopathology of detected nodules. RESULTS: During a 3-year period 89 consecutive patients, with newly developed nodules suspicious of lung metastases from previous cancers in colon-rectum (n=59), kidney (n=15), and other malignancies (n=15) were included, with a total of 140 suspicious nodules visible on CT. During VATS, 122 nodules were palpable (87%). All nodules were identified during thoracotomy, where 67 additional and unexpected nodules were also identified; 22 were metastases (33%), 43 (64%) were benign lesions, and 2 (3%) were primary lung cancers. CONCLUSIONS: In patients operated for nodules suspicious of lung metastases, a substantial number of additional nodules were detected during thoracotomy despite advancements in CT imaging and VATS technology. Many of these nodules were malignant and would have been missed if VATS was used exclusively. Consequently, we considered VATS inadequate if the intention is to resect all pulmonary metastases during surgery.