Background <p>Accurate lymph node (LN) dissection is crucial in the surgical management of lung cancer. However, studies addressing the challenges of anatomically precise LN dissection are limited. This study aimed to evaluate the utility and safety of mixed reality (MR) holograms as an intraoperative support tool for hilar and mediastinal lymph node dissection (HMLND).</p> Methods <p>Polygonal (stereolithographic) files of the thoracic cavity were created from SYNAPSE VINCENT images and uploaded into Holoeyes MD virtual reality software. The three-dimensional (3D) holograms generated from these images were displayed on head-mounted displays (HoloLens2) worn by the surgeons and their assistants during HMLND. Intraoperative hologram support (IHS) safety was assessed in 10 patients who underwent HMLND with anatomical lung resection. Additionally, the utility of the intraoperative hologram was evaluated through a questionnaire completed by four thoracic surgeons experienced in hologram manipulation.</p> Results <p>IHS was used for a median duration of 5&#xa0;min (interquartile range: 4–6). No 90-day postoperative complications were observed. Surgeons unanimously agreed that the holograms accurately represented the vascular and bronchial structures of the hilar and mediastinal regions. Additionally, none of the surgeons disagreed that the holograms provided greater benefit intraoperatively compared to preoperatively. In particular, IHS was found effective for the dissection of non-adjacent interlobar LNs post-segmentectomy and LN #4L.</p> Conclusions <p>IHS improved the surgical understanding of thoracic anatomy during HMLND, potentially leading to more precise and reliable LN dissection.</p>