Laparoscopic Median Arcuate Ligament Release

Introduction: Median arcuate ligament (MAL) syndrome is a rare condition caused by abnormally low insertion of the median arcuate ligament or diaphragmatic muscle resulting in external compression of the celiac trunk. This leads to postprandial epigastric pain, nausea, vomiting, and weight loss. Conventional surgical treatment of this condition involves a release of MAL via a midline laparotomy. Although the feasibility of the laparoscopic approach to MAL release has been established, world experience with this procedure remains limited. We present a video detailing the technique of laparoscopic MAL release.

Methods: MALS diagnosis was established by MRA and angiogram. Standard 4 trocars approach was utilized. Nathanson liver retractor was used to provide excellent exposure of he GE junction. The hepatogastric ligament was transected and the retrograstric space was entered. The right crus was dissected in order to identify the take off of the celiac artery from the aorta . The pancreatic head is exposed. The hepatic artery, left gastric artery and splenic artery were identified. The median arcuate ligament was seen coursing anterior to the celiac truck. The celiac artery was clearly compressed by these muscle fibers. The narrowing of the celiac artery was released by dividing these muscle fibers using electrocautery.

Results: The body mass index of the patient was 20.5 Kg/m2. The procedure was completed laparoscopically. Intraoperative ultrasound confirmed significant improvement in the blood flow of the distal celiac artery. The operative time was 170 minutes. Estimated blood loss was 25ml. There was no perioperative complication. Hospital stay was 1 day.

Conclusions: Laparoscopic release of MAL is feasible. It can be performed without significant perioperative morbidity by experienced laparoscopic surgeons. A team approach of a vascular and MIS surgeon should be utilized. We advocate the laparoscopic release as the first line surgical treatment in patients with MAL syndrome.

Session: Video Channel

Program Number: V071

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