Robotic-assisted Median Arcuate Ligament Release: Phrenoesophageal Membrane Preserving Step-by-Step Technique and Early Outcomes

Median arcuate ligament syndrome (MALS) is a rare entity that presents with severe and life-limiting abdominal pain and food fear. The robotic platform has recently emerged as a tool for MALS release owing to enhanced visualization and ergonomics. The aim of this study was to evaluate the feasibility and results of robotic phrenoesophageal membrane preserving release of the median arcuate ligament (PEMP-MALS) for the treatment of celiac artery compression syndrome. We retrospectively reviewed the records of patients who underwent robotic MALS release between October 2019 and October 2022 at our institution. Demographic information, symptoms, radiologic imaging details, postoperative complications, and follow-up were analyzed. The median was used as a measure of centrality for continuous variables. All surgeries were performed using the DaVinci Xi platform, and an experienced vascular surgeon was present for the entirety of the procedure. Eleven patients were evaluated for MALS. Ten patients were female (91%) with a median age of 20 [17-33] years and a median body mass index of 22 [19.7-23.5] kg/m2. Preoperative symptoms included postprandial pain (100%), exertional pain (91%), and weight loss (81%) (Table I). Celiac artery compression was confirmed on duplex (median peak systolic velocity, 360 [335-418] cm/s) and computed tomography angiography in 56% of patients. Nine (81%) patients reported symptom relief with preoperative celiac ganglion block. Robotic release was successfull in all 11 patients (100%) by the PEMP technique. Estimated blood loss was <100 mL, with a median hospital stay of 2 [2-3] days. One patient was converted to laparotomy due to intraoperative bleeding. Nine (81%) patients showed complete symptom resolution (Table II). One patient improved symptomatically at the 6-month median follow-up. One patient showed persistently elevated velocities on the duplex (peak systolic velocity >200 cm/s) with no symptom relief and was reoperated for a residual low-lying MALS. In our experience, robot-assisted PEMP-MAL release appears to be safe and associated with a short postoperative stay and a low risk of postoperative complications. Three-dimensional magnified visualization, instrument stability, and wristed ergonomics facilitate precise and effective dissection of critical vascular structures. A vascular co-surgeon’s presence during surgery is critical for timely conversion to laparotomy in the event of bleeding.Table IDemographics and preoperative variablesDemographics and preoperative variablesValuesAge, median [CI], years20 [17-33]BMI, median [CI], kg/m222 [19.7-23.5]Sex, No. (%) Female10/11 (91) Male1/11 (9)Symptoms, No. (%) Postprandial pain11/11 (100) Exertional pain10/11 (91) Weight loss9/11 (81)Relief with preoperative ganglion block, No. (%)9/11 (81)Preoperative PSV, median [CI], cm/s360 [335-418]BMI, Body mass index; CI, confidence interval; PSV, peak systolic velocity. Open table in a new tab Table IIResultsResultsValuesOperative time, median [CI], minutes229 [110-140.3]Follow-up, median [CI], months11 [2-19]Postoperative PSV, median [CI], cm/s193 [175-202]Hospital stay, median [CI], days2 [2-3]Complications, No. (%) Conversion to laparotomy1/11 (9) Incomplete release1/11 (9)Complete symptom resolution9/11 (81)Improved postprandial pain1/11 (9)Persistent postprandial pain1/11 (9)CI, Confidence interval; PSV, peak systolic velocity. Open table in a new tab