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Background: Median arcuate ligament syndrome is a rare disorder characterized by abdominal pain, weight loss, and isolated celiac stenosis. Though the diagnosis is often difficult to determine, it can be made with vascular ultrasound, axial imaging with angiography, or formal angiography. Several reports have shown that surgical release of the median arcuate ligament is a durable and effective treatment option for symptomatic patients. We present our experience using a laparoscopic approach for this particularly uncommon problem.

Methods: This is a prospectively collected, retrospective analysis of 14 patients at our institution. Between March 2007 and June 2011, patients treated with laparoscopic median arcuate ligament release were analyzed. Data collected included patient demographics, pre-operative symptoms, operative approach, and post-operative outcomes. Pre-operative evaluation included vascular ultrasound or axial imaging (CT or MR angiography) in all cases. Minimally invasive surgical options included laparoscopy and robotic assisted laparoscopy. Endovascular management was used in select cases. Using an IRB approved database, patients were then contacted to complete a post-operative survey aimed at assessing resolution of symptoms and overall satisfaction.

Results: The mean age was 34 years (17-68) and 92% of patients were female. Mean pre-operative BMI was 24.1 kg/m2 (19-32) and 64% of patients had prior abdominal surgery. Mean celiac velocity was 374 cm/s (210-600). Pre-operative CT angiogram was performed on 10 patients with 7 patients demonstrating celiac stenosis. Thirteen patients had laparoscopic median arcuate ligament release while 1 patient had robotic assisted laparoscopic release. Mean operating time was 184 minutes (79-473) and average estimated blood loss was 229 cc (5-2000). There were two intra-operative complications. One was an aortic injury and another was an ulnar artery occlusion from endovascular stenting. The aortic injury occurred with the robotic assisted approach and required a laparotomy for vascular repair. All other cases were completed laparoscopically. Eleven patients had post-operative vascular ultrasounds with a mean velocity of 215 cm/s (135-306). Mean post-operative BMI was 24.7 (18-32). Response rate for the post-operative survey was 79% at a mean follow-up of 16.5 months (5-32.6). All but one patient experienced complete resolution of symptoms with no persistent pain.

Conclusion: Laparoscopic release of the median arcuate ligament is a safe, feasible and effective means of managing median arcuate ligament syndrome. Post-operative symptomatic relief is seen in the vast majority of patients undergoing this procedure.