Purpose: Lung cancer is the leading cause of cancer-related mortality worldwide and in Australasia, prompting the introduction of lung cancer screening programs in Australia and New Zealand. As screening identifies increasing numbers of pulmonary nodules, surgical pathways must ensure timely and effective intervention. This study evaluated the impact of pre-operative biopsy on time to surgery and rates of benign lung resection in patients with high clinical suspicion of malignancy. Methodology: A retrospective review was conducted of all patients undergoing lung resection between January 2023 and December 2024 at a tertiary referral centre responsible for approximately one third of New Zealand’s thoracic surgical workload. Cases were identified from hospital databases, with clinical data obtained from electronic medical records. Patients were grouped according to pre-operative biopsy versus direct resection based on high clinical suspicion confirmed at multidisciplinary meeting (MDM). Statistical analysis was performed using IBM SPSS version 31. Results: A total of 440 patients were included. Mean age was 66 years (SD 12), with 177 patients (40%) female. Mean Eastern Cooperative Oncology Group (ECOG) performance status was 0 (SD 1). Lobectomy was performed in 307 patients (70%). Pre-operative biopsy was undertaken in 130 patients (30%), while 295 patients (70%) proceeded directly to resection. Median time to surgery was longer in the biopsy group (42 days [IQR 30–55]) compared with the non-biopsy group (32 days [IQR 21–55]). Final histopathology demonstrated primary lung cancer in 378 patients (86%), metastatic disease in 22 patients (5%), and benign pathology in 59 patients (13%). Conclusion: Most patients undergoing lung resection based on high clinical suspicion had malignant pathology despite low biopsy utilisation. The benign resection rate of 13% aligns with international benchmarks. Pre-operative biopsy was associated with delayed time to surgery, supporting the importance of patient selection for pre-operative biopsy.