Feasibility and Safety of Robotic Assisted Surgical Approach in Median Arcuate Ligament Syndrome – A Systematic Review

Abstract

Median arcuate ligament syndrome (MALS) is rare syndrome and is diagnosis of exclusion. Though first robotic median arcuate ligament release (MALR) was described in 2007, there are only a few case reports (CR), case series (CS) and retrospective cohort studies (RCS) published in literature. The purpose of this study was to assess the feasibility and safety of robotic assisted MALR (r-MALR). PubMed, Embase and Cochrane databases were searched (last search December 2023) for articles reporting R-MALR. All studies including CR, CS, RCS reporting technical feasibility (operating time and rate of conversions; safety (intraoperative complications, blood loss, post-operative complications), and outcome (length of stay [LoS]) were included (PROSPERO: CRD42024502792). A total of 23 studies (8-CR, 5-CS, 10-RCS) with total 290 patients were available in literature. Except 1-RCS, all studies reported age and mean age for CR was 40.38 ± 17.7, for CS 36.08 ± 15.12, for RS 39.72 ± 7.35 years; except 2-RCS, all studies reported gender distribution and there were 57 males and 214 females. Operating time – 3-CR, 4-CS, 9-RCS reported operating time and mean time was 111 ± 54, 131.69 ± 7.51, 117.34 ± 35.03 min respectively. Conversion rate: All studies reported data on conversion and only 4 (1.37%) cases were converted – 1 to laparoscopic approach, 3 to open approach (1-inadvertent celiac arteriotomy, 2-reasons not mentioned). Intra-operative complications: only 5-CR, 4-CS and 9-RCS reported data on intra-operative complications and there were only 6 complications (1.5%): 1-inadvertent celiac arteriotomy converted to open; 3- unnamed vascular injuries (2 managed robotically, 1-converted to open); 1-bleeding managed robotically; There were no other reported injuries. Estimated blood loss ranged from 5-30ml. Post-operative complications: 5-CR, 4-CS, 8-RCS described post-operative complications in 21 (7%) patients. 20 cases were grade I, 1 was grade IIIa and all managed successfully. LoS stay: 2-CR, 4-CS, 10-RCS reported LoS and overall, it was 2 days. R-MALR is reasonable, technically feasible, safe and has acceptable outcomes. Additionally robotic approach provided superior vision, improved dexterity, precise and easy circumferential dissection. PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42024502792).