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Robotic Median Arcuate Ligament Release with Intraoperative ICG Angiography

Matthew Surrusco, MD, Kaushik Mukherjee, MD, Sheela Patel, MD, Marcos Michelotti, MD, Carlos Garberoglio, MD. Loma Linda University Medical Center

Case: The patient is a 36 year old male who presented with 10-12 years of sharp, burning epigastric pain that increased in frequency to several episodes per month and was associated with loose bowel movements, cold sweats, nausea, and vomiting, but not with meals. The patient was diagnosed with median arcuate ligament syndrome via stenosis seen on CT angiography with elevated velocities in the celiac artery seen on ultrasound.

Background: Median arcuate ligament syndrome results from compression of the celiac axis by the median arcuate ligament, resulting in demand ischemia and epigastric, typically postprandial, pain, nausea, vomiting, diarrhea, or weight loss. It is most common in women in their 3rd to 5th decade of life. Diagnosis is by CT or MR angiography or duplex ultrasound. Surgical treatment involves release of the ligament.

Operative Technique: We used 4 robotic ports and a liver retractor. We entered the hepatogastric ligament, taking care not to injure the left gastric artery. We created a plane behind the stomach. We then took down the short gastric vessels and passed a Penrose drain behind the stomach and esophagus. We dissected between the crura to take down the fibrous connective tissue on top of the aorta and great vessels. After isolating the median arcuate ligament we doubly clipped and divided it. Indocyanine green angiography demonstrated excellent flow, as did postoperative ultrasound.

Results: The patient has been discharged and is tolerating a diet and awaiting outpatient followup.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 79933

Program Number: V056

Presentation Session: Thursday Exhibit Hall Video Presentations Session 3 (Non CME)

Presentation Type: EHVideo

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