JETT Median Arcuate Ligament Release CTSnet edited.mp4 (152.48 MB)

Robotic-Assisted Median Arcuate Ligament Release With Celiac Artery Lysis and Celiac Ganglion Neurolysis

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posted on 31.08.2020 by G. Kimble Jett, Lee Hafen, William Shutz, Dennis Gable, John Kedora

The celiac axis is the first branch of the abdominal aorta and is the source of arterial supply for the entire foregut. Compression of the proximal celiac artery by the fibrous attachments of the diaphragmatic crura and/or celiac ganglion was first described in 1963, and the symptom complex associated with it is referred to as the median arcuate ligament (MAL) syndrome (1). Severe compression is seen in 1% of the population (2). Compression classically varies with respiration and can result in a variety of symptoms (pain, weight loss, nausea, and vomiting). MAL syndrome is typically a diagnosis of exclusion and confirmed by computer tomography angiography (CTA) (3).

Surgical treatment involves the release of the MAL resulting in celiac artery lysis combined with celiac ganglion neurolysis. Traditionally MAL release is performed with open laparotomy and may be combined with revascularization (4), but the morbidity of laparotomy may outweigh the benefit. Minimally invasive techniques using laparoscopy have resulted in decreased morbidity, quicker recovery, and reduced pain (5-8). Robotic assisted surgical treatment was first described in 2007 (9) and has been gaining acceptance as an effective treatment with excellent results (10). An advantage of the robotic approach is improved vision with a more stable platform, allowing circumferential celiac artery lysis and celiac ganglion neurolysis.

This video demonstrates the technique of robotic assisted MAL release. The patient was a 32-year-old woman with a two-year history of abdominal pain with exercising. Workup was negative except for a large gallstone. She underwent laparoscopic cholecystectomy, but had persistent postoperative abdominal pain. A CTA of the abdomen demonstrated high-grade stenosis of the origin of the celiac artery. She underwent robotic-assisted MAL release. She was discharged home on postoperative day one. She was pain-free at one year.

References

  1. Harjola PT. A rare obstruction of the celiac artery. Report of a case. Ann Chir Gynaecol Fenn. 1963;52:547-550.
  2. White RD, Weir-McCall JR, Sullivan CM, Mustafa SAR, Yeap PM, Budak MJ, et al. The celiac axis revisited: anatomic variants, pathologic features and implications for modern endovascular management. Radiographics. 2015;35:879-898.
  3. Horton KM, Talamini MA, Fishmann EK. Median arcuate ligament syndrome: Evaluation with CT angiography. Radiographics. 2005;25:1177-1182.
  4. Duran M, Simon F, Ertas N, Schelzig H, Floros N. Open vascular treatment of median arcuate ligament syndrome. BMC Surgery. 2017;17:95(1-6).
  5. Kohn GP, Bitar RS, Farber MA, Marston WA, Overby DW, Farrell TM. Treatment options and outcomes for celiac artery compression syndrome. Surg Innov. 2011;18:338-343.
  6. Roseborough GS. Laparoscopic management of celiac artery compression syndrome. J Vasc Surg. 2009;50:124-133.
  7. Vaziri K, Hungness ES, Pearson EG, Soper NJ. Laparoscopic treatment of celiac artery compression syndrome: Case series and review of current treatment modalities. J Gastrointest Surg. 2009;13:293-298.
  8. El-Hayek K, Titus J, Bui A, Mastracci T, Kroh M. Laparoscopic median arcuate ligament release: Are we improving symptoms? J Am Coll Surg. 2013;216:272-279.
  9. Jaik NP, Stawicki SP, Weger NS, Lukaszczyk JJ. Celiac artery compression syndrome: Successful utilization of robotic-assisted laparoscopic approach. J Gastrointest Liver Dis. 2007;16:93-96.
  10. Relles D, Moudgill N, Rao A, Rosato F, DiMuzio P, Eisenberg J. Robotic-assisted median arcuate ligament release. J Vasc Surg. 2012; 56:500-503.

Disclosure

G. Kimble Jett is a proctor and speaker for Intuitive Surgical, Inc.


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