Laparoscopic Median Arcuate Ligament Release After Whipple

Raymond Laird, DO, Jeff Harr, MD, MPH, Fred Brody, MD, MBA, FACS. George Washington University Hospital

We present a 21 year old female who presented to multiple academic institutions with a 3 year history of daily epigastric and right upper quadrant abdominal pain. The pain was exacerbated by vigorous physical activity and eating. At that time, her BMI was 20 and she required escalating amounts of narcotics to control her abdominal pain.

An extensive workup was performed and all of her tests were within normal limits. The patient underwent a diagnostic laparoscopy and a laparoscopic cholecystectomy. Her symptoms resolved for approximately 6 months, then recurred. Three ERCPs were performed to find the etiology of her abdominal pain. She developed a pancreatic duct stricture in the head of the pancreas. She underwent an endoscopic ultrasound guided celiac plexus block that resolved the abdominal pain for 10 days. Although MAL syndrome was considered, it was not thought to be the cause of her symptoms.

A laparoscopic pancreaticoduodenectomy was then performed at an outside hospital. She continued to have abdominal pain with increased narcotic use. All of her labs were normal. She was referred to our institution for laparoscopic MAL release.

After a laparoscopic MAL release, she was started on a liquid diet on post-operative day #1 and advanced to a regular diet on post-operative day #2 and discharged home. At six months postoperatively, she remains asymptomatic, exercises daily, and is tolerating a regular diet.

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