Laparoscopic treatment in a patient with median arcuate ligament syndrome identified at the onset of superior mesenteric artery dissection: a case report

Abstract

BackgroundMedian arcuate ligament syndrome (MALS) is a rare clinical entity caused mainly by extrinsic compression of the celiac axis by the median arcuate ligament (MAL). Severe celiac artery stenosis can lead to the development of collateral circulation, aneurysms, and, rarely, superior mesenteric artery (SMA) dissection. The treatment of MALS involves the surgical release of the MAL. However, a standard procedure with the use of laparoscopy has not been established, and intraoperative complications can lead to severe vascular injury.Case presentationThe patient was a 43-year-old man with MALS identified at the onset of SMA dissection. After treatment for the SMA dissection, he underwent laparoscopic MAL release. Using the technique of laparoscopic gastrectomy within the surgical field, we performed laparoscopic MAL release and ganglionectomy safely with a good view. Immediate symptomatic improvement was acquired, and no recurrence was observed at the 20-month follow-up.ConclusionWe reported a rare case of MALS and SMA dissection. A horizontal 3D laparoscopic approach of the celiac axis allows for safe, meticulous, and radical MAL release and ganglionectomy.

Median Arcuate Ligament Syndrome

“…Collateral circulation and retrograde blood flow via the SMA may develop in patients with long-standing MALS because of prolonged ischemia in the foregut organs supplied by the stenosed celiac artery [5]. With increased blood flow through these collateral vessels, there is increased risk of aneurysm formation and subsequent rupture.…”

Laparoscopic treatment for celiac artery stenosis caused by median arcuate ligament compression with Adachi V type vascular anomaly: a case report

“…Recently, use of the laparoscopic approach for MAL treatment has been reported [3,4]. The laparoscopic magnification view and wide working space make it possible to identify the anatomic orientation of the MAL.…”

“…Radical treatment for MALS involves ligament dissection. Although the laparoscopic approach for treatment of MALS has been recently reported [3,4], the standard procedure for laparoscopic MAL dissection has not yet been established. This case report describes laparoscopic MAL dissection for a patient with MALS and an Adachi V type vascular anomaly.…”

Laparoscopic treatment of median arcuate ligament syndrome without ganglionectomy of the celiac plexus in the hybrid operating room: Report of a case

“…The most accepted theory is that increased blood demand caused by compression of the CA leads to mesenteric ischemia, and another theory is that midgut ischemia causes pain through steal syndrome, wherein blood from the SMA area is diverted through the collateral circulation to compensate for inefficient blood flow from the CA. A third theory is that pain in MALS is caused by a neurogenic dysfunction resulting either directly from compression of the celiac plexus or indirectly from splanchnic vasoconstriction [ 5 , 11 ]. Based on the third theory, complete celiac trunk decompression is recommended and only simple MAL release is not enough, additional neurolysis and wide excision of the celiac plexus is necessary.…”

“…Initial attempts to treat MALS by endovascular angioplasty or stenting are not recommended, because the extrinsic compression of the CA may cause recoil restenosis, dissection, and fracture of the stent [ 4 ]. Definitive treatment for MALS involves surgical release of the MAL, and recently a laparoscopic approach has been used by surgeons due to its minimally invasive manner [ 4 , 5 ]. It has been reported that MAL release with ganglionectomy of the celiac plexus is necessary for the result in a decrease of the pain associated with MALS [ 6 ].…”