Background <p>Right middle lobe (RML) torsion is the most common form of lobar torsion. It usually happens after right upper lobe (RUL) lobectomy, especially when pneumopexy is not performed. Although various surgical techniques have been introduced to prevent RML torsion, the efficacy of these techniques is not yet fully understood. We herein report a case of RML torsion that happened after RUL lobectomy despite pneumopexy together with a literature review.</p> Case presentation <p>A 62-year-old female patient underwent RUL lobectomy due to adenocarcinoma of the lung. Prophylactic pneumopexy with a single stitch was performed to fix RML to the right lower lobe. RML was well inflated and did not rotate before wound closure was performed. However, the patient complained of foreign body sensation inside her chest on postoperative day 5, and a chest X-ray revealed atelectasis of RML. Bronchoscopy showed a collapsed middle lobe bronchus. Exploratory thoracotomy showed congested RML with a twisting bronchovascular pedicle, and therefore, RML lobectomy was performed.</p> Conclusions <p>RML torsion is a rare but potentially fatal condition requiring high clinical alertness. Through our literature review and the presented case, we demonstrate that RML torsion may occur despite pneumopexy. A combination of surgical methods, such as the use of continuous sutures or fibrin glue, may be more effective in preventing torsion.</p>