Laparoscopic Release of the Median Arcuate Ligament for Celiac Artery Compression Syndrome in the Community Hospital Setting: A Case Report

Abstract

Introduction: Celiac artery compression syndrome (CACS) is a rare disorder causing postprandial abdominal pain and weight loss secondary to mechanical compression of the celiac axis by an abnormally low insertion of the diaphragm at the median arcuate ligament (MAL). Historically, correction was performed through an upper midline laparotomy and release of the muscular fibers of the MAL causing celiac axis compression. Advanced laparoscopic techniques have been recently employed by some authors to confer the benefits of minimally invasive surgery to this patient population1–4 in the academic setting. We present a case of successful laparoscopic release of the MAL for CACS in the community hospital setting. Case: A 66-year-old man with longstanding history of postprandial abdominal pain and weight loss was referred for possible CACS. A mesenteric arteriogram was performed, which demonstrated a high-grade stenosis in the proximal celiac axis. The patient was prepared for a laparoscopic release of the MAL. A fellowship-trained minimally invasive/bariatric surgeon (T.S.D.) and a fellowship-trained vascular surgeon (W.K.) performed the operation. The patient was placed in the supine position with arms extended. A footboard was utilized to allow full reverse Trendelenburg position to be employed. Abdominal access was achieved using an Optiview approach through a left subcostal anterior axillary 12-mm incision. A 12-mm trocar was placed midway between the umbilicus and xyphoid process, two additional right upper quadrant ports were placed (5 mm, 12 mm), and a Nathanson liver retractor was placed through a 5-mm subxyphoid incision. The lesser sac was accessed by opening gastrocolic and gastrospenic attachments using an ultrasonic dissector. Both the left lobe of the liver and stomach were retracted anteriorly using the Nathanson retractor, allowing full view of the lesser sac and retroperitoneum. The left gastric, common hepatic, and splenic arteries were identified and traced back to the celiac trifurcation. The celiac axis was then circumferentially dissected and a vessel loop was applied. The area of compression was readily apparent upon gentle caudal retraction of the celiac artery. Monopolar hook electocautery was employed to carefully release the muscular attachments of the MAL that were causing arterial compression. The MAL was completely released when the supraceliac aorta was fully exposed from muscular diaphragmatic fibers. The patient did well postoperatively and was discharged home with an indwelling Foley catheter secondary to urinary retention and benign prostatic hypertrophy. Upon 2-week follow-up, the patient described full resolution of postprandial symptoms. Before surgery, the patient describes only tolerating full liquids, but at follow-up, is able to tolerate a regular solid diet for the first time in years. Conclusion: Laparoscopic release of the MAL for CACS is a technically demanding procedure with a high risk of open conversion and complications, even in the academic setting. However, with appropriately trained surgeons, this rare disorder can be treated in community hospital setting. No competing financial interests exist. Runtime of video: 5 mins 03 secs