A diagnostic workup and laparoscopic approach for median arcuate ligament syndrome

Abstract

Background: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by the compression of the coeliac trunk and plexus by fibrous arches of the median ligament. It commonly occurs in young women with postprandial epigastric pain, weight loss and nausea. We present a single surgeon experience on the diagnostic approach and management of MALS with a focus on laparoscopic surgery. Methods: A retrospective review of adult patients diagnosed with MALS during a 10-year period (2011-2021) was conducted at Bankstown-Lidcombe hospital in New South Wales, Australia.Results: MALS was diagnosed in six patients (mean 46 years, range: 27-74 years old), all confirmed on mesenteric duplex ultrasound and computed tomography angiography. The most common presentations were women with post-prandial pain, exercise induced pain and an average weight loss of 14.5 kg. The median interval from onset of symptoms to surgical referral was 10.5 months. The average BMI was 24.1 kg/m 2 and most had a grade III American Society of Anaesthesiologist physical status. All patients underwent laparoscopic release of median arcuate ligament with one patient requiring endovascular stenting. The mean operative time was 119 minutes with two minor post-operative complications, but no mortalities. The median hospital length of stay was 3.5 days with a median follow up of 3.5 years. Conclusion: Laparoscopic median arcuate ligament release with endovascular support for selected cases provides sound clinical resolution of symptoms and long-term results.

A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study

“…The first description of a laparoscopic MAL release was in 2000 by Roayaie et al [ 21 ]. After their original report, other groups reported their experience in small single-institution case series [ 4 , 8 , 11 , 12 ]. A main concern of the laparoscopic approach is uncontrolled bleeding, reported in 9.1% of cases, necessitating a rapid conversion to a laparotomy [ 6 ].…”

“…This procedure can be done open, laparoscopic or more recently robotic-assisted. However, there is not enough evidence to help guide surgeons as to which operative approach is superior over the other, with limited data coming from single-institution series [ 4 , 7 , 8 , 11 – 16 ]. In the largest study to our knowledge, no difference was found in postoperative outcomes between the laparoscopic and open approach [ 6 ].…”

“…The disease predominantly affects female patients with a lower body mass index in whom psychiatric comorbidities are frequently present [5]. Although there is no group consensus agreement for the diagnosis of MALS, several authors have proposed diagnostic criteria [1,3,[6][7][8]. These criteria are and Other Interventional Techniques aimed at aiding the diagnosis of MALS, in which patients have a negative gastrointestinal workup and evidence of celiac axis compression on imaging, most commonly dynamic duplex ultrasound measuring flow velocities and computed tomography and angiographic reconstruction.…”