Laparoscopic Median Arcuate Ligament Release

Tatiana Hoyos, MD, John Stauffer, MD, Albert Hakaim, MD, Horacio Asbun, MD. Mayo Clinic, Florida.

Median arcuate ligament syndrome is a rare condition in which the median arcuate ligament fibers from the diaphragm compress the celiac artery (CA). This is thought to be due to a low diaphragmatic insertion, a high celiac artery origin from the aorta, or a compression of the artery by the celiac ganglionic fibers. The clinical manifestations include non-specific gastrointestinal symptoms that include epigastric pain usually post-prandial and nausea/vomiting among others. Imaging studies usually show a narrowing in the artery and a distal dilatation of the CA. The treatment goal is to release the ligament that compresses the proximal CA.

We present the case of a 19 year-old female with a chief complain of chronic abdominal pain and constipation, without a significant past medical history and with a normal physical examination. Both angiography and MRA were consistent with CA compression. Furthermore, the provocative visceral arteriogram with papaverine reproduced the symptoms and showed a loss of collateralization from SMA to the CA circulation.

The procedure is described in a step-wise manner. A laparoscopic arcuate ligament release using a lesser sac access approach is demonstrated. A clear exposure of the a anatomic structures of the celiac trunk through a meticulous dissection is shown. A successful release of the muscle, ligament and celiac plexus fibers is accomplished, resulting in a complete release of celiac trunk compression. The patient recovery was uneventful with complete resolution of preoperative pain.