Background <p>Concerning elderly individuals diagnosed with stage IA non-small cell lung cancer (NSCLC), the best surgical strategy is still up for discussion. This research analyzed the outcomes of wedge resection (WR) and segmentectomy in individuals aged ≥ 75&#xa0;years with stage IA NSCLC.</p> Methods <p>This randomized open-label study involved 50 cases aged 75 years or more with stage IA NSCLC who underwent either WR or segmentectomy. The primary outcome was overall survival (OS). Secondary outcomes included lymph node (LN) examination, nodal upstaging, surgical margin positivity, recurrence, readmission, mortality rates, and hospital stay.</p> Results <p>Segmentectomy was associated with higher rates of nodal upstaging (28% vs. 4%, <i>p</i> = 0.048) and more extensive LN examination (84% vs. 48%, <i>p</i> = 0.015) compared to WR. No substantial variations were observed in surgical margin positivity, cancer recurrence, hospital stay, 30-day readmission, or OS at 2&#xa0;years. There was no 30-day or 90-day mortality in either Group.</p> Conclusions <p>WR and segmentectomy are feasible options for older patients with stage IA NSCLC, offering similar short-term survival. While segmentectomy may offer more extensive LN evaluation and lower recurrence, these differences do not significantly impact survival. WR's simplicity and lower nodal upstaging make it a suitable option for selecting cases with early-stage lung cancer.</p> Graphical Abstract <p></p>