Hamada Yosuke, Fujimori Sakashi, Suzuki Souichiro, Karasaki Takahiro, Kikunaga Shinichiro, Mihara Shusei
Department of Thoracic Surgery, Respiratory Center, Toranomon Hospital, Tokyo, Japan.
Mediastinum. 2025 Jun 25;9:15. doi: 10.21037/med-25-9. eCollection 2025.
Phrenic nerve resection is sometimes necessary during tumor removal when the nerve is infiltrated by malignancies. However, this can result in diaphragmatic paralysis and respiratory insufficiency. While mechanical ventilation and diaphragmatic pacing may temporarily support respiratory function, phrenic nerve reconstruction offers a potential long-term solution. Nevertheless, its use during tumor resection remains underreported. This review assesses current evidence on phrenic nerve reconstruction, focusing on surgical techniques, nerve graft selection, and the feasibility of minimally invasive approaches.
A literature search was conducted in PubMed for phrenic nerve reconstruction studies. English-language studies published between January 1, 1980 and January 30, 2025, that focused on immediate phrenic nerve reconstruction following tumor resection were included in the review.
Phrenic nerve reconstruction can be performed either immediately after nerve resection or as a delayed procedure. Immediate reconstruction, especially when conducted concurrently with tumor resection, has been shown to promote optimal nerve regeneration and functional recovery. In contrast, delayed reconstruction is generally associated with greater technical challenges and less predictable outcomes. Direct anastomosis is preferable when feasible; however, nerve grafting is often required due to insufficient residual nerve length to achieve a tension-free repair. Among graft options, the intercostal nerve is favorable due to its anatomical proximity and minimal additional surgical burden, whereas the use of other nerves, such as the sural nerve, requires an additional incision at a separate site, which may be less desirable. Successful reconstruction can also be achieved using minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). Notably, the additional time required for reconstruction in minimally invasive procedures is manageable and does not significantly affect patient outcomes.
Immediate phrenic nerve reconstruction, either by direct suturing or intercostal nerve grafting, is a feasible and effective method for preserving respiratory function. The ability to perform reconstruction using minimally invasive techniques further supports its clinical adoption. Given its advantages in functional recovery and its relatively low additional surgical burden, phrenic nerve resection followed by immediate reconstruction may be considered in most cases involving phrenic nerve invasion.
在肿瘤切除过程中，当膈神经被恶性肿瘤浸润时，有时需要进行膈神经切除术。然而，这可能导致膈肌麻痹和呼吸功能不全。虽然机械通气和膈肌起搏可能暂时支持呼吸功能，但膈神经重建提供了一种潜在的长期解决方案。尽管如此，其在肿瘤切除术中的应用报道仍然较少。本综述评估了膈神经重建的现有证据，重点关注手术技术、神经移植物选择以及微创方法的可行性。
在PubMed上检索膈神经重建研究。纳入1980年1月1日至2025年1月30日发表的、聚焦于肿瘤切除后立即进行膈神经重建的英文研究。
膈神经重建可在神经切除后立即进行，也可作为延迟手术。立即重建，尤其是与肿瘤切除同时进行时，已被证明可促进最佳的神经再生和功能恢复。相比之下，延迟重建通常伴随着更大的技术挑战和更不可预测的结果。可行时，直接吻合是首选；然而，由于残余神经长度不足无法实现无张力修复，通常需要进行神经移植。在移植物选择中，肋间神经因其解剖位置接近且额外手术负担最小而较为有利，而使用其他神经，如腓肠神经，则需要在单独部位额外切开，可能不太理想。使用电视辅助胸腔镜手术（VATS）和机器人辅助胸腔镜手术（RATS）等微创方法也可成功实现重建。值得注意的是，微创手术中重建所需的额外时间是可控的，且不会显著影响患者预后。
通过直接缝合或肋间神经移植立即进行膈神经重建是保留呼吸功能的可行且有效方法。使用微创技术进行重建的能力进一步支持了其在临床上的应用。鉴于其在功能恢复方面的优势以及相对较低的额外手术负担，在大多数涉及膈神经浸润的病例中，可考虑在膈神经切除后立即进行重建。
