Does Fixation of Middle Lobe/Lingula During Right Upper Lobectomy/Left Apical Trisegmentectomy Reduce Postoperative...

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

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 after surgery and atelectasis on ∼6-month postoperative computed tomography.

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 = .20-.93). Thoracotomy approach was more common in the pexy group (64 [44.8%] vs 65 [18.4%], P < .001), whereas chronic obstructive pulmonary disease (69 [19.5%] vs 10 [7.0%], P < .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 = .94). These findings were unchanged in subgroups of patients without chronic obstructive pulmonary disease and with only right upper lobectomy patients. In a multivariate logistic regression model, undergoing fixation was not a significant predictor of atelectasis on 6-month postoperative computed tomography (odds ratio, 0.94; 95% CI, 0.48-1.86; P = .87).

Routine fixation/pexy of the right middle lobe/lingula during right upper lobectomy/left apical trisegmentectomy does not reduce rates of postoperative torsion or atelectasis. Although ensuring no malrotation of remaining lobes during lung reexpansion is likely important, the routine practice of pexy, which has downsides, should be abandoned.