Abstract Background Right middle lobe (RML) torsion is a rare but life-threatening postoperative complication that may occur following pulmonary resection. Among lobar torsions, the RML is most commonly affected—likely due to its anatomic position, small size, and increased mobility after right upper lobectomy (RUL). This mobility predisposes the lobe to rotation around its bronchovascular pedicle, leading to bronchovascular compromise. This case describes RML torsion following RUL lobectomy and underscores the importance of early identification and multidisciplinary management in optimizing outcomes. Case Presentation A 67-year-old man with a history of hypertension, gastroesophageal reflux disease, and tobacco use disorder underwent an elective right upper lobectomy following biopsy confirmation of stage I RUL adenocarcinoma. His immediate postoperative course was uncomplicated, and he was discharged home on postoperative day one. Five days later, he re-presented with progressive weakness, dyspnea, tachycardia and tachypnea. CT of the chest revealed complete collapse of the right middle lobe concerning for RML syndrome. Urgent bronchoscopy demonstrated patent primary and segmental bronchi but collapse of the medial and lateral subsegments of the RML without obvious endobronchial obstruction. These findings presented high concern for lobar torsion. Thoracic surgery was consulted and performed robotic assisted thoracoscopy, which confirmed RML torsion with associated necrosis. The RML was detorsed, however did not reperfuse and the decision was made to proceed with right middle lobectomy. A chest tube was placed and the patient was then admitted for a four-day stay with close monitoring. He was discharged home in stable condition following an unremarkable readmission course with plans for close follow up with both surgery and interventional pulmonology teams. Discussion Right middle lobe (RML) torsion is an uncommon but recognized complication following right upper lobectomy, characterized by rotation of the bronchovascular pedicle leading to vascular occlusion and airway obstruction. Clinical presentation is often nonspecific, making diagnosis dependent on a high index of suspicion supported by imaging and direct visualization with bronchoscopy. Collaboration between interventional pulmonology and thoracic surgery teams is critical for timely identification and management. Serious complications of RML torsion include infarction, necrosis, hemorrhage, and hemodynamic instability leading to shock. Prompt recognition and intervention are vital, as delayed diagnosis carries significant morbidity and mortality. Minimally invasive modalities such as bronchoscopy and robotic-assisted thoracoscopy play key roles in both diagnosis and definitive treatment. This abstract is funded by: None
Scott et al. (Fri,) studied this question.