Median Arcuate Ligament Syndrome Robotic Celiac Axis Release & Celiac Plexus Neurolysis

Median Arcuate Ligament (MAL) syndrome is the symptomatic compression of the celiac trunk by the median arcuate ligament (an attachment of the diaphragmatic crura) and other ganglionic periaortic tissue. Despite its rarity, this condition is significant from a clinical, diagnostic, and management standpoint. It is usually a diagnosis of exclusion. It has been treated with open or laparoscopic surgical decompression of the celiac axis with neurolysis.

Materials and methods

We describe the case of a 25-year-old lady with severe epigastric pain and weight loss. Routine blood investigations including serum amylase and lipase were normal. Upper GI endoscopy and ultrasound abdomen were also normal. CT scan revealed 80% focal stenosis of the celiac axis at its origin, due to extrinsic compression by the median arcuate ligament. Doppler studies confirmed the presence of a severe obstruction to the celiac axis blood flow. The patient was planned for robot-assisted MAL release and celiac ganglion neurolysis. An operative video is presented with a detailed, step-wise explanation of the procedure. Preoperative investigations, patient position, robot docking, and port placement are described. Post-operative results are described.

Results and Conclusions

The operative time was 90 minutes with minimal blood loss, with a hospital stay of 2 days. The operation was successful in relieving the patient's pain. The postoperative celiac axis doppler showed significant improvement in the flow velocities compared to the preoperative state. Robotic-assisted MAL release with celiac ganglionectomy can be safely performed with minimal patient morbidity.