Releasing the band of pain: A Laparoscopic approach to Median arcuate ligament syndrome
EAES Academy. Dutt A. 07/05/22; 363145; P190
Prof. Dr. Aishwarya Dutt
Contributions
Contributions
Abstract
Background:
Median arcuate ligament syndrome (MALS) is a clinical syndrome characterised by the compression of the celiac artery by the median arcuate ligament due to the fibres of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Surgical repair in MALS by laparoscopy can be done to relieve the pressure over the artery. The purpose of this study was to review our experience of the laparoscopic management of MALS, and its outcomes after surgical intervention.
Method:
After diagnostic workup and confirmation of MALS, 14 cases were taken up for laparoscopic decompression of median arcuate ligament over celiac artery. There were two approaches to the median arcuate ligament considered, with relation to the stomach- an anterior approach in 11 cases and posterior approach in 3 cases by hitching the stomach towards the anterior abdominal wall. Coeliac ganglia were removed to enable better decompression and pain relief. On table repeat indocyanine green angiography was performed 3 times to confirm the release on the celiac artery. Postoperative stay was monitored and pain measured as per visual analogue scale.
Result:
Laparoscopic release of median arcuate ligament was shown to cause a decrease in pain postoperatively in 78% (11 out of 14) cases. The common intraoperative complications included bleeding in 28%(4 out of 14) and pneumothorax in 14%(2 out of 14). There was a conversion of laparoscopy to open surgery in 21%(3 out of 14) cases due to bleeding. Postoperative complications included pancreatitis in 1 patient and surgical site infection in 2 patients. Dumping syndrome was seen in 35%(5 out of 14) cases while recurrence was seen in 21%(3 out of 14) patients.
Conclusion:
The available evidence shows that laparoscopic ligament release and celiac ganglionectomy with celiac artery revascularization can bring about effective symptom relief in the majority of patients diagnosed with MALS. With good patient prognosis and minimal post operative complications, it can be effectively used for MALS.
Median arcuate ligament syndrome (MALS) is a clinical syndrome characterised by the compression of the celiac artery by the median arcuate ligament due to the fibres of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Surgical repair in MALS by laparoscopy can be done to relieve the pressure over the artery. The purpose of this study was to review our experience of the laparoscopic management of MALS, and its outcomes after surgical intervention.
Method:
After diagnostic workup and confirmation of MALS, 14 cases were taken up for laparoscopic decompression of median arcuate ligament over celiac artery. There were two approaches to the median arcuate ligament considered, with relation to the stomach- an anterior approach in 11 cases and posterior approach in 3 cases by hitching the stomach towards the anterior abdominal wall. Coeliac ganglia were removed to enable better decompression and pain relief. On table repeat indocyanine green angiography was performed 3 times to confirm the release on the celiac artery. Postoperative stay was monitored and pain measured as per visual analogue scale.
Result:
Laparoscopic release of median arcuate ligament was shown to cause a decrease in pain postoperatively in 78% (11 out of 14) cases. The common intraoperative complications included bleeding in 28%(4 out of 14) and pneumothorax in 14%(2 out of 14). There was a conversion of laparoscopy to open surgery in 21%(3 out of 14) cases due to bleeding. Postoperative complications included pancreatitis in 1 patient and surgical site infection in 2 patients. Dumping syndrome was seen in 35%(5 out of 14) cases while recurrence was seen in 21%(3 out of 14) patients.
Conclusion:
The available evidence shows that laparoscopic ligament release and celiac ganglionectomy with celiac artery revascularization can bring about effective symptom relief in the majority of patients diagnosed with MALS. With good patient prognosis and minimal post operative complications, it can be effectively used for MALS.
Background:
Median arcuate ligament syndrome (MALS) is a clinical syndrome characterised by the compression of the celiac artery by the median arcuate ligament due to the fibres of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Surgical repair in MALS by laparoscopy can be done to relieve the pressure over the artery. The purpose of this study was to review our experience of the laparoscopic management of MALS, and its outcomes after surgical intervention.
Method:
After diagnostic workup and confirmation of MALS, 14 cases were taken up for laparoscopic decompression of median arcuate ligament over celiac artery. There were two approaches to the median arcuate ligament considered, with relation to the stomach- an anterior approach in 11 cases and posterior approach in 3 cases by hitching the stomach towards the anterior abdominal wall. Coeliac ganglia were removed to enable better decompression and pain relief. On table repeat indocyanine green angiography was performed 3 times to confirm the release on the celiac artery. Postoperative stay was monitored and pain measured as per visual analogue scale.
Result:
Laparoscopic release of median arcuate ligament was shown to cause a decrease in pain postoperatively in 78% (11 out of 14) cases. The common intraoperative complications included bleeding in 28%(4 out of 14) and pneumothorax in 14%(2 out of 14). There was a conversion of laparoscopy to open surgery in 21%(3 out of 14) cases due to bleeding. Postoperative complications included pancreatitis in 1 patient and surgical site infection in 2 patients. Dumping syndrome was seen in 35%(5 out of 14) cases while recurrence was seen in 21%(3 out of 14) patients.
Conclusion:
The available evidence shows that laparoscopic ligament release and celiac ganglionectomy with celiac artery revascularization can bring about effective symptom relief in the majority of patients diagnosed with MALS. With good patient prognosis and minimal post operative complications, it can be effectively used for MALS.
Median arcuate ligament syndrome (MALS) is a clinical syndrome characterised by the compression of the celiac artery by the median arcuate ligament due to the fibres of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Surgical repair in MALS by laparoscopy can be done to relieve the pressure over the artery. The purpose of this study was to review our experience of the laparoscopic management of MALS, and its outcomes after surgical intervention.
Method:
After diagnostic workup and confirmation of MALS, 14 cases were taken up for laparoscopic decompression of median arcuate ligament over celiac artery. There were two approaches to the median arcuate ligament considered, with relation to the stomach- an anterior approach in 11 cases and posterior approach in 3 cases by hitching the stomach towards the anterior abdominal wall. Coeliac ganglia were removed to enable better decompression and pain relief. On table repeat indocyanine green angiography was performed 3 times to confirm the release on the celiac artery. Postoperative stay was monitored and pain measured as per visual analogue scale.
Result:
Laparoscopic release of median arcuate ligament was shown to cause a decrease in pain postoperatively in 78% (11 out of 14) cases. The common intraoperative complications included bleeding in 28%(4 out of 14) and pneumothorax in 14%(2 out of 14). There was a conversion of laparoscopy to open surgery in 21%(3 out of 14) cases due to bleeding. Postoperative complications included pancreatitis in 1 patient and surgical site infection in 2 patients. Dumping syndrome was seen in 35%(5 out of 14) cases while recurrence was seen in 21%(3 out of 14) patients.
Conclusion:
The available evidence shows that laparoscopic ligament release and celiac ganglionectomy with celiac artery revascularization can bring about effective symptom relief in the majority of patients diagnosed with MALS. With good patient prognosis and minimal post operative complications, it can be effectively used for MALS.
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