Laparoscopic Retrogastric Median Arcuate Ligament Release

Abstract

Introduction: Median arcuate ligament syndrome (MALS), originally described in 1963 by Harjola, is defined as compression of the celiac axis by an abnormal median arcuate ligament (MAL), characteristically causing postprandial abdominal pain and weight loss. Patients may also complain of nausea, diarrhea, and food aversion. Here we describe a laparoscopic technique for release of the MAL through a retrogastric or retrograde technique. Materials and Methods: We describe a case of an 18-year-old male with MALS, characterized by abdominal pain, 20 kg weight loss, and food aversion. On work-up, he was found to have a normal barium swallow and esophagogastroduodenoscopy. Nuclear gastric emptying study was normal. Abdominal ultrasonography revealed elevated velocities and CT angiogram showed compression of the celiac axis with velocities greater than 200 cm/s. He was taken to the operating room for release of his MAL through a laparoscopic retrogastric approach. Results: Our patient was taken to the operating room for a retrogastric MAL release. This was performed with five trocars including a liver retractor. The MAL was approached by retracting the stomach anterior. The initial goal is to identify the left gastric, hepatic, or splenic artery and then follow one or all of those branches back to the celiac trunk and aorta where the MAL can be identified and divided. He was admitted after surgery, advanced to regular diet, and discharged home on postoperative day 2. He has returned to clinic on multiple occasions for follow-up. He reported complete resolution of his symptoms, including abdominal pain and food aversion. He has recovered the majority of his weight loss at 3 months. Discussion: Traditionally, MAL is approached through laparotomy through the gastrohepatic ligament, with dissection continued through the fibrous MAL found in proximity to the diaphragmatic crura at the origin of the celiac artery.1 Laparoscopic MAL release is becoming more common and can be approached through the antegrade or retrograde (retrogastric) approach.2 The retrogastric approach has the advantage of a better angle of dissection along the aorta and a better angle to divide the MAL as it arches over the celiac trunk. The observation of the origin of the celiac and its branches with the stomach retracted anteriorly is also excellent using this approach. Conclusion: MALS is an uncommon cause of abdominal pain. Here we describe a novel approach to the release of the MAL by utilizing laparoscopy and approaching the celiac axis from beneath the stomach, providing a unique surgical exposure. No competing financial interests exist. Runtime of video: 4 mins 26 secs This research was presented at the American Pediatric Surgery Association in 2015.