Robotic-Assisted Median Arcuate Ligament Release With Celiac Artery Lysis and Celiac Ganglion Neurolysis
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.
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G. Kimble Jett is a proctor and speaker for Intuitive Surgical, Inc.