Advances in vagus nerve management strategies in thoracoscopic lung resections: a narrative review

Introduction

Background

Thoracoscopic surgery is now widely applied in treating lung diseases due to its minimally invasive nature. Proper management of the vagus nerve (VN) during these procedures is crucial for optimal postoperative recovery, as VN injuries can lead to complications that severely impact the patient’s quality of life.

Rationale and knowledge gap

Although various strategies for VN protection have been explored, effective VN management during thoracoscopic surgery remains a significant challenge. Current evidence lacks consensus on the best approach to balance nerve preservation and surgical outcomes.

Objective

This review discusses VN management strategies in thoracoscopic pulmonary resection, aiming to improve clinical practice and enhance postoperative recovery quality. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2211/rc).

Methods

A systematic literature search was conducted using PubMed, China National Knowledge Infrastructure (CNKI), and Google Scholar databases to identify relevant studies published between January 2010 and March 2025. The search strategy combined Medical Subject Headings (MeSH) and free-text terms, including “vagus nerve”, “thoracoscopic lung resections”, “intraoperative monitoring”, and “postoperative complications”. Boolean operators (AND/OR) were used to refine the search, ensuring comprehensive coverage. An example of the search strategy for PubMed is provided in Appendix 1.

The inclusion criteria were: (I) original full-text studies in English or Chinese; (II) studies that described or evaluated the impact of VN management on postoperative complications; (III) studies involving patients undergoing thoracoscopic lung resections. Exclusion criteria included expert opinions, animal experiments, case reports, conference abstracts, and publications that were not peer-reviewed. Duplicate records were removed after importing the search results into Endnote 20. The characteristics of the included studies are summarized in Table 1.

Anatomical and physiological basis of the VN

Anatomical overview of the VN

The VN is the tenth pair of cranial nerves, the longest in the human body, and is part of the parasympathetic nervous system. It originates from the medulla oblongata and is widely distributed along the cervical, thoracic, and abdominal cavities (1). The VN has a complex anatomy, giving off several branches: the pharyngeal branch, the superior laryngeal nerve, the supra- and infra-cardiac nerves in the cervical region; the recurrent laryngeal nerve (RLN), the pulmonary branch, the cardiac branch, and the branch in the thoracic cavity; and the anterior gastric, hepatic, posterior gastric, and abdominal branches after passing through the diaphragm into the abdominal cavity (2). These branches perform important physiological functions in their respective anatomical regions. The RLN, a key branch of the VN, takes a vulnerable anatomical course—especially the left RLN, which loops under the aortic arch. Surgical intervention for mediastinal or lung tumors involving nodal resection often places the RLNs at considerable risk (3). The anatomical features of the VN make it vulnerable to injury during thoracic and abdominal surgeries, thereby increasing the complexity and challenges of surgical operations (4-6).

Physiological functions of the VN

As a crucial component of the parasympathetic nervous system, the VN, with its extensive network of branches, plays a vital physiological role in various anatomical regions and is involved in several systems, including the respiratory, cardiovascular, digestive, and immune systems (7). Afferent fibres of the VN transmit sensory information from visceral organs to the central nervous system, such as gastrointestinal distension and changes in blood pressure. Meanwhile, efferent fibres convey central commands to various organs, primarily including the heart, lungs, and gastrointestinal tract (8). For example, the VN protects the heart by lowering the heart rate by releasing acetylcholine and regulating peristalsis and secretion in the gastrointestinal tract to facilitate digestion and nutrient absorption (9-11). Additionally, the VN is involved in respiratory regulation, modulation of the immune response, and inflammatory responses (12,13). The Hering-Breuer reflex is a vagally mediated pulmonary stretch reflex that helps regulate the depth and rhythm of breathing by inhibiting inspiration when the lungs are overinflated (14). Disruption of this reflex due to VN injury may contribute to postoperative respiratory instability. Under stress, the VN participates in the organism’s self-protection and recovery through a complex reflex arc (15). In summary, the VN is essential for maintaining internal environmental stability and coordinating the functioning of multiple organ systems. In addition to its role in regulating pulmonary and cardiovascular functions, the VN also contributes to the sensory innervation of the mediastinal pleura (5,16). Irritation or injury in this region may result in atypical chest discomfort, vagally mediated cough, or altered autonomic responses during thoracic surgery.

Types of VN injury and potential for recovery

VN injuries during thoracic surgery can result from a variety of mechanisms, including mechanical traction, compression, thermal damage (e.g., electrocautery or cold solutions), electrical conduction interference, and even vascular ischemia. Pathologically, these injuries are categorized as neurapraxia (a temporary conduction block without axonal disruption), axonotmesis (interruption of axonal continuity with preservation of the nerve sheath), and neurotmesis (complete transection of the nerve) (17).

Neurapraxia, the mildest form of injury, often resolves spontaneously within 8 to 12 weeks due to remyelination. Axonotmesis may lead to Wallerian degeneration, requiring several months for recovery depending on the extent of axonal damage. In contrast, neurotmesis represents the most severe and typically irreversible form of injury, unless surgical repair or nerve grafting is performed (18).

The RLNs, as critical branches of the VN, are particularly susceptible to injury because of their long and circuitous anatomical course—especially the left RLN, which loops beneath the aortic arch. Nodal dissection and pulmonary resections increase the risk of direct trauma, thermal spread, or excessive traction. Such injuries may lead to hoarseness, dysphagia, or aspiration due to vocal cord dysfunction (19,20).

Early recognition of VN or RLN injury is essential for minimizing long-term complications. In selected cases, intraoperative nerve repair—such as end-to-end anastomosis, nerve grafting, or reinnervation using the ansa cervicalis—has shown promise in restoring function (21,22). For unilateral vocal cord paralysis, medialization procedures like injection laryngoplasty may effectively improve voice quality and airway protection (23).

Thoracoscopic VN

Thoracoscopic anatomy of the VN

In thoracoscopic surgery, understanding the anatomy of the VN is crucial for surgical safety. After giving off the RLN in the thoracic cavity, the VN continues alongside the oesophagus, where it gives off pulmonary and cardiac branches to form the oesophagal plexus. These branches then rejoin at the oesophagal hiatus of the diaphragm before entering the abdominal cavity (5). The VN supplies the lungs through an extensive plexus situated behind the main bronchus. The vagal trunk is readily identifiable once the posterior mediastinal pleura is opened (24). Several branches emanate from the trunk to form the posterior pulmonary plexus. The right vagal trunk divides into large pulmonary branches that travel along the bronchial arteries and further differentiate into branches that innervate the lobes of the right lung. The left vagal branches are more intricate, with the left upper lobe receiving innervation from multiple branches that either cross the pulmonary artery or lie between the pulmonary artery and the left main bronchus, creating a complex innervation network. The left lower pulmonary branch travels along the lower edge of the left main bronchus and is more easily distinguished (2).

Importance of VN management in thoracoscopic lung resection

During thoracoscopic lung surgery, the VN and its branches are highly susceptible to mechanical and thermal injuries due to their specific anatomical location (25). Damage to the VN can result in a range of serious postoperative complications, including hoarseness, dysphagia, arrhythmia, and abdominal distension and discomfort (2,26). Notably, postoperative hoarseness or even loss of voice, caused by damage to the RLN, can significantly impact patients’ quality of life (27). Given the important physiological functions of the VN in various systems, effective management of the VN during thoracoscopic lung surgery is crucial for preserving these functions and improving postoperative quality of life. Advances in microscopic instruments, high-definition imaging techniques, and the precise anatomical mapping of the pulmonary VN branches by Weijs et al. have enabled more refined management of the VN (24).

Different strategies for VN management in thoracoscopic lung surgery

Fine retention or highly selective severance?

VN and chronic postoperative cough

Chronic postoperative cough is a common complication following video-assisted thoracoscopic surgery (VATS), with an incidence rate of 25–50%. In severe cases, patients may experience interrupted speech, sleep disruption, and even depression, which can significantly impact their quality of life (28-30). The sensory neurons of the VN are the primary source of nerve fibres innervating the lungs and airways and play a crucial role in regulating lung functions such as cough reflex, mucus secretion, and bronchial diameter (25). Transient receptor potential vanilloid 1 (TRPV1) expressed on the C fibres of the VN are sensitive to chemical stimuli (31). Intraoperative injury to the VN’s lung branches can promote the release of inflammatory factors such as bradykinin and PGE2 (32). These inflammatory factors then stimulate pulmonary mechanoreceptors, activating the TRPV1 pathway, which excites the cough centre, leading to bronchoconstriction and coughing (33).

Strategies for fine retention

The strategy of fine retention of the pulmonary branches of the VN has gained considerable attention in thoracoscopic surgery due to its crucial role in regulating lung function and inflammatory responses. Studies have demonstrated that intraoperative preservation of the pulmonary branches of the VN can effectively shorten the inflammatory response process in the cough pathway and is a potential strategy to reduce postoperative cough (2,25). Previous research has also shown that preserving the pulmonary vagal branches during endoscopic surgery for oesophagal cancer effectively reduces postoperative pulmonary complications (26,34). Huang et al. reviewed 80 patients who underwent radical surgery for lung cancer using VATS, indicating that preserving the pulmonary branches of the VN is feasible and may reduce postoperative pulmonary complications while improving recovery (2). Wang et al. observed a lower incidence of cough at 8 weeks postoperatively and higher quality of life scores [Leicester Cough Questionnaire in Mandarin-Chinese (LCQ-MC)] in the VN branch-preserved group among 125 patients who underwent single-port thoracoscopic stage I radical surgery for peripheral lung adenocarcinoma (35). Additionally, a study by Gu et al. confirmed the benefits of preserving the vagal nerve branches in VATS surgery, showing a reduction in the incidence of postoperative cough from 30.43% to 13.89% (P=0.02) compared to conventional surgical treatment, and significant improvements in postoperative LCQ-MC scores at 2 weeks (P=0.01) and 5 weeks (P=0.037) (31). Notably, Liu et al. found that preservation of the VN branch during thoracoscopic radical surgery for right lung cancer not only reduced the incidence of postoperative cough but also significantly decreased the risk of postoperative arrhythmia, potentially contributing to shorter hospital stays and more stable postoperative heart rates (25). Collectively, these findings underscore the significance of fine preservation of the pulmonary branches of the VN in improving postoperative patients’ quality of life and physiological function.

Highly selective severance strategy

In thoracoscopic lung resections, although the preservation of the vagal pulmonary branches is widely recognized as an effective strategy to reduce postoperative cough, Zhang et al. present a new perspective (36). In a randomized controlled trial with long-term follow-up, they found that employing a highly selective severance strategy for the vagal pulmonary branches significantly reduced the incidence of chronic cough at 3 months (19.0% vs. 41.4%, P=0.009) and 2 years (1.9% vs. 12.7%, P=0.032) postoperatively (36). Importantly, this severance strategy did not increase the incidence of postoperative complications or adversely affect lung function. The highly selective transaction strategy described by Zhang et al. involves severing the largest pulmonary branch of the VN that innervates the bronchial stump and the caudal VN travelling along the subglottic lymph nodes (36). This approach is based on the theory that the pulmonary branch of the VN serves as the primary afferent pathway for the cough reflex. In animal models, complete blockade of cough induced by mechanical laryngeal stimulation has been demonstrated through bilateral vagotomy (37). Additionally, the intrathoracic vagal blockade has proven effective in suppressing cough induced by surgical manipulation in patients undergoing lobectomy under non-intubated anaesthesia (38).

Retention versus severance strategy

Zhang et al.’s strategy of VN pulmonary branch severance contrasts with studies advocating a retention strategy (36). This discrepancy may arise from several factors, including the timing of postoperative cough assessment, variations in clinical staging, and the extent of intraoperative lymph node dissection and sampling. The retention strategy demands a high degree of anatomical knowledge and fine surgical technique, as the anatomy of the VN can vary significantly among patients. While reversible, this strategy poses challenges in maintaining intraoperative consistency and lacks long-term follow-up data to substantiate its impact on chronic postoperative cough. On the other hand, highly selective severance, while easier to standardize operationally, is irreversible and may affect other physiological functions of the VN if anatomical variations are misidentified. Additionally, this approach may be overly simplistic, as the cough reflex serves as a protective mechanism for the airway. Furthermore, studies focusing on retention strategies often lack long-term follow-up regarding chronic postoperative cough. Most current studies on both strategies are limited by single-centre settings and small sample sizes, which may introduce bias. The precise mechanism by which preservation versus severance of the pulmonary vagal branches affects the severity of postoperative cough remains unclear, and no specific recommendations for managing vagal branches are included in thoracic surgery guidelines. Therefore, future research should adopt a prospective, multicenter, randomized controlled approach to elucidate the underlying mechanisms of chronic postoperative cough after pulmonary resection. This includes tracking symptom progression and evaluating the effectiveness of different interventions. Such studies will support the development of more precise vagal management strategies to prevent postoperative cough and improve patients’ quality of life.

Intraoperative monitoring and protection of the RLN

RLN injury is a known risk during thoracoscopic lung resections, particularly on the left side where the RLN loops under the aortic arch and may be damaged during subaortic or para-aortic lymph node dissection (20). Such injuries can lead to hoarseness, dysphagia, and aspiration, with a reported incidence as high as 31% (3). These complications can severely impair postoperative quality of life. Preserving RLN function has therefore become a key objective in minimally invasive thoracic surgery. Recent studies have explored the feasibility of intraoperative neuromonitoring (IONM) as a strategy to reduce the risk of RLN injury in thoracoscopic procedures (39,40).

IONM is based on electrophysiological principles: the VN or RLN is electrically stimulated, and the integrity of the motor pathway is assessed by recording electromyographic (EMG) responses from laryngeal muscles. There are two main modes: intermittent IONM (I-IONM), which involves stimulation at discrete time points, and continuous IONM (C-IONM), which provides real-time feedback throughout the operation (41). Modern C-IONM systems use sensitive electrodes and advanced signal processing to track nerve function dynamically. Chai et al. reported that EMG signals can be reliably acquired during VATS lobectomy by placing surface electrodes on double-lumen tubes, enabling timely detection of RLN dysfunction (39). In their pilot study involving 30 patients, EMG signals were successfully recorded in all cases (100%), and early changes in EMG amplitude facilitated the identification of potential RLN impairment (39). Only 1 (3.3%) patient developed transient RLN palsy, which resolved within 3 months (39).

The accuracy of IONM depends on intact neuromuscular transmission. Non-depolarizing muscle relaxants, such as rocuronium, can suppress EMG activity and cause false-negative results (42). Thus, anesthetic protocols should avoid or minimize neuromuscular blockade once monitoring begins. Technical challenges—such as electrode displacement, mediastinal traction, or surrounding tissue interference—may also affect signal quality and should be carefully managed intraoperatively.

Although most IONM research to date has been performed in thyroid or esophageal surgery, thoracic applications are gaining traction (19,41). Seong et al. demonstrated that C-IONM is technically feasible during thoracoscopic left-sided lung resections, showing promising results in reducing RLN injury (40). In their study of 20 patients, continuous monitoring was successfully implemented in all cases. Only 1 (5%) patient experienced transient vocal cord palsy, with full recovery and no permanent deficits observed (40). These findings support the potential value of neuromonitoring in thoracoscopic settings, though further large-scale studies are still needed to confirm its long-term efficacy and clinical benefits.

Vagus nerve block (VNB)

Application of VNB in thoracoscopic lung surgery

The application of VNB in thoracoscopic lung surgery has garnered increasing attention in recent years due to its effectiveness in neuromodulation, achieved by blocking nerve conduction with local anaesthetic agents (43). VNB has shown promise in managing cardiovascular, inflammatory, and neurological conditions (44,45). For instance, in cardiac surgery, vagal blockade has been effective in reducing postoperative arrhythmias (46,47). Additionally, VNB has demonstrated significant efficacy in managing chronic pain and inflammatory diseases, as it plays a crucial role in transmitting visceral pain signals, with its blockade notably reducing acute visceral pain (48,49). VNB is also employed in various other surgeries requiring control of autonomic reflexes, including ophthalmic and gastrointestinal procedures (50,51).

The significance of vagal block is particularly evident in non-intubated, autonomic breathing thoracoscopic surgeries. It enhances surgical safety and patient comfort by effectively suppressing the cough reflex (52,53). During such surgeries, intrathoracic manipulation can provoke severe coughing, which can disrupt the procedure and elevate perioperative risks for patients. A study by Xiang et al. demonstrated the efficacy of VNB in single-hole thoracoscopic pulmonary wedge resection, where a mixture of local anaesthetics was injected near the pulmonary branch of the VN, thereby reducing intraoperative coughing and providing a clearer view of the surgical field (54). Similarly, Jiang et al. successfully applied this technique to more complex thoracoscopic rongeur and trachelectomy procedures (55).

In contrast, Chen et al. reported that preoperative left-sided VNB significantly reduced the incidence of postoperative nausea and vomiting (PONV) within 24 hours after thoracic or abdominal laparoscopic surgery (25% vs. 60%, P<0.001) (56). However, this randomized controlled trial has certain limitations, such as the use of left-sided VNB only and the inclusion of patients undergoing either thoracic or abdominal laparoscopic procedures rather than focusing solely on thoracoscopic surgery. In addition, the article is currently available as a preprint and has not yet undergone peer review. In conclusion, future research should more comprehensively evaluate the diverse potential roles of VN blockade to enhance patient recovery outcomes.

VNB modalities

There are two main approaches to VNB: cervical VNB and thoracoscopic VNB.

The cervical VNB is achieved by injecting a local anaesthetic near the cervical VN under ultrasound guidance. Since the cervical VN is located superficially and can be easily visualized with ultrasound, the operator can precisely identify the nerve between the common carotid artery and the internal jugular vein and perform an accurate injection. Anatomically, this block may also affect the ipsilateral RLN, potentially leading to hoarseness; however, this is often considered an indication of a successful block. Despite the advantages of minimal invasiveness and clear visualization in cervical VNB, the procedure requires significant ultrasound manipulation skills. This approach can be challenging in patients with anatomical variations or obesity.

Thoracoscopic VNB involves separate injections at different sites for right- and left-sided procedures during surgery. For right thoracic procedures, local anaesthetic is injected near the VN at the level of the superior paravalvular vein in the lower trachea. For left thoracic procedures, the injection is made near the VN at the level of the aortopulmonary window (57). This method is less likely to affect the RLN, thereby reducing the incidence of hoarseness. However, it requires the surgeon to have advanced skills and experience, as the lobes and hilar structures must be retracted to expose the VN before injection. This process can lead to patient discomfort and increased risk of damage to surrounding structures.

The duration of the block is related to the concentration and dosage of the local anaesthetic used. Commonly used drugs include 0.375% ropivacaine, 0.5% ropivacaine, 2% lidocaine, and 0.25% bupivacaine, typically administered in doses of 2–3 mL. These drugs are effective in suppressing the cough reflex for 3 hours or longer (38,58,59). In prolonged surgeries, repeated administration may be necessary. However, there are no established guidelines for the optimal drug and dosage for VNB in non-intubated thoracoscopic surgery.

In summary, the choice of VNB modality in thoracoscopic lung surgery should be tailored to the patient’s specific needs and the requirements of the surgery. Additionally, the surgeon’s skill and experience are crucial for ensuring the safety and effectiveness of the procedure.

Strengths and limitations

This review provides a comprehensive synthesis of VN management strategies during thoracoscopic surgery, highlighting advancements in surgical techniques and technologies. However, limitations include reliance on single-center studies, lack of large-scale randomized trials, and heterogeneity in clinical practices across studies.

Conclusions

Research on VN management strategies in thoracoscopic pulmonary resection highlights the complexity and diversity of this field (60). The VN’s role in thoracoscopic pulmonary resection is critical, and its management directly impacts the incidence of postoperative complications and patients’ quality of life. Current studies reveal a divergence in strategies for VN preservation versus severance, underscoring the limitations in our understanding of VN function and its mechanisms in postoperative recovery. Advances in technology, particularly C-IONM, provide new opportunities for intraoperative nerve preservation and have shown benefits in reducing postoperative RLN palsy and other complications. Additionally, the potential application of artificial intelligence in thoracoscopic surgery shows promise, with its use in thoracoscopic oesophagectomy indicating potential for real-time detection of the RLN, which could further enhance surgical safety in thoracoscopic lung resections (61-63).

The use of VNB techniques in non-intubated, voluntary breathing thoracoscopic surgery has been proven effective in suppressing the cough reflex and improving surgical safety. However, both ultrasound-guided cervical VNB and thoracoscopic VNB have their advantages and limitations. Selecting the appropriate method requires careful consideration of individual patient factors and the technical expertise of the surgical team.

While current literature on VN management in thoracoscopic lung resection primarily addresses short-term postoperative outcomes, its potential influence on long-term complications warrants further attention. Although direct clinical evidence remains limited, existing studies suggest that the VN not only plays a central role in modulating systemic inflammation and neuroimmune interactions, but also serves as a high-speed neural conduit for the propagation of surgically induced neuroinflammatory signals—mechanisms that are increasingly recognized as contributors to chronic postoperative pain, cognitive dysfunction, and psychological disturbances (64-70). Surgical trauma to vagal pathways may disrupt autonomic balance and the cholinergic anti-inflammatory reflex, potentially contributing to prolonged neuroinflammatory responses (71). Experimental studies have shown that VN stimulation can attenuate hippocampal inflammation and ameliorate cognitive decline in postoperative animal models (72). Similarly, alterations in vagal tone have been implicated in the pathogenesis of anxiety and depression through dysregulation of the hypothalamic pituitary-adrenal axis and limbic circuitry (73,74). These mechanistic insights suggest that intraoperative handling or stimulation of the VN—though rarely evaluated in long-term follow-up—may have downstream effects beyond immediate recovery. Further investigation is needed to determine whether refined VN management strategies can mitigate long-term morbidity and enhance patient-centered outcomes after thoracoscopic lung resections.

In conclusion, future research on VN management strategies should focus on large-scale, multicenter, randomized controlled trials to verify the effectiveness and safety of various approaches. A deeper understanding of the physiological mechanisms of the VN in postoperative recovery is essential for developing more precise and individualized management protocols. These efforts aim to improve surgical outcomes in thoracoscopic lung resections, enhance patient recovery processes, and ultimately elevate patients’ quality of life.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2211/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2211/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2211/coif). The authors have no conflicts of interest to declare.

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