The inferior phrenic nerves (left and right) are branches of the celiac plexus or directly from the aorta, supplying the inferior surface of the diaphragm and the adrenal glands. They are the primary sensory nerves of the inferior diaphragmatic peritoneum and carry referred pain to the shoulder via the phrenic pathway.
Inferior phrenic nerve irritation from subphrenic collections, liver pathology, or adrenal tumours produces referred ipsilateral shoulder pain via the phrenic-C3/4 pathway. In adrenalectomy, the inferior phrenic vessels and accompanying nerve must be identified and controlled. The inferior phrenic artery is the primary blood supply to the adrenal gland and is ligated as the first step in laparoscopic adrenalectomy.
Ipsilateral shoulder tip pain from inferior phrenic nerve irritation by subphrenic abscess or free peritoneal fluid, a classic presentation of abdominal pathology referred to the shoulder via the phrenic nerve C3/4 pathway.
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