Does fixation of the right middle lobe/lingula during right upper lobectomy/left apical trisegmentectomy reduce rates of postoperative torsion/atelectasis?

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