Laparoscopic release of median arcuate ligament

AIMS
Median arcuate ligament (MAL) syndrome is an uncommon condition caused by the external compression of the celiac trunk by the median arcuate ligament. MAL syndrome involves a constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Diagnosis is difficult and is made after exclusion of other more common causes of abdominal pain. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical options include isolated arcuate ligament chylotomy or associated angioplasty vs vascular reconstruction.

METHODS
We report the case of a 31-year-old man who presented epigastric abdominal pain and nausea without vomits for three years. The symptoms had not clearly relation with oral intake. He had not any significant prior medical history. The diagnosis of MAL was made by computed tomography angiography showed extrinsic compression of the celiac trunk by MAL.
The patient was operated on laparoscopically using five trocars, two of 10 mm and three of 5 mm. Neumoperitoneum was created with Veress needle in lthe left hypochondrium. The oesophagus hiatus was dissected. The aorta was identified under the diaphragmatic crura and dissection was carried inferiorly on the aorta until the origin of the celiac artery and left gastric artery were identified. A wide dissection of diaphragmatic crura was performed with a section of the base of the left crura, which was thickened. The arcuate ligament and fibrous bands were cut at the origin of the celiac trunk. The diaphragmatic crura was closed with Ethibond points.

RESULTS
The postoperative period was uneventful, and the patient was discharged on the third day post-op with normal digestive tolerance. With a follow-up of one year, the patient is asymptomatic and with an adequate oral intake.

CONCLUSION
Patients who have evidence of median arcuate ligament syndrome should undergo surgical decompression, which can be accomplished laparoscopically with good results.