Robotic Median Arcuate Ligament Release

Median arcuate ligament syndrome (MALS) results from the compression of the celiac trunk by an anatomically abnormally median arcuate ligament. Symptoms of nausea, vomiting, and epigastric pain are attributed to ischemia of the foregut stemming from compression. Due to presentation variability and rare prevalence, MALS is often a diagnosis of exclusion. The diagnosis of MALS can be unclear, as such, large, open, invasive surgery for such a problem is not idea. We present the case of a patient with atypical symptoms found to have MALS and underwent minimally invasive robotic surgical treatment. A 43-year-old woman presented with 3 months of severe epigastric pain initially associated with eating and then progressing. Initial GI workup was inconclusive, but computed tomograph scan of the abdomen and pelvis demonstrated narrowing of the celiac artery origin with patent distal celiac, superior mesenteric artery, and inferior mesenteric artery. Mesenteric duplex ultrasonography indicated elevated celiac artery velocities consistent with >50% stenosis worse with expiration. She underwent a celiac block which initially improved her pain by roughly 50%, which returned. Patient elected to proceed with surgery and underwent robotic median arcuate ligament release (RMALR) and celiac plexus neurolysis. The patient was discharged on postoperative day 1. Patient had complete resolution of symptoms 2.5 weeks and one month postoperatively, as confirmed by a repeat mesenteric duplex ultrasonography demonstrating resolution of celiac artery stenosis. MALS, a poorly understood syndrome presenting mostly in younger women, results from the compression of the celiac artery by the median arcuate ligament. Due to the nonspecific presentation and lack of diagnostic criteria, MALS is typically determined by ruling out other causes of symptoms, and diagnosis is confirmed with imaging studies such as computed tomograph scan or duplex ultrasound examination. Treatment options include surgical intervention, with laparoscopic or open approach used more than RMALR, despite advantages in visualizations, control, maneuverability, and reduced operation time. Additionally, RMALR has been associated with higher rates of symptom relief, with lower recurrence rates and complications. RMALR remains a safe and effective management for patients with symptomatic MALS.