Vagus nerve management in lung cancer surgery: anatomical preservation, functional modulation and postoperative outcomes-a narrative review.

BACKGROUND AND OBJECTIVE: The vagus nerve plays a fundamental role in regulating bronchomotor tone, cardiac rhythm, cough reflex pathways, and neuroimmune inflammatory responses. During lung cancer surgery, particularly during mediastinal lymphadenectomy, cardiopulmonary vagal branches may be exposed to traction, thermal injury, or intentional transection. With the progressive development of minimally invasive and robotic-assisted thoracic surgery, increasing attention has been directed toward functional preservation and postoperative quality of life in addition to oncological radicality. This narrative review aimed to summarize the current anatomical, physiological, and clinical evidence regarding vagus nerve management during lung cancer surgery. METHODS: A comprehensive literature search was conducted using PubMed/MEDLINE, Scopus, Web of Science, and manual bibliography screening to identify relevant anatomical, physiological, clinical, and translational studies addressing vagus nerve management during lung cancer surgery. No strict temporal restriction was applied. Clinical studies evaluating preservation or transection of vagal branches during thoracoscopic lung resection were qualitatively analyzed. KEY CONTENT AND FINDINGS: Current evidence suggests that preservation of pulmonary vagal branches may reduce postoperative cough, inflammatory response, autonomic dysfunction, and impairment of postoperative recovery. Conversely, selective transection of specific pulmonary vagal afferents has also shown potential benefit in selected patients with refractory postoperative cough. Recent advances in robotic magnification, intraoperative neuromonitoring, and neuromodulatory strategies such as transcutaneous auricular vagus nerve stimulation (taVNS) may further improve perioperative functional outcomes. CONCLUSIONS: The vagus nerve represents both a critical anatomical structure and a major functional regulator during thoracic oncologic surgery. Integration of autonomic preservation strategies into modern minimally invasive lung cancer surgery may contribute to improved postoperative recovery and quality of life. Further prospective multicenter studies are required to standardize vagus nerve preservation and neuromodulatory approaches.