Abstract

Objective Frank torsion, or lesser atelectasis, of the right middle lobe/lingula may occur following right upper lobectomy/left apical trisegmentectomy. While some surgeons fix/pex the right middle lobe/lingula to the lower lobe, the necessity for this is unclear.

Methods We retrospectively reviewed patients who underwent right upper lobectomy/left apical trisegmentectomy at our institution (2008-2023). We compared patients who underwent fixation vs. those who did not. The primary outcomes were incidence of acute torsion within 6 months following surgery and atelectasis on ∼6-month postoperative CT.

Results Of the 497 patients, 438(88.1%) underwent right upper lobectomy and 143(28.8%) underwent fixation. Age, sex, race, comorbidities, and operative diagnosis were similar between the pexy and no-pexy groups (p=0.20-0.93). Thoracotomy approach was more common in the pexy group [64(44.8%) vs. 65(18.4%), p<0.001], whereas COPD [69(19.5%) vs. 10(7.0%), p<0.001) was more prevalent in the no-pexy group. On the primary outcomes, there was no difference between the groups in frank torsion [0(0%) vs. 0(0%)] or any atelectasis [23(22.5%) vs. 64(22.9%), p=0.94]. These findings were unchanged in subgroups of patients without COPD and with only right upper lobectomy patients. In the multivariate logistic regression model, undergoing fixation was not a significant predictor of atelectasis on 6-month postoperative CT (OR:0.94, 95% CI:0.48–1.86;p=0.87).

Conclusions Fixation/pexy of the right middle lobe/lingula during right upper lobectomy/left apical trisegmentectomy does not substantially reduce rates of postoperative torsion or atelectasis. While assuring no malrotation of remaining lobes during lung re-expansion is likely important, the practice of pexy, which has downsides, should be largely abandoned.

Central picture legend No significant difference in frank torsion or atelectasis of middle lobe/lingula with pexy

Central Message Routine prophylactic fixation of the right middle lobe/lingula to the lower lobe does not substantially reduce rates of postoperative torsion or atelectasis and may be abandoned as a routine practice.

Perspective statement This large retrospective study evaluated the impact of prophylactic fixation (pexy) of the right middle lobe or lingula during “upper lobectomy.” Findings show no reduction in torsion, atelectasis, or early postoperative complications in the fixation group. Given the lack of benefit and potential risks, routine fixation should be reconsidered.

Legend Graphical abstract summarizing this retrospective study evaluating the impact of prophylactic lobar fixation (pexy) during upper “lobectomy.”

Competing Interest Statement

Joseph Shrager, consulting with Becton Dickinson and Lungpacer Inc.; Leah M. Backhus, advisory panel member with Johnson and Johnson, AstraZeneca, Genentech/Roche, and Bristol Myers Squibb; Natalie S. Lui, consulting with Intuitive Surgical Inc. and Centese, grants from Intuitive Foundation; None of the other authors have anything to declare.

Funding Statement

This study did not receive any funding

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Institutional Review Board of Stanford University School of Medicine gave ethical approval for this work (IRB-70048). The requirement for informed consent was waived due to the retrospective nature of the study involving only chart review.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Footnotes

Disclosure statement: Joseph Shrager, consulting with Becton Dickinson and Lungpacer Inc.; Leah M. Backhus, advisory panel member with Johnson and Johnson, AstraZeneca, Genentech/Roche, and Bristol Myers Squibb; Natalie S. Lui, consulting with Intuitive Surgical Inc. and Centese, grants from Intuitive Foundation; None of the other authors have anything to declare.

Funding statement: None.

This work was presented orally from podium at the Western Thoracic Surgical Association Annual Meeting, Dana Point, California, June 25-28th 2025.

IRB: Approved by the Stanford University School of Medicine IRB (IRB-70048).

Data Availability

All data produced in the present study are available upon reasonable request to the authors.

Glossary of AbbreviationsARDSAcute respiratory distress syndromeCOPDChronic obstructive pulmonary diseaseCTComputed tomographyCVACerebrovascular accidentCXRChest X-rayFEV1Forced expiratory volume in 1 secondLATSLeft apical trisegmentectomyNSCLCnon-small cell lung cancerRMLRight middle lobectomyRMLSRight middle lobe syndromeRLRight lungRLLRight lower lobeRULRight upper lobectomyVATSVideo-assisted thoracoscopic surgery